Discussion
Communication involves listening and asking, as well as imparting information. Creating space for discussions and encouraging patient involvement by asking questions are important. Doctors should deliver core content about why to take medication and actionable messages about how to do so. Regular summing-up and checks of patient understanding are important. Communicating benefits and harms can be facilitated by including numbers, if done carefully (include time periods, natural frequencies, absolute figures). Scheduling extra time, using written resources and enlisting support of pharmacist colleagues can assist with effective communication and help patients navigate the sometimes-confusing world of medications.
Doctor–patient communication about starting, continuing, changing or stopping medication can sometimes be difficult. Paying attention to communication is an important part of respect for patients as individuals, to foster the principles of patient-centred care and shared decision making, and to promote better medical outcomes. Poor communication between patients and their doctors is a well-established factor in medical errors and adverse events, including medication errors.1–6 As a result, good communication between doctors and patients is now seen as a critical part of involving patients in healthcare and supporting safe and effective use and adherence to medications.3,6–10
Communication between general practitioners (GPs) and patients about medications encompasses many diverse approaches across different diseases and healthcare settings, often with very different purposes.11 These include: providing information or education about medications to enable informed decision making, providing practical behavioural support for medication taking, reminding, skills training (eg correct measurement of liquid medication), counselling and medication review (eg optimisation of regimens, including deprescribing medications where required), and promoting involvement in communication and decision making.8,12–16 Good communication is also an important element of shared decision-making practice. It facilitates structured, inclusive discussion about medications and alternatives, and about patient values and priorities in relation to these options, in the context of healthcare management plans.6,9,10,12,17–19
Communication about medication use with patients (and their carers) has been a major focus of research for decades.8,15,20–23 A vast array of simple and complex approaches to communicating with people about their medications have been evaluated in trials and systematic reviews.8,10,15,19,21 The overwhelming message from this research is that there is no single effective approach that works across all diseases, populations and healthcare settings to help people to understand what is required and how to safely adhere to medications.8,15,21 However, there are some surprisingly clear messages about effective communication that have emerged from the body of research evidence on health communication more generally.12,14,24 These general features of good communication can help to inform encounters between patients and doctors in many healthcare contexts, including where medications are the main focus.
Key features of good communication
There are many possible frameworks for doctor–patient communication.11,25–28 Essentially, imparting information about the why and how of taking medication should be interwoven into two-way conversations with patients about their views, experiences and values, and finished with summarising discussions that check patient understanding and address any concerns. The major features and one suggested order for good communication practice are summarised in Box 1, with selected elements discussed in more detail in this article. Case studies (Boxes 2–4) illustrate possible management of common challenges in general practice and how good communication can be embedded in discussions about medications.
| Box 1. Key features of good communication |
1. Recognise that communication is a two-way process
- Involve both listening and conversing. Prompt patients to become involved in the consultation, using questions such as ‘What do you already know?’, ‘What is your preference?’
2. Include core content about why to consider medication
- Briefly explain how medication works/what it does.
- Provide information on options such as not taking any medication or using another medication.
- Discuss benefits and harms with accurate, up-to-date, evidence-based information.
- Provide information about side effects.
- Consider addressing uncertainties, including uncertainty about what will happen to an individual patient, and uncertainty in the evidence base.
- Acknowledge any inconsistencies or conflicting information raised by the patient.
3. Include actionable messages on how to manage medication
- Provide information about how to take medication, such as explaining number of tablets versus number of milligrams; discuss self-monitoring, such as blood pressure measurement.
- Acknowledge burdens of managing and self-monitoring health and medications; be prepared to discuss barriers to medication taking with practical advice.
- Consider practical tools to improve medication-taking ability and support adherence.
4. Summarise and check patient understanding
- Review patient’s comments: ‘Let me summarise what you have told me/what we’ve talked about so far.’
- Check patient’s understanding: ‘Can you summarise for me what we have discussed so far?’ or ‘What will you tell your [spouse, family member, carer] about the changes we have made to your medication today?’
- Invite questions: ‘What questions do you have?’
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| Box 2. Case study 1: Poorly adherent patient |
Ms A, aged 45 years, has essential hypertension. She has made lifestyle changes and has taken medication for several years. At her last few general practice visits, Ms A’s blood pressure has been high, and on direct questioning she says she often forgets to take her tablets. Dr Y does not have time to discuss this in detail today so says, ‘I’d like to spend some time talking about your blood pressure and your medication. Can you come in next week? Please write down any questions or things you want to talk about when we meet.’
