Mastering Difficult Doctor-Patient Interactions

Introduction

Interactions among patients and medical practitioners may be challenging at many times. Studies have shown that open and transparent communication can facilitate ideal healthcare delivery.¹ The article delves into the difference between “noncompliance” and “nonadherence” in the context of patients not following their doctor’s recommendations. Noncompliance implies that the patient is not following orders, while nonadherence refers to a procedure in which the patient intentionally chooses not to adhere to treatment guidelines.²

External factors such as cost, discomfort, and misinformation might make it challenging for patients to follow their doctor’s instructions. Furthermore, patients may not follow through because they may not understand the value of a treatment or procedure.¹ According to studies conducted in Southeast Asian settings, the communication challenges include a mismatch between the desired communication style of cooperation and the prevalent pattern of paternalistic or one-way communication owing to cultural and educational differences between doctors and patients.³

Why don’t patients listen?^1,2

• Patient nonadherence has various reasons, including socioeconomic variables that affect health, such as transportation, poor health literacy, finance, and difficulty getting to pharmacies.²
• Patients will be concerned with what went wrong instead of checking for the best approach to proceed.
• Patients may not want to take medicine, not prioritize their health, or find dietary and lifestyle modifications too difficult.
• The patient does not accept the doctor’s diagnosis or test results and demands a second opinion.
• Cost and ability to afford treatment is a hindrance.
• Intentional nonadherence is often based on experience, belief systems, and knowledge. The patient conducted internet research, is convinced by their results and demands particular treatments.
• Patients may not comprehend why they require particular treatment, be overmedicated, fear drug dependency, mistrust pharmaceutical firms or the health industry, or exhibit symptoms of depression.
• Language barriers, cultural diversity, and previous interactions with professionals or authority figures can also contribute to and affect interactions.

Doctor-patient relationship across SEA

Southeast Asian cultural characteristics³

• Characteristics enabling social distance include:

1. Respect for elders or those of higher social rank in a hierarchical manner.
2. Emphasize surface agreement rather than developing an open, long-term connection.
3. The social norm allows for informal, individually modified interpretations.
4. A tendency for hesitant behavior.
5. The need to maintain harmony and be unaware of any evidence that may challenge ideas.

• Characteristics relating to the closeness of relationships are:

1. A strong family support system.
2. Widespread use of traditional medicine.
3. A considerable significance is given to nonverbal etiquette of courtesy.

Doctors mistakenly encourage social distance, while patients appear frustrated with such behavior. On the other hand, patients seem to have developed a preference for a close relationship, which physicians unknowingly fail to acknowledge or recognize.

Contributing factors for poor doctor-patient relationship in SEA³

• Patients express dissatisfaction with doctors’ paternalistic/one-way consultation style but do not articulate this during consultations.
• Patients of low educational backgrounds are timid and hesitant, while those with higher education levels are reluctant to express disagreement or dissatisfaction.
• The doctors do not use a paternalistic communication style deliberately. They state that they would prefer to pursue an interactive way of communication. Inadequate communication skills, insufficient training, a lack of time due to a significant patient load, and the notion that patients are not prepared for a more participative approach compel doctors to adopt a paternalistic style.

Potential effects of a challenging interaction¹

Challenging interactions can arise due to factors such as the patient’s beliefs and emotions, the healthcare system, and the doctor’s communication and behavior. These interactions can make patients feel unheard and lose trust in the doctor.

Additionally, doctors may feel stressed and unsure of how to handle the situation. These interactions can also pressure the healthcare system, leading to overuse of resources and “doctor shopping” (seeing several different doctors for the same issue and trying to collect various opinions) behaviors from patients.

What to do when patients don’t listen¹

The following are methods for managing the communication between a doctor and a patient:¹

• Establishing a good rapport and building mutual trust is crucial for understanding the patient’s point of view.
• Effective communication is essential in dealing with challenging interactions in the healthcare system.
• A team-based approach, including pharmacist care, can increase treatment understanding and adherence.
• Patients respond better when they feel they are part of the team and are not judged or blamed for their struggles with treatment. It is essential to create a blame-free space for patients to speak openly about their reasons for non-adherence.
• Involving the patient’s partner and caretaker in the session is also helpful since they can assist the patient and provide a different perspective.
• It is critical to plan the interaction, structuring thoughts, use proper phrases, and break down information into easy-to-understand pieces to avoid challenging circumstances.
• It is crucial to convey the news appropriately, pay attention to nonverbal signals, and provide access to additional information and support.
• Keeping the initial information basic and avoiding complex medical terminology.
• It is worth emphasizing that there is no one-size-fits-all method and that different situations and personality types necessitate different communication approaches.
• Being open to learning and developing one’s practice is critical to effectively communicating with patients.

Conclusion^1,3

There are multiple reasons why patients may not follow their doctor’s recommendations, including external factors such as cost and discomfort and internal factors such as mistrust or lack of understanding of the treatment.¹ In Southeast Asian settings, cultural factors play an essential role in doctor-patient communication, with a paternalistic communication style and cultural divide leading to less satisfied patients. Southeast Asian doctors and patients prefer a more equitable partnership communication approach, but cultural constraints can make implementation challenging.³ However, effective communication between a doctor and patient is crucial for understanding the patient’s point of view, dealing with complex interactions in the healthcare system, and increasing treatment understanding and adherence. It is important to note that different circumstances and personality types may need different communication strategies.¹

References

1. Hardavella G, Aamli-Gaagnat A, Frille A, et al. Top tips to deal with challenging situations: doctor-patient interactions. Breathe 2017; 13: 129-135. DOI: 10.1183/20734735.006616
2. Anderson J. Why word choice matters when describing patients who do not follow medical advice. [Cited: 24 January 2023]. Available from: https://www.clinicaladvisor.com/home/the-waiting-room/word-choice-describe-patients-do-not-listen-to-medical-advice/#:~:text=According%20to%20Merriam%2DWebster%20Dictionary,or%20quality%20of%20not%20adhering.
3. Claramita M, Nugraheni MDF, van Dalen J, et al. Doctor-patient communication in Southeast Asia: a different culture? Adv in Health Sci Educ 2013; 18: 15-31. DOI: 10.1007/s10459-012-9352-5