Doctor-patient communication: Cornerstone for diagnosis, treatment success and rationalization of health care costs in nephrology

Chronic diseases, in particular renal diseases, are responsible for high health care costs and decreased quality of life. Early intervention and prevention, crucial to reduce the impact of these diseases, should be based on multidisciplinary care where effective communication with the patient is the basis for success and therapeutic adherence. Although communication skills are taught in the early years of medical undergraduate education, it tends to be postponed to the 2nd plan in the last years of medical school in favor of the acquisition of technical and cognitive skills. This article aims to draw attention to the need to strengthen the basic communication skills teaching for ungraduate and postgraduate students and for all professionals involved in early multidisciplinary care of chronic kidney disease as a cost-effective health measure.


Introduction
Chronic kidney disease is associated with cardiovascular events, hospitalizations and a higher risk of death (Go AS et al, 2004). In the past two decades, the number of patients with chronic kidney disease and the burden in health care costs has dramatically increased due largely to the therapeutic costs of renal replacement therapies (dialysis or transplantation).

Barriers to an effective communication
Given the increased cardiovascular risk and the high prevalence of diabetes in renal patients, lifestyle modifications on diet, salt intake, smoking, alcohol consumption and exercise are essential to slow the progression of the disease.
The aging population and low literacy on health are barriers to communication that can be overcome through the acquisition of skills in this area. According to the Accreditation Council for Graduate Medical Education Physicians must be competent in five key communication skills: 1. Listening effectively; 2. Eliciting information using effective questioning skills; 3. Giving information using effective explanatory skills; 4. Counseling and educating patients and 5. Making informed decisions based on patient information and preference (Duffy FD et al, 2004). It is important be honest and hopeful, to access the patient knowledge about his disease, the information that he desires and is able to understand and the feelings of the patient. Marvel et al. found that most physicians only allow the description of the chief complaint during 23 seconds. The interruption and redirection of the discussion can lead to missed opportunities to gather important data and decrease the patient satisfaction (Marvel MK et al, 1999). Also, the use of technical language without checking for understanding and an incorrect body language of the physician negatively affect the quality of the communication between patient and doctor doctor-patient communication. Physician should pay attention to his body position and facial expression. During the consultation time, the physician needs to pose questions, to choose words and to manage silences, tones and facial expressions, overcame any linguist and cultural differences.
Professionalism and humanism are essential to the holistic care in all stages of chronic renal disease. Effective communication leads patients to acknowledge health problems, to understand treatment options and it related risks, to modify their behavior accordingly and to adhere to treatment (Stewart MA, 1995;Bull SA et al, 2002;Ciechanowski PS et al, 2001;Bogardus ST et al, 1999). It is also associated to a reduced risk of conflicts or malpractice claims (Sutcliffe KM et al, 2004;Levinson W et al, 1997) and lower health-related costs (Cronan TA et al, 1998;Johannesson M et al, 1995;Simmons J et al, 1996). Nevertheless, most studies related to cost effectiveness in kidney disease mostly consists of reviews of individual pharmaceutical therapies and treatment strategies and do not analyzed the impact of an effective communication in reducing costs with chronic kidney disease. Among patients with stage 1-4 CKD, several pharmacological and non-pharmacological interventions are reported to be cost effective and associated with slowing the progression of kidney disease (Menzin J et al, 2011). The early referral to a multidisciplinary clinic was one of the non-pharmacological interventions cost-effective but it could be enhanced by increasing medication adherence, achieved through good communication skills (McLaughlin K et al, 2001). In fact, the implementation of clinical practice guidelines, per se proved to have limited impact and nephrologists cannot alter outcomes on their own but must do so in partnership with patients (Philipneri MD et al, 2008). As any other skill, learning communication skills needs practice and constructive feedback. Teaching communications requires attention to both verbal and non-verbal communication, since physician's personal reactions can influence the doctor-patient interaction positively or negatively. Basic communication skills acquisition is an objective of all curricula of medical schools. In spite of this, it is generally addressed in the early years of the pre-graduate education and assumes a secondary goal in the last years of medical school, where attention is focused on teaching diagnostic and technical competencies and patient management.
According to the Accreditation Council for Graduate Medical Education (ACGME), the resident trainers should acquire six "core competencies": medical knowledge, patient care, professionalism, interpersonal and communication skills, system-based practice and practice-based learning and improvement (Harden RM, 2006). Most of the available programs designed and implemented to teach patient-centered care were based on role-playing sessions because it is easy to use, with low cost and effective (Levinson W et al, 2010). Residents' learning of communications skills tends to occur in a non-systematic manner with little feedback. Results from a survey of nephrology fellows revealed that they receive little formal training in communication skills and end of life care (Holley JL et al, 2003;Combs SA et al, 2015). Some communication tools have been developed to enhance patientcentered care, for example Nephro Talk, a published framework to teach how to discuss bad issues, express empathy and assisting with treatment decision making (Schell JO et al, 2012). In general, good clinical communication is associated to positive health outcomes, including a significantly great reduction in blood pressure (Kaplan SH et al, 1989). Such effective communication is possible without prolonging the duration of the clinical encounters (Roter D et al, 1995). Page | 4 (Finkelstein FO et al, 2008).
In Portugal, the communications skills are not formally taught or assessed during post-graduate training. A greater investment in this area and the inclusion of medical education workshops in the congress of nephrology area may be a simple measure but cost-effective in the chronic kidney disease approach.

Conclusions
A new approach to chronic disease management for 21st Century is being developed and a good multidisciplinary team is indispensable for good centered-patient care. There is evidence of opportunities to lower costs in the treatment of patients with CKD, while either improving the quality of care through the development of good communications skills. To be successful, this network of care must involve close working relationships with primary care providers and patients and have to necessarily include systematic and standardized teaching of communication skills. This education should start in medical school and be extended to postgraduate training and continuing medical education. This may be an important measure in reducing health costs with chronic diseases, particularly in chronic kidney disease for better adherence to lifestyle changes and therapies and control of the patient's risk factors with consequent delay in disease progression and less use of additional diagnostic procedures.

Take Home Messages
Chronic renal disease is a growing burden for the health systems. An early intervention and prevention based on multidisciplinary care are crucial. Effective communication with the patient is the basis for success and therapeutic adherence. Communication skills teaching needs to be strengthened in both ungraduated and post-graduated curriculum, since the investment in communication is a cost-effective measure.

Notes On Contributors
Idalina Beirão, nephrology consultant at the Centro Hospitalar do Porto, responsible for nephrology outpatient clinic and director of Undergraduate Medical Education Department. Professor of Semiology at Institute for the Biomedical Sciences Abel Salazar, Porto University. Member of the Scientific Council of ICBAS and Pedagogical Committee of the Medicine Course.