How can Doctors Improve their Communication Skills?

Piyush Ranjan,1 Archana Kumari,2 and Avinash Chakrawarty3

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Abstract

The process of curing a patient requires a holistic approach which involves considerations beyond treating a disease. It warrants several skills in a doctor along with technical expertise. Studies have shown that good communication skill in a doctor improve patient’s compliance and overall satisfaction. There are certain basic principles of practicing good communication. Patient listening, empathy, and paying attention to the paraverbal and non verbal components of the communication are the important ones that are frequently neglected. Proper information about the nature, course and prognosis of the disease is important. Besides, patients and attendants should always be explained about the necessity and yield of expensive investigations and risks/benefits involved in invasive procedures. One should be extremely cautious while managing difficult encounters and breaking bad news. Formal training of the doctors in improving communication skills is necessary and has proven to improve overall outcome. The authors recommend inclusion of formal training in communication skills in medical curriculum and training of practising doctors in the form of CMEs and CPEs.

Keywords: Breaking bad news, Doctor patients conflict, Verbal component

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Introduction

Good communication skill has been considered extremely important for medical practitioners in the western world since decades. Its significance is now being acknowledged in our country and some authors have expressed the view that it is “the need of the hour” to train medical professionals in this important yet ignored aspect in clinical medicine [1,2]. Recently, the medical system has witnessed an increase in the incidences of conflict between doctors and patients or their attendants [3]. There has been an increase in both the number of lawsuits against doctors as well as the mass level agitations by doctors. Such incidents are not only appalling but also ignominious for the noble medical profession. There is enough evidence in literature to suggest that poor communication between doctors and patients is an important attributing factor [4]. Good practices like detailed explanation by clinicians along with enduring listening to the patients or their families have been found to decrease such incidences [5]. This article strives to underline basic principles of the communication skills along with some practical suggestions useful in day to day practice of doctors.

Benefits of good communication skills

The practice of good communication skills in the medical profession is integral for the development of meaningful and trustworthy relationship between the doctors and patients and, thus, is beneficial to both of them. The diagnostic capability of the doctor is greatly enhanced because of better understanding of patient’s problems [6]. Furthermore, it is also useful in managing difficult clinical encounters and thus decreases the frustration of both the doctor and the patient or attendant in situations of emotional outbursts [7]. It has also been shown to decrease work stress and increase job satisfaction [8].

Patient’s level of satisfaction is improved by better recognition and understanding of their ailment and the treatment available [9]. This further increases their compliance to the advices given by the doctor [10]. Besides, it has positive impact on patient’s psychology, mental health, tolerance power and quality of life [11].

Components of communication

Effective communication has three basic components-Verbal, non- verbal and paraverbal. Verbal component deals with the content of the message including selection of the words. Non-verbal component includes body language like posture, gesture, facial expression and spatial distance. Paraverbal component includes tone, pitch, pacing and volume of the voice. While communicating, most of us focus on the verbal component that constitutes only ten percent of the message delivered whereas non-verbal and paraverbal components contribute ninety percent of the total message delivered.

Verbal component (content) is important and it includes information about the nature, course and prognosis of the disease; various treatment options available; nature, cost and yield of the investigations and risks/benefits of invasive procedures. Although nonverbal component of the communication is frequently considered less important, literature suggest that it significantly influences important outcomes like patient’s satisfaction, adherence to advices and clinical outcome [12].

Barriers to good communications

There are several barriers to effective communication between patients and doctors [13]. The most important one is lack of insight due to inadequate knowledge and training in communication skills. Many a times, doctors do not give enough heed to the importance of keeping patients adequately informed. Non-verbal components of the communications are frequently neglected. Language barrier is also important. It is not unusual for patients speaking in their local languages and giving tough time to doctors. Another important barrier is lack of adequate knowledge about the disease or treatment options. Finally human failings like stress, tiredness or lack of time are major contributing factors in an overburdened setting.

