Communicating with patients

Our patients come to the consultation with a host of preconceptions and beliefs that may get in the way of our attempts to communicate with them. In this article in our occasional series on communication, we look at the some of the barriers to effective communication with patients and how to overcome them

Our patients get their information on health matters from all sorts of odd places. There is a steady drip of information from television: a mixture of the latest breakthroughs and the latest NHS disasters. Newspapers have a particular place in the affection of healthcare workers. Some of the nationals have acquired notoriety not only for the extent of their coverage, but also for their unreliability. There are books. There is the Internet, ever ready with advice about health topics, and which also reminds us how different healthcare is in Britain compared with, say, the United States. Now Clinical Knowledge Summaries (CKS) has been subsumed by NICE, a bewildering range of clinical guidelines can be accessed by anyone with a modem who wants to know either what best care looks like, or (looked at another way) what you should expect from the NHS. Add to this the folk wisdom of our communities (e.g. headaches are caused by brain tumours; itching is caused by a blood disorder) – these are the so called ‘explanatory models’, the way that people try and make sense of their symptoms.¹

So there is a lot of knowledge out there, but unfortunately much of it is inaccurate or just plain wrong.² Our patients do not come to their consultations free of preconceptions, ideas and beliefs which may help or hinder your efforts to communicate. And all this is in place before you even get to talk to your patient, before you commence the healthcare consultation, the cornerstone of all medical practice.

Over the last few years a lot has been written about the medical consultation, and this all has relevance for all healthcare professionals. You may already be aware of some of the important names of consultation models: Calgary-Cambridge;³ Neighbour;⁴ BARD.⁵ So in an attempt at a summary I offer you a distillation of key themes, a personal list of Top Tips for the Serious Consulter.

1. SHUT UP AND LISTEN

You are the expert on healthcare, but your patient is the expert on his or her symptoms. The vast majority of the information that you need to do your job is not derived from a clinical examination or fancy tests and investigations, it is obtained from what your patient tells you. So sit back and pay attention.

‘Listen to your patient, he is telling you the diagnosis.’ Osler (1849-1919)

Some patients need a little help to tell you their story. If this is the case, then ‘active listening’ may assist.⁶

• Use a seat at the same height as your patient.
• Sit close but not too close. Doing things – dressings, injections – means that you are allowed into their personal space, space usually occupied only by family members and almost never by strangers. Respect their space.
• Face your patient. You can see each others’ expressions, and see their lips – half of people over 60 have a hearing problem.
• Keep eye contact, but don’t stare.
• Use an open body posture – legs not crossed, arms not folded, don’t slouch in the chair.
• Grunt – use little noises or an irrelevant word to encourage. ‘Yes’, ‘uh-huh’ and ‘right’ are all popular.
• Echo – use your patient’s own words. This is like a grunt only better as it proves you are listening.
• Use open questions. Questions that can only be answered ‘yes’ or ‘no’ offer little scope for elaboration.

Some patients of course need absolutely no encouragement to talk. My own rule is that if you are being told the same thing for the third time then (and only then) is it OK to interrupt.

2. WATCH FOR CUES

Less than 10% of communication between people is done with words. Speech tonality and body posture are far more important (but trickier to interpret). In any event, not all patients are articulate enough to express their feelings in words. And what you are discussing is pretty scary – illness, pain, operations, treatment, death – things which most right-minded people put out of their polite conversation. Research suggests that half of patient views are expressed covertly.³ You may fear that reacting to cues takes up more time. However, picking up on a patient cue does not lengthen a consultation, but failing to pick one up certainly does.³

So be alert to the sadness that appears in a patient’s eyes as she talks about her mother, or the throw-away, jocular ‘Well at least it’s not cancer’.

It is better if, when you find a cue, that you confirm it verbally. Cues are by their nature imprecise and you need to know that there is no misunderstanding. ‘Do you think you have got over the death of your mother?’

3. JARGON IS THE LAST REFUGE OF THE SCOUNDREL

Like all professions, healthcare has its own language. Indeed the cynic might argue that this is one way that professions keep their secrets from the lay public. It has been estimated that in their training doctors learn new words to the equivalent of two foreign languages.⁷ Some jargon is useful, verbal shortcuts to help communication. But what is the effect on those who either don’t know the language or (and this may be worse) who think they do know the language? The scope for miscommunication is huge.

So much of this is unnecessary. Some words are made up (an activity which in another sphere might well indicate psychosis): what exactly is the difference between a fractured femur and a broken thigh? Some words are used differently: the professional and lay meanings of the words ‘hysterical’ and ‘vertigo’ are quite different. You may be old enough to remember when publishers would produce ‘medical dictionaries’ (I suppose these days people just use the Internet), translations of our diabolical talk into real English.

Let us also not forget the rise and rise of the acronym. We still see the instruction, PRN on prescriptions: you know and I know that it means ‘as required’ – but would your patient? Your patient, overwhelmed in any event by the topic under discussion (his or her suffering) may not be in a position to remember much anyway, and certainly won’t if they are told things in gobbledegook. Paradoxically they may throw their own medical jargon word into the conversation – if they do, then check that you understand the word or acronym in the same way as they do. Failing to do so will make the chaos complete.

If you can only describe something using jargon or acronyms then you don’t really understand it.

