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Patient communication and counseling

Last updated: May 6, 2021

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Patient counseling is the process of providing information, advice, and assistance to patients to improve their health, treatment adherence, and quality of life. A patient-centered approach facilitates and improves the patient-physician relationship and communication. This approach is based on open communication and shared decision-making. Health care decisions should be discussed using understandable terms and straightforward language. If there is a language barrier, medical interpretation services should be provided to the patient. For counseling and communication in specific circumstances, see the individual sections below.

Key principles of communication and counseling [1][2]

  • Patient counseling: the process of providing information, advice, and assistance to patients to improve their health, treatment adherence, and quality of life
  • Establishing the patient-physician relationship [1]
    • Patients may feel vulnerable and have a fear of rejection/apathy from caregivers.
    • A patient's first visit is critical to the patient-physician relationship (e.g., establishing trust).
    • Empathy, interest, and continuity of care are valued by patients.

Patient-centered approach

  • Objectives
  • Interviewing techniques
    • Start with an introduction of all people present at the visit, address the patient by their preferred name, and sit at eye level.
    • Identify the patient's concerns and set goals collaboratively.
    • Listen actively; : Use open-ended questions and allow the patient to speak freely.
    • Express genuine interest, compassion, and empathy to legitimize the patient's point of view.
    • Summarize information provided by the patient to ensure it has been understood correctly.
    • Communicate that questions asked by the patient are valued, accepted, and valid at any time throughout the interview.
    • Provide information on (working) diagnosis and treatment options.
    • Provide reassurance to reduce and address fear or anxiety regarding a diagnosis or treatment.
    • Ask for the patient's perspective on a proposed medication or procedure to ensure there have been no misunderstandings and to explore and support the patient's emotions.

PEARLS model

  • Definition: a psychosocial model that aims to help caregivers express empathy and support emotions in order to build a trusting relationship with patients
  • Components
    • Partnership: Reassure the patient of your commitment to the collaborative goals, offer resources.
    • Empathy: Acknowledge and validate the patient's emotions.
    • Apology: Take responsibility if appropriate (e.g., for a long waiting time).
    • Respect: Commend constructive patient behavior (e.g., attending a doctor's appointment, remaining optimistic).
    • Legitimization: Validate and acknowledge the patient's emotions (e.g., frustration, anger).
    • Support: Offer and ensure support.

Language

  • General considerations
    • Avoid judgmental or defensive language or behavior.
    • Discuss health care decisions with patients in relatable terms (e.g., avoid medical jargon, tailor language to the patient).
  • Language barriers
    • Ask the patient questions to assess language proficiency before starting an interview.
    • If there is a language barrier between the patient and caregiver, establish the patient's preferred language and use a professionally trained medical interpreter.
    • Spoken interpretation services are available in person, via video call, or telephone.
    • Deaf patients or patients with hearing impairment should be offered a medical interpreter trained in American Sign Language. Other communication options include computer-assisted real-time transcription and assistive listening devices.
    • Having a family member interpret should be avoided unless it is the patient's wish (in which case, this should be recorded in the patient's chart).
  • Interviewing techniques when an interpreter is present
    • Introduce the interpreter to the patient.
    • Position of the interpreter
      • Spoken language: slightly behind or next to the patient
      • Sign language: behind the physician
    • Address the patient, not the interpreter, and maintain eye contact.
    • Avoid third-person statements; , keep phrases short, and ask one question at a time.
    • Allow extra time for the interview.

Psychosocial counseling

  • Definition: care related to the emotional and psychological well-being of the patient and their family members.
  • Principles
    • Aims to reduce both psychological distress and physical symptoms by increasing quality of life and enhancing coping (e.g., identify and treat anxiety and depression)
    • Based on good communication, assessment, and interactional skills (e.g., compassion, empathy) to build a rapport with the patient and their family.
    • Encourages patients to express their feelings about the disease (e.g., consequences, relationships, self-esteem issues)
    • Provides psychological and emotional well-being tools for patients and their caregivers

Enabling behavioral change

  • Patients should be encouraged to participate in treatment and therapy decisions.
  • Shared decision-making enables patients to make informed choices.
  • Motivational interviewing can be a helpful tool to strengthen a patient's motivation to change behavior (e.g., substance use disorders, lifestyle changes).
    • Aims to explore and resolve ambivalence about changing behaviors by eliciting the patient's reasons for change
    • Helps to assess the barriers that make behavioral change difficult for the patient

