Ein Artikel von Jean-Pierre Himpler und Carmen Ullrich.
Direct and indirect communication in the health care practice – challenges, strategies and education
Health is raising in importance in society and education. Health-oriented living for young generations turned to a trendy lifestyle. This has fundamentally changed relationship and communication between practitioner and patient. Communication is manifold including direct and indirect channels. Direct communication includes diagnosis and treatment in the classical analogue setting and digital communication in a telemedical treatment setup. A young field in the only recently competitive outpatient market is indirect communication, including digital media, marketing and corporate identity communication. New digital communication techniques in a socially relevant health culture are discussed. The content is part of a newly developped certification course about practice management addressing health professionals at the „European Medical Business Institute“ at E.H.E. EurAka University.
Communication in our globalized and modern society is a topic of raising interest. Besides and due to the general relevance to humanity, it is of paramount importance in health care which generally is the most important aspect in life throughout all societal groups1. This study – as visualized in Figure 1 – intends to give an overview over the wide array of communicational areas in the field of care, particularly outpatient care and how these changed in recent years due to societal and structural changes in Germany and beyond. The article closes with recommendations for course content to help practitioners to master the modern communication challenges in a health care practice setup. The suggestions are applied in a training for practice management at the “European Medical Business Institute” at EurAKA University, that is supported and promoted by Prof. Dr. Markus Mau, and connected with the consulting agency med3.net.
Digitalisation is changing our modern society and so it also has a significant impact on the behaviour of patients and the respective communication process in health care. Therefore, practitioners need to master not only the communication within the analogue health care provision process, but also in a digital setup e.g. in a telemedical examination that has been growing in relevance in recent years. Outpatient care, further, used to be strictly regulated for many decades and competition in public outpatient care was neglectable. However, since about 15 years, back at the legal introduction of health care centres in 20044, this started to change: outpatient care has continuously been significantly liberalized in all fields and can be assessed by hospitals via health care centres. This competitive force of big players entering the outpatient market is new and thus significantly changing the provision and the management requirement in outpatient care. This change also has a significant impact on communication procedures – particularly on the indirect communication between the health care provider and the patient. This article makes a first attempt to summarize the changes and their game-changing impact as much on direct as on indirect communication.
This article also describes the course content of a communication module as part of certification course at the “European Medical Business Institute – EMBI” at EurAKA University, Switzerland, which helps the modern and future practitioner to master the new tasks, challenges and duties.
2. Direct communication in the health care practice
The communication between physicians and patients has changed fundamentally in recent years. As a result of everyday internet use, a large number of patients come into the medical practice with an own hypothesis of their illness and ideas about the best treatment. This does not always cause joy and approval from the specialist staff, because the risk of misdiagnosis is high; there is numerous dubious pages around health advice on the World Wide Web. The medical practitioner usually insists on making the diagnosis himself, after all, he has studied his subject, he is part of the scientific community and responsible for the treatment.
Nevertheless, from a wide array of sources there is an immense knowledge growth in the population in relation to the own body and potential measures to be taken to raise well-being. This crosses the boundaries of the specialist disciplines and seems to be more holistic. The importance of one’s own health and self-care has increased immensely. The possibility of prior information affects the communication between the physician and the patient, who is usually also part of the social education system that conveys skills like analysis, information gathering, interpretation and reflection. Therefore, the patient asserts his right to participation. This changes both, the expectation of the doctor’s role and the group of people involved. Consequently, two questions are to be raised, which are partially discussed below:
- Which communication strategies are suitable for diagnosing and tre- ating diseases?
- What potential does telemedicine have – in relation to different pha- ses of counselling, treatment methods and the networking of possible actors?
2.1. Communication strategies in the diagnosis and treatment of diseases
The pre-informed patient generally wants less instruction and more inclusion and participation in the ‚own recovery project’. While the physician is the designated expert in his medical field, the patient is the expert of himself – he knows his body, his symptoms and his context, in which certain treatment methods are possible and others are not (due to his family situation, his professional obligations, economic situation, local possibilities, cultural affiliation etc.).
In recent decades – due to perceived deficits – many models have been developed to improve communication in medical practice and a lot has changed since then to the advantage of a more informative and emphatic physician-patient relationship. The interview model by Lazare, Putnam, and Lipkin (1995), which focuses on the relationship aspect as an essential part of a successful treatment may be mentioned as an example6. Due to the already indicated increase of knowledge of patients within the modern and educated society and the highly respected principle of participation (which is also one of the most successful leadership styles in companies), the expectation of goal- oriented dialogue techniques also rises in the medical context. This means that patients generally want a relationship based on trust and respect and they want to be involved in the measures of the examination and treatment. As a result, physician and patient are both involved in the recovery project with different tasks. Both are responsible for the success of the project.
