There is an exhaustive literature devoted to communicative skills, and in the corporate world, certainly in politics, and in most endeavors in which management of people is important, achievement of this basic social asset is followed by reward. One frequently hears the colloquialism, “people skills”, in reference to one’s ability to deal with human interactions. Truth be know, this is not a simple construct, but it’s not a stretch to say that the ability to communicate is the key ingredient to people skills. It follows, therefore, in that most important human endeavor - the practice of medicine – especially cancer related medicine – clarity and comprehensibility of words are critical. Essential to the reader’s grasp of this entire discussion is the subtle but important duality of this statement. Let me explain what I mean.
In my recently published book, The Cancer Experience: the doctor, the patient, the journey, I devoted several chapters to the communication between doctor and patient; that when the cancer is discovered; that which occurs after treatment with looming chance for cure; and that when treatment failure becomes obvious. Additionally, in the book I devoted considerable thought and script to the death and dying discussion with patients and the family. Fundamental to all of this – a point that I repeatedly and consistently make – is the notion that communication is a two way phenomenon, and no matter how detailed or how much time and energy the doctor devotes to explanation, if the patient does not understand what he/she has been told, then there has not been communication. In reality, such a conversation is nothing more than a doctor’s monolog. By practical definition, communication is both talking and understanding; this is what I meant in the preceding paragraph when I referred to “duality”. Furthermore, I strongly contend that achieving this ideal is mainly the responsibility of the doctor. Despite educational deficiencies, language barriers, and patient fear and anxiety, the doctor must find a way to connect – whether by diagram, repetitive explanation, translators, or whatever is needed.
The emotional issues related to communication aside, the legal part of this problem is paramount. Consider this: patients who are given a piece of paper, euphemistically called an Informed Consent, are not infrequently disinclined to sign it regardless of their level of comprehension. This is especially so when the consent form is presented to them just prior to a surgical procedure, a time of peak pre operative anxiety. Aside from this document being terrifying in its potential list of complications, it is a bit much for the average patient to read, assimilate, and sign in the bright lights of the moment, no matter how legally important. On several occasions, I have had patients who happened to be attorneys who refused to do this and as a result, the surgery was rescheduled for a later date. In years past, patients were prepared well in advance, documents were read and digested, questioned were asked and answered, and the patients were brought into the hospital the night preceding the operation. They were given sedation to sleep, and then an injection for more sedation was administered just before being taken to the operating room the following morning; thus, the level of anxiety was minimized and the memories rendered vague. Those were the “good old days”. In today’s climate of medical care, patients come in the day of the operation, often shortly before surgery, and in a rapid succession of well orchestrated events are prepared and sent to the operating room, often without sedation until just before induction of anesthesia. My point in discussing this is not to compare the old to the new, but instead to realistically address the hand that has been dealt to both patients and caregivers of contemporary times. In today’s economic climate, even though more comforting, the old method is inefficient and unaffordable. Suffice it to say that the doctor’s discussion with a patient waiting to go to the operating room should be limited to process; that is to say, how long the surgery should take, where the family should meet the surgeon following the surgery, and so on. Essentially, during this tense time, a surgeon should avoid talking details about the operation or referring to any potential problems. Better scenerio, an optimistic surgeon, a hand on the arm, reassurance that they will be protected - respecting the patient's need for quiet visitation with family or friends –avoidance of being forced to comprehend and process information regarding important technical/therapeutic or prognostic matters. Those important discussions regarding such details - the disease, the actual operation, the potential complications – all "must discuss issues" – should be done in another setting, well before the hospital experience. There is a more appropriate time for questions and answers, patient education, comprehensible details, and it is during this dialog in which the doctor’s communicative skills are at play. Reader, take note – I said dialog, not monolog.
I plan to write future blogs on physician’s communicative skills, or lack thereof, but as it pertains to the above point in question, it is important to say that the ability of the physician to recognize when he/she is not really getting through to the patient and family is just as important as the methods and techniques used. Remember, it’s not really communication if the message is not received and understood, and if the doctor doesn’t pick up on this lack of connection – ie, duality, the entire problem is compounded. The patient’s failure to ask questions often belies comprehension; embarrassment and fear of hearing unpleasant facts both play a part in such silence.
Why am I making such a big deal out of all of this? Basically, because I believe that of all of the problems in the complex world of medical care and its delivery, communication issues are at the top of the list. In my next blog, Doctor – Patient Communications: Part II, I will deal with those important matters at play in the day to day interactions between the parties involved.
Roy B. Sessions, MD, FACS
References: Sessions, Roy B., The Cancer Experience: the doctor, the patient, the journey; publ Roman Littlefield, 2012