Communication Issues in Physical Medicine and Rehabilitation

Overview and Description

Effective interprofessional collaboration is defined as a process of communication and decision-making that enables the separate and shared knowledge and skills of health-care providers to synergistically influence patient care.¹ Communication is an essential foundation of any healthcare team to solve complex and multifaceted patient-care problems. In 1999, the Accreditation Council for Graduate Medical Education (ACGME) mandated Interpersonal and Communication Skills as one of the six required core clinical competencies to be achieved during residency, stating “[r]esidents must care for patients in an environment that maximizes effective communication. This must include the opportunity to work as a member of effective interprofessional teams that are appropriate to the delivery of care in the specialty”.²

As an interdisciplinary field, physical medicine and rehabilitation relies on communication among multiple healthcare professionals, patients, and their families in a variety of settings (inpatient, outpatient, and community-based).

Table 1: Team Members in Physical Medicine and Rehabilitation

Communication barriers potentially exist within each component of the interdisciplinary team as described in Table 1, making effective communication a difficult but attainable goal of quality patient care. The Joint Commission showed that communication problems were the root cause of 64 percent of reported sentinel events from 2013 to 2014³and consistently remains as one of the leading causes for reported sentinel events.⁴ Research suggests that improved communication leads to better patient outcomes, high levels of patient and family satisfaction, safer work environments, decreased adverse events, improved symptoms control, decreased transfer delays, and shortened lengths of stay.^5,6 The following is an overview of five different levels of communication barriers: individual, interdisciplinary team, environmental, medical recordkeeping, and patient-provider.^1,6,7

Relevance to Clinical Practice

Individual

Given the increasing and seemingly endless demands placed on healthcare professionals, physicians must learn more effective communication skills and coping strategies to provide better patient care. In Physical Medicine and Rehabilitation Patient-Centered Care: Mastering the Core Competencies, Sorush Batmangelich reviews the components of communication–listening, speaking, body language, emotions, needs, empathy, styles, and preferences–and offers self-reflective exercises for better communication strategies.⁸ One target of self-reflection that is at times the most difficult to address, but the most influential in our decision-making is one’s implicit biases, These unconscious attitudes and perceptions shape how individuals interact with others and their environment, often in times of stress or time-constraints commonly encountered by healthcare professionals. The online implicit association test (IAT) from the Harvard Education Project Implicit assesses for such biases in common domains such as race, gender, and disability.⁹

Table 2: Individual Communication Barriers and Strategies for Improvement^6,7

Team

Patients’ impairments, activity limitations, and participation restrictions affect many parts of their lives. making a well-functioning team equipped with a variety of essential healthcare professionals (see Table 1) essential in improving function and quality of life.

Table 3: Team Communication Barriers and Strategies for Improvement^1,6,9

Communication models

The following communication models may be utilized to improve communication between team members and providers with their patients and caregivers.

Table 4: Potentially Useful Communication Models

Kuziemsky et al. identifies electronic data support and video conferencing as potential tools to enhance the accurate and up-to-date transmission of health-care information between multiple providers.⁵ A convenient system should include an electronic patient record that would allow the health-care team in one setting to update the patient’s data while simultaneously granting real-time access to all providers involved in the patient’s care. This would be most feasible with a secure web-based electronic patient record system. Video or web conferencing can be used for real-time discussions about patient care when not everyone can physically attend a meeting. Many physicians feel it is more convenient and efficient to have real-time communication with external team members to address patient care problems.¹⁵

Environmental context

Physical medicine and rehabilitation at the inpatient level is unique due to its ability to exist in multiple different environments– as a stand-alone acute rehabilitation hospital, as a unit in a larger acute care hospital, a long-term care center, and as a subacute skilled nursing facility (SNF).

In an ethnographic study at a single inpatient spinal cord rehabilitation care unit in Canada, the authors concluded that the physical layout of the unit influenced the quality of communication between team members. In that particular hospital, the therapy gyms, meeting spaces and clinicians’ offices were located off the unit. “…Separation appeared to exacerbate distinctions between clinicians and nursing staff and made collaborative decision making difficult”.¹

Medical records and documentation

Recordkeeping in healthcare changed dramatically in the 21^st century. In 2011, only 28% of hospitals and 34% of office-based physicians had adopted an electronic health record (EHR). By 2021, those numbers rose to 96% and 78%, respectively.¹⁶ Even with the nearly ubiquitous use of EHRs, documentation and medical record keeping modalities still pose threats to effective and efficient communication, as detailed in Table 5.