One of the best-known models that take the patient’s competencies into account is the Common Sense-Model of Self-Regulation (CSM), which was developed in the 80s by a working group led by Howard Leventhal. Until today this approach inspires numerous research projects, however is rarely used in practice. The widely confirmed acceptance of the CSM is the self-regulation process of the patient, who copes with the perceived health threat himself, not only by taking prescribed medication, but also by self-management strategies – provided that he is psychologically healthy and stable! The CSM also takes the patient’s cultural and social background, i.e. subjective disease concepts, preferences (according to biography and family disease management) and the individual coping behaviour into account. Interviews and questionnaires – e.g. the very well validated Illness Perception Questionnaire (IPQ and its revision IPQ-R)8 – are used to determine the personal health concept. The aim of the CSM is to use educational intervention programs to expand attitudes, understanding and behaviour of patients with regard to the health process, while reducing stressful emotions9.
In practice it could look like this: The patient conveys all available information about suffering and symptoms and may also name possible hypotheses. The assumptions do not question the expertise of the medical practitioner, rather they are useful information about the patient’s body awareness, his medical history and his ability to identify and also solve problems. Therefore, the physician determines an actual analysis in which the facts, i.e. the largely measurable suffering, and the evaluation of the problem are separated. By naming the previous coping or solution attempts, the physician gets knowledge of the available and developable resources of the patient. Then, the medical practitioner presents one or more treatment options and gives information about risks, limits, or other actors that can increase the success of the project. The self- responsible patient clearly states his goals and his contribution to change the situation. As a result, he is able to recognize the doctor’s performance as well as his own involvement and self-efficacy. For further treatment fields or specialist transfer he can take advantage of the medical network.
The medical network naturally includes specialists, physiotherapists, and psychologists. Starting from an increasingly holistic perspective on physical and/or psychological complaints, the inclusion of social health care is also recommended, namely sports offers, nutritional advice, wellness holidays or discussion groups with those affected similar diseases. A larger health network requires communication at different levels.
The increasing acceptance within the population to include technological possibilities for health-promoting measures could be efficiently used to link dialogical forms of communication with the self-regulation competence of the patient through telemedicine.
2.2. Digital medical consultations in a health culture context
Undoubtedly, there could be dubious offers and charlatanism among the many advice pages on the Internet. However, if it were possible to place a) the latest results of medical research, b) validated treatment options, c) the tasks of the doctor and d) the tasks of the patient in an understandable manner on reputable internet portals, the technologically transfer of knowledge could immensely improve our healthcare system as it did in many other countries in which digital health has risen to be significantly more important than in Germany. It is conceivable – as it already exists in some cases – to expand scientifically certified internet portals that reach people also in remote regions or even gain international range. The patient’s effort, which is in any case unstoppable, first gain knowledge of his suffering and remedies, would at least be better protected from misinformation.
In addition, a more comprehensive concept (see Figure 2) was developed, to visualize the ways the patient can communicate with the medical practitioner in various digital and analogue formats. The figure also involves other actors of the networked healthcare system that can be taped on in order to treat his suffering.
According to this model (Figure 2), the patient first visits the Digital medical consultation with the doctor, to clarify the concern and the following measures. If the patient e.g. has a severe cold and the medical practitioner is able to recognize this without doubt on the screen, it is not recommended to visit the doctor’s office, to sit in the waiting room and put other patients at risk. What usually happens during a physical consultation with the doctor – namely making a diagnosis, making out a prescription for medication to cure the infection and writing out a sickness certificate (figure 1, part II) – can also be done online, which relieves the patient.
Another measure that can easily be carried out digitally for certain issues is the referral to a specialist. If a patient suffers e.g. of back pain, the general practitioner usually does not investigate himself, but issues a referral to an orthopaedic specialist. The patient does not have to visit the practice for referrals to specialists (figure I, part III).
In many cases, however, the patient’s treatment by the medical doctor is inevitable. But where does it begin? Digital medical consultation can be a first step in treatment: a short video chat between patient and physician, which builds trust and communicates the matter, is followed by an electronic questionnaire, which the patient can fill in at home (the mentioned Illness Perception Questionnaire could serve as a template). The physician can use this as an important information basis for the physical consultation (figure 1, part IV). So, he has enough time to choose the treatment method that promises the greatest success in relation to the specific patient and his self-management capacity. It is also possible to use interactive systems, which could help patients with the need of daily control to record body data (automatically) including the monitoring of food intake and the extent of exercise.
A Digital Medical Consultation can specifically recommend a healthcare network (figure 1, part V) that complements medical treatment on current scientific standards through the questions: Why are people healthy? How do you stay healthy? – The patient’s involvement is indispensable, especially in the case of protracted or chronic illnesses. As far as the patient is mentally and physically able to act, he can actively help shape and speed up his own recovery process by taking advantage of sporting activities or nutritional advice (figure 1, part VI), as many studies have shown.
