Jennifer Marie J. Yang, MD

A recent blog post tackled the importance of communication in healthcare, and how good communication can lead to better patient outcomes, safety and population health. I also wrote about how I enjoyed a course on healthcare communication in my last semester of school. One of the required assessments for the course was a final research paper. I chose to write about the communication issues in rehabilitation since that was my world (and still is) immediately before the two-year (expensive) sabbatical from clinical medicine.

Rehabilitation is a team approach, as I’ve written before here and here. A rehabilitation medicine physician works with a team whose members are experts in their own fields; all of us bring our own professional skills to the table in order to get a patient more functional and improve quality of life.

Good, clear communication among team members, and between the team and the patient (who is arguably the most important team member) and their family leads to better rehabilitation outcomes. This is especially important in the patient-centered care approach which “focuses on the patient and the individual’s particular health care needs. The goal of patient-centered health care is to empower patients to become active participants in their care… Patient-centered care is associated with a higher rate of patient satisfaction, adherence to suggested lifestyle changes and prescribed treatment, better outcomes and more cost-effective care” (Reynolds, 2009).

The most fundamental difference between acute care (i.e., patient diagnosis and treatment) and rehabilitation makes practicing patient-centered care principles absolutely necessary. In acute care, patients often passively wait for things to be done to them, while in rehabilitation the patient is an active participant in care: “Rehabilitation is something that persons have to undertake themselves… The rehabilitation team supports the person… and offers expert advice and guidance in an interactive process” (Dressler & Pils 2009).

Add to that the patient and family adjusting to the “new normal” of living, after a life-changing and perhaps catastrophic event (the aftermath of a stroke, for example, is bread-and-butter for rehabilitation). Imagine all the emotions and coping strategies as they adjust to living with a disability. Now imagine that, complicated by being a member of a cultural minority (e.g., Latinx in the USA) with limited command of the majority language (e.g., English). Patient-centered care would ideally address this with interpretation, translation, signage/way finding, language classes and a policy of recruiting diverse staff (Dressler & Pils 2009). The solutions may not be perfect, but they are steps in the right direction.

The quality and timing of verbal and non-verbal communication greatly contributed to having an excellent patient-centered care experience. For example, patients may have difficulty in absorbing large amounts of information contained in a pre-admission package to the hospital – typically a binder or a booklet of sorts. While information is necessary, the way it is delivered can make it more palatable by avoiding medical jargon and using different media like audio-visual presentations.

Keeping patients informed about schedule changes could also help: for instance, patients can be frustrated with cancelled appointments due to inadequate communication among staff, patients and families. Up-to-date communication boards in patient rooms listing their daily schedule, precautions for therapies (e.g., whether they are allowed to bear weight on the fractured lower limb), current functional status (e.g., whether they need assistance in getting on or off a commode), staff involved in care, and a potential discharge date were also valuable. Finally, being able to readily identify staff and their team roles (e.g., using identification badges or uniforms) was also important to patients and family; this reduced the frustration of speaking with several staff members before finding one that was able to assist (Gill et al. 2014).

A supportive environment is also essential to patient-centered care in the rehabilitation world. Emotional support from staff through advice, encouragement and direction conveyed “a genuine sense of caring and concern… and did not take away hope” (Cott 2004, p.1417). Communicating hope is an art – hope provides patient motivation, but clinicians want to avoid giving a sense of false hope. The task of delivering bad news is made even more complicated by the difficulty in accurately predicting rehabilitation potential, making giving information and managing expectations a delicate balancing act among rehabilitation professionals (Peel et al. 2019). Clinicians also have to consider whether the patient is ready to accept the prognosis and expectations for recovery. Introducing the topic gradually and access to a psychologist have also been found useful (Peel et al. 2019).

Bad news delivered poorly may result in confusion, long-lasting distress and resentment while skillful delivery facilitates understanding, adjustment and acceptance (Kirshblum & Fichtenbaum 2008). Building rapport and establishing a good relationship involving trust and clear communication between the rehabilitation team and patient early in the relationship is important. Breaking bad news is a skill that can be learned; however, some professionals may lack the confidence and practice for doing so (Kirshblum & Fichtenbaum 2008; Peel et al. 2019).

A note on the last two bits: communicating hope and breaking bad news are two sides of the same coin and choosing the correct words (coupled with nonverbal communication) is like walking a tightrope. The rehabilitation team member has to give enough information so that the patient knows what to expect as they go through rehabilitation, but temper that with information that does not give false hope. Delivering news is certainly a skill that comes with experience.

Thus ends part 1. Look out for patient information and education, goal setting and shared decision-making, and discharge to home/transitioning from institution to one’s own environment in the next part.