In this essay, we talk about the importance of the relationship between doctors and patients, and the need for patient-centric communication rather than that with a paternalistic approach. Training of a medical student should include communication skills besides technical training in healthcare. As patient care evolves, communication becomes more crucial; therefore, it is important to understand the repercussions of poor communication skills and how improvement in this vital area can be beneficial.
Keywords: patient–doctor communication, paternalism, communication skills, training, beneficence
As medical students and doctors, it is imperative that we are able to stay on top of our game and to diagnose and manage the medical conditions that confront us. In this process, we must be aware of the repercussions even our mere words may have on the life of the patient before us.
The man pacing up and down the corridor waiting for his lab results; the woman bent over her lap, crying for the child she lost in an accident; another woman, worried sick about her child who is yet to be born. They are not just “cases”, they are someone’s parent, son, daughter, or sister.
We doctors are trained to tackle innumerable medical conditions and syndromes as we study day in and out, burning the midnight oil over that last cup of coffee, which is never the last. We walk down the hospital corridors trying to learn as much as we can, and strain our necks in the operation theatre, just to get a look at how the surgeon ligates an artery, hoping to use that same skill another day.
We start medical school hungry to serve patients, but along the way, we move from treating the patient as a whole, to merely managing the illness. This problem has multiple facets, of which one definitely is the impairment of communication skills, rooted probably in the training of medical students.
Another essential part of a satisfactory doctor–patient relationship is empathy, yet many reports point to its steady decline in medical students as they progress through medical school and residency programmes [1].
A 2002 study by Haidet et al in Texas analysed the attitudes of medical students towards the doctor–patient relationship. They concluded that there is a definite need for curricula that inculcate patient‐centred attitudes among medical students. Their findings suggested that students in the senior years of medical school showed increasingly doctor‐centred or paternalistic views as compared to students in the junior years [2]. On our journey to becoming doctors, we probably lose that touch of humanity and compassion that motivated most of us to join medical school in the first place.
As one grows in one’s career, the need for empathy and good communication becomes an important part of patient care and though we know that a doctor’s perceptions of patients and mode of communication do affect medical outcomes, studies have brought out how exactly these perceptions affect doctors’ interaction with patients [3].
The Covid-19 pandemic illustrates how the communication gap is exacerbated. A 2021 study carried out by Gopichandran et al with 359 participants in Chennai [4] found that more than 60% of the participants had difficulty communicating with their doctor. The personal protective equipment that doctors wore only added to the mistrust and magnified the communication barrier.
Communication plays an integral role in establishing trust and honesty, so essential to a strong relationship between the patient and the doctor. Patients have high expectations when it comes to the ethics and righteousness of their doctors. The way a doctor behaves with a patient may alter patient outcomes, satisfaction, their adherence to treatment, and recall and understanding of information [5]. The way a doctor explains a medical procedure, therapy or test result to their patient, the patience and time put in to discuss medical issues, and their responses to the patient’s questions are some of the factors indicating good communication. Though subjective, these should not be left to chance. Fallowfield et al, in their report on oncologists and their interactions with patients, found that after a three-day communication training, the quality of questions improved significantly, thus decreasing the number of leading questions, and increasing empathy and appropriate reactions [6].
A study by Paternotte et al underlined that most patients would prefer a physician with a professional patient-centred attitude, irrespective of the physician’s background. Most patients reported a preference for generic communication skills, such as listening, as cardinal skills and were aware of their own role in communicating with a doctor. Being treated as a unique person and not as a mere condition or disorder was also mentioned to be a beneficial factor by some patients [7]. “Structuralized conversation, doctor domination of the conversation and a focus on technology during outpatient encounters” was found to negatively impact effective doctor-patient communication [8].
There is a “confusion of tongues” in the exchange between a patient and their physician, especially so when negative facts have to be conveyed to the patient [9]. It is emotionally stressful to receive bad news, and a herculean task for the physician to break it in the best way possible. The six steps of SPIKES may be used in delivering bad news, namely: setting up the interview; assessing the patient’s perception; obtaining the patient’s invitation; giving knowledge and information to the patient; addressing the patient’s emotions with empathetic responses; and strategising and summarising. Doctors have reported greater confidence in breaking bad news after following this protocol [10].
It is not only important to communicate the right information in the right manner but also in a way that the patient will understand. This includes using a language the patient is proficient in, and speaking to them at a level with which they are comfortable. For example, a high school dropout may not understand the medical jargon “tension pneumothorax” but explaining to them that there was air trapped in their chest due to an injury will get across to them. With a better understanding of their problem, a patient is more likely to cooperate with the doctor, make an informed decision regarding their healthcare and follow treatment recommendations.
With violence against doctors becoming an epidemic in India, it is imperative that a healthcare professional pays attention to their communication and the relationship they establish with their patient. A study done by Ambesh found that most violent incidents occur in the Intensive Care Unit (around 50%) and a majority of these are caused by the relatives of the patient (70%) [11]. The study found that miscommunication by doctors caused attendants to have unrealistic expectations. Young doctors often show less empathy towards patient attendants and this may trigger a violent response [11].
Good communication does not only mean speaking clearly, but being inclusive and ensuring that all patients, especially those living with disability, receive helpful communication, as effective communication assumes more importance across disability experiences [12]. It is critical that physicians engage patients in decision-making to ensure autonomy over their healthcare experience [12].
Finally, with the evolution of healthcare information being available at the patients’ fingertips, the right communication delivered in the correct manner is key to long lasting successful patient-physician relationships and to a better standard of healthcare. Both up and coming doctors and established ones are going to have to learn and adapt to the changing times with better communication. This will improve patient health via greater clarity, adherence, compliance, and overall patient satisfaction.