Personal coaching has also a positive effect on the recovery process (figure 1, part VII): Therefore, the indicated physical suffering is reflected in the context of the specific phase of life; the patient, in this case the client, becomes aware of his ability to resilience. Since most people have already mastered many crises in their lives, they are able to activate personal and social resources when dealing with illness. With the awareness of being able to act, being able to cope with crises and not being alone, the disease can lose its threatening character. In the case of life-threatening illnesses or permanent restrictions, coaching as a professional support is highly recommended, which accompanies the patient in the various emotional phases and supports him in finding a good way of dealing with restrictions and in identifying specific solutions.
A very effective strategy to cope with feelings like fear, dependency, loneliness – that often occur e.g. in cancer diagnoses – is to participate in patient groups with similar diseases (figure 1, part VIII). Attendees of these groups generally save themselves from counterproductive pity and look instead for practical strategies to deal with the disease in everyday life. The participants experience themselves as particularly protected, cared for, understood or even self-effective, since they not only find themselves in the role of the person seeking help, but also of the person encouraging others. In particular during life-threatening diseases, these groups offer existential support. These and many other measures and health-promoting offers are conceivable. A Healthcare Network, which is established and regularly updated by proven doctors and consultants in medical and health management and is accessible to all interested parties, would be desirable for each region. The advantages for the patient are immense.
Nevertheless, digital business models in the health sector have to be generally accepted and financed. In Germany, the Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung) promotes modern and more efficient health systems, but there are still strict regulations and sceptical patients. However, the demand for electronic health services is increasing strongly, also a result of the corona pandemic, as the Swedish telemedicine providers Kry such as Teleclinic and Zava report. The telemedicine providers advertise the benefits for patients: time savings, less risk of infection and a measure against the shortage of medical practitioners in the country. According to medical experts, every fifth visit to the doctor can be replaced by digital consultations. A breakthrough of telemedicine is more than likely. So far, only privately insured people in Germany use telemedicine, and they often turn to providers abroad, e.g. in Switzerland, since, despite the recent liberalization of remote treatment, there are only a few offers in Germany. However, it is very likely that a sensible combination of digital and analogue communication forums and a greater involvement of health – promoting offers save health insurers costs. The model would be accessible and viable for everyone if the digital medical consultation and the establishment and maintenance of the health network were recognized and financed as medical advice15. Numerous studies have highlighted the changes in health care as a result of telemedicine and emphasize their benefits.
Another challenge the modern health care practitioner is facing is the actual sales process of his service. Whereas beforehand the word of the practitioner was written in stone, the modern practitioner needs to promote his service and sell the added value to the patient. Especially since many services are not paid for by insurances but have to be covered by the patient himself. Including the challenges of and duties in this specific part of the communication would exceed the scope of this paper. There are ways and promising opportunities to improve our health system by linking a) dialogic interpersonal forms of communication, b) interactive digitization and telemedicine and c) a diverse social-medical network with different actors. The presented model is a pool of ideas that can be supplemented, updated and adapted to the respective environment and technological developments.
3. Indirect Communication in the Health Care Practice
Next to the direct communication with the patient – letting it be digital or analogue – there also is the indirect communication via marketing and corporate communication as part of the corporate identity. Only very few small and medium-sized health care practices in outpatient care invest in marketing. Recommendations are seen as the way to get patients. Many doctors even still believe that marketing for medical practitioners is still forbidden17. However, marketing in medical professions is not prohibited, it is just regulated in Germany by the “Heilmittelwerbegesetz”. With the increase of competition19, marketing is growing in importance in practice management20. And in fact, implementing marketing measures does not need to be expensive21; listening to patients e.g. via surveys can already be a valid first step to help feeling more comfortable and thus it can increase the quantity and quality of given recommendations.
3.1. Marketing Communication – The Patient as a Customer
Marketing Communication requires the development of an appropriate marketing strategy. Without that at first, marketing actions lack the initial fundament and thus may lead to results rather by coincidence then by active planning. Straesser23 in her book addressing dentists, therefore suggests structuring marketing alongside a 12-step process as visualized in Figure 3. When looking at the process from a business perspective, the work is more than just a marketing guide. It is a tool that – if fully applied – supports the development of an entire marketing and sales strategy that also includes a complete inclusion of related expenses. The adequate marketing communication that addresses the desired patient-customer is to be chosen and developed based on the formulation of the aforementioned goals.
A growing number of books is looking at the patient as a customer. Research has proven that a significant shift of the patient’s demands has changed the way to handle the patient and deliver adequate communication and care to the deciding and responsible customer-patient. The best way to know about the patient and his desires is to regularly conduct surveys that allow the patient to share his values and his perception on the quality of the delivered services, a duty that also could be completed digitally – meaning in a tele-treatment setup. The responsible patient actively wants to participate in the decision-making process and – prior to visiting the doctor – is informing himself, in order to be aware of the potential illnesses he may suffer from and the respective treatments he may receive (see section 2.2 for more explanation). The image that influences the patient’s good feeling can actively be influenced by the right marketing and communication strategy and also the adequate corporate communication (see next section).
