Communication Skills

When it comes to being a clerk, I consider myself pretty average. I keep up with my readings, know my patients pretty well, and generally put in a good effort into my clinical duties. However, I'm far from exceptional in any of these domains. Where I do consider myself a bit stronger is when it comes to communicating with patients and their families. I have plenty to learn and perfect on that front, but I'll put myself a bit ahead of the pack on that front.

I though I'd take a post to go through some of the basics of my approach to patient communication, as it's not something I feel is well taught or reinforced in medical education. I often see clerks, residents and staff committing some very basic errors when speaking with patients.

1) Establish rapport first, don't forget to maintain it

That having a good rapport with patients is critical to achieving optimal care with patients is no surprise to most medical students. It's an art - no two people will have the same method for achieving a good rapport yet drastically different approaches can be equally effective depending on the circumstance and the physician's personality. However, there are some basics to establishing and maintaining rapport which I've seen get forgotten, neglected, or perhaps never learned.

To start, taking 10-15 seconds at the beginning of an interaction for some simple pleasantries can go a long way. It's fine to get down to business quickly, but don't forget that your trust hasn't been earned just because you're a physician, and that first minute or two can make a world of difference. I try to work in a quick joke within that time if an appropriate opportunity arises - I find it puts people at ease far more easily than anything else. Most physicians understand this critical introductory period and do make an effort to come across as an actual human being for the first few minutes, though some are more effective than others, some use blatantly scripted approaches, and some forgo this entirely.

Where I see more stumbles is that once that initial phase passes, the physician's attempt to connect with patients disappears entirely. Once those pleasantries are completed, it's on to business, no time for things like emotions or empathy! This kills a lot of physician-patient relationships. Trust not only has to be earned, it has to be maintained. A few empathetic statements, jokes, or check-backs with the patient to establish understanding throughout the interaction are practically essential. They show that the patient is heard and that their presence is appreciated rather than simply tolerated.

2) Manage expectations

People will accept almost anything if they can prepare themselves for it. I've seen patients take news of a death sentence in stride because they knew it was coming before any words were spoken. The opposite is also true. People react very badly to surprises, even rather benign ones. Sick patients and their families, who may be emotionally and physically exhausted, are that much more prone to dealing with the unexpected poorly.

Medicine is inherently unpredictable. Doctors make educated guesses and can be pretty good at it, but very little is known with certainty. Good communication requires imparting some of that uncertainty to patients and their families. It's also vital to communicate exactly where that uncertainty lies. Are you uncertain because you don't know, or because you can't know? If you don't know, is it because you need input from a colleague, results from a test, or simply the time to let things play out?

Ultimately, the goal is to have their expectations be your expectations. You want your patients to hope for the best but plan for the worst, just as you will in your practice.

Being proactive is the key. Physicians frequently assume their patients are on the same page as them without confirming that this is the case. Taking 30 seconds to explain the plan, with considerations for how the plan might change and why, is an extremely important yet often neglected point of any patient interaction.

3) You're not all-powerful - don't pretend to be

Similar to the previous, be very clear about what is in your power and what isn't. Patients think doctors have a lot more authority and ability than we actually do. Physicians, sadly, tend to play into this myth. Fortunately, it's an easy trap to avoid.

Being clear about your role from the beginning is important, particularly for trainees. Never assume a patient knows what you can and can't do.

A major component of this is learning how to say "no" without it seeming like an exercise in power. The phrase I hear some doctors rely on which irks me so much because of the problems it causes patients (and other providers) is "I won't". A patient makes a request and the physician says "I won't do that". There is typically a good reason for the refusal and the physician either can't or shouldn't fulfill the request in the first place. Even with an explanation of the refusal, "I won't" sticks in patients minds, because they see the physician as being capable of helping, but actively choosing not to. It hurts a lot of patient-physician relationships. I like using "I can't" as much as possible, provided it's appropriate. Fortunately, most "I won't"s can be framed as "I can't"s. Patients are still disappointed by refusals presented this way, but I find they're less disappointed in me as a care provider, and that helps to maintain the therapeutic relationship a bit better. Physicians and patients have a natural imbalance, which patients certainly feel. By emphasizing your own lack of ability to change things with phrases like "I can't", it can help to lessen the feeling of that imbalance, and to make it clear that even if you aren't able to solve all their problems, you're still trying to do what you can.

4) Ensure you're on the same page

Even when a physician is an amazing communicator, patients don't always understand the full plan. Medicine is vast and confusing, even to the initiated. Human memory is flawed in healthy people and gets worse when we're sick or stressed. Letting patients know what's coming is only effective if they absorb what was said and remember it.

Some easy strategies can help retention. I frequently try to repeat whatever plan we agree on in a concise way at the end of an interview. I then provide an opportunity for questions, in case there are any points of confusion.

Even that leaves plenty of room for things to slip through the cracks. Two approaches I'd like to use more often - but have difficulty implementing as a learner - is having patients repeat back the plan and/or writing down the plan. At this stage, all my plans are tentative, subject to approval by my supervisors and, in many cases, subject to change without my knowledge. I can't pin down anything I say at the risk of having the patient remember my suggestions ahead of the attending physician's actual recommendations. I've already had at least one instance where this has caused trouble. So, for now, I've held off these strategies, but would like to implement them once I gain some more ability and independence.

