Consultation, referral, and collaborative management are at the heart of patient care and rely on successful communication. The communication may be verbal or nonverbal, and it may be given in person, by telephone, or by written correspondence. The necessary skills must be second nature to physicians and evolve with the recognition that each patient is culturally and spiritually unique, with an idiosyncratic life situation blessed and beset by physical and emotional assets and limitations. The physician needs to understand the patient's and the parent's verbal and nonverbal language and search for hidden agendas—concerns not overtly expressed.

Primary care physicians (PCPs) also need to understand the language of their specialist colleagues. They, too, have vulnerabilities, assets, and limitations, as well as particular practice habits. Indeed, language and culture inconsistencies are likely because specialists have more narrow concerns. The role of the PCP is to understand both the patient's and the specialist's cultures and provide the bridge between them.

Good communication is hampered by the uncertainty that underlies patient care, the often intangible factors that influence decision-making, and the need for the patient to grasp the uncertainty. Communication is aided when the physician can:

• Listen attentively and sensitively.
• Be precise.
• Be prompt in making contact.
• Avoid rigidity.
• Avoid the use of jargon.
• Be sensitive to and comfortable with uncertainty.
• Confirm what other professionals have asserted.
• Avoid the confusion of mixed messages.
• Avoid impromptu off the cuff or corridor consultations or discussions.
• Maintain a rightful voice in decision making (respect for a patient's or a colleague's autonomy in decision making does not void responsibility).
• Maintain concise, complete records, confirming spoken communication (including telephone conversations).
• Define precisely the role of each professional involved.
• Ensure that orchestration of the entire process is delegated to 1 person, most often the primary care physician.

Also beneficial to a patient is to:

• Ensure a comfortable, private setting for conversation.
• Understand the patient's and family's perspective, worries, and goals.
• Describe the process and sequence of care in understandable, unpatronizing words.
• Gauge the family's response by reading their body language and listening carefully.
• Review the conversation and decisions and ask to hear a summation to be sure of appropriate understanding.
• Involve the patient and family in decision making.

Also important to your specialist colleague is to:

• Report any behavioral, emotional, social, and economic factors that can influence decision making.
• Define clearly individual responsibilities according to the skills, intentions, and goals of all the professionals involved.