Definition/Introduction

Patients with alcohol or other substance use disorders often have complex presentations of addictive behaviors and medical comorbidities, making these patients uniquely challenging to treat. Because of the complex nature of these cases, communication failures can lead to missed therapeutic opportunities. Given the shift in healthcare to a more patient-centered approach and the positive association between high-quality communication with a healthcare provider and improved patient outcomes, it is essential to acknowledge and assess factors that generate dissonance between the patient and the clinician.[1][2] Furthermore, providers can better manage interventions, referrals for treatment, and assessments of patient’s willingness to change with more effective communication tools.[3]

Issues of Concern

Verbal Communication Barriers

When asking questions or explaining a diagnosis or treatment plan, word choice may contribute to discord within the doctor-patient relationship. Clinicians may use complicated medical terms that patients may not understand. Patients come from different socioeconomic backgrounds and have different literacy levels. If confronted with a word or phrase not understood, patients will often avoid the embarrassment of not knowing the medical term by affirming a yes or no response, which can be unreliable during interviews.[4]

Studies have shown that clinicians do not disclose enough pertinent information to patients, which can impact a patient’s involvement in their care.[2] Proper communication allows patients to be more knowledgeable about their prognosis and to be more proactive in seeking assistance.

Nonverbal Communication

Nonverbal language, including facial language, body posture, and paralanguage, influences a patient’s perception of a clinician. For example, a patient may interpret a negative facial expression and a raised voice as feelings of annoyance.

Clinician Attitudes

Medical school, residency, fellowships, and extended careers often take an emotional and physical toll on clinicians.[5] As a result, their ability to empathize with patients decreases over time and may often lead to the belittling of patients.[6] Clinicians have predisposed biases about patients arising from their values and experiences. These stigmas can negatively affect a patient’s quality of care. For example, addicted patients usually are on some type of medication to suppress their addictive habits. If these patients request more medication to alleviate their symptoms, they may be labeled as “drug-seeking” and would not receive proper treatment or even a smaller dosage.[7]

Patient Anxiety

Patients may hesitate to provide accurate information because they feel distressed or distrustful. They may worry about the violation of their security or autonomy. They may feel anxious about being in an unfamiliar environment, such as a hospital, clinic, or outpatient facility, and worry about the next steps in their medical intervention. Remembering that patients sense negativity and disinterest with certain facial expressions and nonverbal gestures is helpful.

Irritable Patients

Angry, irritated, or combative patients may lead to frustration and biased treatment. Identifying the reason for the patient’s frustration is crucial. Educational background, socioeconomic status, and other patient-level characteristics may lead to untruthfulness. Practitioners should avoid spontaneous judgments and assume a neutral position. Understanding a patient's spectrum of responses allows for appropriate follow-up. Identifying the cause of dissatisfaction and adequately addressing it is essential. Clinicians can respond to frustration by validating a patient's unhappiness and providing a solution.[8] For example, “You seem upset. Can we go through the plans for your care together and see how we can help you succeed?" The clinician should use appropriate body language to show empathy and care.[9] If one chooses to touch a patient, the shoulders are the most appropriate location.

Clinical Significance

Effect on Patient Satisfaction

In addition to improving patient satisfaction, clinicians ultimately want to reduce the number of times patients have to be hospitalized or visit specialists. Positive patient interactions correlate with better emotional recovery and decreasing follow-up imaging and referrals.[10] Patients are more apt to comply with treatment and appropriate follow-up if they better understand their prognosis. Additionally, effective communication not only reassures patients but also lowers the rate of malpractice claims and complaints.[5] Inadequate doctor-patient communication increases the dissonance between the clinician and patient, which can negatively impact patients' confidence in their clinician. Patient-centered communications have also correlated with higher job satisfaction and reduced work-related fatigue and stress.[5]

Maintaining a positive attitude and believing that patients can recover is an essential motivator for the provider. If patients sense that the clinician is offering positive social support, they may be less apt to give up on themselves. It is important to realize that patients seek assistance in some of the most vulnerable and sensitive moments in their lives. Patients may have experienced some form of socioeconomic hardship and have resorted to using substances as a coping mechanism. Furthermore, explaining a diagnosis transparently gives patients the sense that the disease is treatable and offers closure and peace of mind.

