At the time of this interview, Dr Hari Dhir was Medical Director at Concentra Health Services in Texas, and Adjunct Associate Clinical Professor of Occupational and Environmental Medicine at the University of Texas Health Centre at Tyler. RTW Matters became very interested in the work of Dr Dhir after he gave a talk on therapeutic communication at the American Occupational Health Conference in New York earlier this year. We asked for his expert view on the ins and outs of doctor-patient communication and why it's so important in the return to work process.

When is good communication between a doctor and patient most important?

Good communication between the doctor and patient is important during all aspects of the doctor patient interaction. It is important at all times. The purpose of good communication is to create a good interpersonal doctor-patient relationship, and facilitate the exchange of information allowing effective decision making.

I feel that the doctor has to be a good communicator at all times during the doctor-patient interaction, with all interactions, and at every stage. This is because it is important for the physician to address the patient's concerns within the patient's framework of beliefs. The 'Model of Uncertainty in Illness' suggests that patients go to their doctor to attach meaning to illness, and uncertainty is the inability to determine the meaning of illness. This is usually due to:

• ambiguity of the illness
• complexity of treatment/care
• lack of information regarding diagnosis/prognosis, and
• unpredictability of disease.

Uncertainty has to be addressed within the framework of the patient's health beliefs. This is very important because a patient can have a trivial injury or illness, but their belief may be that it is very serious with dire consequences. For example, I had a patient who had a simple back strain. After taking a careful history and examining the patient, I explained the diagnosis and treatment. From various verbal and non-verbal clues, I found the patient had concerns regarding this diagnosis and treatment. When I further questioned the patient, I found that he had an uncle who was told he had a back strain and eventually had surgery and now is in a wheelchair. Now that I knew the patient's health beliefs, I was able to address his concerns within his framework. Once I did this he was happy with the diagnosis and treatment plan.

Communication at all times is important because the injury/illness may seem trivial to the doctor, but the patient's perception of it may be totally different – and patient perception is most important.

In an article in the British Medical Journal it was stated that:

• 45% of patient concerns and 54% of patient complaints were not elicited by physicians
• psychiatric diagnoses were missed in 50% of general medical cases, and
• in 50% of the visits the patient and the doctor did not agree on the nature of the presenting complaints.

If the patient's concern is not elicited during the doctor-patient interaction then it is unlikely that they will improve.

The 'Health Belief Model' suggests that the patient has their own belief regarding their injury/illness and this includes:

• 1) Their perceived susceptibility to the condition
• 2) Perceived severity – how severe the injury/illness is to them. In the example of my patient with back strain, he perceived the back pain as being very severe and this could, in his mind, make him wheelchair bound
• 3) Perceived benefits of treatment
• 4) Perceived barriers to treatment
• 5) Cues to action, and
• 6) Self efficacy – the belief in one's self.

Once the physician is aware of the patient's beliefs, s/he can talk to the patient in terms of those beliefs and even change those beliefs. I had told my patient with the back strain that while his uncle may have had a herniated disc which required surgery, on examination he had no signs or symptoms of a herniated disc. I also told him that he did have a simple back strain which is easily treated without surgery and he should improve within a week or so – as research shows most back strains resolve within four weeks or so, even with minimal treatment. Judging by his body language and verbalisations I could see that he was now happy with the diagnosis and treatment.

What are some of the negative effects of poor communication between a doctor and patient? What are some of the problems the patient can carry back to the workplace?

There are many positive benefits of effective communication such as:

• 1) Improved patient satisfaction
• 2) Improved health outcomes: emotional health, resolution of symptoms, improved function, pain control, improved physiological measures (blood pressure, glucose level)
• 3) Improved compliance
• 4) Reduced doctor shopping [looking around for different doctors' opinions]
• 5) Reduced malpractice litigation
• 6) Fewer clinical visits
• 7) Reduced medical costs
• 8) Fewer worker's compensation complaints

If the doctor-patient interaction has not been a favourable one, then a patient can spread negative beliefs regarding the physician provider, affecting other employees. Inadequate communication can cause reduced patient compliance with poor health outcomes and more days off work or on light duty with reduced productivity. Ineffective communication leads to poor patient satisfaction which can cause increased clinical visits, more complaints and doctor shopping which may substantially increase medical costs.

Look out for the second half of Dr Dhir's interview.