Earlier this month, a newer patient came in to see me for a check-up and discussion about her extremely high cholesterol level. In her late 50s with a family history of early-age heart attack, she was in a high-risk group for future stroke and coronary heart disease. When I suggested that a statin drug would help mitigate this risk, she replied with something I’m increasingly hearing from patients: “I’m really not a medicine person.”
She went on to tell me about her extensive reading on the dangers of statins and the various natural products that have proven superior to statins in controlling cholesterol levels. I listened, thanked her for sharing her perspective, and asked if she could send me one or two of the references that swayed her views most. We agreed to follow up in three months and recheck her bloodwork to assess the impact of her methods.
A medical student I was working with had observed the interaction. After we left the exam room, they seemed perplexed and asked the obvious question: Why didn’t I challenge her misinformed view on statins?
I told the student that if I had, the visit could have become contentious and she may have decided not to come back. We don’t know each other that well yet, and without an enduring relationship, I have no chance of helping her reconsider.
We then discussed how the way doctors listen and allow patients to feel understood can sometimes be more important than what we say in clearing a path to desirable health outcomes.
Relationship-centered communication has always been a fundamental, evidence-based part of doctoring, yet historically there have been periods when it has been given more or less emphasis. Effective communication, for instance, was foundational to the Institute of Medicine’s report on “Crossing the Quality Chasm” in 2001, which specifically called out the need for a care approach that actively incorporates patients’ perspectives in care decisions.
Relational communication is more important in medicine today than ever before. Now, especially in primary care, it has become a survival skill of doctors for three fundamental reasons: the increasing prevalence of medical misinformation, which is a threat to public health; worsening physician burnout; and growing competition with medical artificial intelligence.
Doctors have always been challenged by misinformed patients, more so since the internet and social media became so accessible. Both the number of misinformed and the ferocity with which they cling to erroneous beliefs have peaked since the Covid-19 pandemic, with our current polarized political climate being a likely catalyst. We cannot dismiss or avoid such a large segment of the patient population.
Doctor-patient relationships built on trust are a hopeful path forward. Whereas doctors have always been responsible for providing accurate, factual information, we are now increasingly challenged to receive misinformation without sacrificing therapeutic rapport. We should consider this not a burdensome task, but rather a core skillset; the alternative is to allow erosion of public health and face mounting professional frustration.
Effective clinical rapport requires empathy for all patients, including those who embrace misinformed narratives about their health. This is not easy, since these narratives can be triggering; they may feel like a direct affront to everything we stand for as physicians and beg for defensive responses. The confrontational approach may provide fleeting satisfaction, but often makes skeptics dig their heels further into the erroneous and lessens the likelihood that they will follow up or adhere to our recommendations.
It may help to consider why patients embrace misinformation in the first place. In her 2023 book “Wrong: How Media Politics and Identity Drive Our Appetite for Misinformation,” University of Delaware professor of communication and political science Dannagal Goldthwaite Young argues that people embrace misinformation in order to comprehend events, feel a sense of control, and connect with a community. Social media presents a broad array of options for achieving all three of these aims, which challenges doctors and medical teams to create safer and more supportive environments for our patients.
Beyond building trust and improving patient satisfaction, effective communication is also a physician well-being intervention. Research has shown that physicians who pursue supplemental training in relational communication show improvement in measures of empathy and burnout. In the midst of our current burnout crisis in medicine that is driving early retirements and severe workforce constraints, this is an invaluable dividend.
Finally, in the current artificial intelligence epoch, leveraging well-honed verbal and nonverbal skills to evaluate complex patient stories may be the least replaceable aspect of human doctoring. We must view AI as a Trojan horse. There are already many helpful applications, such as virtual scribes, that complement physicians’ work, but make no mistake — technology developers are not complacent; they will try their best to bring AI to a place where it can match as much of what clinicians do as possible.
Physicians’ foremost challenge establishing therapeutic rapport may be in managing our own emotions. Tapping into compassionate curiosity about what drives irrational health beliefs is a good place to start. Shifting from an assumption that pushback toward doctors derives from patients’ ill will to a place of wonder about the feelings and needs that give rise to a reaction can get doctors into a more empathic, constructive mindset. Just imagine — communication skills, possibly the most historically taken for granted aspect of our craft, may end up being the key to keeping us relevant in the future.
Jeffrey Millstein is a primary care physician and regional medical director for Penn Primary Care.