Good communication is key to good care
BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1704 (Published 19 April 2018) Cite this as: BMJ 2018;361:k1704
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Dear Editors
I am responding to Dr Yeung's rapid response in which he comments, "articles lament the lack of direct verbal communication between colleagues in the NHS nowadays"
The response also 'laments' about being "often interrupted when attempting proper SBAR (situation, background, assessment, recommendation) handover"
The simple reason to this observation is also actually given in his same response, that "the referrers give too much irrelevant information during busy handover" although I am unsure if the author is conscious about this.
While there is no real time limit on the concept of SBAR, we must remember the presentation of SBAR is the referrer talking about a case without even the listener asking the questions and formulating a management plan as yet.
Practically, even for a complex case, if the referrer cannot communicate SBAR effectively to give a sense of where this handover is going within 1-2 minutes, then there is a problem in communication.
Often this is a result of lack of preparation for the task by the referrer and shows little consideration/respect for the listener who has many other priorities to consider; this kind of attitude (reflected by referrers) is a phenomenon particularly common even in handover between doctors of similar grades.
People claiming to be using the SBAR technique must understand that writing it down on paper (as described in the original technique) help prioritise the order of information and organise what is important and what is ancillary.
If a referrer just take 2 minutes to do the SBAR communication, and the listener takes 3 minutes to ask questions and give instructions/advice, how many cases can you handover within 30 minutes in a busy clinical unit?
Hence we should aim for communication to be far more effective and succinct if we are truly using SBAR technique properly as intended. SBAR is actually designed to be used by all grades and type of health care professionals and hence intended to be simple, and yet is often poorly executed by all.
And before someone wants to get side-tracked by calling this "victim-blaming", I shall pre-emptive this line of argument by asking this:
"Who is the victim here?
The referrer who did not do SBAR properly as taught
The listener who by receiving the poorly-performed SBAR, now has to bear the burden of the responsibility of the care of the patient from here-on
The patient who has complex problems, but probably really only has 1-2 urgent issues to address right now, but this may not be even identified properly by the referrer."
Hint: There may be more than one victim, but only one person is doing the SBAR.
Competing interests: No competing interests
These recent articles lament the lack of direct verbal communication between colleagues in the NHS nowadays.<1><2> Let us step back and ponder why direct communication has declined. First, we are often interrupted when attempting proper SBAR (situation, background, assessment, recommendation) handover.<3> It is ironic why we are taught SBAR in school and life support courses -- in reality, people cut you off when you are still talking about the situation, and do not always care about your assessment and recommendation. We may have to rely on written referral forms to ensure all pertinent information is given.
Secondly, handover hostility is a barrier to direct verbal communication.<4> Some colleagues could be reluctant to make direct referrals to avoid embarrassment. For example, my general practice colleagues find it unpleasant when a hospital junior declines their telephone referrals, and even criticise their assessment. Similarly, hospital seniors usually delegate their juniors to make referrals. Some bad referrals could be like, “This patient needs a review. I don’t know why, but that is what I’m handed over.” Written referral forms are meant to ensure referrers have performed all basic assessment before asking for help. These forms are not simply a way to avoid more work, but a system to prevent inappropriate referrals and protect healthcare funding.
I learnt some tricks to avoid interruption and hostility during handover, such as asking my questions at the end,<3> and writing down my thoughts and the information given. A previous instructor of mine would stand in the middle of the lecture hall in silence until the class quieted down – this is a good strategy against those who repeatedly interrupt during handover. I also feel for those who must interrupt because the referrers give too much irrelevant information during busy handover. One good solution is to politely tell the referrers you are running out of time and would like to have a more concise presentation. Communication is often a two-way street.