Transtheoretical model of behavioral change

  • Definition: a biopsychosocial model that focuses on an individual's intentional change of behavior
  • Objectives
    • To assess an individual's readiness to modify a certain behavior
    • To provide strategies to guide the individual, e.g., in overcoming substance use disorder, managing weight, adhering to medication
Stages of behavioral change
Patient behavior Interviewing techniques
Precontemplation
  • Denies or is unaware of the problem and its consequences
  • Encourage introspection by asking open, probing, and nonjudgmental questions that explore the patient's perception of the situation.
  • Emphasize your availability and the importance of follow-up visits.
  • Demonstrate the discrepancy between the patient's personal goals and values and current behavior.
Contemplation
  • Aware of the problem but unwilling to change it
  • Discuss the benefits and disadvantages of the patient's current behavior.
  • Suggest possible ways to support behavior changes.
Preparation
  • Preparing to make a change
  • Help to set achievable goals and provide resources.
  • Encourage changes and adjust expectations as necessary.
Action
  • Demonstrates a change in behavior
  • Help to maintain change by collaboratively developing coping strategies (e.g., identifying/avoiding triggers) and self-help strategies.
  • Emphasize positive changes that have been made.
  • Acknowledge difficulties.
Maintenance
  • Maintains behavioral changes and integrates them into lifestyle
  • Support and praise ongoing positive changes.
  • Assess the risk for relapse.
  • Provide support, encouragement, and reinforcement.
Relapse
  • Behavioral changes are reversed.
  • Reassure the patient of ongoing support, availability, and the possibility of change.
  • Encourage a return to prior behavioral changes.
  • Help the patient to learn from the relapse.

5 As model of behavior change

  • Definition: an evidence-based behavioral intervention strategy originally developed for smoking cessation that can be adapted for multiple behaviors and health conditions to help individuals with intentional behavior change [3][4]
  • Components
    • Assess the patient's behavior, beliefs, knowledge, and level of motivation.
    • Advise the patient on personal health risks and the benefits of change.
    • Agree on appropriate treatment goals and methods (shared decision-making).
    • Assist the patient to identify personal barriers, create self-help strategies, access social or environmental support for behavioral change, and supplement with adjunctive medical treatments if appropriate.
    • Arrange specific plans for follow-up support to provide ongoing support and adjust the treatment if necessary.

Using the 5 As model of behavior change, the clinician should:

  • Ask: Inquire about and document the use of tobacco.
  • Advise: Urge quitting with clear and personalized language.
  • Assess: Assess the patient's willingness to quit.
  • Assist: Provide resources to help the patient quit.
  • Arrange: Schedule regular follow-ups.

Smoking is the single greatest preventable cause of death in the US, regardless of age at the time of quitting or the number of previous pack years. [6]

  • Provide feedback to the patient regarding their level of alcohol consumption and engage the patient in a conversation using reflective or motivational listening (a technique in which the topic is broached by repeating or rephrasing the patient's own words and using open-ended questions).
  • Inform the patient about psychosocial support groups (e.g., Alcoholics Anonymous).
  • Inform the patient about pharmacological treatment options (e.g., naltrexone, disulfiram).
  • Assess the patient's readiness to change by using the transtheoretical model, and schedule regular follow-ups.
  • Engage the patient in a conversation using reflective or motivational listening.
  • Provide feedback to the patient regarding their level of drug consumption.
  • Assess the patient's readiness to change by using the transtheoretical model and schedule regular follow-ups.
  • Lifestyle modifications involve altering long-term habits, and adopting and maintaining healthier behaviors.
  • Lifestyle modifications can be used to treat a wide range of conditions (e.g., cardiovascular diseases, obesity).
  • Cardiovascular diseases are the leading cause of death in the US for both men and women.
  • Many people in the US are affected by sleep disorders (e.g., insomnia) or insufficient sleep. [7]
  • The prevalence of obesity in the US is approx. 42% and has been increasing substantially in the past decades, and behavior modification is a cornerstone of therapy. [8]

Reference:[6]