None of the above elements are overly difficult to implement and with practice become second nature. However, they are not always intuitive, rarely taught, and virtually never reinforced in medical training. We could be doing a lot better to develop a culture of effective physician-patient communication.

The Ontario tPSA - A Flurry Of Information

Well, it's been an interesting week or so for Ontario physicians. The tentative Physician Services Agreement (tPSA) outlined by the OMA was bound to be controversial from the offset, but I don't think many were predicting the situation would get this acrimonious this quickly. A lot of information has been flying around about the tPSA, not all of it true, most of it unhelpful, and virtually all of it biased in one direction or another.

Here's what I've been able to piece together from reading everything I can on the subject and talking to some people directly.

1) Whoever you provide as a proxy must vote the way you indicate.

That goes for the OMA too. The OMA's initial communications implied otherwise, but they confirmed to both me and now to the OMA members publicly that preferences are indeed binding and that no other substantive measures can be brought forward. Talking to those within the OMA in one form or another, the explanation for this apparent attempt to deceive seems to come from incompetence rather than intentional deception. For this reason, I've chosen to let the OMA represent me as my proxy, despite voting against the tPSA. I'll be keeping an eye on my own vote to ensure my wishes are respected. If they aren't, it sounds like the Coalition of Ontario Doctors will be more than happy to sue the OMA on my behalf.

2) The OMA doesn't particularly like this deal either.

With the sheer volume of one-sided marketing the OMA is putting out about this deal, you'd think they really like what they agreed to! Well, I don't think they do. They've been brushing aside their own reservations in order to whip up support for the vote - which all else aside is a terrible way to convince on-the-fence people that you hear their concerns - but I think those on the inside really do see this as the best option they're going to get. They'll be the first to admit that it's far from what they'd prefer and privately more than a few will admit it's below what they think is fair. The OMA sees physicians as powerless to get a better deal, however, and accepted the tPSA on that premise.

3) Trust in the OMA is low. Trust from the OMA is lower.

It's fairly clear to any half-interested observer that the OMA is not well-liked right now. Physicians don't even believe the OMA will execute a fair vote, let alone fight on their behalf. Lots of conspiracy theories abound about the OMA's true intentions or allegiances. For their part, the OMA doesn't seem to like many of the physicians they represent either. There doesn't appear to be much belief that rank-and-file physicians can be trusted to behave like reasonable adults. The OMA's negotiation and marketing with respect to the tPSA reflect this mistrust. That's not to say that the OMA is trying to work against its members or anything that nefarious, but there appears to be an attitude that being completely open and honest with members will only make a viable deal more difficult to obtain.

4) Both sides claim moral high ground, but vested interest prevail.

There are plenty of people on each side who are voting the way they are for noble reasons. However, the groups supporting or opposing the tPSA most vigorously clearly have reasons to do so beyond the overarching merits of the agreement. On the "No" side, there are a lot of high-earning specialties who would be the hardest hit by any deal which seeks to reign in the salaries of wealthier physicians, something both the Ontario government and the OMA appear to support in principle. On the "Yes" end, there are groups deeply connected to the OMA who would benefit professionally from continues ties with the OMA and/or the Ontario government. I don't doubt the sincerity of most individuals' convictions in this debate, but it's worth noting how often a person's opinion on the tPSA happens to line up with what will benefit them the most.

I'll follow up shortly with a more substantive post on the tPSA considering the new developments. For now, I'll continue to try to learn a lesson from this whole mess - namely that communication, especially with colleagues, is a tricky business, but absolutely vital to working together in our healthcare system.

Communication

Errors in medicine are common. Really common. Like, shockingly, awfully common.

Luckily many of these errors result in no or minimal harm to patients, either because they're caught in time or because they're relatively minor mistakes. Yet, small errors could just as easily be big errors and small errors have a tendency to snowball, where a series of small errors results in big harm.

Most commonly, medical errors are due to poor communication. That is, everyone is acting as they think is appropriate, but they're missing information that would change their actions, information other persons have.

I'm on my CTU rotation now and it's striking to see how often communication errors occur in inpatient medicine. It's not just every day, it's every hour of every day, involving every patient who steps through the hospital doors.

Yet, the prevailing attitude seems to be that most communication errors are either expected, someone else's fault, or weren't actually errors at all. It's not a horribly surprising outcome, considering the system in most hospitals is not set up for effective or efficient transmission of information, there is little accountability for communication errors, and training in proper communication is practically non-existent. Heck, even training in the improper communication typical of inpatient hospital services is practically non-existent, being delivered "on the job" in bits and pieces, typically while a student or resident is already being given patient care responsibilities and having to figure out how to perform on the fly.

I knew communication was a big problem in medicine before I started medical school, one that contributed to sub-optimal patient comes. Nevertheless, being on the physician side of things has been disturbingly revealing. Communication errors are routine, pervasive, and we're nowhere close to fixing those issues. For the most part, I'm not even sure we're trying to fix them.