Improving Communication Between Patients and Providers Surrounding the Legal Basis for Admission

Communication in health care is critical, more so in psychiatry. It could be called the art of psychiatry if neurobiology is the science of it. Although medical schools encourage learning scientific standards of disease and nomenclature, it is just as important to learn the essentials of effective communication. By refining the skills of communication, the treatment outcome could be positively influenced and a sustained therapeutic relationship can be achieved. Recently, medical education has recognized communication as the area that needs the most improvement. The Accreditation Council for Graduate Medical Education and the American Board of Psychiatry and Neurology have integrated communication as a subsection of the psychiatry milestone project.

In the July 2015 edition of Psychiatry Milestones, it is recommended that psychiatry residents recognize failures in teamwork and communication as a cause of preventable patient harm (1). Psychiatry residency programs evaluate the development of communication skills on different levels. To achieve a level 2 in the category of patient safety and health care team, psychiatry residents are expected to use structured communication tools, such as checklists, and safe hand-off procedures to prevent adverse events (1).

It was found that communication skills tend to decline during the time of medical training (2). Contributing factors identified include the “emotional and physical brutality” of medical training, which has been found to erode the pillars of communication (2).

Currently, in the Psychiatry Milestone project 1, “Communication and Patient Safety” is a subheading under “Patient Safety and the Health Care Team.” To highlight its importance, a separate section in the milestones should be dedicated to communication.

Case Scenario

A code orange was called as a suicide alert over the hospital speaker on the medical floor. On interview, the patient revealed that he had a specific suicidal plan to hang himself with a rope. After careful evaluation, it was determined that he met the criteria for inpatient psychiatric hospitalization. He was not happy about staying in the hospital and tried to convince the psychiatrist that he did not need to be hospitalized.

The explanation of involuntary and voluntary processes of admission only upset him further. It was difficult to balance the patient’s rights and autonomy with concerns about patient safety. Establishing a therapeutic alliance became even more important considering the ongoing disagreement about the need of inpatient psychiatric care.

After reading the voluntary admission form carefully to the patient, he was at first reluctant to sign it and requested to go home. He posed a risk of harm to himself, and therefore inpatient psychiatric hospitalization was required and allowing him to go home was not possible. He was unfamiliar with this process, since he had no history of inpatient psychiatric admission.

In the back of my mind I thought, “How can I communicate this in a way the patient understands the importance of his safety?” The patient felt as though he was being placed in a prison and all his rights were being taken away from him. After some consideration, he agreed to voluntary commitment, and after 5 days of treatment he was ready for discharge.

At the end, he expressed thankfulness to the treatment team for caring for him during this stressful time in his life. In hindsight, one of the difficulties in communication with this patient was the balance between the physician-patient relationship, which might have benefitted from longer explanations to questions the patient posed and directly answering the patient’s questions to avoid confusion. While explaining the inpatient hospitalization process to the patient, I found that I provided long responses to the questions the patient had. In hindsight, providing short concise responses may have aided in the understanding of his concerns.

Discussion

Although the legal standards differ from state to state, generally, criteria for inpatient commitment include presence of mental illness, dangerous behavior toward self or others, and the need for treatment (3). Rights in all psychiatric admissions include the right to refuse medications and the right to meet with legal counsel, and in some cases of involuntary admission, committing a patient requires that two separate physicians independently evaluate a patient and conclude that the patient would pose an imminent danger to him- or herself or to others that might be modified with hospitalization (4).

Communication becomes especially important for patients who suffer from mental illness. Psychiatrists especially need the language, communication skills, and empathy to communicate effectively with some of the most challenging patients in the population.

Some ways that health care workers can enhance communication include avoiding medical jargon and having the patient repeat back his or her understanding of the intended concept. Simple measures such as offering food or water can help to form sound therapeutic relationships between patients and their health care providers.

A meta-analysis was conducted to study whether enhanced communication skills of the clinician can affect clinical outcomes (5). The investigator found that effective communication exerts a positive influence not only on the emotional health of the patient but also on symptom resolution, functional and physiologic status, and pain control (5). Some of the elements that were considered to be effective communication involved the physician asking many questions about the patient’s understanding of the presenting problem, concerns, and expectations (5). Other elements that were considered to be a part of what is regarded as effective communication include showing support and empathy during the encounter. Some limitations of this study include confounding factors, such as response to medications, as well as psychosocial factors, which also influence outcomes. Another study found that poor communication among patients and physicians can result when the physician focuses on technical aspects of diagnosis and treatment without eliciting the patient’s values and goals (6). By focusing on the goals of treatment, physicians can enhance communication with their patients.

One way to enhance communication between providers and patients is through implementation of a treatment plan. In the state of Michigan, a treatment plan is referred to as an individual plan of service, and it is an assessment that is tailored to the health and safety needs of the patient. It is developed with the involvement of the patient and, when indicated, the patient’s guardian and/or family. Individual plan of service includes the coordination of care by the mental health team, primary care provider, and any other health care providers. A plan is developed with a list of close contacts and the outlined steps to take in the event of a crisis. Dates and frequency of follow-up appointments and support services are arranged and communicated to the patient and/or guardian, as well as to the family (7).

One study evaluated the effect of individualized plan of service and the rate of hospital admissions and readmissions in 24 medically and psychosocially complex patients with high health care utilization. Six and 12 months after the implementation of individualized plan of service, hospital admissions decreased by 56% (p<0.001) and 50.5% (p=0.003), respectively (8). Thirty-day readmissions decreased by 66% (p<0.001) at 6 months and 51.5% (p=0.002) at 12 months after care-plan implementation (8). Limitations of this study include its small sample size and the generalizability of the data to psychiatric patients given the studied patients were not on psychiatric units when the treatment plan was formulated.

Communication was found to contribute to better adherence to pharmacotherapy in a study that examined patients with schizophrenia (9). Furthermore, patients with good therapeutic alliance with their physicians were also more likely to be compliant with medications (9). Qualities found in physicians that promote a better relationship with patients include being nonjudgmental and open to addressing the patient’s concerns. The physician’s understanding of the patient’s perspective on his or her illness was found to be essential in establishing the ground work for effective communication (10).

Ways of enhancing communication include incorporating the “five A’s” (assess, advise, agree, assist, and arrange) (10), described in detail in Table 1.

Conclusions

Incorporating formal teaching in communication skills within medical school and residency training programs will not only promote patient safety and compliance with medication, but also help in earning trust from patients. This will further help to build the basis of an empathic psychiatrist and possibly provide more effective ways of treating distressed minds.

Key Points/Clinical Pearls