Rx: Say What?

Johns Hopkins internist Mary Catherine Beach is on a mission to improve the way clinicians communicate with patients.

A woman speaks into the ear of a male doctor.

“Good communication is one of the most important ways we can deliver high-quality clinical care,” says Mary Catherine Beach, who holds a joint appointment with Johns Hopkins’ Berman Institute of Bioethics. “If we can’t communicate accurately and make sure we’ve conveyed information in a way that is understandable, our patients won’t be able to be healed because they won’t take their medication correctly or we will get their diagnosis wrong.”

Some key takeaways from recent research by Beach and her colleagues:

Setting the Agenda in Patient Exams

How are you? The well-worn greeting most often elicits the reflexive response: “I’m doing well.” For that reason, Beach has found that clinicians should not stop there when starting off a patient visit. The most effective follow-up? “Is there anything in particular you want to discuss today?”

 “When it comes to ‘agenda setting,’” she says, “we found that doctors should elicit patient agendas by using direct language and solicit additional concerns using ‘what else?’ vs. ‘anything else?’ because patients are more likely to raise concerns to direct questions.” Unfortunately, she says, her team’s research (published in Patient Education and Counseling, 2023) has shown the most effective agenda-soliciting questions “are used least frequently by clinicians.” The result? Patients leave their visit without getting important concerns addressed.

Eliciting Medication Adherence

Much of Beach’s clinical work has focused on care for patients with HIV. Medication adherence is crucial for them but studies have shown that one-quarter to one-half of patients don’t take their antiretroviral medication consistently. Moreover, clinicians often fail to detect the non-adherence, “which means lost opportunities for them to counsel their patients,” she says.

So what are the best questions to elicit truthful responses? In a study that involved analysis of dozens of audio recordings of physician encounters with non-adherent patients, she and her team found that one type of question clearly outperformed all others: negatively framed questions — that is, asking when (rather than if) doses had been missed (“When was the last time you missed a dose? Do you remember?”)

“The goal for doctors is not to make the patient feel worse by admitting they haven’t taken their medication, or to put them on the defensive — but to open the conversation further,” says Beach. “With this and other ongoing studies, we’ve found that negatively framed questions do that best, allowing doctors to follow up with neutral questions, such as: ‘What happened then?’ Or, ‘Tell me more about that.’”

Objectively Speaking

In the past, says Beach, “we tended to think of this general idea of ‘bedside manner’ as a vague, subjective concept that was ‘nice’ but not definable.” In fact, she emphasizes, effective doctor/patient communication can be measured and analyzed, resulting in actionable information valuable to clinicians at every stage of their careers.

“Teaching effective communication can’t just happen with a single course during the first year of medical school,” Beach says. “We need to reinforce a culture where it’s a constant source of learning throughout medical school and residency training, and it should be revisited in continuing medical education.”