In the past weeks many of us watched the real life drama of the cave rescue in Thailand. The International team, who had never worked together, achieved what seemed impossible, not only to those of us watching but, we are told afterwards, to the rescuers themselves – the survival of all the young soccer players and their coach.
In my twenties, I had ventured into caves with intrepid speliopods, slithering down narrow muddy tunnels, wading in murky water, climbing slimy fixed ropes for the reward of seeing spectacular crystal caverns of cathedral dimensions. Frightening enough, but nothing like the conditions in this rescue. Wondering at this rescue I reflected on the level of disciplined communication and trust all these men must have practised, alone in the pitch black, anaesthetised child in tow, communicating through tugging on guide ropes, relying on the larger team for oxygen tanks to be fully functioning, for equipment to be in place. No place for individualism, for heroics, for argument.
Yesterday my colleague, an emergency physician and educator, told me how the day before she had been doing a teaching session on life support for doctors and nurses in a rural hospital, not her own place of work. Just as they finished, without any prior warning, leaving no time to prepare, a moribund child was brought in having been found floating in a swimming pool. The team, many inexperienced, resuscitated the child who was transferred to a city hospital. Included in her teaching session had been training in effective communication in an emergency setting, vital in a team who had not worked together before and who were unfamiliar with the setting. This same colleague, together with a rural GP, have developed a course on non-technical skills. They run it with very experienced air force and commercial pilots and trainers who shared with us how vital these skills are in aviation, how often in the past lack of such skills has led to major disaster and what a difference such training has made in their industry. (1)
A recent John Hopkins study reported that medical errors are the third leading cause of death in the USA, coming only after heart disease and cancer, with 250,000 people dying each year, which is 10% of all US deaths. (2) In many cases, poor communication is implicated.
The harm of poor communication
Poor communication is not only harmful in an emergency setting. The Western Australian Health Department data showed 4.9% of Aboriginal people in hospital were discharging themselves against medical advice, compared to 0.4% for the rest of the population. 7.5% of Aboriginal people presenting to emergency departments did not wait to be seen, compared with 2.7% of non-Aboriginal people. (3)
There may be many reasons for any patient, not only Aboriginal, to discharge themselves, but we must consider the possibility that they were made to feel uncomfortable, maybe implied racial slurs, cultural insensitivity, a sense of being judged and a sense of not being cared for or cared about. Self-discharging patients may leave with their problem not fully investigated, with their treatment incomplete or with little understanding of what they need to do for their own self-care.
Not only can this affect a current illness, but it can discourage the patient from seeking future medical care. Current policies to minimise hospital stay, risk patients leaving hospital with their treatment incomplete, psycho-social issues not addressed and follow up care not effectively relayed.
Communication which fails to take into account social determinants of health, language barriers, health literacy, cultural or religious factors and the patient’s own wishes can all lead to harm rather than healing. These communication issues have the potential to be as dangerous for a patient’s wellbeing as failing to ligate a bleeding vessel in surgery. Emotional harm from disrespect is not an uncommon result of hospital admissions and we should not underestimate the enduring pain this causes. (4)
“Medicine is an art whose magic and creative ability have long been recognised as residing in the interpersonal aspects of patient/physician relationship.”
MA Stewart (5)
It is very important for us not only to reflect on but act on what it is our patients are asking of their doctors. A psychologist friend of mine, after many years of pain decided to have lumbar spine surgery, a difficult decision made after much investigation and deliberation. Three neurosurgeons were recommended. He felt the first did not connect or take the time to fully explain the procedure. The second was quite disrespectful, having his feet up on the desk during the consultation. His final choice was the doctor who carefully explained the procedure using diagrams, presented the pros and cons and listened to his patient’s concerns and fears. Our patients do not only choose their physician because of their technical skills.
“The patient will never care how much you know, until they know how much you care.”
Terry Canale (6)
A recent article reviewing the literature on doctor-patient communication states that patient surveys consistently show that they want better communication with their doctors. Effective doctor-patient communication is determined by the doctors’ “bedside manner”, which patients judge to be a major indicator of their doctor’s general competence. It has also been observed that doctors at times avoid discussion of the social and emotional impact of their patients’ problems, because of their own distress or because they did not have time to do so. Failure to have a holistic approach to health care may result in patients being reluctant to disclose problems which affect their adherence to care, their timely presentation to the doctor and possibly drive them to seek alternative medicine. (7)
The healing power of communication
On the other hand, compassionate and effective communication may in itself be healing and the potential power in the doctor/ patient relationship should not be underestimated. Patients see doctors, in particular their primary care physician, as being not only the one who diagnoses and treats their illness but their primary source of emotional support. Good doctor-patient communication has the potential to help regulate patient’s emotions, facilitate comprehensive medical information and allow for better identification of patients’ needs, perceptions and expectations. Patients are more likely to adhere to treatment and a shared decision on the nature of treatment is strongly associated with recovery. Patients, among other things, report an increased sense of control, better ability to tolerate pain, faster recovery from illness, decreased tumour growth, enhanced psychological adjustment and better mental health. All of which improve the patient’s experience of health care and improve physician satisfaction.(7)
We know, for instance, that in the care of patients with chronic diseases in the general practice and other clinical settings, continuity of physician care improves not only patient well-being and satisfaction with their care. When a doctor knows their patient well, knows who they are beyond their illness, knows their family and their community, they are better able to support them to make the decisions about their healthcare which are right for them, and patients are more likely to adhere to treatment if they believe their clinician values and cares about them. We know that patients value doctors who will listen to them so that they feel heard and understood.
When teaching about continuity of care, I show my students a picture of a local GP obstetrician who has delivered the grandchildren of patients he delivered when he set up practice. He has delivered a majority of the younger people in this small town and has never been sued. Continuity of physician care is associated with increased patient satisfaction, increased take up of health promotion, greater adherence to medical advice and decreased use of hospital services. Not only this but a recent study has shown that it is associated with lower mortality rates. (8)
Care for one another
Good communication is not only about communication in our care of our patients or in team work in emergency situations. It is also about our day to day care of one another. It is about us honouring, respecting and valuing every member of our health team. For our doctors to be able to care for patients effectively, they themselves need to be supported in their physical, mental and spiritual health. It has been shown that many young doctors, some from before they even qualify, are suffering from burnout or worse, depression and suicidality.
Let us for a moment consider how our mode of communication may affect them. Lack of self-confidence and self-worth are compounded by bullying or harassing behaviours and put downs, by a culture which demands overwork and lack of rest, by a career pathway which generates competition rather than team work and by a system which is uncaring.
Attitudinal changes can only come from within – they start with us.
Let us look at our medical schools and workplaces. Are they supportive, caring and nourishing environments? Do we really support one another? Do our modes of communication support our trainees to be the caring, compassionate and competent doctors our profession needs? Do they feel cared for and cared about? Is the way we are communicating healing for the health-care system and for our profession, which is surely in need of healing.
We can make a choice in our communication – to harm or to heal, our patients, their families, our colleagues and the trust in our profession.