Conversations in MedicineOne

Skill in communication is a matter of personal ability, which varies widely between individuals in health care as in any other field. Many doctors handle conversations with their patients well. Some, on the other hand, do not show enough confidence or empathy in their interactions with patients or worse still, demonstrate a cold, uncaring attitude. Some are reluctant to engage in a conversation altogether, fearing the emotional impact of the news they seek to communicate.

Good communication is important because it forms the basis of all transactions in healthcare. Evidence from recent research suggests that good communication improves specific medical outcomes for patients, positively affects patient perception and improves quality and safety in healthcare. However, for this to be accomplished communication needs to be patient-centred, informative and interactive.

The ultimate objective of healthcare is improvement in outcomes. Not surprisingly, these can be achieved as much by effectively communicating to the patient the need for lifestyle changes as with the introduction of a new drug. A wide variety of medical outcomes improve as a 2result of effective communication. Examples include improved postsurgical pain, severity of headaches, compliance with medications and better glucose control.² This improvement in outcomes is related, in part, to adherence (or compliance) with prescribed treatment. Doctors, who are skilled communicators “enlist” their patients better.

All doctors make mistakes but not all get sued. Research has examined the difference between clinicians who are named in malpractice suits and those who are not. Poor communication and relationship is the most important factor to emerge from this investigation. When researchers reviewed the medical records from a group of doctors with higher than average malpractice claims, they found no difference in the number of technical or clinical errors compared to a control group of doctors with no claims. They found that sued doctors were no more likely to have adverse outcomes compared to others but they did have a significantly higher rate of dissatisfaction and complaints against them. The “no claim” doctors spent, on average, more time with patients and engaged and interacted with them more. Not unexpectedly, they found patient satisfaction to be the highest, if a doctor was a good communicator.^3,4

Most doctors accept the incredible long hours of work because they expect a very high degree of satisfaction in their careers as physicians. Higher ratings of job satisfaction among physicians appear to be closely linked to good relationships and therefore, to good communication with patients and others health professionals.

Several studies have highlighted that poor communication between healthcare workers contributes significantly as a latent source of medical error.⁷ Evidence exists that patients have better outcomes when doctors and nurses communicate effectively about patient care.^8,9 Not only is the likelihood of error minimised, the extent and inclusiveness of communication across role boundaries impacts positively on patient safety. At the very least, good and open communication influences the degree to which patient care duties are understood and executed.3

There are formidable barriers to successful communication across the divide between patients and doctors. Communication gaps sometimes limit the real good that medicine has the power to deliver. Some of these barriers have been identified and they include the following.

Kuhn pointed out that as a science becomes more successful, it becomes harder to communicate the latest advances in simple terms.¹⁰ Eventually scientists are able only to communicate with other scientists working within the same discipline. This theory has, as its basis, observations made during the course of discoveries in quantum mechanics and the string theory.

The complexities of probability, as it relates to clinical decision making, makes conversations between doctors and patients more difficult than they already are. Clinicians armed with frequential probabilities as their ‘objective data’ are forced to rely upon subjective probabilities when they deal with one patient. They cannot try their treatment 100 times on each patient. Doctors must, therefore express their level of confidence in each choice, or offer the patient an array of data and ask them to choose the treatment. This remains a difficult task even for the most enlightened. In other words, the process of helping patients arrive at a decision is complex and challenging.

Medical information is generated at a staggering rate of 34,000 articles each month in medical journals. A new article is added to medical literature every 26 seconds.¹¹ The quality of articles worthy of attention has increased substantially over the last 10 years with nearly 200,000 RCTs indexed in MEDLINE between 1994 and 2001. For even the most attentive, it is simply no longer possible to keep up to date by reading the latest, as the volume of published material far exceeds the human capacity to read and understand it all.

There are several vested interests in and around medicine. Certain groups within and outside the profession, use health issues to their advantage and are reluctant to give up their position or privilege. While the motive of most doctors is good, the necessity of curing for profit creates a set of vested interests in medicine that is hard to ignore. Most doctors want to preserve or increase their income; on the other hand patients want to minimise expenditure. This creates a tension in the relationship between doctors and patients and adds to difficulties in communication.

Social class, age, race, culture and ease of communication influence a patient's trust and co-operation with the doctor. The possibility of misunderstanding arising out of communication difficulties is substantial. Quite apart from obvious problems posed by patients who do not speak the same language as their doctor, conversations in a shared language that is understood differently by the patient can also seriously compromise communication. Common medical terms such as cancer, shock, stroke and heart attack are poorly understood by the general public. Using them in explanations tends to inadvertently create the impression of subsequent disability and suffering, which the doctor never intended to convey.5

To some extent communication skills can be taught even though the context of each conversation is different. Most doctors do not get the same type of clear, systematic guidance in learning communication skills as they do with other procedures during their training years. As with clinical examination techniques, communication can be mastered over time.