Shared Decision Making

Healthcare is shifting from a period in which clinicians “know best” because they spent numerous years on education, and therefore their recommendation should be taken firmly,[1] to an era of informed consent. Appropriate patient communication exemplifies satisfactory interpersonal relationships, information exchange, and involvement in decision-making.[3][11] Management of a patient’s illness should take into account their patient-level characteristics, including their socioeconomic background, expectations, and preferences.[6] For example, what role does insurance play in covering their care? Given their social situation, how will they react to the associated side effects of a medication?

Solutions

Decreasing Patient Anxiety

• Ask for permission to gather specific information that could improve their care. Be transparent and explain why such information is useful. 

• If confidentiality issues arise, address them appropriately. Inform patients of the provider's legal responsibility to safeguard them from unauthorized disclosures. However, recall that patient-clinician confidentiality is usually preserved but does not guarantee full protection from legal discovery. Clinicians must report information if a patient is harming himself/herself or others or is involved in domestic violence. Legal policies and procedures differ from state to state.

• Providers need to be cautious of how they word questions, keeping questions professional but understandable. For example, instead of saying “illicit” drugs, say “street” or “recreational” drugs. Avoid subjective words such as “healthy,” “drunk,” “happy,” or “sad,” as these words have different meanings to different people.

• Ask close-ended questions and offer response choices. Closed-ended questions increase specificity, which increases the likelihood of getting an accurate history and reduces stress for the patient. For example, instead of “Do you use cocaine?” ask, “How often do you do cocaine? Daily? Weekly? Monthly? Yearly?”

• Ask for pertinent history, such as the frequency and duration of their drug. For example, identify current and past drug use, frequency of drug use, and assess for dependency to determine proper treatment and referral. For example, “Have you used meth”? “How often do you use meth”? “On a scale of 1 to 10, how likely are you to quit”?

• Normalize the problem by saying a generalizing statement. For example, use words such as “These are routine interview questions that I ask all my patients… ”. By doing so, patients feel like they belong to a generalized group and that they are not the only ones with problems. Patients who understand that they are part of a collective community may be more inclined to be open.

• Explain the medical reasoning behind your diagnosis in plain terms. 

Nursing, Allied Health, and Interprofessional Team Interventions

Organize information before speaking with the patient. Specific instruction is associated with higher compliance.[12] 

Reminding patients of upcoming appointments and assisting with referrals can also yield higher compliance.[13] 

Productive communication programs, such as videotaping patient encounters, provide feedback.[14] 

Interact with patients when there are no administrative duties to perform, such as drawing blood or administering medication. For example, ask about how their day is going or ask if they have any worries.[15] 

Nursing, Allied Health, and Interprofessional Team Monitoring

Nurses should:

• Address patients appropriately. Do not refer to patients by associating them with their disease process ("the patient with hypertension," "the patient with bilateral tibia/fibula fracture").
• Talk to patients as if they were individuals rather than assignments.[16]
• Not rush patients.
• Be readily available and accessible in case patients call for assistance.
• Recognize patients' feelings and know that their feelings require acknowledgment.[16]
• Observe patients' physical and psychological well-being.[16] 
• Offer patients the chance to ask questions and assess their understanding of the issues to resolve misunderstandings.
• Be trained on professional behavior, including proper etiquette, how to behave with emotional patients, and how to handle disruptive team members.[17] 

Health care providers should be made aware of some “red flags” that indicate heavy substance abuse disorders. Some signs include the smell of alcohol on breath, aggressiveness, abnormal gait, slurred speech, impaired judgment, or withdrawal symptoms. Patients with substance abuse disorders may also have difficulty maintaining friendships, staying interested in hobbies, or be struggling financially. They may also have prior records of driving under the influence, involvement in assaults or domestic violence, theft, or drug possession.[18]