Learn to listen to the patients patiently

The importance of listening, extends far beyond the academic and professional settings and is extremely important in creating a trustworthy doctor-patient relationship which is a prerequisite for therapeutic success [14,15]. It is an active process that involves imbibing all the information expressed verbally or nonverbally by the patient. It is a major part of communication process. It helps in better understanding of the patient’s problem and finding better decisions. Studies exploring the reasons for filing litigations against doctors found that a significant proportion of the patients were dissatisfied because the doctor had not listened or understood their problem fully [16,17].

Listening not only involves understanding the verbal component but also eliciting patient’s attitudes, needs and motives behind the words. The goal of listening is, also, to delve into the physical, social and emotional impact of these problems on the patient’s quality of life so as to provide holistic care and satisfaction. Some of the communication strategies that may help the doctor to improve listening skills are listed below [15,18]:

1. Make the patient and the attendant comfortable. Never have discussions while walking in the corridors.

2. Show interest in what the patient is saying with your mannerism, body language and active involvement like leaning towards the patient.

3. Mannerism like patting shoulder, holding hands or nodding may convince the patient that you care for them and have understood his/ her problem. Although, it is considered as an important etiquette in western countries, it may not be socially acceptable in many parts of the world including India.

4. Be careful not to interrupt him/her when he/she is expressing something.

5. While concluding, one must ask the patient if he would like to add something more.

Before starting formal interview with patient

One can actually win patient’s confidence in the first interaction even before starting formal interview. First impression is extremely crucial and instrumental for building doctor-patient relationship. The major determining factor for this first impression is not what the doctor says but how the doctor says it. Some of the practice points are listed below [19,20]:

1. Respect the patient’s confidentiality and maintain privacy. Patient should not be made to state the reason for their visit when other people are present.

2. Be the first one to greet the patient. Do not wait for the patient to speak because some patient will interpret your reticence as indifference. Shake hands and introduce yourself wherever feasible and socially acceptable.

3. Be prepared and know the patient’s name. Address a patient by his/her name whenever required. Do not fumble for name after the patient is in the room. If it is an old case, greet him and ask him how he is.

4. Establish eye contact and maintain it at reasonable intervals.

5. Put the patient at ease. Some patients may be nervous, so begin with a general non-medical inquiry in order to develop a comfortable scenario for the patient.

Conducting medical interview with the patient

The medical interview is an opportunity for the doctor to understand the patient’s problems and learn its psychosocial bearing. Simply writing a prescription has got no value and is actually wastage of time and energy unless and until it is adequately honoured by patients. It is extremely important, especially in cases with chronic illness, where good communication skill is useful in allaying anxiety and motivating the patient for good compliance regarding advices. The interview should be patient centric rather than disease centric [21]. It is vital that the patient’s interview is conducted to achieve three essential goals that is gathering of information, building a healthy doctor-patient relationship, and education of the patient [19]. Some of the very important practical advices are listed below [18-20]:

1. Pay attention to both the verbal and non-verbal clues from the patient and explore whenever there is any discrepancy 2between the two. Meanwhile, the physician too should be alert about his own non-verbal clues like body language, gestures, eye-contact.

2. Always provide information on what the patient wants to know and promptly respond to the patient’s reaction.

3. Discuss nature, course and prognosis (both short term and long term) of the disease, treatment options available and necessity of the investigations.

4. Discuss in detail regarding necessity and feasibility of expensive investigations and drugs and their effect on main course and outcome of disease.

5. Involve the patient in the decision making. The treatment plan must conform to the patient’s understanding, beliefs, cultural values and concerns.

6. Put additional efforts in motivating patients regarding adherence to lifestyle modifications.

7. Always comprehend details in simple language. The use of medical jargons and abbreviations can have a negative effect.

Communicating with the attendants

This scenario usually comes when a doctor is treating an indoor patient. Attendants are apprehensive and at times full of doubts and queries. Communicating with the attendants assumes great importance especially when patient is critically ill or admitted in ICU. Here are certain tips that will definitely improve one’s ability to communicate [18,22][23]:

1. Never be informal with them. Conduct conferences once and if possible twice daily.

2. Talk about and appreciate the efforts made by them.

3. Most of the attendants surfs internet and gather lots of information. Try to satisfy their queries by giving better references.

