"Tailor-made instead of scattergun approach"

medinlive: Patient-centered medicine is, after all, relatively young. The idea of patients meeting physicians at eye level hasn't been around for very long, right?

Birigit Hladschik-Kermer: No, because for centuries the medical profession was considered the unchallenged expert on what patients needed. Which is, of course, a very paternalistic view. And patients had to follow these recommendations without fuss or quibble. Of course, the first priority was the well-being of the patients, but what this welfare actually was was determined solely by the medical profession.

After that, the patients' self-image began to change, they became more responsible, and information became more accessible. When patients ask questions or obtain information in advance via Google, as is of course common practice, I would recommend that this should not be seen as a curtailment of competence. Rather, this is a person who is concerned about his or her own life, his or her own personal health. And what do I do as a patient in such a situation in 2021? I turn to the greatest source of information there is, the Internet. Which is perfectly legitimate, because it's a simple attempt to control fears that arise from uncertainty. Physicians should therefore try to see it as completely normal approach, not as a threat.

But back to the historical evolution: After the paternalistic approach, the will of the patient eventually became supreme. Which is also difficult, however. Here, in fact, the question "What can I do for you?" often comes up in the doctor's conversation. This question is well-intentioned. But as a patient, I don't have the information to know what the doctor can do for me. I do, however, know what pains, fears and worries I have and what I have read in advance. What I don't know, though, is whether I got everything right in terms of prior knowledge. So patients can't make the decision about what should happen. And it doesn't make sense to outline all the information to them, right down to the last horrible side effect. That doesn't work.  We should therefore move in the direction of a change based on partnership. And doctors should act as guides and navigators. Patients can then be involved in this decision, they can be asked, what would you want, what do you already know? And physicians then provide the structure. This is more or less where we are at the moment.

medinlive: When it comes to communication itself, how do you experience gender-specific differences here?

Hladschik-Kermer: Data shows that female physicians talk longer with patients. Female physicians address psychosocial aspects more, but they don't overlook biosocial aspects. Incidentally, female students in training rate their communicative competence lower than that of male students, although their performance is often better or equivalent. 

medinlive: If we now talk about performance, what does this mean on a communicative level?

Hladschik-Kermer: The goal of any communication is for the conversational partners to get closer to each other. To take patients seriously and to see them with all their needs, concerns and also their expertise on the disease. This does not necessarily have to coincide with the expertise of the doctor, but patients are experts on their own bodies and their problems. On the other hand, there are doctors who, based on their expert knowledge and the patient's medical history, make a diagnosis and recommend a therapy. The goal is to mutually find a course of treatment that is medically justifiable and can be accepted and implemented by the patient. The gold standard is: both are talking about the same thing, both agree on what is best to do, and both understand the same thing. This is where exchange and ensuring understanding is needed.

The most important thing is to listen, so an open question is important at the beginning. And after that, the doctor should remain silent - and just listen. Without an open, hypothesis-generating question, it will be difficult to get answers. Good questions to ask here would be something like: What is your concern today? What do you think about it? What is your opinion? What has happened so far? The classic W-questions. Then the next step is to include the patient's perspective in the therapy planning. This therapy planning must also be actively inquired about.

medinlive: To put it provocatively, can doctors already do this, or is there a lot of catching up to do and deficits?

Hladschik-Kermer: I think there is a lot of potential. At MedUniVienna, there has been a standardized evidence-based communication training program for several years now, which all students undergo. From taking medical histories to conducting conversations in clinically challenging situations, such as breaking bad news, to communicating with depressed patients, students repeatedly develop their communication skills in small groups. Concrete conversational situations are practiced in role play with actors portraying patients. An essential didactic element is the concrete practice and structured feedback by the actors and the peers. Institutions in general are increasingly recognizing how important the topic is.

Be it hospitals, rehabs or practices...they all have their employees trained. Where there is also room for improvement: creating systemic framework conditions. This starts already with creating a space for conversations with patients, for example in the hospital. Or that these conversations are not seen as a waste of time, but as important as equipment medicine or infusions. And, of course, it's also a question of paying for medical consultations.

medinlive: Did anything happen in the hospital system in this regard?

Hladschik-Kermer: At the moment, it is of course difficult due to Covid, but there was a lot of training up until the beginning of the pandemic. I think the importance of communication has arrived, as far as I can see over the last 25 years, but of course we are still a long way from reaching our goal. If doctors see patients non-stop in the morning in the outpatient clinic, it is difficult to achieve quality, but patient-centered communication à la longue actually saves time, as many studies have shown. Why? If patients can understand what they have, why you can use which therapy, then there is a greater chance that they will actually do it and comply. If, instead, they don't know their way around well because something is explained to them too quickly or in too little detail, then there will be multiple returns or a change of doctor...in other words, all things that cost time.

Compliance (adherence to measures, editor's note) is also a major problem. With all "lifestyle diseases" such as diabetes 2 or things like high blood pressure and chronic diseases, it's about patients adapting their lifestyle, and that demands a lot from them. It's about winning patients over, listening to them, finding out: Who is actually sitting in front of me? What is his need for information, what is his need for communication? Is this someone who already has a lot of prior information? How would he like to be involved? What possibilities does this person have to implement therapy options? All of this has to fit the person. It is not a matter of pouring information out with a watering can, but rather of tailoring it a bit.

The healthcare system costs a great deal of time and money if there is too much of a communication deficit here. Because either patients keep coming back, as I said, or they go to other doctors, or the therapy doesn't work. We train doctors and students to have conversations that last a maximum of ten minutes, and in these ten minutes everything relevant is addressed, from the diagnosis message to the therapy. It's also important to be aware that you don't have to solve everything in the first meeting. Instead, the first thing is to ask what our common goal is today.

medinlive: How do you feel doctors see themselves, how important is this topic?

Hladschik-Kermer: Just as there is no such thing as the patient, there is of course no such thing as the physician. But what I perceive in terms of self-image is that for younger physicians there is little doubt about the importance of doctor-patient communication. And we know, physicians suffer, of course, when things don't work out in communication with patients. Because if I, as a physician, have the impression that I am talking and trying to convey information with no result, that naturally frustrates me. The structure and the tools for successful communication are often lacking. The systemic conditions must also be created to enable good communication. And physicians must be compensated for this. Traditionally, however, equipment medicine is better compensated than conversations, taking medical histories, and so on. However, a change is to be expected here, starting with younger physicians.

And there is also a completely different self-image; doctors no longer see themselves as gods in white who can do everything and knows everything. By that I don't mean that all older physicians see themselves that way; rather, this image used to be projected very strongly onto physicians from the outside. In any case, the communication training is perceived as very valuable by the students, as we know from the feedback. When I was young, it was said that communication and conversation skills could not be learned. In the meantime, however, it has become accepted that communication is behavior and, like any behavior, it consists of different competencies that can be learned as a matter of course.

About the person

Dr. Mag. Birgit Hladschik-Kermer is a clinical and health psychologist, psychotherapist, supervisor, Master of Medical Education and communication (teaching) trainer for the health sector according to the ÖPGK-tEACH standard. She works as a communication trainer and psychotherapist in independent practice and heads the Department of Medical Psychology at the Medical University of Vienna. She was the first psychotherapist at the Oncology Department in the General Hospital of the City of Vienna and has since been intensively involved with the importance of the relationship in doctor-patient communication. At the Medical University of Vienna, she is largely responsible for the evidence-based and behavioral communication teaching of medical students.