  • Counseling on regular exercise
    • Patients should have 150 minutes of moderate aerobic activity or 75 minutes of vigorous aerobic activity per week. [9]
    • The specific activity or sport should be tailored to patient preferences to increase the likelihood of adherence.
  • Counseling on weight and diet changes
    • Suggest including family members or friends in diet and exercise plans to enhance social support.
    • Encourage patients to increase physical activity.
    • Encourage regular weighing.
    • Encourage patients to monitor what they eat and develop stimulus control (e.g., buying fewer calorie-rich foods).
    • Provide education on nutrition.
    • Set realistic goals in collaboration with the patient.
  • Counseling on sleep hygiene
    • Recommended amount of sleep per night [10][11]
      • Older adults (> 65 years): 7–8 hours
      • Adults (18–65 years): 7–9 hours
      • Teenagers (14–17 years): 8–10 hours
      • School-aged children (6–13 years): 9–11 hours
      • Preschool children (3–5 years): 10–13 hours
      • Toddlers (1–2 years): 11–14 hours
      • Infants (< 1 year): 12–15 hours
      • Newborns (< 4 weeks): 14–17 hours
    • Encourage patients to maintain a regular sleep schedule.
    • Advise patients to avoid the following:
      • Stimulants (e.g., caffeine, nicotine) in the evening
      • Exposure to electronic screens before bedtime
      • Naps
    • Encourage regular exercise.
  • Counseling on lifestyle modifications to improve mood
    • Educate patients on relaxation techniques.
    • Encourage regular exercise.
    • Educate patients on mindfulness and meditation.
  • Inform patients about the possibility of opioid intoxication, addiction, adverse effects, and opioid withdrawal (see “Opioids”).
  • Educate patients on buying opioids only from licensed pharmacists and stores.
  • Stress that patients should take opioids exactly as prescribed and that they should not use opioids prescribed for someone else.
  • Patients should avoid mixing opioids with any other drugs, especially alcohol or sedatives (e.g., benzodiazepines).
  • Establish specific SMART goals for opioid therapy.
  • Opioids should be stored in their original containers, out of sight/reach of children.
  • Physicians should address suspected opioid misuse in a nonjudgmental, collaborative discussion with the patient that aims to understand the reasons for misuse.
  • Screening for intimate partner violence (IPV)
    • At initial visits or routinely
    • If a patient mentions a new intimate relationship
    • At prenatal and immediate postpartum visits
    • If a patient presents with concerning trauma or symptoms consistent with IVP
    • Screening should be conducted using standardized questioning tools (e.g., abuse assessment screen).
  • Counseling on IPV
    • Encourage disclosure by asking direct questions and ensuring confidentiality.
    • Express empathy, validation, acknowledgment, and nonjudgmental support following disclosure of IPV.
    • Thoroughly document the details of abuse.
    • Assess the patient's willingness to take action and evaluate whether the patient is currently safe.
    • The patient should be referred to a social worker or domestic violence advocate/hotline for advice on preparing a safety plan.
    • Do not encourage patients to leave the relationship.
    • Counsel and evaluate for psychological comorbidities.
    • For more information on IPV, see “Domestic violence” and “Ethically challenging situations” in “Principles of medical law and ethics.”

Clinicians should not encourage patients to leave an abusive relationship but should support them if they come to that decision on their own.

General considerations

  • Evaluate emotional stability (e.g., suicidality), safety risks, adequacy of supervision, and whether there is evidence of neglect.
  • Clinicians should have contact information for the patient's caregiver or next of kin, who should be advised to determine whether the patient is adequately handling finances, medications, and other responsibilities.
  • Interviewing techniques
    • Use concrete, direct, and specific language.
    • Provide a quiet, nondistracting space for the interview.
    • Adjust questions to the patient's level of comprehension.
    • Do not make assumptions about a patient's abilities (e.g., literacy).
    • See “Communicating with patients with disabilities” below.
  • General considerations
    • Patients with chronic/terminal diseases can feel isolated, frustrated, and/or hopeless.
    • These patients should be counseled on learning how to handle difficult emotions and develop an understanding of their disease.
  • Counseling for chronically/terminally ill patients
    • Emphasize that the patient is not alone and offer referral to support groups.
    • Listen to the patient's frustrations and challenges and empathize with them; do not dismiss their concerns.
    • Avoid platitudes such as “Everything will be OK” or “I'm sure you'll feel better soon.”
    • Discuss why treatment adherence is important for slowing or reversing disease progression.
    • Counsel the patient on lifestyle modifications to improve mood.
    • Educate patients on mindfulness and meditation.
    • Spiritual counseling/care: Health care professionals should assess the spiritual needs of patients and provide support.
      • Spirituality: an individual's experience, expression, or search for purpose, connection, meaning, and transcendence
        • Can be expressed in various ways (e.g., as religious beliefs, art)
        • Can be an important and effective coping mechanism, as it can reduce suffering and pain
      • Spiritual care: interventions that facilitate the expression of spirituality
        • An essential component of palliative care
        • Has positive effects on the patient's quality of life
      • The lack of spiritual support by health care providers is associated with dissatisfaction with care, less hospice utilization, more invasive treatments, increased costs, and poor quality of life.
      • Benefits include positive mood changes, relaxation, perception of support, and facilitation of verbal and nonverbal communication./end/
    • See also “Psychosocial models” in “Overview of palliative medicine” and “Psychosocial counseling.”
  • End-of-life counseling for families
    • Assess and support family caregivers during the prebereavement period and develop pathways for bereavement care.
    • Ensure the family members are aware and informed of the changes in the condition of the dying relative.
    • Assess preparedness for death.
    • Ask what kind of support the family desires leading up to or after the death of the relative.
    • Answer questions in detail and address the next steps (e.g., what to expect, deterioration, loss of abilities)
    • Listen and offer support, while also remaining professional
    • Encourage gathering information on the illness and offer resources about the illness, grief, and bereavement services.
    • In some cases, follow up with caregivers to assess how they are coping and plan a follow-up appointment.
    • See “Communicating with bereaved patients.
  • Following disfiguring injuries or surgeries (e.g., amputations, facial injuries), patients frequently experience psychiatric distress and are at an increased risk for psychiatric disorders (e.g., major depressive disorder, posttraumatic stress disorder, social phobia).
  • If a patient feels unattractive:
    • Explore the patient's reaction to their condition with an open question.
    • Do not give false reassurance.
    • Use a patient-centered approach to listen actively to the unique concerns expressed by the patient.
    • Discuss further treatment options if necessary.