4. Always explain the dynamic nature of disease. This is especially important for critically ill patients.

5. Second opinion should be sought proactively. This is important not only in patient management when one is in doubt but also helpful in building attendant’s confidence. One will be more convinced and ready to accept bad outcome if the same fact is explained by more than one consultants.

6. Never express shock. Try to convince that all efforts are being made to bring situation under control or will be controlled.

7. Consent taking is very important part of counselling. Never neglect this and give it to paramedical staffs or interns who may fail to explain convincingly.

Communicating with colleagues

Junior doctors including postgraduate students, fellows and interns along with nursing and supportive staffs are part of the team. It is important to keep them united and motivated. Following principles should be followed [24]:

1. Never talk low about your colleagues or scold residents, fellows or other students in front of patients or attendants. One should be extremely cautious while asking questions from Junior Residents on rounds. Patient may feel insecure in absence of senior consultants who may not present at all the time. This may also create doubts in the minds of patients even if Junior Residents prescribe drugs for common complaints.

2. Greatest courtesy should be displayed for all staffs including nurses, paramedical staffs and other supporting staffs. Make them realise that they are a part of the team and their role and responsibility is also important. A system with effective teamwork can improve the quality of patient care and reduce workload among healthcare professionals [25].

3. Lead by setting examples. Supporting staff will never work with full sincerity unless and until they appreciate the hard work and ability of doctor.

4. Try to teach them the basics and the principles of management of commonly encountered diseases in your ward. This will keep them motivated.

5. Audit and regular feedback improves in professional practice. Never delay to give appreciation and dare to give positive criticism [26].

Managing difficult encounters

Difficult encounters are not uncommon in medical practice and, in a study, approximately 15% of the doctor-patient interactions were labelled as “difficult” encounters [27]. It is worth noting that difficult encounters may be consequent to a combination of factors related to doctor, patient and even the circumstances. It is precipitated by an imbalance between the expectations, perceptions and the conduct of the doctor and the patient involved [28]. Difficult encounters may occur when a doctor deals with a patient having multifarious medical ailments that are exacerbated by complex social issues. At times, a patient may present with misleading information from internet and pose challenging situation leading to professional burnout of the physician [29,30]. Furthermore, lack of adequate knowledge or time or even negative bias towards the patient’s ailment may attribute to difficult encounter. Besides, poor communication skills and psychosocial attitudes along with lesser job satisfaction among the doctors may also be contributory [28,31]. It may be a rather taxing situation for the doctor to tackle the dependent, argumentative and manipulative patients or patients with certain behavioural issues. Difficult encounters, also, occur due to circumstances like language, cultural and time barriers. A clinician should always be ready to deal with these challenges. Whatever may be the factor(s) responsible for difficult encounter, the doctor has both ethical and professional obligations to treat the patients of their ailments. Following strategies have been found to be useful in maintaining a healthy therapeutic relationship with specific type of patients [31-33].

Dependent patients- Such patients are vexed with the idea of being deserted. Hence, they demand more of the personal time from the doctor making him resentful. Thus, it is essential to maintain a professional demeanour with well established boundary. Many a times, involving the patient in decision making is helpful. Assure him that he will not be abandoned/neglected and will be given full attention in subsequent visits also.

Demanding patients- They are often aggressive, intimidating and do not want to go through the stepwise assessments or treatment. In such a situation the doctor should avoid judgemental approach and empathetically ensure the patient that he will get the best medical care and there is no need to show anger.

Manipulative patients- These attention seekers who have been rejected previously often revisit the doctor in cycles of help-seeking/rejecting treatment and do not improve despite appropriate advice. Their firm belief that his/her health cannot improve even puts the doctor in doubt about his own diagnosis and treatment. However, the doctor in such circumstances should be empathetic and listen to his problems attentively while sharing frustration over poor outcomes. The doctor must reformulate the treatment plan with the patient after having set limitations over expectations.

