Communicating with Patients and Families

Overview and Description

(This topic will discuss issues such as having family meetings, delivering bad news, responding to patient emotion, etc. For information on communication within the medical and healthcare team please see Communication Issues in Physical Medicine and Rehabilitation)

Communication in healthcare, and specifically the dialogue between a clinician and a patient/family, is more than a simple exchange of medical information; it is the bridge where medical expertise meets the human. This interaction encompasses a blend of active listening, non-verbal cues, and the translation of medical jargon into lay understanding. A strong communicative rapport is often the most effective diagnostic tool a provider possesses. When patients feel heard and understood, the results are measurable, ranging from increased diagnostic accuracy and higher treatment adherence to improved physiological outcomes and reduced patient anxiety.^1,2 Effective communication isn’t just a “soft skill”; it is the delivery system that ensures clinical interventions actually succeed.

The physiatrist’s role, centered on functional recovery, chronic disease adaptation, and interdisciplinary care, demands a communication style that is not only informative but also therapeutic. Over the past decade, emerging literature has reinforced that communication is directly linked to patient outcomes, adherence, satisfaction, and healthcare utilization, making it a core clinical skill.^3-5

Effectively navigating conversations is a career-long developmental process. For trainees, mastering communication is tied to ACGME Core Competencies and Systems-Based Practice (SBP) serves as a crucial foundation; understanding how a clinic, rehabilitation facility, or hospital system functions allows a trainee to coordinate multidisciplinary resources, manage transitions of care safely, and utilize system assets to reinforce patient comprehension. For established practitioners, communication requires ongoing maintenance through continuous professional development, ensuring that veteran clinicians adapt to shifting patient populations and evolving healthcare delivery systems.

PM&R is inherently patient-centered and longitudinal. Patients frequently present with life-altering diagnoses such as stroke, spinal cord injury, or traumatic brain injury, requiring ongoing adjustment to new functional baselines. Communication in this context involves prognostication, goal setting, expectation management, and sometimes sharing bad news and re-evaluating treatment plans. This article will look at a few of the many communication tools through sample patient interactions.

Relevance to Clinical Practice

“Tell me more” and NURSE statements

Consider the case of Sarah, a 28-year-old professional dancer who recently suffered an incomplete spinal cord injury following a motor vehicle collision who is meeting her rehabilitation goals. During a routine check-in, her physiatrist notices she is unusually terse and avoids eye contact. “Tell me more” is an effective communication tool to ask about someone’s experience with empathy. This patient may, for example, express that she is grieving her past life and experiencing a profound loss of identity, fearing she will never be “whole” if she isn’t a dancer. Using NURSE statements, a clinician can express empathy and build rapport, understanding a patient’s “why” instead of just their “what.”⁶ Consider keeping an emotion wheel (such as this, viewable at https://feelingswheel.com/ and downloadable here) handy to broaden your range of discernable emotions. Listening to patients in this way can help to redefine what “progress,” build a therapeutic alliance, and provide more whole person care by bringing in other specialists to assist in the neuropsycho-spiritual domains.

Anchoring

Consider again Sarah, who starts crying during your interaction. She explains that every step she takes in the parallel bars feels like a “betrayal.” To her, walking with a brace isn’t a victory; it is a mourning of the fluid, effortless movement she once possessed. She expresses a profound loss of identity, fearing she will never be “whole” if she isn’t a dancer. In this context, she appears to be using her prior-to-injury life as an anchor by which she is measuring her future; it may be beneficial to prompt her to consider features that are different from the anchor to reduce this effect and help her see her future differently.⁷

Prognostication

Clinicians’ predictions for the future are dependent on available prognostication tools and gestalt. Prognosticating in some instances has consistently improved but, in some areas, there is a continued gap. Prediction of outcomes and quality of life after severe stroke, for instance, is imprecise.⁸ In this situation, eliciting patient goals, values, hopes, wishes, etc. are critical to design and implement a care plan.

Consider Robert, a 55-year-old high school principal who suffered a massive left-hemisphere ischemic stroke. Six months into intensive subacute rehabilitation, the initial rapid gains in his mobility have stalled. He has Broca’s aphasia and his right arm remains functional only for basic stabilization.

Robert and his wife, Elena, arrive at the follow-up appointment expecting a new “aggressive” therapy plan to get him back to his podium by the fall. Instead, the physiatrist must deliver the news that Robert has likely reached a functional plateau. Using a “warning shot” that s/he has something important to discuss, the clinician can begin the conversation using the SPIKES mnemonic as a roadmap. By “holding space” for their grief and frustration, the clinician ensures that the patient doesn’t feel abandoned by medicine just because he isn’t “getting better” in the traditional sense.

