Doctors spend a significant amount of time learning communication skills. Firstly in medical school, with skilled “medical actors” playing the role of patients. Most speciality post-graduate training includes some further training in what used to be known as “good bedside manner”.
I was reminded of the importance of sensitive communication when I interviewed broadcaster and author Sinead Gleeson at the recent festival of medical curiosity, dotMD, in Smock Alley theatre. (Full disclosure: I am an organiser and co-curator of the conference.)
Sinead first read from her essay Blue Hills and Chalk Bones (published in Granta Magazine), which deals with the time she developed a mono-articular arthritis in her hip as a teenager.
“Aged 13, the synovial fluid in my left hip began to evaporate like rain. The bones ground together, literally turning to dust. It happened quickly, an inverse magician’s trick: now you don’t see it, now you do.”
Early contact with orthopaedic surgeons (this was the 1980s) was not auspicious: “What I felt more than anything was overwhelming embarrassment. On one visit to the surgeon, to check my spine for scoliosis, I was told to wear a swimsuit. I cried, and he grew impatient, throwing a towel over my waist.
“THERE, is that better?” It wasn’t. I was young, and humiliated and the complicated roots of female bodily shame are sown early.”
She continues: “The doctor/patient relationship has its own imbalances. I have never forgotten the sense of powerlessness in instruction: lie down, bend forward, walk for me. I have felt it counting backwards from ten under the lights of an operating theatre. You are in someone else’s hands. Steady, competent hands – but the patient is never in charge. The kingdom of the sick is not a democracy.”
I asked her to elaborate on these imbalances. In her experience, they haven’t improved with time. In the 2000s, she finally had a hip replacement, “after eventually convincing this doctor that it was the only solution to 24-hour pain. Granted as if this were a privilege, instead of something essential. The familiar need to plead and convince, to prove myself worthy of medical intervention. My body is not a question mark, and pain is not a negotiation.”
Writing in the Guardian last year, Australian oncologist and author Dr Ranjana Srivastava noted that "good medicine means understanding the power of not just what we say to our patients but how we behave towards them. Ralph Waldo Emerson once said that life is short but there is always time for courtesy. It's a message that may well have been scripted for the modern healthcare professional."
That the message may still need an audience is reflected in a 2013 American College of Physician Executives study of 840 doctors, which found that two out of three doctors had witnessed doctors behaving badly towards patients or colleagues. Discrimination, inappropriate jokes and profanity all found a mention.
There is no doubt that one of the most effective things doctors could do to improve patient communication is to listen more. Studies show that physicians have a tendency to interrupt patients before they’ve had a chance to tell doctors what’s on their minds. Patients are interrupted an average of 23 seconds into their opening statements and allowed to complete their initial thoughts in less than 25 per cent of consultations.
But we need to facilitate doctors by allowing them more time with patients. If we want doctors to further improve communication skills, then it’s time we paid them, at least in part, for spending additional time with patients. As presently structured the health system rewards “doing things”. If we change reimbursement to value “talking time”, then we will change behaviour.
I'm glad to report that Sinead has had some positive medical experiences; she shared the detail of the empathetic care she receives from a consultant haematologist at St James Hospital with the dotMD audience.