Reference:[13][14]

To prevent SIDS, physicians should educate parents on the following measures:

  • Babies should be placed to sleep on their backs and on a firm surface.
  • Encourage mothers to breastfeed for as long as possible.
  • Avoid exposing the baby to cigarette smoke.
  • There should be no pillows, loose bedding, or blankets in the crib where the baby sleeps.
  • Avoid overheating the baby.
  • The baby should sleep in the same room as the parents but not in the same bed.
  • The use of a pacifier can also reduce the risk of SIDS.

The National LGBTQIA+ Health Education Center recommends the following when communicating with transgender and gender-diverse patients: [15]

  • Use gender-neutral language until a setting can be established to ask the patient what name and pronoun they prefer.
  • Try to ensure that registration systems allow for including information on preferred name and pronouns.
  • Provide signage to indicate that restrooms are all gender.
  • Be honest about mistakes made in gendered language and show a willingness to learn and improve.
  • Offer open communication about gender identity and do not assume gender binarism.
  • Provide information, resources, and contacts of specialists in transgender care if the patient expresses interest.
  • Reassure patients of confidentiality.
  • Only address gender identity if it is relevant to the patient's visit.
  • Only discuss a patient's gender identity with team members or colleagues involved in the patient's care if it is relevant, i.e., the information is needed to address the patient respectfully.
  • Evaluation of grief
  • Interviewing techniques
    • Express sympathy and concern.
    • Provide a space to discuss the patient's feelings.
    • Discuss further treatment options if necessary.

Reference:[16][17]

  • General considerations
    • Use a normal tone of voice and talk directly to the patient.
    • Caregivers accompanying the patient may provide additional information if necessary.
    • Ask the patient if they need assistance, do not assume help is needed.
    • When communicating with family members or caregivers, apply people-first language, e.g., “a person with a disability” instead of “the disabled (person).”
    • Make eye contact.
    • If a physical examination is necessary, do not miss out any relevant components.
    • Only address the patient's disability if it is relevant to the visit.
  • Communicating with patients who have hearing loss
    • Ask the patient about their preferred means of communication (e.g., sign language, lipreading).
    • Allow extra time for the interview.
    • Make use of visual/tactile signals to maintain the patient's attention.
    • See “Use of an interpreter” in “General concepts of patient counseling” above.
  • Communicating with patients who have speech difficulties
    • If you have difficulties understanding a patient, ask them to write down the information.
    • Repeat information provided by the patient to ensure correct interpretation and/or understanding.
    • Eliminate background noise and distractions.

