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re :The teaching of communication skills may be misguided
- fenella lemonsky, Emma Burkitt Wright, Christopher Holcombe, and Peter Salmon (9 April 2004)
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UNCERTAINTY IS THE ONLY CERTAINTY
- BM Hegde (9 April 2004)
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Many health care provider just Ignore it.
- Ali H Rasheed (9 April 2004)
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Ability , Affability or both
- Srinivasan Ravi (9 April 2004)
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There is more to communication than being nice
- Christine Bundy (13 April 2004)
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Teaching communication skills: a lot more to do
- David M Lewis (14 April 2004)
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Imperfect knowledge.
- Richard Rosin (15 April 2004)
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The definition of communication skills
- Jill E Thistlethwaite (15 April 2004)
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Communication in the NICU
- T.H.H.G Koh (1 May 2004)
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fenella lemonsky, mental health service user representative London borough of Barnet N20 9JA, Emma Burkitt Wright, Christopher Holcombe, and Peter Salmon
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I am involved in the communication skills and psychotherapy training of junior doctors in psychiatry. At the end of the eight workshops with mental health service users each rotation, each SeniorHouseOfficer is asked to fill out an anonymous evaluation form on how they found working with a mental health service user. At one of the feedback meetings with the senior clinical tutor only one SHO didn't think that the involvement of service users was useful at all. My point being that patients being directly involved in postgraduate training has a lot to offer with respect to communication skills.Often patients have an attitude of "doctor knows best" however my concern is when patients have a fear of a doctor before they have even entered the consulting room. Patient involvement in postgraduate training and communication skills can do much to make the patient banish those fears and get on with the real clinical issues.This can also increases the satisfaction and quality assurance, and as a result both doctor and patient are happy, and clinical negligence as well as poor prognosis is far less likely. Competing interests: None declared |
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BM Hegde, Retired Vice Chancellor Mangalore-575 004, India
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Dear Editor You have hit the nail on the head in that last sentence of your thought provoking editorial. Doctors have been predicting the unpredictable outcomes of their interventions to patients all along. Time evolution does not depend on the patchy knowledge of the initial state of the patient. This myth of wrong future predictions is at the root of patients losing confidence in their doctors. The answer to this is to teach medical students in training that doctors, like everyone else, are fallible and could make mistakes, but should try to learn from them to avoid repetition. Being honest about the mishap and sharing one’s joys and sorrows with the patient could ease the situation and enhance communication. The crux of the healing process is the coming together of two human beings-the one who thinks s/he is ill or imagines that s/he is ill and the other in whom the former has confidence. This coming together of two human beings with mutual trust is the summit of medicine from where all other aspects like diagnosis, therapy, future management etcetera follow. It is here that the patient gains confidence in his/her doctor. Sincerity, honesty and being open about the hollowness of the myth that the medical profession could even bring back people from the jaws of death would create a better rapport between the doctor and the patient. Technology, in the last half a century, has deified the medical profession sending wrong signals to patients to expect the sky from their doctors-one of the reasons for the burgeoning consumer suits in the west against the medical profession. This has transformed the holy doctor-patient relationship into that of a seller and a buyer, resulting in the market forces uprooting medical ethics. “Cure rarely, comfort mostly, but console always” was a good Hippocratic advice. It is not what the doctor tells the patient that counts but what the doctor really does that impresses the patient. When once the patient realizes that his doctor does walk his talk, patient confidence could easily be won. William Osler had this to say to the young medicos of his time that the doctor needs two great qualities-imperturbability and aequanimitas. His speech on the occasion of his retiring finally from the Johns Hopkins- Aequanimitas-is a piece worth its weight in gold for all times to come. If the doctor knows the communication skills well, diagnosis becomes a pleasure on the bedside. “If you listen to your patient long enough, he/she will tell you what is wrong with him/her,” wrote Lord Platt in 1949. Recently, five of his old students, conducted a prospective study using the latest research methods to confirm the truth of Platt’s statement in an article in the BMJ in 1975 on the role of history taking and other methods of diagnosis on the bedside! Confidence builds on the doctor’s capacity to listen to the patient. Listening is a very difficult art. Every medical student should be trained to master the art of listening. Most of us are good talkers but poor listeners. True listening is to be attentive while the patient pours out his sorrows with appropriate responses as and when needed. Prof. Calnan in his very good book Talking with Patients elaborates on the art of listening. Henry David Thoreau wrote, “To affect the quality of the day- that is the highest of arts.” The art of listening to the patient is the capacity of the doctor to enhance the quality of the patient’s day! Listening to the patient is not