It Takes Two to Communicate
A review of the PAIR model and PEARLS statements.
MARIANA G. HEWSON, PH.D.

Case Study

A 52-year-old female schoolteacher has an appointment at 9:00 a.m. at the eye clinic. She takes off a half-day from teaching, believing this will be ample time, because she lives and works near the clinic. Her eyes have been bothering her lately, and it has been 6 months since her last check-up, but she has been experiencing some blurry vision. She is anxious about her vision problems because they interfere with her life – sometimes she simply cannot see to read. She wonders whether she may have a cataract or some other problem.

At 1:05 p.m., Dr. O comes into the exam room. He is harried and the patient is angry. Without greeting or looking at her, Dr. O goes straight to the file to read the notes. "Put your chin here, and let me take a look."

"I came for an appointment at 9:00 a.m. and now it is nearly 1:30 p.m."

"I will be very quick," Dr. O says.

"No," she tries again, "the problem is that you are running late and if you had let me know, I would have rescheduled. I want your full attention on my eye problem."

"Can you imagine what time I am going to get home tonight?" retorts Dr. O. He remains cold and aloof, despite the noticeably aggravated patient.

When she eventually leaves the clinic she fills in a Quality of Care evaluation form and rates Dr. O very low on most categories. She adds a note: "At least he could have spoken to me. If he had apologized, I am sure I would have understood. As it is, I will look for another ophthalmologist. Thank you."

What are the Issues in this Case?

Everyone knows that in medicine there are situations, such as medical emergencies, that can cause a physician to run late. However, in this particular case, it is not the reason why the doctor was running late that caused the problem, but rather, the manner in which the situation was handled by the physician and the staff. If the patient had received a more compassionate, thoughtful response to her anger, the problem could have been resolved with that conversation.

When a patient is sufficiently upset or annoyed to leave the practice to find another physician, the cost to the institution is high. The lost revenue includes not only the lost patient, but also the negative advertising that comes from such events. No medical institution can afford to lose patients, especially for situations where avoidance is easy.

By the time the ophthalmologist saw the patient in this scenario she felt angry and noncompliant. Tears filled her eyes – an annoyance to all including her. There was no apology, no explanation for the lateness and no reassurance. The treatment she received at the eye clinic made her feel that neither the assistant nor the ophthalmologist noticed or cared about her anxiety. It was as if she had brought them in eye-socket purses for a mechanical check-up.

The patient felt disrespected by the way the situation was managed in part because the late examination compromised her good standing at work by forcing her to take additional time off. She was not only offended by the ophthalmologist's sparse and terse tone in his conversation with her, but he also seemed to blame her for his late schedule. The lack of empathy from the ophthalmologist did nothing to convince her that the practice was considering her best interests and therefore, the relationship between physician and patient broke down.

What Could Have Been Done?

A postponed appointment might have been a good option for this patient. The reception desk staff could have informed the patient of the situation and offered the choice to either reschedule the appointment or to wait. A system is needed in this eye clinic to alert patients when a delay is likely, allowing patients to make phone calls, visit the cafeteria, or provide them with refreshments while waiting. If the front desk staff had told the patient what was happening with intermittent updates on the schedule they could have alleviated the problem. The interaction need not have been so fraught and unsatisfactory to the care providers and the patient.

The communication between the caregivers and this patient were minimal. Effective medical communication involves two people – it takes two to communicate. The steps in medical communication between a physician and patient can be described using the PAIR model1:

PREPARE

Review your schedule each half-day and stay aware of time. Alert your staff when delays are likely. Ask them to alert patients with regular updates.

► Review the patient's chart plus notes from assistants before entering the room.

► Prepare yourself emotionally to be ready for this patient.

► Notice your own mood (e.g., Tired? Frazzled? Frustrated? Lethargic?).

► Be aware of your feelings concerning this patient. These often take the form of judgments about patients (e.g., He/she is oversensitive; He/She is difficult to work with; I do not like him/her).

► Clear your mind and your own emotional baggage in order to work with the patient. You can take a quiet calming breath (one second will do it) just before you walk into the examination room.

► If you are running late, prepare to defuse the patient's probable negative emotions (i.e., annoyance, frustration) by acknowledging your lateness with an apology plus explanation.2

► Before turning down the lights attend to the patient's comfort. Some patients are uncomfortable being in the dark at close quarters with someone they do not know.

Ask About Patient's Symptoms and Explanations

► Greet your patient using appropriate titles (Mr., Ms.) and ask how his/her eyes are doing in general. Engage in light conversation to relax your patient.