Reference: [18]

  • Behavioral health screenings for patients with a history of trauma
    • Substance use
    • Social support
    • Suicide risk
    • Trauma-related symptoms interfering with social/occupational function
  • Interviewing techniques [19]
    • Avoid asking the patient to repeat their trauma history. Review the patient's chart instead
    • Emphasize confidentiality.
    • Inform the patient about what to expect during the history taking and, if relevant, during a physical examination.
    • If the patient requires a physical examination, inform them beforehand that they determine the pace and/or continuation of the examination and can signal at any time if there is emotional or physical discomfort.
    • Ask the patient for permission before conducting each part of the physical examination.
    • Let the patient know that they can have one or more friend or family member present in the room for support.
  1. National Health report highlights 2020. https://www.cdc.gov/healthreport/publications/compendium.pdf. . Accessed: February 11, 2021.
  2. Ravi A, Little V. Providing Trauma-Informed Care.. Am Fam Physician. 2017; 95 (10): p.655-657.
  3. Communicating with People with Disabilities. http://www.nln.org/professional-development-programs/teaching-resources/ace-d/additional-resources/communicating-with-people-with-disabilities#:~:text=General%20Recommendations%20for%20Communicating%20with,would%20talk%20to%20anyone%20else.&text=Ask%20the%20person%20with%20a,is%20needed%20until%20you%20ask.. Updated: January 28, 2017. Accessed: February 15, 2021.
  4. A guide to taking a sexual history. https://www.cdc.gov/std/treatment/sexualhistory.pdf. . Accessed: February 11, 2021.
  5. Sleep and sleep disorders. https://www.cdc.gov/sleep/about_sleep/sleep_hygiene.html. Updated: July 15, 2016. Accessed: February 11, 2021.
  6. Adult obesity facts. https://www.cdc.gov/obesity/data/adult.html. Updated: June 29, 2020. Accessed: February 11, 2021.
  7. Shear MK, Simon N, Wall M, et al. Complicated grief and related bereavement issues for DSM-5. Depress Anxiety. 2011; 28 (2): p.103-117. doi: 10.1002/da.20780 . | Open in Read by QxMD
  8. Mitnick S, Leffler C, Hood VL. Family Caregivers, Patients and Physicians: Ethical Guidance to Optimize Relationships. J Gen Intern Med.. 2010; 25 (3): p.255-260. doi: 10.1007/s11606-009-1206-3 . | Open in Read by QxMD
  9. Fitness. https://www.mayoclinic.org/healthy-lifestyle/fitness/expert-answers/exercise/faq-20057916#:~:text=Get%20at%20least%20150%20minutes,provide%20even%20greater%20health%20benefit.. Updated: April 27, 2019. Accessed: February 11, 2021.
  10. Watson NF, Badr MS, Belenky G, et al. Recommended Amount of Sleep for a Healthy Adult: A Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society. Sleep. 2015 . doi: 10.5665/sleep.4716 . | Open in Read by QxMD
  11. Paruthi S, Brooks LJ, D’Ambrosio C, et al. Recommended Amount of Sleep for Pediatric Populations: A Consensus Statement of the American Academy of Sleep Medicine. Journal of Clinical Sleep Medicine. 2016; 12 (06): p.785-786. doi: 10.5664/jcsm.5866 . | Open in Read by QxMD
  12. Providing Affirmative Care for Patients with Non-binary Gender Identities. https://www.lgbtqiahealtheducation.org/wp-content/uploads/2017/02/Providing-Affirmative-Care-for-People-with-Non-Binary-Gender-Identities.pdf. . Accessed: February 11, 2021.
  13. Bhutani S. Living with Amputation: Anxiety and Depression Correlates. J Clin Diagn Res.. 2016 . doi: 10.7860/jcdr/2016/20316.8417 . | Open in Read by QxMD
  14. De Sousa A. Psychological issues in acquired facial trauma. Indian J Plast Surg.. 2010; 43 (2): p.200. doi: 10.4103/0970-0358.73452 . | Open in Read by QxMD
  15. Dang BN, Westbrook RA, Njue SM, Giordano TP. Building trust and rapport early in the new doctor-patient relationship: a longitudinal qualitative study. BMC Med Educ. 2017; 17 (1). doi: 10.1186/s12909-017-0868-5 . | Open in Read by QxMD
  16. Hashim MJ. Patient-Centered Communication: Basic Skills.. Am Fam Physician. 2017; 95 (1): p.29-34.
  17. Whitlock E. Evaluating primary care behavioral counseling interventions An evidence-based approach. Am J Prev Med. 2002; 22 (4): p.267-284. doi: 10.1016/s0749-3797(02)00415-4 . | Open in Read by QxMD
  18. R. E. Glasgow. Assessing delivery of the five 'As' for patient-centered counseling. Health Promot Int. 2006; 21 (3): p.245-255. doi: 10.1093/heapro/dal017 . | Open in Read by QxMD
  19. Screening, Brief Intervention, and Referral to Treatment (SBIRT). https://www.samhsa.gov/sbirt. Updated: September 15, 2017. Accessed: February 11, 2021.