3.2. Corporate Identity and Corporate Communication
Other marketing literature for practitioners next to all examples and explanations, primarily stresses the importance of a strong CI and a constant image, as continuity and consistency would be the most important for marketing success and a cost-efficient image creation28. The development of an image, that truly communicates the identity of the practice, is required. This image includes aspects such as service, the presentation of the practice, communication procedures amongst personal and with patients, competency of practitioners, offered products and services and morals of the serving team. However, the image creation is not only an internal process influenced and created by the company. It is also guided by competition, media, opinion leaders and happenings on the market. Existing opinions and prejudices as well as lack of information – let it be internal or external – also play a major role.
As shown in Figure 4 – corporate identity, apart from the widely accepted and in fact also to some extent implemented corporate design, further consists of corporate behaviour and corporate communication. In accordance with the personal goals of the owner-manager, a corporate behaviour develops for the company. This can be developed following an active process. In the context of owner-run practices it, however, mostly evolves passively meaning there is no active decision-making and no strategic approach to corporate behaviour building behind. Corporate behaviour includes aspects such as the behaviour between team members of the practice, in case of a bigger practice the hierarchical distance between management and operations. Corporate communication includes the direct communication with the patient – let it be at the reception or with the practitioner – but also the less direct communication in the marketing process – so in e.g. the advertisement design or the style of reaction to social media comments as part of digital marketing strategy. Considering the above-mentioned telemedical treatments, corporate communication and corporate identity is more. Figure 5 serves as a visualisation of all aspects that play a role in applying corporate identity to telemedical treatments.
Corporate design – say two-dimensionally – as usual is also part of telemedical corporate identity. This here includes aspects such as the visualisation of the telemedical treatment platform and the login process (see Figure 5, I), that should actually already somehow reflect the very specific health care provider to which the patient is about to talk.
However, this may also include the setup of the camera, the background of the video-setup or even the use of a greenscreen background (see Figure 5, II) so that any doctor working for a specific telemedical provider could deliver the service with the same background behind. That way the patient – even if the practitioner eventually changes – is situated in a familiar surrounding and may feel a certain amount of comfort.
All setup appreciated, part of the corporate identity in telemedical treatments is a certain form of standardization of the telemedical treatment process (see Figure 5, III). Such standardization may include the process of a treatment, the amount of questions asked, and a certain procedural approach that allows for getting to a result. This would not happen with the idea of limiting the individual doctor, but in fact with the concept of giving the potential patient customer a certain extent of familiarity.
As some practices do today with their analogue personal patient appointments, there is also an after-treatment action (see Figure 5, IV), such as following up on the patient, his well-being and as such the potential after sale of treatments. If this is implemented as part of an overall corporate strategy and with some standardized implementation behind, then patient satisfaction can be raised significantly at bearable expense.
4. Conclusion and Teaching Recommendations
In the modern outpatient healthcare environment, communication is manifold and consists of direct and indirect communication aspects as shown in Figure 1. Given that previous research in Germany has shown, that business and communication trainings in practices seems to be of mediocre importance, even though being closely linked to quantifiable results (+7%), a communication training module has been developed to help the practitioner to face the modern communicational demands in outpatient care (see Figure 6.).
Training of communication skills enhances the communicational process between team members in the practice and also the sales process of additional services to the patient. And in fact, such training is not only good for additional services but also comforts the patient and increases chances for word of mouth recommendations. Figure 5 visualizes the content of the training in communication as part of the practice management certification offered at the European Medical Business Institute at EurAKA University.
Currently loads of relevant educational offers are provided by a range of private academies. Many if not most of such offers are driven by profit-oriented companies rather than internationally interconnected research institutions and thus are not or at least hardly accessible to many graduating practitioners. The financial background to go for additional more business-oriented education is also often missing. The majority of these programs is not addressing exclusively practitioners and other university-educated professionals, but also assistants, wherefore the background knowledge and learning speed of participants may significantly vary. It is becoming increasingly common, that educational offers of non-medical nature are being counted as part of the regularly required training of practitioners (see above: business administration for dental health), however, there could and should be much more first of these courses and second enhancement of such training among specialists. A University-level certification course including the here addressed content about communication is offered at the ”European Medical Business Institute – EMBI” at EurAKA University, Switzerland. Providing such courses in a European international collaboration between institutions in different countries and extending such programmes from certifications to undergraduate and graduate level degrees is an opportunity that could be a way to foster international exchange and should be an answer to this international challenge.