How do we cure, relieve or console without communicating?
By Dr R Neerunjun Gopee
The Covid-19 pandemic has brought forcefully, almost brutally we could say, into focus the importance of proper communication both with individual patients and families but also with the public. This means giving as accurate and correct information as is available, and where this is possible give reassurance about whatever condition one is dealing with. But it is also a fact that quite often in medicine, there is bad news, and how far one can go in disclosing this depends on the psychology of those concerned, and this is a judgement that the treating doctor must make before s/he decides to go further. Some patients and family want to know the blunt truth, others may not and leave it to the doctor to handle the situation. That does not make it easy for the latter, but it is a call that all doctors have to take in their career, which will be strewn with innumerable episodes where this dilemma arises.
Communication in Healthcare. Pic – cesblog.sdsu.edu
It is no different when the doctor has to face the public in the larger context of Public Health problems, such as the current pandemic. The skills for these encounters – with individuals, the public – begins at the bedside. It cannot be dispensed by lay ‘communication specialists,’ who have quite often been foisted upon practitioners in Ministry of Health settings, and who do not have the foggiest idea of what this highly specific field demands in terms of addressing the apprehensions and fears of the subjects.
During my passage at MOH as Director General Health Services, a number of times I had to meet patients, parents of patients or their relatives for various reasons connected invariably with their treatment in the public service.
There was this couple who had lost their 9-year old daughter following a brief illness. According to the medical report by the treating doctors this was a rare case of viral myocarditis. By the time the child was brought to the hospital she was already in acute heart failure, and unfortunately despite aggressive supportive treatment she passed away.
The parents were pious, semi-educated and of modest means. They had accepted that everything had been done to save their child, and stressed that they had not come to complain about the treatment that was given. Their main concern was that the succession of doctors who saw the child did not keep them sufficiently informed about the seriousness of her condition, and they were not allowed to be near her during her last moments: doesn’t this ring a bell about the complaints made regarding Covid-affected patients?
The other example I can give was a Public Health issue. It is about the panic that gripped the University of Mauritius when one, then four students were diagnosed with tuberculosis. Not only their fellow classmates, but practically all the UOM students were refusing to attend classes. At the request of the UOM authorities and the government, I along with a Chest Physician from the Poudre d’Or Hospital and the Principal Medical Officer (Public Health) went to the UOM, and we addressed the students who had packed the Octave Wiehe Auditorium.
The next day all students were back on campus.
Proper communication is fundamental to the practice of good medicine. Neglect of it not only leads to a lot of dissatisfaction, but can be a source of great distress or misunderstanding as the examples given above show. Clearly, it is primarily our duty, as doctors, to address this problem and find the solutions appropriate to our given context, and apply them.
When I was doing my postgraduate studies in surgery in the late 1970s, I remember coming across a set of lectures collected in book form on the theme of communication in medicine. If my memory serves me right, it was in the introductory section that the editor, a surgeon, observed that practically 50% of problems in medicine arise from poor communication: amongst doctors and other colleagues, and between doctors and their patients. Judging by the content and tenor of the majority of complaints that are brought to light, I would think that that observation is still as valid today as when it was made more than three decades ago.
In those days, communication skills were neither formally taught nor assessed in the medical curriculum. One had to acquire them ‘on the job’ as one went along, so to speak. But in developed countries, teaching communication skills has since become an integral part of undergraduate medical education – which is where it should start, from the very beginning, not after one has qualified. It goes without saying that in countries with formal, established medical education structures the culture of communication is more likely to be present and to permeate the health services. With several medical colleges in the country, this is something that needs thinking about if it is not being done already.
Communication really begins at the point of first contact with patients or their families in the usual clinical settings: the A& E department, the health centre, the outpatient clinic, the bedside, the operation theatre. It does not matter whether the situation at hand is an emergency or not: the necessity of proper communication, which will add to the sense of professional accomplishment as well as most likely leave a satisfied patient, underpins the whole process which involves a number of players – doctor, patient, family/close ones of the latter, nurses and other ancillary staff. For obvious reasons, however, it is the doctor-patient relationship which receives the most attention: it is the pivot around which revolves and which sets in motion the medical chain of events. That is why it falls primarily upon the medical profession to lead its own and the other members of the health professionals team in care and communication.
This is all the more important in today’s world with the explosion of information and the ready access to it via the modern means of communication. They allow many people to come to us armed with some familiarity with medical conditions, including modalities and techniques of treatment, and even the relevant ethical issues, all of which heighten their expectations. Once upon a time we might have dismissed all this as ‘a little knowledge is a dangerous thing’ – today, it would be …dangerous to do so, because like it or not we have to take the time and the trouble to explain what is possible and what is not possible.
Because time is precious and limited, we have to constantly hone our skills, whether we are new to the field or are experienced. What this means in practice is that the junior doctor has to be prepared to join and remain on the learning curve, and the experienced doctor must be willing to support the juniors and impart to them the required skills: it is a two-way process for mutual benefit with the objective of serving the patient better. It follows that juniors must seek and seniors must use every opportunity to learn and share communication skills, for example – but not only! — during Continuing Medical Education sessions and clinical meetings where real-life clinical situations based on actual cases can be discussed and the lessons drawn.
I would go as far as to say that proper communication is the critical element in the quality of the medical care that we deliver, if only because of the truism of enunciated by Armand Trousseau, an outstanding doctor and teacher of the 19th century, about the role of the doctor: ‘Guerir parfois, soulager souvent, consoler toujours’ – ‘Cure sometimes, relieve often, console always.’ For let us not forget that, however far medical technology will advance, our mortality will ever remain the one finality that we cannot escape from. How do we cure, relieve or console without communicating?
* Published in print edition on 17 September 2021
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