References:
1. Cook S. Good communication is key to good care. BMJ. 2018;361:k1704.
2. McCartney M. Margaret McCartney: Let’s start talking to colleagues. BMJ. 2018;361:k1602.
3. Fletcher B. Listening: a neglected aspect of safe handover. BMJ. 2017;359:j5200.
4. Al-Rais A. Why we should avoid handover hostility. BMJ. 2017;356:j1272.
Competing interests: I have been paid for working as a medical doctor, but not writing this letter.
As a GP good communication is the most important part of health care. In present day GP practice where there is so much transparency - alomg with hear say, literacy, the internet and affordability - the art of communicating is becoming an important task and tougher by the day. With awareness and priority of health becoming of prime importance in my country, responsibility has gone up many times for a GP.
Communicating to the patient what one has learnt in a local language is a major challenge. In busy practice, explaining with a diagram, getting the right local words that make the patient understand better, convincing the patient with the latest developments in medicine and its advantages is an arduous task itself. At the end of it, there is a satisfied patient and a satisfied GP!
If communication is not good then the art of medicine and delivering is not complete. But it is a challenge for GPs, always.
Competing interests: No competing interests
There is no denial that good communication leads to good care. This communication begins with an unhurried history taking which includes going through all previous prescriptions and investigations. Needless to say, in a busy clinic, some part sometimes gets overlooked.
The practice of “shared decision making” is not only helpful for the patient and their relatives but also helpful for the doctor as well. A decade of experience of working in National Health Service in its golden days, this practice of informed decision making was very satisfying. Last twenty years, being actively engaged in obstetric practice in India, practice of shared decision making is a real challenge. “Deductive decision making” is the law of the land. Only few die hard supporter of shared decision making are really struggling. However, a small section of the people really appreciates it.
Sadly we still find majority of women with epilepsy still come during pregnancy and not before. So optimization before pregnancy still remains an elusive dream.
I do agree that communication with a colleague directly is very helpful in managing pregnant women with medical problem like epilepsy. Method of communication has changed and being changed. If possible, talking the consultant colleague verbally still remains and probably will remain a good method of communication.
National Health Service is one of the best models of health care in the world. It is heartening to see the difficulties it is going through. Change is the inevitable, but we have to look back and see the uniqueness of this system. We have to remember, a good and effective system especially health care system is extremely difficult to build, and losing it will be loss to the country and to the world as well.
Sukumar Barik
MD, DNB, FRCOG
Associate Professor
Department of Obstetrics and Gynaecology
ICARE Institute of Medical Sciences and Research
Haldia, West Bengal, India
Consultant Obstetrician and Gynaecologist
Narayana Multispeciality Hospital
Howrah, West Bengal, India
Competing interests: No competing interests
Wordy but worthy, conversations are defined by context and driven by purpose. The context of a conversation is its background, which involves the past and present. The purpose of a conversation is its goal, which involves the present and future. Combining the past, present, and future with pining, whining, and divining, conversations intertwine time with design, and mine with thine.
Competing interests: No competing interests
Re: Communicating effectively by lamenting the issues correctly
Thanks for Dr. Goh’s interest in my response. Dr. Goh quoted my comment about too much irrelevant information given. However, he interrupted my following sentences, which include a suggested solution, and most importantly the conclusion: "Communication is often a two-way street." It is often more than one person's responsibilities.
I wonder whether this miscommunication occurred due to Dr. Goh having only 1-2 minutes to read my response, which he alluded to as his usual attention span. This incident clearly demonstrated one major theme in my letter: the problem with interruption. I rarely encounter handover meetings that require 5 minutes on each patient. Nevertheless, I have been involved in some complicated individual cases that took us longer than 5 minutes, but helped the team members to reach a clear consensus.
I do not recall ever calling the referrers or recipients of poor handover as victims in my letter. As such, I do not see Dr. Goh as a victim of this miscommunication we had. But I do feel sorry for patients who receive suboptimal care due to poor communication. I understand some recipients value their own priorities, and hope that patient safety is at least one of their priorities.
Competing interests: I have been paid for working as a medical doctor, but not writing this letter.