At the following visit, Dr Y starts with asking and listening, ‘What do you know about high blood pressure? What do you know about why medication might be useful for you?’ It emerges that Ms A is keen to have normal blood pressure but does not like taking medication every day because it makes her feel like she has a health problem. She also struggles with the cost of the tablets, particularly since she has recently lost her job and now has a child requiring regular medications. The doctor checks in with what they’ve heard, ‘This is what you seem to be saying …’ and acknowledges her feelings. Dr Y talks through the evidence that having normal blood pressure and a healthy lifestyle helps keep people well and prevent heart disease, using a cardiovascular risk profile calculator together with Ms A. Dr Y takes time to review their prescription with particular attention to cost (eg thinking about higher versus lower cost medications) and talks to Ms A about the use of generic medications. They also discuss the Pharmaceutical Benefits Scheme Safety Net, which caps the annual cost of medication for individuals and their family, with a reduced threshold for concessional patients.56 Dr Y talks about self-monitoring options (eg blood pressure measuring at home/in pharmacy) and provides printed instructions on accurate measurement.57 Dr Y also mentions tablet reminders and dose aids that Ms A might like to think about. At the end of the consultation Dr Y summarises: ‘This is what I think we’ve talked about today ... Just to check, can you tell me what you heard from our discussion today? What questions do you have?’ After listening and answering Ms A’s residual questions and concerns, Dr Y asks Ms A if it is okay to check in with her about how she is going with taking her medication at the next few visits. |
| Box 3. Case study 2: Patient with low health literacy |
| Ms B, aged 20 years, attends with her mother. Ms B has cellulitis around an insect bite. Ms B lives alone and independently with a mild intellectual disability; her mother lives on the other side of town and does not visit every day. Dr Y, Ms B and her mother are all concerned about Ms B’s capacity to remember to take regular antibiotics and unsure about her ability to measure liquids accurately. Ms B says she can swallow tablets, so Dr Y rings the local pharmacist for advice on an appropriate tablet medication with a simple dosing schedule that is easy to swallow (eg with a comfortable coating). Using speaker phone, Dr Y talks with the pharmacist, Ms B and her mother about buying a pill dispensing box from the pharmacy that the pharmacist can fill appropriately with the tablets. The pharmacist assures Ms B that they can provide education on the pill box at the time of collection. Dr Y provides simple written information about the medication for Ms B to take home, ‘Take [n] tablets, [x] times per day, before/after meals’, as a memory aid and suggests she puts it on the fridge at home. The doctor asks Ms B to explain the medicine schedule so that they are assured she has understood. |
| Box 4. Case study 3: Deprescribing |
Mr C, aged 75 years, is a long-term patient who attends for a regular check-up. Over the years he has been looking increasingly frail and is taking 10 medications regularly. Dr Y decides to review Mr C’s medications and notes that he is taking a proton pump inhibitor. On questioning, Mr C says he started it five years ago when he had indigestion following use of ibuprofen after falling off his bicycle and obtaining some soft tissue injuries. He is no longer taking the ibuprofen and has not had indigestion since starting the proton pump inhibitor. There is no time to discuss this today, so Dr Y asks Mr C to return next week for a discussion about his medication.
At the next visit, Dr Y talks through the rationale for stopping the proton pump inhibitor (ie unlikely to be providing ongoing benefit; harmful number of medicines).58,59 Dr Y provides Mr C with some information on proton pump inhibitors to take away, and asks ‘What questions do you have?’ Together they plan a trial of cessation whereby the medication dose is tapered and then eventually stopped.6 Dr Y explains the possibility of rebound acid hypersecretion and how to manage this. Dr Y writes a short note for Mr C’s pharmacist about this trial to let them know what is going on and minimise the chance of Mr C receiving mixed messages, attaching the note to Mr C’s prescriptions for his other medications. At the same time, Dr Y takes the opportunity to talk with Mr C about the new generic prescribing program, which might mean the pharmacist dispenses tablets with different brand names and appearance to those he is used to.
Dr Y reviews Mr C over the coming weeks/months, specifically asking about indigestion. Mr C reports one episode of indigestion, which was readily controlled with antacids; there have been no problems since. Dr Y talks with practice colleagues about a plan to consciously consider deprescribing, especially in patients taking more than five medications,16 and/or referring those patients for a Home Medicines Review. |
Communication is a two-way process
As a starting point, it is critical to ensure that doctors, patients and carers (where appropriate) understand that good communication is a two-way process.29 This may require some prompting by the provider, and it can be helpful to begin the discussion with a general opener such as ‘What do you know about [this condition]/ [this medication]?’ Listening is important to learn about patient understanding as well as patient experiences, values and preferences, and to determine if treatment needs to be changed to make sure it aligns with these.6
Risk communication and talking with numbers
Discussion about benefits and harms is necessarily an important component of the discussion content. This may include discussion of public health benefit where appropriate (eg vaccination, antibiotics). There is a large evidence base related to risk communication regarding benefits and harms in the healthcare context.6,9,12,30–34 Providing numbers in addition to general ‘high/low risk’ statements is welcomed by many patients. It can reduce common errors in risk estimation and may also enhance trust.30 Building and maintaining trust is a key part of effective communication, influencing how receptive people will be to the information, options or decisions being discussed.24 However, for many people, interpretation of numbers can be challenging. Some tips for how to use numbers clearly and effectively in discussions are provided here:
- Include quantitative estimates about probability of benefit and harm, and help the patient understand numbers using explainers such as: good/bad, more/less likely.
- Use phrases that include time periods, natural frequencies (two out of 100 people) and figures of absolute risk, such as, ‘every year, 10 in 100 of people with [risk factor] develop [disease].’
