Western Regional Blog – BC, YK, AB, NWT and Nunavut
Recently one of us attended a daylong retreat designed to help doctors communicate more effectively with patients. The course was taught by a colleague with whom we had consulted in the past on patient-related matters but who was known better by his reputation, which was almost laughably stereotypical: brilliant technically, but stunted when it came to interacting with people.
A close family friend with cancer had gone to see him some years back. When the friend started asking questions about the treatment plan, the doctor had stopped him midsentence, glared at him and said, “If you ask one more question, I’ll refuse to treat you.”
“What could I do?” the friend later said. “He’s the best, and I wanted him to take care of me, so I shut up.”
Now that same doctor greeted us as we filtered into the conference room by looking us in the eyes, smiling and shaking our hands.
“Did you have any trouble finding the place?” he asked warmly, waiting for a response. Those of us who knew him were left speechless by his new demeanor. “Great! We’re going to have fun today. Why don’t you go get something to eat and grab a chair. I’m looking forward to working with you.”
A wealth of research suggests that physician communication about important topics like end-of-life care is associated with a better quality of life for patients, and a better quality of dying, with less intensive use of unnecessary tests and treatments.
Teaching communication skills to doctors, though, isn’t easy.
Physicians and medical students often have limited insight into how they come across when talking with patients, and little opportunity for formal feedback. While most doctors really are invested in their patients making the right decisions for their circumstances, many lack the skills to show that they care.
After all, their admission to medical school was not based on a validated assessment of their ability to relate to other human beings.
In response to the growing recognition that effective communication with patients is a basic competency of our profession, and that doctors often have inadequate training in it, medical schools and hospitals have invested substantial resources over the past decade to teaching communication skills.
But some place the blame for the stilted way we interact with patients squarely on the shoulders of our training, which teaches us methods for objectifying and quantifying symptoms. Prior to medical school, if we saw a neighbor fall and hurt their leg, we would likely run over and say. “Are you O.K? That looked painful. What can I do to help you?” As doctors, we ask, “On a scale of one to 10, how bad is your pain? What makes it worse? Does it radiate to your foot?”
But can giving doctors a script for empathy actually make them more empathetic? Our patients know better.
A recent study published in JAMA highlights the difficulties of teaching effective communication. In the study, 472 internal medicine and nurse practitioner trainees were randomly assigned to either participate in an eight-session, simulation-based communications course, or to forgo communications training. Patients with end-stage cancer and other fatal illnesses or their families then evaluated the quality of their caregiver’s communication and their end-of-life care. Patients were also evaluated for signs of depression.
The results? Physicians and nurse practitioners participating in the course were no better at communicating or providing end-of-life care than those who did not receive communications training. And patients cared for by health care providers receiving such training were more likely to be depressed.
How could this occur? It is possible that those receiving advanced communications training spent more time talking about impending death in their end-stage patients, and that this was depressing. Perhaps those residents participating in the study were too early in their training to lead these sorts of difficult conversations and participation in the study emboldened them in inappropriate ways.
It is also possible that, as we devote more time to teaching students and doctors effective communication techniques, we risk muting their authentic human voices, and instead of learning to connect they apply rote tools and scripts.
In the communications training course that one of us took, the doctor who at one time refused to take patient questions but who was now leading the course began speaking.
“Today we’re going to review some techniques to better communicate with our patients,” he said. “This has really helped me in my practice and has made me much happier at work. And believe me,” he paused and smiled, “if I can learn to do this, anyone can.”
He then turned to a woman who sat beside him, an actor who had been hired to play the role of a patient for the day, asking the same question we had heard before — “Did you have any trouble finding the place?” – before asking her what brought her here today.
“I had a belly pain and my doctor told me I may need an operation,” she told him.
“Go on,” the doctor said.
“My doctor said I may have a tumor.”
“But he said it’s curable with surgery.”
It was hard to imagine relating to another human being like this. The doctor sounded stiff and his repetition of the phrase “go on” contrived, though he did encourage the patient to tell her story. And to ask questions.
It was hard not to wonder what might have motivated this doctor to change his ways. Did taking the course cause him to “see the light,” and now he was truly a changed man? Or was he pressured into taking and then leading the course because of patient complaints?
No communications course will magically transform lifelong introverts to hand-holders and huggers. At the same time, we must ensure that we are not converting people who genuinely care about their patients into people who only sound as if they care. Having physicians sound like customer service representatives is not the goal.
For those doctors who are emotionally challenged, communications courses can provide the basics of relating to other human beings in ways that, at the very least, won’t be offensive. But for the rest of us, we should take care to ensure the techniques and words we learn in such courses don’t end up creating a barrier to authentic human contact that, like the white coats we wear, make it even harder to truly touch another person.