This component is easy to understand and assess. It consists of what is actually said, including the language used and information given. Most of the skills are intuitive such as avoiding technical language and using a level of explanation appropriate to the relative's understanding of events.

These skills consist of how a meeting with the family is structured. Although some doctors develop process skills spontaneously, most do not. The doctor, who has trouble getting across all he/she wanted to say or who finds the start or finish of a conversaion awkward, may benefit from learning process skills.

These relate to recognising and dealing with feelings and emotions that arise in the course of a conversation. Experience alone is a poor teacher of process and perceptual skills and there is some evidence that these skills deteriorate over a medical career¹³. Examining perceptual skills can reveal underlying problems of attitude and relationships, but these can be improved with training.

There are a number of difficult communication tasks, which doctors have to carry out including breaking bad news of a serious illness, coping with denial or managing patient distress or anger. Doctors who work in critical care face, in addition, special circumstances during which, 6well thought out levels of communication are particularly important¹⁴ (Table 1.1). An approach to some of these tasks is detailed in the section below.

There is justifiable major interest in defining medical outcomes and communicating these to family members of critically ill patients. When prognosis is poor, it is important to avoid instilling false hope. Hedging and focussing on irrelevant positives such a pulse or blood pressure serve to distract the family from the work of acceptance that they must begin.

The world of medicine has become increasingly foreign to lay people, so patient families have a number of questions, some unspoken, that need clarification. Simple concerns about the diagnosis and interpretation of test results are easy to address. Concerns about available options, especially those that require a procedural intervention or a need for further tests are more difficult to answer. Even more difficult are questions related to the future course of events or questions about why the illness occurred.

When faced with denial, it is tempting to force family members to confront reality. This may turn out to be counter-productive. Denial is generally a temporary defence mechanism and lasts until family is ready to face the reality. Patience and repeating the same message over and over again is the key to managing denial. Occasionally, certain inconsistencies in the arguments used by families need to be confronted. Challenging inconsistencies works frequently, but on occasions when they fail to dent denial, the treating doctor must work on a different approach to develop awareness among family members.

The antipathy that develops between family and doctors as a result of unrealistic expectations can be prevented by early, honest and consistent communication. Public expectations are generated by socio-cultural norms and are sustained by the media and access to medical information. Once formed, expectations are difficult to change, particularly when it is necessary to lower them. Medical profession unwittingly encourages these expectations by emphasising the power of science to solve any problem. The expectation that medical science should cure every illness is thus, taken for granted.7

No doctor wants to give bad news, but most accept it as part of their duty. There are special skills that can help effectively communicate bad news. In addition, qualities such as empathy are crucial in engaging with those receiving bad news. This is covered in greater detail in the next chapter.

Family members can become tearful or upset while receiving bad news. Sometimes, it is best to say nothing and allow for tears to flow. At other times, the assurance that it is perfectly acceptable to feel sad can be helpful. Crying patients or relatives tend to make doctors anxious and do something silly like leave the room or send in someone else to comfort the grieving. Empathic lapses such as these can leave a lasting impression.

Although honesty and transparency in matters between the doctor and patients is the expected norm, there exist family members who seek to protect their sick relatives from information that is likely to cause undue distress. These families often seek the doctor's support in misleading the patient, for example by not discussing the diagnosis or its seriousness. This must be gently but firmly avoided.

Good inter-professional communication influences the quality of care and patient safety. Regular rounds, documentation of important treatment goals and review of progress by the ICU lead 8clinician has been shown to reduce ICU length of stay.⁹ Failure of inter-professional communication, on the other hand, is associated with avoidable medical mishaps.¹⁶

The way in which clinical management of an ICU patient is negotiated with other specialists has received little attention.¹² Clear communication is also central to clarifying and resolving differences of opinion that arise in the course of management of an ICU patient. However, little is known about how best this can be achieved. At the very least, ongoing contact with the primary team needs to be actively encouraged in order to build a joint understanding of the patient's progress through the ICU.

It is now widely recognised that good communication skills are a necessary feature of good medical practice. Conversations with patients or their near ones must be effective and ethical. A measure of whether this is the case or not, is reflected in the extent to which patients express their satisfaction with the care and support they receive in hospital. Healthcare professionals have traditionally learnt communication skills by modelling the practice of their seniors. Although a time-honoured method, this results in a series of anecdotal lessons that rarely equip the doctor to handle difficult communications tasks in the ICU. With increasing emphasis on teaching communication tasks and structured feedback, doctors can expect to develop a number of skills that, in turn, can improve teamwork and help patients and relatives through difficult times.