► Before turning down the lights ask the patient specific details about:

• His/her eyes and sight, and the details of the symptoms he/she may be experiencing.

• His/her explanations for the symptoms: "What do you think is going on?"

• Acknowledge the patient's statements, whether you agree or not. The patient's explanatory model provides the physician with insight into the patient's levels of knowledge as well as her anxiety level.3

Investigate the Clinical Signs and Symptoms

► Perform the required eye examination(s).

► Intersperse explanations for what you are doing so that the patient has some understanding of the general purpose of the various tests.

Respond

► Tell the patient your diagnosis

► Inform the patient of the diagnosis with sensitivity and understanding, especially if it involves bad news (e.g., loss of sight).

► If the news is likely to be upsetting, prepare the patient by forecasting: "I have some bad news for you – you have a condition called ..."4

► The news should be given within the context of the patient's own fears: "You said earlier that you are worried about blindness. This is a likely problem for you. But it is not a punishment for your sins — it's a genetic trait."3

► Tailor your language and the amount of information you provide to the patient's need to know. Avoid "doctor babble." The patient cannot absorb excessive and complicated information when feeling shocked and upset. Provide extra information with a brochure or a follow-up phone call.

► Respond to your patient's emotions. The emotions may range from open hostility to stoic silence, including anger, sadness, and frustration. Use the PEARLS statements:5

Partnership – Ensure your patient knows that you plan to work with her in managing her eye problems. Long relationships between patients and their ophthalmologists are common.

Empathy – Express your patient's apparent feelings in words: "You look surprised," or "You are crying, this must be very upsetting to you," or "This is a tough diagnosis to accept, isn't it?"

Apology – Commiserate with the patient with an apology plus explanation: "I apologize for being late, an early patient needed more time," or "I wish things could have turned out differently for you."4,6

Respect – Indicate that you understand how difficult it must be to deal with declining vision, and that you respect her coping efforts.

Legitimization – Let your patient know that his/her emotional response is understandable and normal for any one facing this problem, and that you are not critical of his/her feelings.

Support – Tell your patient that you will continue to work with him/her and help deal with the eye problem(s) over time, and will monitor the situation, updating him/her on possible new therapies.

Outline the prognosis. Be realistic when you describe the likely prognosis, without being unduly pessimistic or optimistic. Explain the role of uncertainty in medicine. Give the patient hope wherever appropriate.

Negotiate the treatment plan. Outline your proposed treatment, check that your patient understands the plan, find out if he/she is ready to follow the plan or whether there are obstacles and barriers. Make compromises that encourage patient adherence with the plan, and review your common understanding with the patient.

Respond to emotions. Once again, handle your patient's emotional response to the diagnosis, prognosis, and plan. Use the PEARLS statements (see above).

The application of these two models to the case of the patient mentioned in the case study appears as a dialogue illustrating principles from the PAIR model and the PEARLS model of building relationship through handling emotions (Table 1).

This example is not necessarily the only or "right" way to talk with a patient, but it suggests how ophthalmologists can incorporate a patient's feelings and ideas in medical communications. The context of each medical encounter determines what can and will be said by the physician to the patient. The patient is more likely to follow the physician's recommendations when he/she has a therapeutic relationship with the physician. Good communication is likely to enhance the quality of care provided – the ultimate goal of both physician and patient.

Mariana G. Hewson, Ph.D., is a professions education consultant. Dr. Hewson has no financial interest in the information contained in this article. She can be reached by e-mail at hewson@professions-educator.com.

References

1. Hewson MG. Patient education through teaching for conceptual change. J Gen Intern Med. 1993;6:393-398.

2. McCord RS, Floyd MR, Lang F, Young VK. Responding effectively to patient anger directed at the physician. Family Medicine. 2002;34:331-336.

3. Kleinman A, Eisenburg L, Good B. Culture, illness, and care. Ann Intern Med. 1978;88:251-258.

4. Maynard DW. Bad News, Good News: Conversational Order in Everyday Talk and Clinical Settings. Chicago, Ill.: University of Chicago Press, 2003.

5. Clark W, Hewson MG, Fry M, Novack D. The Medical Interview: Summary Card. American Academy on Physician and Patient, 1996.

6. Quill TE, Arnold RM, Platt F. "I wish things were different": expressing wishes in response to loss, futility, and unrealistic hopes. Ann Intern Med. 2001;135:551-255.