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 Improvement6,7
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 Improvement1,6,9
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 21st 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 Improvement17–19
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 Improvement6,13
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
- Sinclair LB, Lingard LA, Mohabeer RN. What’s So Great About Rehabilitation Teams? An Ethnographic Study of Interprofessional Collaboration in a Rehabilitation Unit. Arch Phys Med Rehabil. 2009;90(7):1196-1201. doi:10.1016/j.apmr.2009.01.021
- Ranatunga S, Myers S, Redding S, Scaife SL, Francis MD, Francis ML. Introduction of the chronic care model into an academic rheumatology clinic. Qual Saf Health Care. 2010;19(5). doi:10.1136/qshc.2009.035030
- The Joint Commission. Sentinel Event Data 2023 Annual Review.; 2024.
- Joint Commission T. The Joint Commission Sentinel Event Data 2023 Annual Review Sentinel Event Data 2023 Annual Review The Joint Commission.; 2023. http://www.jointcommission.org/Sentinel_Event_Policy_and_Procedures/
- Kuziemsky C, Maeder AJ, John O, et al. Role of Artificial Intelligence within the Telehealth Domain. Yearb Med Inform. 2019;28(1):35-40. doi:10.1055/s-0039-1677897
- Merlino J. Communication: A Critical Healthcare Competency-PSQH.; 2017. https://www.psqh.com/analysis/communication-critical-healthcare-com…
- Sisk BA, Harvey K, Friedrich AB, et al. Multilevel barriers and facilitators of communication in pediatric oncology: A systematic review. Pediatr Blood Cancer. 2022;69(1). doi:10.1002/pbc.29405
- Cristian A, Batmangelich S, eds. Physical Medicine and Rehabilitation Patient-Centered Care: Mastering the Competencies. Demos Medical ; 2015.
- Matthew DB. Just Medicine: A Cure for Racial Inequality in American Health Care. In: ; 2015.
- Keates C. The Five C’s Of Effective Communication. https://www.forbes.com/councils/forbescoachescouncil/2018/09/10/the-five-cs-of-effective-communication/.
- Communication Community. The 6 Communication Functions and AAC (Augmentative and Alternative Communication). https://www.communicationcommunity.com/communication-functions-and-aac/.
- Cleveland Clinic. R.E.D.E. to Communicate Model. https://my.clevelandclinic.org/departments/patient-experience/depts/experience-partners/licensed-programs/rede-to-communicate.
- Panchuay W, Soontorn T, Songwathana P. Exploring nurses’ experiences in applying AIDET framework to improve communication skills in the emergency department: A qualitative study. Belitung Nurs J. 2023;9(5):464-470. doi:10.33546/bnj.2789
- Agency for Healthcare Research and Quality. Types of Health Care Quality Measures. https://www.ahrq.gov/talkingquality/measures/types.html.
- Kirby SG. Communication among Health Care Professionals: An Essential Component of Quality Care.; 2010. www.ncmedboard.org%2Fresource…
- Office of the National Coordinator for Health Information Technology. National Trends in Hospital and Physician Adoption of Electronic Health Records . https://www.healthit.gov/data/quickstats/national-trends-hospital-and-physician-adoption-electronic-health-records.
- Quinn M, Forman J, Harrod M, et al. Electronic health records, communication, and data sharing: Challenges and opportunities for improving the diagnostic process. Diagnosis. 2019;6(3):241-248. doi:10.1515/dx-2018-0036
- Gaffey AD. Communication and documentation considerations for electronic health records. J Healthc Risk Manag. 2009;29(2):16-20. doi:10.1002/jhrm.20010
- Resneck Jr. J. Refining rules on data release can prevent harm to patients. https://www.ama-assn.org/about/leadership/refining-rules-data-release-can-prevent-harm-patients.
- Olson DP, Windish DM. Communication Discrepancies Between Physicians and Hospitalized Patients. Arch Intern Med. 2010;170(15):1302-1307. doi:10.1001/archinternmed.2010.239
- Morris MA, Wong AA, Dorsey Holliman B, Liesinger J, Griffin JM. Perspectives of Patients with Diverse Disabilities Regarding Healthcare Accommodations to Promote Healthcare Equity: a Qualitative Study. J Gen Intern Med. 2021;36(8):2370-2377. doi:10.1007/s11606-020-06582-8
- Northeast ADA Center. 8 Tips for Communicating with a Patient Who Has a Disability. https://northeastada.org/resource/eight-tips-for-communicating-with-a-patient-who-has-a-disability#:~:text=Address%20the%20individual%2C%20not%20their,unless%20the%20patient%20specifies%20otherwise.
- Haskard Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: A meta-analysis. Med Care. 2009;47(8):826-834. doi:10.1097/MLR.0b013e31819a5acc
- World Health Organization. Advice for the public: Coronavirus disease (COVID-19). https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/.
- Totten AM, Womack DM, Eden KB, et al. Telehealth: Mapping the Evidence for Patient Outcomes From Systematic Reviews.; 2016.
- Tenforde AS, Hefner JE, Kodish‐Wachs JE, Iaccarino MA, Paganoni S. Telehealth in Physical Medicine and Rehabilitation: A Narrative Review. PM&R. 2017;9(5S). doi:10.1016/j.pmrj.2017.02.013
- Department of Health and Human Services. Licensure Licensing Across State Lines.; 2024. https://telehealth.hhs.gov/licensure/licensing-across-state-lines
- Mehta SJ. Telemedicine’s Potential Ethical Pitfalls. AMA J Ethics. 2014;16(12):1014-1017. doi:10.1001/virtualmentor.2014.16.12.msoc1-1412
- Kim J, Chen ML, Rezaei SJ, et al. Perspectives on Artificial Intelligence-Generated Responses to Patient Messages. JAMA Netw Open. 2024;7(10):e2438535. doi:10.1001/jamanetworkopen.2024.38535
- Sarkar U, Bates DW. Using Artificial Intelligence to Improve Primary Care for Patients and Clinicians. JAMA Intern Med. 2024;184(4):343-344. doi:10.1001/jamainternmed.2023.7965
- mobile devices and apps for health care professionals ptj3905356.
- Gianfrancesco MA, Tamang S, Yazdany J, Schmajuk G. Potential Biases in Machine Learning Algorithms Using Electronic Health Record Data. JAMA Intern Med. 2018;178(11):1544-1547. doi:10.1001/jamainternmed.2018.3763
- Alexander M, ed. Telerehabilitation: Principles and Practice. Elsevier ; 2022.
- Ratwani RM, Sutton K, Galarraga JE. Addressing AI Algorithmic Bias in Health Care. JAMA. 2024;332(13):1051. doi:10.1001/jama.2024.13486
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