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Clinician-patient communication contributes to an effective antiretroviral treatment

Introduction
A good clinician’s interpersonal communication skills are essential elements to facilitate accurate diagnosis, provide proper advice, give treatment instructions, and establish caring relationships with HIV patients¹. This will ensure better health-care outcomes. It is now widely recognised that poor clinician-patient communication is the ‘Achilles heel' of a successful health outcome. The effectiveness of ARV treatment in resource-limited regions is still threatened by poor clinician-patient interpersonal communication skills rather than clinicians failing in the technical aspects of medical care².

Poor clinician-patient communication deprives HIV-patients of the necessary information to properly manage HIV/AIDS. ARV drugs are still the only treatment available to mitigate the devastating impact of the epidemic; however, HIV patients in resource-limited regions are not adhering to treatment because of the onset of side effects³. Therefore, clinicians are encouraged to constantly provide suitable guidance to HIV-patients to encourage positive medication-taking behaviour that will immensely affect an individual's response and ARV adherence.

Clinician’s most important activity
Clinicians in resource-limited regions should be proficient in involving patients in treatment decisions, recognising them as experts with unique knowledge of their own health and their preferences for treatments, health states, and outcomes. Good clinician-patient interpersonal communication skills facilitate the creation of a good interpersonal relationship, facilitating the exchange of information, and including patients in decision-making. Therefore, effective clinician-patient interpersonal communication can be a source of motivation, reassurance, and support in complying with ARV treatment and appointments.

Here, we present four patterns of behaviour, The Four Habits model that health-care professionals can use to enhance their clinician-patient interpersonal communication skills in order to achieve an effective HIV/AIDS outcome⁴.

The use the Four Habits model for good clinician-patient communication
The Four Habits model is a stepwise approach to enhancing patient relationships, optimising the amount and quality of information available for making clinical assessments and diagnosis mutually satisfying for the clinician and patient⁵. The word ‘Habits’ in this model is used as an indicator of an organised approach of thinking and acting during the clinical encounter.

The Four Habits model is an approach that lays out the clinician’s basic task during the patient meeting, and also conceptualises how the elements of patient visits relate to one another within and across medical visits. During the patient visit, clinicians are encouraged to adhere to the guidelines of The Four Habits model.

The model encourages the clinician to invest in the beginning of an interview, elicit the patient’s perspective, demonstrate empathy, and invest in the end of an interview.

The first habit, Investing in the beginning of an interview, allows the clinician to create a welcoming atmosphere. This will provide a platform for the clinician to quickly connect with the patients, eliciting their concerns, and thereby increasing diagnostic accuracy by planning the reason behind the visit.

The second habit is to Elicit the patient's perspective which requires a clinician to show compassion while obtaining a patient's point of view concerning the meaning of symptoms.

The third habit is to Demonstrate empathy by being open to the patient's emotions. 

At the end of the patient visit the clinician moves to Invest in the end (fourth habit) by providing diagnostic information; motivating the patient to participate in decision making; and negotiating treatment plans and probing for adherence by explaining the rationale behind current, past, or future tests and treatments.

The aim of this model is to bridge the communication gap between clinician and patient by establishing rapport and building trust rapidly, assisting in effective exchange of information, demonstrating care and concern, and thereby increasing the likelihood of adherence and positive health outcomes.

Principles of the Four Habits model during the patient interview
Habit 1. Invest in the Beginning

1. The clinician needs to clearly demonstrate familiarity with the patient's history (e.g., mention recent tests performed or visit information based on previous chart notes).
2. The clinician must greet the patient in a manner that is personal and warm (e.g., asks patient how s/he prefers to be addressed, uses patient's name).
3. The clinician should make a social comment or ask a non-medical question to put the patient at ease.
4. Using primarily open-ended questions allows the clinician to identify the problem(s) (asks questions in a way that allows patient to tell his/her own story with minimum interruption or closed-ended questions).
5. Encourages the patient to expand in discussing his/her concerns (e.g., using various continuers such as: “Aha”, “Tell me more” and “Go on”).
6. The clinician attempts to elicit the full range of the patient's concerns by generating an agenda early in the visit.