Discussing a poor prognosis is not about “taking away hope,” but about realigning goals to prevent future medical and psychological crises. Clinicians can align with patient hopes while still offering accurate medical expectations. Such care can prevent “therapy burnout,” allow for better resource management, and be mindful of caregiver burden and health.

Framing

Framing is the phenomenon where the “packaging” of information can affect how a patient perceives their reality and makes decisions. Even when the underlying data is identical, the emotional and cognitive impact changes based on whether the information is presented through a lens of gain or loss. In physiatry, this shift in perspective can be the difference between a patient engaging in a grueling recovery or surrendering to their diagnosis. For instance

• Negative Framing: “There is a 30% chance you will never walk without a quad-cane again.” This focuses the patient on the permanent deficit and the failure of their body.
• Positive Framing: “There is a 70% chance that, with intensive therapy, you will regain the ability to walk without a quad-cane.” This focuses the patient on functional independence and a reachable goal.

By emphasizing what remains rather than what was lost, a physiatrist can use framing to protect the patient’s agency.⁹ It transforms a clinical statistic into a motivational roadmap, ensuring that the patient views their rehabilitation as a series of attainable victories rather than a slow retreat from their former self.

Normalizing

Normalizing in a clinical context is the act of reframing a patient’s distressing symptoms or emotional reactions as expected, predictable, and shared by others in similar circumstances. It functions as a psychological stabilizer, transforming an isolating, “abnormal” experience into a manageable, “normal” part of the recovery process.

In physiatry, normalizing is particularly vital for maintaining the therapeutic alliance during the longer, post-acute phases of rehabilitation

• Symptom validation: When a patient experiences post-stroke irritability or neuro-fatigue, a physiatrist might say, “What you’re feeling is a very common physiological part of how the brain heals after an injury like this; you aren’t losing your personality, you’re experiencing a known stage of recovery.”
• Destigmatizing adaptive equipment: Normalizing involves reframing the use of a wheelchair or orthotic as a “standard tool for maximizing independence,” similar to using a pair of glasses, as opposed to a sign of failure or “giving up.”
• By showing that a patient’s experience is on an expected trajectory, you can reduce the cognitive load of their anxiety. This allows them to stop asking “Why is this happening to me?” and start focusing on “How do I work through this?”, redirecting their mental energy toward functional gains.

Silence

Consider the case of David, a 65-year-old former carpenter living with advanced Parkinson’s Disease. David has taken great pride in his physical resilience, but lately, his “freezing” of gait has led to three falls in a single month. In the clinic, you recommend a transition to a specialized power mobility device to maintain his safety and community independence.

After explaining the medical necessity and the benefits for David’s autonomy, you stop. You don’t move to the next item on the checklist or offer more statistics. You simply lean back, maintain a supportive posture, and wait.

The room is quiet for nearly forty-five seconds, a duration that can feel like an eternity in a busy clinical setting. During this time, David is visibly processing. He looks at his hands, then at his wife, and then back at the floor. Because you resisted the urge to fill the silence with more medical justification, David finally finds the space to speak.

He whispers, “If I get in that chair, I feel like I’m finally letting the disease win.”

In this moment, the silence acted as a diagnostic bridge. Had you continued talking, the conversation would have remained on the level of “equipment and safety,” likely resulting in David nodding politely but never actually using the device. By embracing the silence, you can achieve several clinical goals:

• Identifying the true barrier: The barrier wasn’t a lack of information; it was a crisis of identity. The silence allowed the real obstacle — David’s fear of “giving up” — to surface.
• Creating emotional safety: The pause signaled to David that his emotional response was just as important as his fall risk. It moved the encounter from a “transaction” to a “relationship.”

Training the next generation of physiatrists and upskilling established clinicians requires moving beyond traditional bedside observation. Incorporating dedicated educational methodologies ensures communication is treated as a sharp, dynamic clinical skill

• Simulation-Based Training: Utilizing standardized patients (SPs) or high-fidelity simulation labs provides a low-stakes, high-impact environment. Trainees and clinicians can practice high-emotion scenarios such as delivering unexpected neurological prognoses and receive immediate facilitator feedback.
• Quality Improvement (QI) Methodology: Communication breakdowns are frequently systemic. Utilizing QI tools like Root Cause Analysis (RCA) or Plan-Do-Study-Act (PDSA) cycles allows rehabilitation teams to identify friction points, like systemic barriers in discharge planning, and systematically implement communication interventions.
• Diversity, Equity, and Inclusion (DEI) Principles: Effective communication demands cultural humility. Training programs must integrate DEI frameworks to help clinicians identify implicit biases, navigate language barriers without compromising care, and recognize how socioeconomic determinants shape a family’s reception of medical data.
• Leadership & Faculty Development Training: For clinicians in practice, leadership programs offer advanced frameworks for managing difficult group dynamics during complex family conferences, negotiating inter-professional conflicts, and leading cross-functional healthcare teams.

