source: opencaremedicalcenter.com
“You have to be brief, straight to the point, address the patient’s concerns and their welfare.”
That was what my friend told me when I was preparing for my MRCP PACES exam the year before. For my junior colleagues who possess that very significant opportunity in the clinical work, use it as an opportunity to communicate with your patients. Don’t wait for exams as you will find that by doing them now, you won’t have to panic when the real deal comes. In fact, just to digress slightly, even Patch Adams impress upon his colleagues back in med school on picking up phones, dialling a random number and talking to strangers. But I won’t go that far to emphasise that point of communication. Bottom line, one needs to understand the power of communication.
Here is a little bit on the breakdown of a case that we would quite often see daily. A patient admitted with severe central chest pain in the middle of the night. A diagnosis of full blown myocardial infarction (commonly known as heart attack) was made and medications started. His pain got better, his ECG showed remarkable improvements and he is now warded into the CCU. His wife fell short of his arrival to the hospital and came only much later demanding to know what happened. This is now four in the morning. Your staff nurses are the first whom she comes into contact with and having given a brief detail of what has happened, she still demands to know more and you are then summoned to give an account as to what has happened.
Source: www.fitness19.com
To most of us who have by now gone back to the on call room and hit the sack, we would be thinking anything other than a detailed explanation. To be frank, we think that this is not urgent as this could wait seeing that the patient has already been stabilised and is heading well onto a good comfortable way of recovery. As bad as it is, some of us may just brush it off and brandish a couple of words and sentences hoping to get back to the call room as soon as possible. Further questioning would invite an ignition of frustration, and believe you me, some questions may seem rather trivial and irrelevant. But they do happen and let’s find out why. Place yourself now in the shoes of the patient’s wife.
You stay about 50 km away from your husband’s workplace. It’s late and you expect your husband to be home by 10 PM but it’s already 12 MN. You receive a call first from your husband’s colleague telling you that he is now in the A&E for a heart attack. Immediately after that, the hospital’s nurse in charge calls you to come as soon as possible and that would stir you from your comfort zone knowing that something serious has happened. You have three kids at home, one age nine, one age four and another two years old. You are all alone and your neighbour’s house light has gone off hours ago. What are you to do? You have no car to get there but by all means have to do so because your husband is all you have. Imagine the fear of the unknown and the mishaps and miscellaneous that could have happened to your husband as you are yet to visualise the real scenario. Goodness gracious, a great deal of possibilities and impossibilities would have found its way into your mind and kick up a fuss in there. When finally, you reach for the phone and get your brother who lives 20 km away to come and pick you up and take you to the hospital which is another 80 km from where you are.
Imagine the hassle of getting there and when you finally do get into the hospital at 3 AM, you found that the directions are quite a bit of a haze as all you can think of right now is the status of your husband. There’s obviously no one to ask for directions at this ungodly hour. The person whom you are able to identify is probably another patient’s relatives who has fallen fast asleep by the marble chair. You find your way finally to the information counter located within the admissions office and make some hurried enquiries. With some lost directions along the way up to CCU, you finally made it and rushing into the ward where your husband is now placed, you shed tears to see him with so many tubings coming out of his hands and a tube that drains out yellowish liquid. He is fast asleep and not arousable from the sedatives they gave him to calm him down and you can’t get a response from him. You imagine the worse that could have happened and you demand to know what has happened.
Source: au.lifestyle.yahoo.com
So now… back to the on call doctor…
You have been working as a medical officer for three years now and have managed hundreds, if not thousands of cases of myocardial infarction. many of these have made you numb to the fact as to their progression in the ward depending on their stability after the initial medications. Seeing that his vitals are now stable and that he has stated that his pain is now lesser, you are convinced that he will pull through based on your limitless experience. You then head on back to your call room and as you are about to dose off, the call from the nursing counter came and you are jolted back up with adrenaline surging through your neurones telling you that the wife is now here and demands to know what is going on. No matter how experienced the nurses are in managing patients in CCU, the relatives retain the final say as to whom they wish to speak to and it is really, not your staff nurses’ fault if they call you up to ask for your help. It is never because of the fact that they failed in their bid to counsel the relatives as to what has happened, but merely, the wife would like to know from the doctor’s point of view as to what has really happened. After all, the doctors are the best person to reach for as they are the ones who are actively managing the patients, adjusting drips, medications and planning for further intervention as time goes by. So… before you hustle up and push open the door harshly, stop for a while, take a break, let it all digest, think of how best you can tell the distressed wife and execute it in a way that is pleasant to her and also to you.