- Minimise use of relative risk figures, ‘number needed to treat’ formats, percentages (2%) and probabilities (0.02), as these may be less well understood.32
- Anchor numbers so that the risk is more meaningful, such as, ‘this risk is the same as a person who smokes.’35
- When discussing the likelihood of an outcome with and without an intervention, use the same format, denominator and time period for presenting each option.12
- Select time periods appropriate to the patient (eg five-year or 10-year outcomes).12
When providing information about side effects, using a positive frame can minimise the nocebo effect,36 such as, ‘95 people in 100 tolerate this medication very well’. It can also be useful to suggest patients attend for review if they notice any new or unusual symptoms that bother them as well as discussing any specific serious side effects to watch for. This could include how the patient would know the side effect has happened, what to do next and in what time frame.
Uncertainty related to medication prescribing includes 1) inherent uncertainties about what will happen when an individual patient takes, changes or stops the medication and 2) uncertainty due to lack of evidence or risk of bias.37 The former can be discussed with verbal and/or visual methods explaining the likelihood of benefits and harms, acknowledging the limitations of applying population-based statistics to individual predictions. The latter might be described in terms of the strength of evidence or confidence in the evidence – noting that this can be psychologically aversive and may be hard to understand.30 Communicating uncertainty might hinder decision making by causing confusion and anxiety in some patients, but it conversely may improve patient trust and encourage medication adherance in others.38–40 There is no clear best practice for how to discuss uncertainty, and more research would be welcome in this area.
Patients may hear conflicting information from other sources, such as Google, family and friends, and it can be helpful to explicitly acknowledge and discuss this. To improve consistency among health practitioners, GPs may encourage and empower patients to regularly check that non-GP specialist providers have correct details for patients’ GPs and include GPs on specialist letters.
Managing medication
Practical tools to improve medication-taking ability and directly support adherence may include pill boxes, dose administration aids, reminders and government Safety Net subsidy for medication costs.6,41 Combined strategies that include a behavioural component as well as education are more likely to help people to take their medications effectively.22 GPs can consider referral to government-funded pharmacist-led services such as Home Medicines Review or encourage patients to ask their pharmacists for a medication review or counselling if appropriate.8
Common communication challenges
Standard consultations may be too short to address all a patient’s questions and concerns. It can be useful to suggest return visits, provide or refer patients to additional information sources for them to read at home, and enlist the support of colleagues such as pharmacists for specialised medication services. Tips to address some common challenges in practice include:
- Manage time constraints: consider asking patients to return for a dedicated discussion of medication issues, such as medication reviews, in their birthday month; give repeated updates over time; schedule a longer appointment; include signage (in practice or on website) that highlights the need for patients and doctors to work together to ensure the best use and monitoring of medications; suggest patients prepare a list of questions or points they would like to discuss and bring it to their consultation.42
- Use multiple modes of delivery: provide visual and written sources to supplement discussions and reinforce key information for patients to review outside the consultation (eg simple written instructions, pictorial or symbolic representations of benefits and risks, suggestions about trustworthy online resources about medications such as NPS MedicineWise).9,12,34,43,44 Written information can complement, extend and reinforce verbal information, and it might be particularly useful if patients are unwell or otherwise unable to readily take in what is discussed, or have limited ongoing access to their practitioner. It may also enhance patient confidence to ask further questions.21,45
- Deliver targeted information: tailor the discussion to the patient’s needs, considering health literacy, language and cultural issues, high information needs, comorbidities and other vulnerabilities, such as polypharmacy or use of high-risk medications. Examples include providing patient information (leaflets, URLs) in appropriate languages and/or targeted at specific cultures,46–49 considering the use of NAATI-accredited translators50,51 and Aboriginal and Torres Strait Islander Health Workers and cultural advisors,52,53 providing information in large print or Braille, and using lay language (avoiding jargon) tailored to patients’ backgrounds or individual needs.6,9,12
Future research
Despite the numerous trials of interventions to improve adherence and medication use, it remains unclear how best to change patient behaviour and improve outcomes.8,21 Research in this area is ongoing, including qualitative studies that aim to better understand the barriers and enablers to good communication regarding medication use in the general practice setting, particularly for patients with complex medication needs.10,19,22,23 Deeper engagement with health consumers and carers may help to determine what research in this area would be most meaningful and of highest priority. Co-producing this research with health consumers would help to ensure it is relevant, appropriate and accessible.54,55
Conclusion
Being more aware of some of the practical features of good communication can help doctors to better support evidence-based discussions about medications and to better understand the place of medications in a patient’s daily life. More complex ways of communicating about medication are not necessarily better – and sometimes listening to improve understanding of key challenges can deliver the most effective solutions, such as simplified dosing schedules.8 This helps doctors to work in partnership with patients to achieve better and safer medication use.
Key points
- Good communication in any setting is a skill, and there are better and worse ways of communicating.
- Communication is a two-way process involving both listening and talking.
- There is not one single way to communicate well with all patients about all medications.