Table 5: Medical Records and Documentation Communication Challenges and Strategies for Improvement^17–19

Patient and family education

At the patient-provider level, language barriers, use of medical jargon, and language or cognitive deficits caused by medical conditions may impede effective patient education strategies. In a cross-sectional study from 2008-2009 Waterbury Hospital in Connecticut, 18 percent of patients were unable to name their primary physician when hospitalized, 43 percent of patients did not know their actual diagnoses, and 90 percent of patients started on a new medication were not told about the adverse events of the medication.²⁰ A qualitative study from Mayo Clinic in 2020 collecting perspectives from patients with disabilities found that these patients would benefit from widely adaptable communication strategies during interactions, such as speaking slower or using terms that patients can easily understand.²¹

Table 6: Doctor-Patient Visit Communication Barriers and Strategies for Improvement^6,13

A meta-analysis showed that patient adherence was positively correlated with physician communication and 19 percent higher risk of nonadherence in patients whose physicians communicated poorly.²³ When patients and families are unclear about treatment plans, frustration ensues, leading to poor management of physical symptoms, function, pain control, medical comorbidities, and potential lawsuits.⁸

Cutting Edge/Unique Concepts/Emerging Issues

In recent years, technology has revolutionized all aspects of medical rehabilitation, from developments in the provision of cutting-edge treatments to the actual delivery of specific interventions. Telemedicine is defined by the World Health Organization (WHO) as the delivery of health-care services, where distance is a critical factor, by all health-care professionals, using information and communications technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and the continuing education of health-care workers, with the aim of advancing the health of individuals and communities.²⁴ As a result of the recent COVID-19 pandemic and the recommended social distancing restrictions, telerehabilitation use has grown significantly over the last decade. For example, the amount of published literature regarding “telerehabilitation” on PubMed tripled from 179 in 2018 to 608 in 2023.

Telerehabilitation uses may include therapeutic interventions, remote monitoring of progress, education, consultation, training and a means of networking for people with disabilities. The technology can also facilitate communications between members of the care team, thus improving coordination of care. Positive outcomes associated with telerehabilitation included reduction of hospitalization admissions, mortality, and possibly cost effectiveness.²⁵ Despite these advantages, there are serious concerns about how the adoption of telemedicine may impact care. Limitations of overall telehealth include barriers in establishing relationships between medical providers and patients, limited ability to perform physical examination, and differences in payment models and liability coverage.²⁶ It is also imperative that providers maintain proper licensure in compliance with state laws to provide telemedicine to patients in other states.²⁷

While telerehabilitation is a great medium for communication, individual and team communication strategies are still vital. Ensuring that telerehabilitation is ethically acceptable will require good communication skills to maintain strong patient-doctor relationships, protect patient privacy, and promote equity in access and treatment.²⁸

Artificial intelligence (AI) is another area that can contribute to improvements in communication and telehealth. For example, AI can use algorithms to make history-taking easier by providing prompting questions based on patients’ responses and symptoms. These questions can be delivered through telehealth applications to improve efficiency of clinical assessment. Automated conversations can also assist in answering health queries, providing education, and reminders of medications or upcoming appointments. Speech-text conversion can assist in drafting notes. Chatbots have also been used in the business sector and can be a communication modality in healthcare. Chatbots can mimic human conversational models and supplement traditional healthcare delivery by providing help to patients and caregivers at any time.⁵ AI could provide solution to increasing patient-physician communication with higher satisfaction than with clinicians.²⁹ Other potential uses include assistance for inbox management, clinician documentation, management, and individualized decision support.^30,31 As AI integrates into patient-physician communication, a process must be placed to mitigate algorithmic biases to not amplify health care disparities.³²

As smartphones have become more commonplace in the healthcare community, the role of applications, or “apps,” has also increased opportunities for communication within medical systems and between patients and providers.³¹ One major use of apps is through secure access to electronic medical record (EMR) systems, which allows providers to quickly review patient charts, access labs or imaging, write orders, upload photos, or chat with team members. Patients can also access this information in a separate app which allows them to schedule and monitor upcoming appointments, review notes from previous appointments, check labs or imaging, and send direct messages to their care teams. The use of apps has also been beneficial during the COVID-19 pandemic to facilitate video calling for telemedicine appointments. The growth of apps has allowed patients and providers a comprehensive way to review pertinent medical information at their fingertips.

Major Applications in Healthcare³¹

Gaps in Knowledge

Future research is required to evaluate methods to best use telehealth for specific patient populations, as there are promising applications for telehealth for PM&R in both inpatient and outpatient settings.^26,33

Future research should investigate alternative ways to overcome communication barriers at the individual, team, environment, record-keeping, and patient-education levels to ultimately improve patient satisfaction, discharge planning, and minimize adverse outcomes.

Artificial intelligence requires further research when considering its full scope in healthcare. While AI can enhance access to services, it is not always readily available to those in underdeveloped countries or remote areas. AI is also limited in its ability to assess emotions and morality which impacts understanding of consequences. AI models require essential learning phases to gather and refine data.^5,34

References

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Original Version of the Topic

Jeffrey Oken, MD, Kristen Jost, MD. Communication Issues in Physical Medicine and Rehabilitation. 5/2/2016

Kareen A Velez, MD. Communication Issues in Physical Medicine and Rehabilitation. 10/21/2021

Author Disclosure

Michael Manguinao, DO, MPH
Nothing to Disclose

Thao Doan, MD, MPH
Nothing to Disclose

Cherry Junn, MD
Nothing to Disclose