Skilled communication

It may be the current bizarre state of the world, or just that I’m getting older, but I’m growing concerned about our ability to communicate with each other. Political partisanship, to begin with, and regional and other factors make us unwilling or unable to share perspectives. But my concern is more personal than that. I think we are just forgetting how to talk to each other. A ride on public transport will confirm this: count the number of people talking to each other compared to those fixated on a smart phone or laptop. It’s unsettling.

This has ramifications for medical practice, of course. In all areas of medicine, we have to be able to communicate—often not just with the patient but also with their family members. I cringe when I remember how dismissively I dealt with some patients early in my career to cover my lack of knowledge and insight. Learning to say “I don’t know, but I’ll find out” took time. Knowing how to communicate sensitively and effectively was not thought to be important during my training, as patients were expected simply to listen and follow directions. I learned how to act and communicate like a professional from observing the teachers I respected. Skilled communication came later.

In two specific activities in medical practice, skilled communication is essential: first, when obtaining informed consent, and second, when breaking bad news. Obtaining informed consent in an emergency is done on the run, and is undeniably directive because time is critical. But even in cases like this, the patient or his or her proxy must be told as clearly as possible what is wrong, what must be done to mitigate the consequences, and what the patient can expect. Failing to do so can leave us open to charges of assault or worse. In less rushed situations, obtaining informed consent requires longer, nondirective discussion, and the CMPA has provided guidance for clinicians in doing so. The most practical advice I’ve had about informed consent has come from a friend who is also a judge; his advice was to imagine that the patient is your best friend, and to ensure that they have as much information as you would want your best friend to have, and then to trust their judgment. I think that’s wise.

Breaking bad news requires possibly the utmost skilled communication. There is evidence that training in delivering bad news (which, I’m pleased to say, is included in the UBC undergraduate curriculum) can improve our ability to do so. I wish that my medical education had included this—my initial faltering efforts in delivering bad news were terrible. But experienced mentors showed me how. A consultant pediatric hematologist, in initial meetings with the parents of a child with leukemia, would take out his pipe and clean it during the long silences in which the parents collected their thoughts. It took me a while to realize that he wasn’t a pipe smoker; the pipe was simply a prop and the silences were part of the process. Subsequently my awkwardness with the process diminished as I learned some of the strategies that can be used to streamline the process of breaking bad news (such as Robert Buckman’s SPIKES—A Six-Step Protocol for Delivering Bad News). It will always be an uncomfortable task, but an essential one.

Each of these forms of communication requires that we are comfortable talking with and listening to patients, and I hope that we are all doing this as much as possible. I worry that our societal trend toward impersonal interactions will slowly infect medical practice as well, leading to our spoken interactions with patients becoming limited. I already see this in the surgical specialties, where regular visits by the surgeon to the postoperative patient (to discuss what happened and what the patient can expect) are becoming uncommon. Therapeutic interventions and their outcomes are our major focus, but communicating to the patient everything we would want to know ourselves should be equally important. Not doing so is not just inconsiderate, it’s bad practice. Let’s talk.
—TCR