This is an essay I wrote for my Social and Ethical Context of Heath and Illness Module answering the question: What research have you read and what contact with patients have you had which can help inform your communication with patients in the future?
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As a doctor communicating effectively with patients is paramount to relay important diagnostic information, for therapeutic effect and to develop a strong patient-doctor relationship. The power dynamic between doctor and patient, the patient being the receiver of care who has come to seek assistance from an ‘expert’, demands a deft and considered approach in the consultation room and beyond. When considering research and personal patient encounters, the importance of active listening and perspective-taking become clear, particularly to aid patients who are part of disenfranchised sectors of society.
Good Doctor, Good Communicator?
In the consultation room, there is a two-way flow of information- from patient to doctor and the doctor to patient- and the doctor must interpret and manipulate the way they communicate to provide the highest level of patient care. A study conducted by the Mayo Clinic (2001-2) collected patient perspectives on ideal physician behaviours. The patients’ narrative descriptions focused on the quality of communication between them and their physicians. The study concluded from the testimonials that patients perceived ideal physician behaviours as being confident, empathetic, humane, personal, forthright, and respectful. When asked to describe their ‘best physician’ the most frequently mentioned was ‘thorough’ and least was ‘empathetic’. This is further justified by research by Fung et al indicating that if patients are forced to choose between technical quality and interpersonal quality in selecting a primary care physician, most will choose the one they judge as the more technically proficient physician. This is telling as it suggests that to communicate well, the physician must display a level of competency and act like the ‘expert’ the patient arrived to see. However, a limitation to interpreting these studies is that they focused on primary care physicians in the USA, when in fact depending on which speciality and what setting they are interacting in patients may value some communicative qualities more than others.
Listening and Perspective Taking
Physicians need to know what to listen for and to understand the significance of what is being heard, to communicate with patients in a meaningful manner. B Bub (2004) posits that the fact a high percentage of physicians report inadequate training in psychotherapy and communication skills stems from the way that listening in medicine is framed as a ‘scientific, essential clinical skill’ rather than an ‘act of benevolence born out of compassion’. Listening and perspective-taking, using the ‘Hair-dresser approach’ (Figure 1) can allow doctors to
understand a patient’s suffering composed of ‘acute laments’ or ‘chronic laments’(B Bub 2004). This is particularly pertinent when dealing with clinical presentations of pain. A patient with Endometriosis, a condition with on average a 12-year gap between onset and diagnosis, recalled her experience of interacting with physicians who ‘didn’t take her pain seriously’. This scenario highlights the negative repercussions of poor communication with patients causing them to feel distrust towards the medical profession. Implementing phatic communication (Malinowski, 1922,1993), and ‘A quiet supportive presence’ (B Bub 2004) are aspects of communication I’ve read from established research that has informed how I wish to communicate with patients in the future.
Disenfranchised Patient Populations
Communicating with patients who are of minority ethnic backgrounds or are displaced is high stakes as these populations as they are disproportionately affected by negative outcomes and display lower rates of satisfaction with interactions with healthcare professionals ( Black people, racism and human rights,2020). The importance of a nuanced and culturally sensitive approach in communication is imperative and challenging implicit and explicit bias, through deeper self-knowledge, empathy and cultural awareness is paramount. Good relationships with colleagues, which rely on sincere and non-discriminatory communication, and other factors which influence the level of comfort and security in the clinical environment are important to facilitate open communication with patients. In the case of caring for transgender people, small changes such as wearing a pronoun badge or putting up inclusivity posters in the waiting room can further such endeavours. Furthermore, using language sensitively is of imperative importance: ‘of all the things that could offend a trans person or lead them to feel misunderstood, excluded and distrustful, mistakes involving forms of gender-related speech are perhaps the most upsetting. Potentially they are also the easiest to pay attention to getting right’ (Trans: A practical guide for the NHS, 2008). Taking into account socioeconomic and political factors are also important, evident in the ‘Sanctuary Doctoring’ approach (Figure 2) to refugee and asylum seeker healthcare in order to facilitate an environment where their trauma, physical and mental can be shared. Overall, communication with marginalised groups should seek to challenge stigma ( Link and Phelan,2001).
My stance on communicating with patients has been informed by reading research and my patient encounters. I realise the importance of becoming a ‘self-reflective interpreter of distinct systems of meaning’ (Kleinman,1988) to communicate well with patients. To ‘recognise’ (Berger, 2016) patients and their suffering doctors must be aware of how they (and their environment and interactions with colleagues) affect the patient and understanding what the patient wants to convey to them about their illness. Communication operates on many different levels in a clinical setting and has a profound impact on diagnosis and prognosis. Being critical of one’s approach, and the way we are taught to think about communication in clinical environments is pertinent.
Berger, J., Mohr, J. and Francis, G. (2016). A fortunate man : the story of a country doctor. Edinburgh Canongate.
Kleinman, A. (1988). ILLNESS NARRATIVES : suffering, healing, and the human condition. Basic Books.
Bendapudi, N.M., Berry, L.L., Frey, K.A., Parish, J.T. and Rayburn, W.L. (2006). Patients’ Perspectives on Ideal Physician Behaviors. Mayo Clinic Proceedings, [online] 81(3), pp.338–344. Available at: https://www.mayoclinicproceedings.org/article/S0025-6196(11)61463-8/fulltext.
Bub, B. (2004). The patient’s lament: hidden key to effective communication: how to recognise and transform. Medical Humanities, 30(2), pp.63–69.
Kuczewski, M.G., Mejias-Beck, J. and Blair, A. (2015). Good Sanctuary Doctoring for Undocumented Patients. AMA Journal of Ethics, [online] 21(1), pp.78–85. Available at: https://journalofethics.ama-assn.org/article/good-sanctuary-doctoring-undocumented-patients/2019-01.
A practical guide for the NHS Trans. (2009). [online] Available at: https://www.gires.org.uk/wp-content/uploads/2017/03/doh-trans-practical-guide.pdf [Accessed 15 Nov. 2020].
Burnard, P. (2003). Ordinary chat and therapeutic conversation: phatic communication and mental health nursing. Journal of Psychiatric and Mental Health Nursing, [online] 10(6), pp.678–682. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1046/j.1365-2850.2003.00639.x.