confined to listing the patients’ symptoms, past history, his social and family history. The crux of the art of listening is to understand patient’s fears, his religious, spiritual and social beliefs, his cultural upbringing and, more than all that, even his irrational obsessions in terminal illnesses. Even if the doctor is a rationalist and thinks that medicine is a pure science, he/she will have to try and understand the irrationality of the patient’s thinking to respond to that to the patient’s satisfaction. The medical profession has to understand that the only truth, even in the king of sciences, physics, is the uncertainty principle of Werner Heisenberg and not the Newtonian deterministic predictability laws or Einstein’s relativity. Watenchap is wot whatenchoppen doen-science is what the scientists do -is the real truth and science is not the truth. “Say not” wrote, Kahlil Gibran in his The Prophet “I have found the truth”, rather say “I have found a truth.” Science is only a search for the truth. When the chips are down even the best of rationalists become irrational. Rock Hudson, once President of American Rationalists’ Society, was quietly going to drink the holy water in Lourdes when he was seriously ill, I am told. People swallow their skepticism when death stars them in the face. If a doctor could understand all this, it is easy to deal with uncertainty on the bedside. Modern medicine also started five thousand years ago as magic, witchcraft and sorcery on the banks of the river Nile, anyway! The “quiet art of medicine” does stimulate the human immune system that really heals. Healing is universally possible while curing is rarely an attainable goal in medicine. A healer must have a large heart coupled with a strong and well trained head. Combining humility and wisdom together is not impossible, albeit difficult. One should follow the advice given by Jesus to his followers. “Be ye therefore wise like a serpent but harmless like a dove.” One of the good books that I could recommend to doctors is On Doctoring by Richard Reynolds and John Stone (Simon and Schuster, New York) My personal experience since 1956, when I first started seeing patients as a medical student, has been that if I have a genuine interest in the patient’s welfare, the patient would have full faith in me. This matters a lot in the final outcome of illness, uncertainty notwithstanding. Faith heals! Yours ever, bmhegde Competing interests: None declared |
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Ali H Rasheed, Consultant Psychiatrist Yarmouk Teaching Hospital-Baghdad
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Sir. I do appreciate highlighting this topic, what I wish is that communications skills should not only be taught to medical students, but also should be part of continious medical education, as many colleagues who are very good physicins in their carrer just lack or ignore communication skills, I believe that the best parameter that will gurantee patient's compliance is to master good level of verbal and non verbal communication skills. Competing interests: None declared |
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Srinivasan Ravi, Consultant Surgeon Blackpool, FY3 8NR
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I am inclined to agree that perceptions of the patient and doctor on what constitutes good communication are variable. This is exemplified by the fact that many patients are surprised when the doctor asks them what they would like next. Even given all the information very few of us can make our minds up about what is appropriate. We make decisions based on experience and over time with wisdom. It is absolutely imperative that the patients are given guidance on what the doctor thinks is appropriate lest they turn to another 'wise' doctor who 'tells' them what they should do. The need for information, I find, is variable. Every patient does not seek the same level of information or knowledge about their disease or operation. I, now titrate the provision of information to need to know. In communicating, I believe, there must be an undercurrent of authority that goes with experience and wisdom lest the doctor comes across as being unsure. Apprenticeship is still one of the best ways of acquiring this skill. Above all, good communication is effective only if backed by competence. Personally, I prefer the 'able' to the 'affable'. Competing interests: None declared |
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Christine Bundy, Senior Lecturer in Psychological Medicine/Health Psychology University of Manchester, Medical School
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At last the medical profession appears to be waking up to the realisation that what is taught under the umbrella of 'communication skills' covers too narrow a range of activity. Good communication skills are the output of a number of more sophisticated inputs. Good observation skills, good listenting skills, ability to reflect, ability to detect emotional content and problem formulation are some. For far too long medical teaching has focused on teaching a narrow set of skills such as 'breaking bad news' in the belief that those skills generalise across situations. They do not. The psychology literature has documented this for some time. Geoff Norman has been saying this for some time also. Doctors need a framework of knowledge in which to make a set of skills work. This framework has been notably absent in many undergraduate curricula resulting in acquisition of a rather wooden set of 'skills' that can only be applied in limited situations. Patients want Medical Practitioners who are skilled in the art of sincerity, able to detect emotions and be able to express genuine interest in why they have been consulted. Communication skills is a form of skilled information pocessing and should be learned in the way that other skills are learned, built on a firm knowledge foundation including how we process information, and practiced. People are happy to accept that doctors don't know everything and even (heaven forbid) that they make mistakes. What people find harder to swallow is disinterest, clumsy questioning or ham-fisted handling around something that has a lot of meaning for most people, threats to health. Competing interests: None declared |