4. ILLNESS IS MORE THAN DISEASE

All illness must be seen in context. The effects of a disease process can only be fully understood by the person who has it, so an understanding of the implications of a health problem is vital when attempting a full patient assessment. A twisted knee can be coped with by an office worker, but not by a builder working on ladders all day. A bout of flu is relatively trivial in life-or-death terms to someone with plenty of family support, but less trivial if you live on your own and have heart disease or want to visit your grandchildren. What of the chap with a back strain who is the main carer for his ailing elderly mother?

My favourite phrase is: ‘How does this problem affect you?’ Some of the disability resulting from a health problem is easy to understand. For example, an underground miner (there are a few left, there used to be many more) can’t go to work with diarrhoea: there are no toilets underground and you rapidly become deeply unpopular. Other disability is caused by what people fear may happen: current medical thought is that exercise is good after a heart attack, which is likely to mightily confuse the patient who had his acute coronary syndrome while out running.

5. EVERYONE HAS SOME FUNNY IDEAS

In the Zulu culture, the most important characteristic of a medicine is its colour. In northern India there is a folk concept of ardha-angani (’half body’). The left side of a married woman’s body is believed to belong to her husband. Marital conflict is expressed by symptoms on the left side.¹ But just in case you now feel superior and sophisticated: only 25% of treatments used in general practice are supported by a randomised controlled trial; the Royal London Homeopathic Hospital is paid for by the NHS, and in 2010 had to change its name to the Royal London Hospital for Integrated Care.

Some health beliefs are so common that they are predictable. Patients presenting with a headache expect to have their blood pressure measured. Other beliefs are equally strongly held, but may only be revealed if they are specifically enquired after. But whatever the beliefs are, they have to be allowed for, as any advice or information that does not accord with those beliefs is literally unbelievable. Our patients are generally rational, and when offered a plausible alternative will usually change their view; but to do this you must first find out what is the belief you are trying to change. Failure to do this will lead at best to a perplexed patient, or at worst one who considers you a fool.

This really matters quite a lot. What people believe about their illness is the single strongest predictor of how well they cope with it.¹

6. YOUR PATIENT’S AGENDA IS IMPORTANT

It would make life simpler if our patients kept to the point. However, even if a consultation is arranged for a specific purpose – say a vaccination or a dressing – many patients will take the opportunity to tell you about other health worries as well. Do they assume that their symptoms are endlessly fascinating to you? Is it just small-talk? Most nurse procedures are intimate hands-on affairs, so having a chat surely breaks the tension. Or are they taking the opportunity to squeeze some extra value out of the event? Normally most patient symptoms are never presented to a healthcare professional at all, but that does not mean that they don’t cause anxiety.

You might be minding your own business trying to complete a Long Term Condition template, and you can still get deflected by other issues. Work done on medical consultations suggests that an average patient will bring between one and four concerns to each consultation. Who would not chance their hand in the company of a sympathetic practice nurse to tidy up their various health concerns? In any event, most lay people will not know whether their symptoms are part of their LTC or its treatment or not – that is the job of the professional to sort out.

7. YOUR AGENDA IS IMPORTANT

Much writing about the medical consultation over the last 30 years has quite rightly focussed on the importance of patient agenda, as a counterblast to the paternalistic approaches traditionally adopted by medical professionals (mainly doctors). But among this it must be recognised that you too have an important job to do, that your skills are relevant to your patient’s wellbeing, and that you would not have a job at all if your patients could do for themselves what you can do for them. You are highly trained, efficient and effective, and worth listening to – in short you are a class act.

8. RESOURCES ARE NOT INFINITE

Everything that you do in your work is a juggling act. If you spend more time with one patient, you have to spend less with another. If you spend more time on one thing, you have less time for the others. You will try and create the illusion that for their 10 minutes (or whatever time is allocated for the consultation) then the patient in front of you is the centre of the universe, the focus of attention. However, you are the professional and have a wider responsibility toward all your patients. You also have responsibility for your own wellbeing, and if you work for too long, or try to work too fast, then something else will suffer in consequence.

Similarly, you are not omnipotent. The perfect consultation has never been delivered. Medical and nursing knowledge is not perfect; it is still being developed and researched. For all your best attentions, human bodies can be arbitrary little devils, and refuse to do what it says in the textbooks. Patient outcomes are important, but they only bear a partial relationship to the quality of nursing procedures. ‘The operation was a success, but the patient died’ – Anon. You can only do what you can do: your professional duty is only to do your job properly.

CONCLUSION

A million times a day in the UK, patients talk to healthcare professionals. It is an exchange of information which is at the very centre of healthcare practice. The desire to communicate better with patients should be a career-long professional quest.

There is now plenty of evidence, and plenty of published opinion, about what a good consultation looks like.³ However at the end of the day it is one patient, with all his or her foibles and idiosyncrasies and concerns, interacting with one nurse (with all hers). Isn’t that why we all do the job? •

Next time – Breaking bad news

REFERENCES

1. Helman C. Culture, Health and Illness. 4th Edition London: Arnold, 2001

2. Pendleton D et al. The consultation. Oxford:Oxford Medical Publications,1996

3. Silverman et al. Skills for Communicating with Patients (2nd edition). Oxford:Radcliffe, 2005

4. Neighbour, R. The Inner Consultation (2nd edition). Oxford:Radcliffe Medical,2004

5. Warren E. B. A. R. D. in the practice. Oxford:Radcliffe Medical, 2006

6. Moulton l. The Naked Consultation. Oxford;Radcliffe,2007

7. McCullough S. Learning to talk. GMC News Review September 1989:V-VI.