Eyeworld

EW NEWS & OPINION 31 their gazes is the patient's compli- ance with instructions and treat- ment regimen. Clinicians respond by bestowing communication re- wards—making eye contact, smiling, being attentive, patting where ap- propriate, being respectful, or allow- ing questions." Phatic communication, or small talk, is important during interac- tions to establish a relationship. Sometimes, however, physicians use communication punishments. If during communication, the patient responds to the physician with non- compliance, physicians tend to take subtle disciplining action. "Senior clinicians use commu- nicative disincentives (by remaining uncommunicative) and delegate junior clinicians (sometimes even the patient's attendant) to respond to the patient's queries," Ms. Mocherla noted. "Clinicians addi- tionally respond by imposing com- munication punishments delivered as visible disapproval, no eye con- tact, glare, raised voice, or words of blame ('Medicines not taken as pre- scribed!' 'We will have to go for a laser surgery'), or not saying any- thing in response to a query, staying purposefully silent." Clinicians may prescribe addi- tional tests, increase medication dos- ing frequency, increase patient return visits, or advise more invasive procedures as additional ways of ex- ercising their power. "Foucauldian analysis yielded typical reward or punishment pat- terns of clinician communication that can potentially rein in the pa- tient's resistance to any change in behaviors, while facilitating patients' understanding of doctors' advice, promoting right activities and per- suading the patient about timely ad- herence to medication," Ms. Mocherla noted. She then recom- mended ideas for better communica- tion between the clinician and patient. Communication reassurance, for example, is critical. "Clinicians' communication of reassurance can prevent patients' self-doubt, patient dissatisfaction and doctor shop- ping," Ms. Mocherla noted. "Often, failure to achieve control over the disease or to manage it properly is the result of poor understanding of the prognosis and the instructions to manage it—both of which are directly linked to communication failure in the clinic. Clinicians have the power to instill self-confidence in the patient to follow a new disci- pline. The clinician's persuasive communication, together with pa- tient's disciplined participation in his or her treatment plan, might contribute to stalling disease pro- gression, thereby avoiding or delay- ing the need for invasive management." Ms. Mocherla advocated more supportive dialogue with patients. "By deliberately infusing supportive talk (communication bonuses and incentives) into their interactions with patients, clinicians can better deliver 'dialogue medicine' to elicit patients' ongoing compliance with instructions," Ms. Mocherla con- cluded. Bjorn Johansson, M.D., Linkoping University Hospital, Swe- den, is an advocate of improved communication. "The communica- tion in our clinic could use improve- ment," Dr. Johansson said. "If doctors transmit information that competes [with what the patient be- lieves], that is likely to cause confu- sion and noncompliance in terms of what they want the patient to do. If the study says that we need to im- prove the structures of our commu- nications and the way we communicate, I certainly agree with that." Further, although there are more information resources avail- able than ever before, doctors' roles as communicators have not dimin- ished, he said. "As doctors, we should use information sources and wield them according to our back- ground information and the system we have to put that information into context," Dr. Johansson said. "I think that we need to explain that we are, in a way, taking responsibil- ity to sort things out for patients as we see them." Undoubtedly, clinical communi- cation has changed to become more of a dialogue between clinicians and patients. "It's not like it used to be 40 years ago when doctors walked on water and issued the orders with staff and patients bowing to them," Dr. Johansson said. "That is no more." EW Editors' note: Dr. Johansson has no financial interests related to his com- ments. Ms. Mocherla has no financial interests related to this study. Contact information Johansson: bjorn.johansson@lio.se Mocherla: mshoba@lvpei.org January 2011

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