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David M Lewis, General Practitioner The Tudor Surgery, Watford WD24 7PH, UK
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Sir The essay in the latest issue of BMJ concerning communication skills may address some of the issues in the article it refers to but misses an opportunity to raise the issue of the effect of the consultation on the doctor herself. Empathic, patient-centred consultations require a high degree of self -awareness. Psychologists receive regular "supervision" to assist in understanding and managing this in the therapist. Michael Balint understood this when he set up the eponymous groups at the Tavistock Clinic in the 1950's and which are continued in one form or other by a small number of enthusiasts throughout the UK and elsewhere, supported by the Balint Society However, in our protocol driven reductionist world this concept seems out of the reach for most doctors. Communication is a two way process and more ought to be made of the impact of consultation on doctors. In general practice the majority of my consultations involve emotional matters. The impact of absorbing all this human misery and suffering day after day is not readily measured. There no doubt in my mind that there is a cumulative effect. I believe this effect may be modified by discussing cases with colleagues formally or informally. However this is so little time that is not patient contact time at work which makes this activity less likely to occur. I can think of several patients who have benefited from taking their case to such a meeting. Improved understanding of the psychodynamics of the consultation certainly enhanced my communication skills. An unexpected effect was reduced stress. While this is anecdotal, I firmly believe that better communication skills, including self-awareness, is an essential element for doctors to remain healthy in their work. Much more should be done to value this aspect of our work for the benefit of our patients as much as, if not more so, for ourselves. Yours etc. Competing interests: Medical Undergraduate tutor |
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Richard Rosin, Consultant Psychiatrist VA Medical Center Puget Sound, Seattle WA 98108, USA
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Would it help communication if in every doctor's surgery there was a poster with the following inscriptions? ' I know that I do not know' - SOCRATES 'There are known knowns, known unknowns and unknown unknowns'- DONALD RUMSFELD Competing interests: None declared |
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Jill E Thistlethwaite, Associate professor in general practice and rural medicine James Cook University, Townsville, QLD 4811, Australia
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The title of the editor's choice 'The teaching of communication skills may be misguided' is certainly misleading. Shock, horror...we are wasting our time with this endeavour I thought when faced with the controversial headline. Of course Richard Smith does not mean what he writes, a communication problem indeed. I prefer to think I am helping medical students and junior doctors learn consultation skills. These include all those attributes defined by the patients in the Liverpool paper. Expertise (and the communication of it), showing respect for the patients' autonomy and the doctor-patient relationship are all important. There appears to be some confusion between the concepts of shared decision making and informed decision making. Patient autonomy is facilitated in the former in which model the doctor and patient choose a management option in partnership. The latter involves the patient having a range of options discussed, but being left to decide on his/her own. Sharing is the skill. There is nothing in the Liverpool paper to refute this or to suggest that skills training is misguided. I believe that the Liverpool paper results reinforce the need to continue to offer consultation skills training in both undergraduate and postgraduate medical courses. The major skills of doctors is to form the right relationship with the individual patient and to recognise that patient's needs and whether he/she wishes to be involved in decision making. Medical educators must ensure that students develop their technical expertise as well as their consultation skills. Competing interests: None declared |
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T.H.H.G Koh, Neonatologist The Townsville hospital, Townsville Queensland 4814 Australia
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Dear Editor, The Neonatal Intensive Care Unit is unique in that health professionals and distraught parents (who often have not met each other until the unexpected arrival of a critically sick baby) have to form effective partnership quickly. Parents' perceptions of staff competence in NICU are based not only on their clinical competence but on their caring behaviour and ability to share responsibility with families(1). We have routinely provided parents with audiotaping of their conversations with neonatologists (2). 96% of the mothers listened to the tapes with 85% stating that the tapes contained information that they have forgotten. Some parents were surprised to have their communication taped and two parents stated that "the fact that you took time to organise to tape the conversation shows that you people care". NICU stands for neonatal intensive care unit and not for neonatal intensive cure unit (3); indeed it could also stand for neonatal intensive communication unit. 1) Cescuitte-Butler L, Gavin K. Parents' perceptions of staff competency in a neonatal intensive care unit. J Clin Nurs 2003; 12:752-61. 2) Koh THHG, Jarvis C. Promoting effective communication in NICU by audiotaping parents-neonatologist conversations. Int J Clin Pract 1998;52:27-29. 3)Koh THHG. Counselling parents of extremely premature babies. Lancet 1997;349: 289. Competing interests: nil |
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