Communication is a two pronged approach – talking about/to the patient and letting the patient talk. You can interchange the word patient for relatives too! And as you find yourself improving your communication skills, you will see that patients will agree with you more, become less agitated, trust you more and legal suits may eventually come to a decline. You may never avoid all of these but at least you did your best in defusing the situation. You will find that the word ‘sorry’ when used in the right circumstance is an indeed powerful word. Humility is another expression poised by the fellow communicator that can win the hearts of many and is a skill that many needs to learn over time and develop. It is never easy to adapt the skill of being humble as in this ever competing world, we are never trained to be like that. When coupled together and used in the right place and time, the word sorry and the humble demeanour would have already won the battle of a difficult communication agenda.
In the case above:-
- Walk up to the wife with a smile
- Introduce yourself casually – name and title as well as job scope and your responsibility to her husband
- Chip in a few random chit-chats – ask how she got here, reveals your concern about her (the utmost powerful random act that you can ever show is to show concern to others and you will be rewarded greatly)
- Gather knowledge and understanding – how much she knows about what happens
- Allow time for her to express herself
- Provide her with the facts, but simple terms that she can understand; in other words, in layman’s terms – talk slowly, pause when indicated to allow the information to sink in, know that there is a lot to absorb and it is not easy for her to understand everything
- Acknowledge the fact that it is a lot to take in, ask her every now and then whether is she alright and can you continue; if you are given the green light, proceed; if you are not, stop
- Tell of current status – stable, improving, lesser pain, what you have done, what you are doing and what you will do later
- What to expect – often more than not, doctors are keen to tell patients that they will do well regardless of the fact that they are not psychics – kindly avert yourself from doing so
- Why CCU and not general ward – using the terminology SOP/protocol is not a good way of expressing the reason why you admit him to the CCU; try saying that you would like to monitor for complications following the heart attack as the next few days are critical, putting him in CCU allows a one to one nurse to patient care and this can help to pick up complications early
- Be gentle, kind and humble as always
- Ask her whether she has any concerns to share further or any hidden agendas that she has
- Address her welfare, social needs and show empathy
- End the consultation by telling her that should she have any further questions, she can write it down and communicate them to us later on as they come
- Provide her with a helpline in that manner (not necessarily your page number or your phone number), but tell her where she can seek for assistance and answers should she need one
All in all, when done right, this would take less than 10 minutes, though sometimes depending on the complications that have risen from the heart attack, this may take longer. The case above is a simple illustration on what went right and what was expected to happen. Things may get more difficult and challenging should the patient deteriorate further and warrants emergent treatment. Regardless, the formula is all about the same. For as long as you do two things, you will be on safe ground – let the patient/relatives talk about their concerns, agendas (often hidden, you will never know that she has three kids at home and how she finds her way to the hospital if you never ask – sometimes these issues may be the catalyst for the patient’s anger if the communication/explanation went awry) and welfares and make sure you address each one of them. If you find that you are at a lost for words and that something is beyond your knowledge, always apologise and tell them that you will get back to them when you have discussed the issue over with your seniors, and make sure you do that!
source: www.examiner.com
Done right – you get to go back to your on call room happy, warmth (hopefully not in your pants from urinary incontinence) and pleased with how good your communication skills are. The expression on the patient’s or relatives’ face is evident of how skilful you are in adopting a communication methodology that does not betray their trust, but reaffirm their faith in you; the doctor that cares for her husband as a human being, and not just only the myocardial infarct. You will find that over time, with practises in various fields of communication that this is essentially the most powerful tool in managing patients in the hospital and as well as the clinic. Noted, that at times, we may never have the time, but always remember that whenever you do and you find that it is a must, your communication habit is what makes the difference for that particular patient. He who never took his medications in the past may switch his habit and listen to you after all for you may be the first who shares his concern and his problems as a whole.
So go ahead – start talking, start communicating and develop a habit to improve yourself. There’s always room for improvement as my friend once says. Needless to say, I had a harsh time being trained by a person who adopted the British communication standards. I had to unlearn everything I have learned in the past and relearn the corrected methodology to properly use the right word at the right time. In the end, it was more than well worth it, it was amazing!
Dr. Chiam Keng Hoong is a internal medicine physician and a MRCP holder. He currently works in Sabah.
This is the personal opinion of the writer and does not necessarily represent the views of The Malaysian Medical Gazette.
[This article belongs to The Malaysian Medical Gazette. Any republication (online or offline) without written permission from The Malaysian Medical Gazette is prohibited.]