Habit 2. Elicit the Patient's Perspective

1. The clinician shows great interest in exploring the patient's understanding of the problem (e.g., asks the patient what the symptoms mean to him/her).
2. The clinician asks (or responds with interest) about what the patient hopes to get out of the visit (e.g., can be general expectations or specific requests such as meds, referrals).
3. The clinician attempts to determine in detail/shows great interest in how the problem is affecting patient's lifestyle (work, family, daily activities).

Habit 3 Demonstrate Empathy

1. The clinician openly encourages/is receptive to the expression of emotion (e.g., through use of continuers or appropriate pauses (signals verbally or nonverbally that it is okay to express feelings).
2. The clinician makes comments, clearly indicating acceptance/validation of the patient's feelings (e.g., ‘I’d feel the same way … I can see how that would worry you …’).
3. The clinician makes clear attempt to explore the patient's feelings by identifying or labelling them (e.g., So how does that make you feel? It seems to me that you are feeling quite anxious about …).
4. The clinician displays nonverbal behaviours that express great interest, concern and connection (e.g., eye contact, tone of voice, and body orientation) throughout the visit.

Invest in the End

1. The clinician frames diagnostic and other relevant information in ways that reflect the patient's initial presentation of concerns.
2. The clinician pauses after giving information with intent of allowing the patient to react to and absorb this.
3. Information is stated clearly and with little or no use of jargon.
4. The clinician fully/clearly explains the rationale behind current, past, or future tests and treatments so that the patient can understand the significance of these regarding diagnosis and treatment.
5. The clinician effectively tests the patient for comprehension.
6. The clinician clearly encourages and invites the patient's input into the decision-making process.
7. The clinician explores the acceptability of the treatment plan, expressing willingness to negotiate if necessary.
8. The clinician fully explores barriers to implementation of the treatment plan.
9. The clinician openly encourages and asks the patient additional questions (and responds to these in at least some detail).
10. The clinician makes clear and specific plans for a follow-up visit.

Conclusion
During a patient interview the clinician must be competent in making first impressions count, eliciting the patient’s perspective, demonstrating empathy thereby increasing the potential for collaboration, improving adherence and encouraging self-care. Strategies to encourage ARV adherence may save direct health-care costs as well as improve patient outcomes in resource limited regions.

An extensive body of literature on healthcare in HIV indicates that bad communication between patient and clinician disrupts the effective treatment of an HIV-infected patient in resource-limited regions. HIV-patients don’t adhere to ARVs in resource-limited regions because of the onset ARV side effects, opportunistic infections, nutrition, and social interaction. A good interpersonal communication empowers HIV-patients, in a complementary partnership with their clinician, that able them to manage the symptoms, treatment, lifestyle behaviour changes, and the many physical and psycho-social challenges that are a part of living with HIV/AIDS diseases.

The Four Habits model is a stepwise approach to enhancing patient relationships, optimising the amount and quality of information available for making clinical assessment, and making the diagnosis more mutually satisfying for clinician and patient. The application of The Four Habits model by healthcare professionals will enhance their clinician-patient interpersonal communication skills. Indeed, a good clinician patient communication is important and has multiple impacts on various aspects of health outcomes including adherence of HIV/AIDS patients to ARV treatment in resource limited regions.

Sources

1. “Clinician Interpersonal Communication Skills and Contact Len... : Optometry & Vision Science,” n.d., http://journals.lww.com/optvissci/Abstract/1990/09000/Clinician_Interpersonal_Communication_Skills_and.3.aspx.
2. Ibid.
3. Karl Peltzer et al., “Antiretroviral treatment adherence among HIV patients in KwaZulu-Natal, South Africa,” BMC Public Health 10, no. 1 (2010): 111.
4. Terry Stein, Richard M Frankel, and Edward Krupat, “Enhancing clinician communication skills in a large healthcare organization: a longitudinal case study,” Patient Education and Counseling 58, no. 1 (July 2005): 4-12.
5. Terry Stein, Richard M. Frankel, and Edward Krupat, “Enhancing clinician communication skills in a large healthcare organization: A longitudinal case study,” Patient Education and Counseling 58, no. 1 (July 2005): 4-12.

Author: Mawethu Bilibana
Reviewed by: Hendra van Zyl and Jean Fourie
Contact: afroaidsinfo@mrc.ac.za
Date: September 2010

Last updated: 3 September 2010