Self-destructive patients –Some patients with an underlying anxiety or depression are often hopeless about their ailment and fear failures. The health problem persists despite adequate counselling and management. The patient continues self-destructive habits and the doctor considers himself ineffective and responsible for patient’s lack of progress. The doctor should set realistic expectations and recognize the fact that complete resolution is limited. The doctor should try to delve into the reasons for non-adherence to therapy (money, time or family support) and offer or arrange for psychological support.

Hence, to deal with difficult encounters, the doctor must be compassionate and empathic and should employ active listening in order to prioritize patient’s immediate concerns and expectations. The doctor must identify all the contributing factors and approach the patient with non-judgemental and caring attitude. Any underlying psychological condition must be identified and appropriately treated. Involving the patients by asking them the possible cause of poor outcome and potential solution would foster a more collaborative relationship leading to therapeutic success.

Breaking bad news

Bad news means any information that has a potential to have devastating influence on one’s life. However, it’s impact is highly dependent on the recipient’s expectation and understanding [34]. Disclosing bad news is a complex communication art that not only involves verbal component of actual news breaking but also includes empathetic response of the doctor to tackle the reaction. Poor communication skills of an inexperienced clinician can ruin the goal of providing support to the patient and eliciting patient’s collaboration for future treatment. Studies have demonstrated that many doctors lack competence as well as confidence in their ability to divulge bad news and there is necessity to provide didactic training [35]. Several protocols have been devised to guide the doctors for imparting this skill [36-38]. It is useful to follow a strategic approach as described below while breaking bad news and provide information according to the patient’s own knowledge or expectations as well as to condense the emotional turmoil into an effective future management plan in the same setting [36].

1. Be primed up for the interview- Breaking bad news is a daunting task and one should mentally rehearse the act of disclosure and the manner of reacting to the patient’s emotions. Following the key communication skills like maintaining privacy, sitting relaxed with the patient, maintaining constant eye-to-eye contact and avoiding any time pressure and interruptions allow an undistracted and focussed discussion. If the patient wishes someone else to be with them, allow the patient to choose among the relatives or friends.

2. Assess the patient’s knowledge and attitude – By asking open-ended questions, the doctor not only gains insight into the patient’s perception of his medical problem but also gets the opportunity to assess patient’s preparedness for the bad news.

3. Assess the patient’s desire to get the level of details of information- Some patients may express the desire for full information about their diagnosis, prognosis and details of their illness while other only want to have a broad idea. Such information makes it easy for the doctor to reveal the information according to the patient desire.

4. Actual breaking of bad news- It is better to plan an agenda with the patients including diagnosis, treatment, prognosis and support or coping. An initial warning may decrease the shock that can follow the disclosure of bad news. Use of simple and non-technical words, giving information in small portions and periodic assessment of the impact are some of the communication tools that can be extremely useful.

5. Addressing the patient’s emotions – Patient’s emotional reaction may vary from silence to disbelief, crying, denial, or anger. It is the physician’s duty to support the patient by making an empathic response. Moving closer to the patient, holding the hands, and using empathic statements help the physician to not only support the patient but also to acknowledge their own sadness and emotion. Validating responses help the patient to overcome and accept the reality. Sometimes when the patient becomes silent or tearful, allow them time to recover. Exploratory questions may be helpful when the patient’s reaction is ambiguous.

6. Treatment plan and summarize- It is important to formulate and discuss future plan of treatment with patients and/or attendants by involving them in the decision making. Those who are having a definite plan of action are less likely to get anxious or panic. Summarizing the whole discussions in the last is extremely useful and helps in assessing if patient has understood the facts correctly or not.

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Conclusion

To conclude, good communication skills among the doctors is crucial in building a trustworthy doctor-patient relationship that not only helps in therapeutic success by providing holistic care to the patient but also leads to job satisfaction among the doctors. Not many doctors are naturally blessed to have good communication skills and there is necessity of formal training in this.