Communication in medical practice
Good communication is the bridge that spans the gap between the mind of the doctor and the patient. In this paper, the scope of the term communication skills has been broadened to include the knowledge, attitude and skills that enable a doctor to know and respond to the totality of the disease process as it affects the body and mind of the patient.
Communication is effective only when it is a two way process. Good communication draws upon knowledge of psychological, cultural, social, educational and economic influences upon the patient and disease. It requires that intellect and emotion be yoked together in the service of the alleviation of suffering and the promotion of health.
At the heart of the practice of medicine is a dynamic process seeking the best fit between the patient's needs, the physician's perception of the patient's needs and what the physician has to offer. Fine tuning of this process requires knowledge of the patient's values, attitudes and beliefs and therefore the social, cultural, religious and economic milieu of the patient. The ability to respond effectively is determined by the extent to which the doctor understands the working of the human mind, can discriminate between the subjective and objective aspects of human experience and can read between the lines of verbal expression.
The bed rock of good communication is the ability to 'feel with' the distress caused by the disease process. Once this ability is in place the trainee becomes motivated to fine tune communication and re-orient service towards a more patient centered approach. In the absence of the 'feeling' element , the 'knowledge' element of communication may never translate into action.
Special challenges in communication
While some basic rules of communication apply across cultures and continents, communication must be sensitive to individual variations. Culture, religion, social systems, and economic structure are some of the influences that determine the manifestations of disease and expressions of distress.
The economically deprived patient with little or no formal education does not come to the consultation alone. He is accompanied by his family or even members of his village unrelated to him. He is also accompanied by an invisible host of authority figures who influence his beliefs, attributions, preferences, values and hopes. The doctor ignores these at his own peril.
Among the general population there can be recognised a group of people whose dependency needs are high. They seem to spontaneously abrogate responsibility and deify the doctor. While this behaviour may invite an authoritative, directive stance, such patients when asked, have revealed their wish to be informed about their disease. It would appear that while the initial picture would suggest that the doctor should remain entrenched in paternalism, the inner wish of the patient is to be informed and to negotiate to the extent possible, the final decisions regarding his own treatment. Decisions regarding confidentiality and autonomy will also be influenced by dependency needs, and communication styles must make allowance for this.
Left unaddressed, these can cause unhealthy practices such as adopting unnecessarily strict cut off for accepting or rejecting monetarily disadvantaged patients, refusing to get "involved", and becoming excessively distant and over intellectualized and resorting to aggressive treatments aimed at "cure at all costs" with disregard for the appropriateness of such treatments for the patient and family.
In situations where staff strength is sub-optimal and work load is overwhelming, a health professional who is at all sensitive, is faced with the need to set limits and preserve boundaries against the never ending sea of patient's needs. People who are not equipped to do so, run increased risk of "burn out". Only when there is a calm acceptance of the limits of one's ability to address need, can there be a consistent, sensitive approach to `what can be done.
Teaching communication skills
Topics such as the importance of communication skills in medical practice, active listening, and being aware of one's own emotional reactions during the process of communication can be discussed in large groups.
Skills that promote the doctor's relationship with the patient - questioning, encouraging the patient to talk, maintaining eye contact, ensuring that the verbal and non verbal messages being transmitted by the doctor are compatible, should be demonstrated and discussed. While pre-recorded videotaped interviews are useful to generate discussion points, the use of participatory learning such as role plays needs to be increased.
Disciplines such as general practice and palliative care where there is a close and robust, one to one connection between doctor and patient would be good settings to initiate the teaching of communication skills. Guiding students through projects to explore patients needs, for example, would allow opportunity and motivation to learn about the local culture, religious beliefs and language.
Philosophy, sociology and psychology as relevant to the medical practitioner could also be taught as elective courses to enable the student to consider the patients problems within the context of the patient's world.
In a tertiary referral hospital the student often observes a fragmented line of care beginning from the post graduate student who examines and investigates the patient, the intern who collects investigation results and is guided through some procedures and ending with the consultant who takes responsibility for diagnostic and management issues.
Another aspect of the milieu peculiar to the halls of academia are the glimpses of the competing demands on doctors of the patients needs on the one hand and the fascinating attraction of the theory and science of medicine artificially separated from the human being in which it is rooted. This is not the ideal setting in which to successfully 'imprint' in the students mind, the over riding importance of building and nurturing the connection between the patient and the doctor. Once the foundations are laid in disciplines such a general practice and palliative care, the structure can be subjected to more challenging environments with obviously competing and equally valid priorities.
Panel discussion is a teaching learning method with potential. The participation of senior specialists focusing on important communication issues in their respective areas brings home the relevance of communicative issues in different settings.
Modules should be focused on the common every day situations arising in the wards, and be graded according to the level of difficulty and the stage of learning of subjects being taught.
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