How well do we really communicate?
I’m pretty sure most clinicians want to believe that they treat people with equal respect, that they listen carefully and respond with empathy when a person has concerns about their health. At the same time I’ve listened to many people with chronic pain describe how they’ve had trouble feeling heard, how they can feel like they’re not being taken seriously, and what the negative effects have been on them.  Maybe as clinicians we don’t always do what we think we do!

A paper just published in Pain by a group of researchers in Norway and Denmark have carried out an interesting study where they video-recorded  interactions between clinicians and patients where the patients were being informed of the results of MRI of their back.

These tapes were reviewed using the ‘Four Habits Coding Scheme’, an instrument developed to evaluate clinician behaviour. This is based on a training scheme built on behavioural elements that are known to be associated with effective communication.

  • Habit 1 ‘invest in the beginning’ involves the ways in which the person is greeted, history taken and the person engaged in the interaction.
  • Habit 2‘elicit the person’s perspective’ is about ensuring the person’s understanding and needs is conducted.
  • Habit 3‘demonstrating empathy’ is about using listening skills to show that the person is really being heard.
  • Habit 4‘invest in the end’ reflects how information should be conveyed to ensure the person understands it, and that recommendations are followed.

In this study, Habit 4 and the total score were used to measure the quality of the interactions, and scoring was rated by one clinician who had been recently trained in the system, while a second clinician re-rated a random sample of 16 videos independently. Inter-rater reliability was 0.835 (CI 0.600; 0.939).

Patients also completed a set of questionnaires about their experience, and several biographical details such as age, duration of pain and so on.

What did they find?

Firstly, the providers included chiropractors, physiotherapists and doctors, and a total of 21 clinicians were included.  79 encounters were rated.  There were no real differences between the various professions, and patient variables such as gender, educational level and social class weren’t associated with any outcome variables.

What they did find was a strong negative relationship between the total score on the 4HCS and patient age and pain duration – so if the patient was older and had their pain for longer, the quality of the interactions as rated by the 4HCS was poorer. 

The differences, as noted by this group of researchers, were not so much about Habit 1, but more about things like interest in the patient’s understanding and psychosocial status, encouraging expressions of emotion, identifying whether the patients understood the findings, involving the patients in decisions about treatment and asking for additional questions.  And this applied to all the different professional groups.

Why is this?

Well, the study didn’t set out to answer this question.   In all of these consultations, the clinicians had met the patient only once before and could have been expected to treat each patient in a broadly similar way, but didn’t. The authors put forward a couple of ideas worth considering. 

Maybe the duration of the pain influences the mindset of the people involved – both the clinician AND the patient.  We all learn over time, so it’s unsurprising that people with chronic pain who may have been seeking help over many years may approach a clinican encounter with a touch of pessimism.  Some will have been looking for ‘the source of the pain’ – and if an MRI doesn’t show this, may well be disappointed and not at all ready to hear what the clinician has to say about treatment.

The clinician, having met people who have been discouraged about their pain, may find it very difficult to ‘motivate’ the patient who has had pain for longer.

We know that people with long-term disability tend to have more psychosocial factors relevant in their presentation – they can be more distressed, depressed, anxious, have difficult family situations, may no longer be working and so on.  This can influence how we as clinicians view the person – before we’ve even met them.  It may influence our attitudes and communication patterns without us even being aware of it.

As I pointed out a couple of posts ago, when patients are more distressed, even in acute low back pain, clinicians are more likely to ask about biomedical factors than psychosocial – so it’s certainly something many of us do, perhaps to minimise our own sense of distress at the person’s emotions.

People who are worried about their health seek treatment more readily than those who are calm.  And what these people are looking for is often not so much an ‘answer’ – but instead, to know that the people they are talking to understand.  The low level of empathy even when first meeting patients with long-term pain suggests that clinicians may not be skilled in truly recognising the impact of pain on things like emotions, losses, the ability to participate in life.  While we might do a good job at identifying pain intensity and even ‘diagnosis’ – this isn’t much help if the person is fearful and there isn’t much to offer in terms of resolution of the pain!

I wonder whether this is because of concerns about needing to take ‘too much time’ if the person starts to discuss emotional issues – the ‘opening Pandora’s Box’ feeling. 

I also wonder whether it is a sign of clinicians feeling helpless when there are no easy answers – minimising the emotional content of a conversation might make this sense of helplessness less distressing to the clinician.

It could also be lack of confidence in clinical communication skills – when so often in general life we are asked to ‘put on a brave face’ or ‘look on the bright side’, our ability to accept and sit with another’s distress is a skill that maybe hasn’t been well-developed.

There are methodological flaws in this study, as there are in any study! And the centre in which the study was conducted does, as a matter of routine, suggest MRI for people with back pain – this could influence the generalisability of findings.  But perhaps it’s worth considering as we spend time with people with chronic pain today – how well do we communicate empathy?

Gulbrandsen, P., Madsen, H., Benth, J., & Lærum, E. (2010). Health care providers communicate less well with patients with chronic low back pain – A study of encounters at a back pain clinic in Denmark Pain, 150 (3), 458-461 DOI: 10.1016/j.pain.2010.05.024


  1. Bronnie thanks for taking the time to write about this research and speculate a bit about the why(s).
    I have heard anecdotal stories about this phenomenon. And I have had quite a different experience with
    the same physician as compared to that as observed by a friend acting as a patient advocate for someone who had minimal verbal capacity after a stroke.

    A noticeable bias affecting the quality of interaction appears between interactions with patients who are Younger, Attractive, Female and Verbal as compared to patients who are Older, Male, and less Attractive and less Verbal especially when the provider is male. But the bias of course is not conscious to the provider.

    I consciously struggle to match the terminology used by a particular client: the clients I see have a wide range of formal education. Some clients prefer medical jargon and would doubt my professional competence if I did not use anatomically correct terminology. Other clients would feel that I am talking over their heads.

    Beyond word choice as you point out, is the ability to hear and acknowledge someone’s pain and suffering.
    I have attended manual therapy trainings wherein we were cautioned “not to be distracted by the client [patient’s]
    story about their pain” because our task was to locate the “real lesion or source of the pain” and treat that! Meaning the fascial tension–we are not even going to refer to nerves except as secondary to fascial distortions.

    I cannot release a client’s “stress” caused by being unemployed or by not being able to vacuum a dirty rug but yes I can acknowledge the frustration and fear without trying to fix it, minimize it or distract from it.
    Although this takes practicing mindfulness on my part.

    1. Hi Bernadette – it’s a really curious thing, that we don’t really get taught how to listen well, even though we all have some training in communication. Certainly, I wasn’t taught to listen first THEN make suggestions! And I guess the biases we have may be unintended at times too – I’m sure these clinicians didn’t think they were responding differently depending on age or pain duration at all!
      Your last sentence really makes the difference, doesn’t it – being mindful and wholeheartedly listening to what the person is really saying beneath the words.

  2. In a recent conversation with a general internist, I asked him “How much of a patient’s medical problems are caused, at least in part, by what’s personally going on in their lives?” He said, “At least 50%.” Then I asked him “How much of the ‘intensity’ of a patient’s medical problems are affected by problems in their personal lives.” He answered, “100%.” This exchange really supports your points about the value of communication between doctor and patient, the importance of showing understanding and empathy toward the patient, and the need for the physician to really listen for underlying information that can beneficial to diagnosis and treatment.

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