Exploring ways to manage healthcare professional-patient communication issues.

Effective communication between clinicians and their patients has a positive impact not only on clinical outcomes but also on their experience of care. Communication skills are a core clinical skill, which can be taught by a number of methods. Understanding the impact of one's own communication skills has on a patient and their family can help hone a clinician's skills to improve both patient and clinician satisfaction.

Increasingly healthcare professionals (HCPs) are recognising that the quality of a patient’s experience of care may be just as important to patients as clinical outcomes. After clinical competence, being valued and treated as an individual is most highly rated by patients [1, 2]. Consequently, ensuring that HCPs have the skills to communicate in effective and satisfying ways is a vital part of quality cancer care.

Sadly, the message that is coming across from patients is that we are not getting this right yet and there are many aspects of our communication, which could be improved. The message is consistent and comes not only from patient audits and surveys but also through the ombudsman’s reports and reviews of complaints and litigation. Ineffective communication between HCPs and patients and their families remains one of the most frequently cited reasons for poor experience of care [3].

The research base shows that:

Poor communication can have serious consequences leading to complaints by patients and their relatives [4]

Poor communication can leave patients feeling dissatisfied, frustrated, anxious and so uncertain that it affects their ability to comply with recommended treatments [5]

Good communication can influence patients’ emotional health, symptom resolution, function and physiological measures such as blood pressure as well as decrease reported pain and drug usage [6]

Insufficient training in communication is a major factor contributing to stress, lack of job satisfaction and emotional burnout in HCPs [7, 8]

54% of patient complaints and 45% of concerns are not elicited [9]

In 50% of visits, the patient and doctor do not agree on nature of presenting complaint [10]

Doctors frequently interrupt as soon as the patient begin their opening statement, so the patient often fails to disclose significant concerns [11]

Doctors often interrupt patients after initial concerns assuming the first concern is the chief complaint, yet the order in which patients disclose complaints is not related to the order of clinical importance [11]

The following four communication problems were present in over 70% of malpractice suits [12]:

Deserting the patient

Devaluing patient views

Delivering information poorly

Failing to understand the patient’s perspective

Patient satisfaction is directly related to the amount of information patients perceive they have been given. To achieve an effective interview, doctors need to be able to integrate four aspects of their work, which together determine overall clinical competence [13]:

Knowledge

Communication skills

Problem solving

Physical examination

Excellent communication skills are no longer a ‘fluffy’ add-on, but a core clinical skill. It is estimated in a career spanning 40 years doctors will conduct between 150,000 and 200,000 interviews with patients and their families [13]. Communication is a two-way process and not just the act of imparting information well. Effective communication involves the ability to actively listen, acknowledge a patient’s concerns have been heard, ensure their agenda is elicited and addressed and then tailoring the information imparted at the appropriate pace and level for the person in the consultation. It also involves coping with the myriad of emotional reactions and difficult questions from both patients and their families, which inevitably occur when difficult information is given no matter how well it is done.

All medical schools in most European countries now include communication skills training as part of their teaching curriculum. However, we know that no matter how well junior doctors are trained, they are still hugely influenced by the behaviour and attitudes of their seniors. It is senior clinicians that possess the knowledge and expertise required to assume responsibility for difficult decision making. If senior clinicians are ineffective communicators with both patients and junior staff, this can negatively influence their own professional development. Juniors must learn how to present difficult decisions to patients in an empathic and sensitive style. Too often clinicians tend to focus only on medical issues, giving less attention to patient understanding, emotional reaction and coping. Senior clinicians are thus important role models in shaping future doctors.

Excellent communication should be a clinical skill that we finely tune and improve constantly. When clinicians experience difficult consultations that do not go as well as hoped, the negative impact affects the professional as well as the patient. Emotions experienced include feeling inadequate and frustrated. This sense of professional and personal dissatisfaction is further compounded if a complaint is made. By working on communication issues that are challenging, one can equip oneself with other strategies to manage the difficult scenario.

In this workshop, 30 senior clinicians were arranged in smaller groups comprising 4–5 people with one facilitator. The group was predominantly medical staff with a smaller number of nurses and pharmacists. All attendees were from an oncology or palliative care background and had been in clinical practice for more than 5 years. They represented a truly international community with delegates from the UK, Spain, Italy, Bulgaria, Estonia, Latvia, Poland, Slovenia, Croatia, France and Israel.

The facilitator created a safe environment to enable the senior clinicians to share the challenges they experience in everyday practice. This was done by initially giving the delegates 5–10 min to discuss the issues in their small groups. Each table then elected a spokesperson to share the issues discussed on their table. The facilitator explored exactly what made communication difficult for each individual who volunteered an example of a challenging communication encounter. She then wrote up the list of scenarios shared by the group along with examples of challenging patients and families. One or two delegates shared their communication challenge with colleagues but not the patient. See Table 1 for the full list of challenges discussed.

Table 1

Communication issues shared by workshop attendees

Communication skills workshop—communication challenges shared by attendees
1. Patient-related issues
• Anger/strong emotion
• Withdrawn/silent patient
• Denial
• Sadness/tears
• Unrealistic expectations (e.g. wants guarantee of cure)
• The ‘internet-guru’ patient
• Patients who will not listen
• Patients who cannot cope with uncertainty
• Patients with unshakable beliefs (e.g. ‘God will make me better’)
• Giving complex information
• Providing informed choice
• Discussing toxic treatments for a patient with poor prognosis
• End of life discussions (e.g. when a patient has young children)
• Discussing DNAR issues towards the end of life
• Patients who choose unproven treatments
• Monitoring hope when moving from a curative to a palliative setting
2. Language issues
• Communicating through an interpreter
3. Carer/family issues
• Family who do not want conventional treatment for the patient
• Family who are withholding truth from the patient
4. Patient/colleague issues
• Wanting to reassure a patient about the current situation without contradicting a colleague’s previous advice
• Managing the consultation when a colleague has previously given the patient unrealistic expectations
• Patient who writes blogs/articles critical of their consultant
5. Clinician/colleague issues
• Dealing with a difficult colleague
• Saying no to unreasonable demands about a patient from a colleague (e.g. wanting ITU transfer for a patient with end stage disease)
• Managing a junior/colleague who is underperforming
• Coping with a colleague who undermines your clinical opinion (e.g. by insisting another colleague gives the final opinion)
6. Clinician issues—personal
• Dealing with patient that reminds you of your own mortality (e.g. same age and family circumstances)
• Showing empathy with a difficult patient

This supported discussion was facilitated by the author, inviting other attendees to share similar experiences and how they addressed challenges. Issues were explored from both a patient and healthcare professional (HCP) perspective.

Many of the challenging scenarios shared were cited by more than one clinician and are difficult areas of clinical practice, such as discussing prognosis, managing strong emotions and managing unrealistic expectations of treatments.

In this workshop, the facilitator provided a safe environment to enable senior clinicians to share the challenges they experience in everyday practice. By exploring exactly what made communication difficult for each individual who volunteered an example of a challenging scenario, the group was able to explore these issues from both the patient’s and HCP’s perspective.

Interestingly, HCPs from some cultures admitted that they rarely explored or addressed the patient perspective as they felt that was not their role. Others firmly believed that being empathic, trying to put the clinician in the shoes of the patient, was absolutely the role of the Senior Consultant.

It follows, then, that the patient experience would be significantly enhanced if we could improve our communication skills. There may be other beneficial effects of improved skills, such as a reduction in complaints and litigation. This shared experience of reflective practice provided an opportunity for increasing self-awareness of one’s attitudes and values about communication, and how in turn these can affect one’s communication style in medical consultations with patients and their families.