Cutting Edge/Unique Concepts/Emerging Issues

Increasing asynchronous and tech-based communication are two emerging concepts in healthcare communication. Digital platforms, telehealth, and remote monitoring allow ongoing engagement beyond clinic visits, helping many in rural communities access previously inaccessible care. This “always on” mode of communication, however, can bring its own challenges: patients expect communication in a way and at a time that is meaningful and convenient for them.¹⁰ AI tools are increasingly being used in clinician/patient communication. Some health systems are using AI-based text message systems to help patients adhere to complex treatment plans and assess for side effects. Others are using generative AI to respond to patient EHR messages. In both examples, AI can help guide with information but cannot replicate human empathy and thus must be guided by clinicians in real time.

Gaps in Knowledge/Evidence Base

Key gaps in the evidence base include limited PM&R-specific data linking communication strategies to functional outcomes, as most studies focus on satisfaction rather than rehabilitation metrics. There is insufficient evidence on optimal communication approaches for patients with cognitive or language impairments, common in this population. The long-term impact of digital tools, AI, and remote communication on adherence and recovery remains unclear. Standardized, validated measures of communication quality are lacking, particularly for interdisciplinary teams. Additionally, disparities in communication related to health literacy, culture, and technology access are underexplored, and few studies evaluate caregiver-specific communication interventions despite their central role in rehabilitation.

References

1. Zeng J, Gao Y, Hou C, Liu T. The impact of doctor-patient communication on medication adherence and blood pressure control in patients with hypertension: a systematic review. PeerJ. 2024 Nov 28;12:e18527. doi: 10.7717/peerj.18527. PMID: 39619180; PMCID: PMC11608562.
2. Matusitz J, Spear J. Effective doctor-patient communication: an updated examination. Soc Work Public Health. 2014;29(3):252-66. doi: 10.1080/19371918.2013.776416. PMID: 24802220.
3. Sharkiya SH. Quality communication can improve patient-centered health outcomes among older patients: a rapid review. BMC Health Serv Res. 2023 Aug 22;23(1):886. doi: 10.1186/s12913-023-09869-8. PMID: 37608376; PMCID: PMC10464255.
4. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995 May 1;152(9):1423-33. PMID: 7728691; PMCID: PMC1337906.
5. Faiman B, Tariman JD. Shared Decision Making: Improving Patient Outcomes by Understanding the Benefits of and Barriers to Effective Communication. Clin J Oncol Nurs. 2019 Oct 1;23(5):540-542. doi: 10.1188/19.CJON.540-542. PMID: 31538972.
6. Childers JW, Bulls H, Arnold R. Beyond the NURSE Acronym: The Functions of Empathy in Serious Illness Conversations. J Pain Symptom Manage. 2023 Apr;65(4):e375-e379. doi: 10.1016/j.jpainsymman.2022.11.029. Epub 2022 Dec 12. PMID: 36521764; PMCID: PMC10883350.
7. Chapman GB, Johnson EJ. Anchoring, Activation, and the Construction of Values. Organ Behav Hum Decis Process. 1999 Aug;79(2):115-153
8. Geurts M, de Kort FAS, de Kort PLM, van Tuijl JH, Kappelle LJ, van der Worp HB. Predictive accuracy of physicians’ estimates of outcome after severe stroke. PLoS One. 2017 Sep 29;12(9):e0184894. doi: 10.1371/journal.pone.0184894. PMID: 28961255; PMCID: PMC5621670.
9. Schwartz PH. The Framing Dilemma: Quantitative Information, Shared Decision Making, and Nudging. Med Decis Making. 2022 Aug;42(6):726-728. doi: 10.1177/0272989X221109830. PMID: 35819270.
10. Zimmerer J. (2025, October 21). Clarity Counts: Four Ways Communication Can Transform the Patient Experience. PSQH. https://www.psqh.com/analysis/clarity-counts-four-ways-communication-can-transform-the-patient-experience/

Author Disclosure

Arpit Arora, MD
Nothing to Disclose