Sleep on it: the art of communication in medicine

AS I lay on the bed, my consultant engaged with us in a dialogue. The sole purpose of our discussion was that, together with my wife, we would make a wise decision. The consultant explained our options; she described the positives and negatives of all of the possibilities; she encouraged us to take our time to discuss our options and to talk together as we sought to achieve a consensus. She was polite, patient and spoke clearly using terminology that we could understand. There was no pressure to make a choice or a commitment and all of us knew that we might leave that day without reaching a decision. She was displaying interpersonal skills in communication that were of the standard that we expect of people in her position.

Our consultant was helping us to choose a new mattress. She works on weekends in a furniture shop to pay her way while studying an allied health specialty. Had she not behaved in that manner, her employer would no doubt have counselled her and offered her an opportunity to learn how to do it better. I don’t think that many of us would be surprised if her ongoing employment was subject to her satisfactory sales performance. As a consultant helping people to make good choices (and buy beds), she must be an effective communicator and facilitator.

So why is it that so many health workers around Australia and the world continue to fail to meet the needs and expectations of their customers, the people who are sometimes expected to pay them large amounts of money?

I know that many clinicians are very good at these tasks, but those of us working in palliative care see too many people who have gone through years of treatment without anyone ever asking them about what is important to them in their choices about treatment, and sometimes not even telling them that their illness has become fatal.

It is not as if we have not always had good role models. I will always remember Dr Dennis Campbell, a surgeon from Townsville who died in retirement a few years ago. One night, when I was a junior doctor working in the emergency department, we admitted a patient straight to theatre because his liver had been ruptured in a car crash. The emergency department was quieter then and the nurse on duty and I waited with his wife. The patient died and at about 3 am Dennis came out of the theatre and spent over 30 minutes with her, just quietly talking.

Several years later, when I was a rookie GP and wary of home visits, Dennis went to the home of one of our shared patients who was dying, sorted out his symptoms, made all the necessary arrangements after he died and supported his family. He never mentioned that he had done what I should have done, but his actions taught me what patients should learn to expect of me as a doctor.

Communication in health care is an art. Every consultation is different and all of us find that some go better than others, irrespective of our experience and intent. As I have travelled around Australia over the years, I have heard many stories of excellent communicators, but far too many tales of woe.

We all know of colleagues who seem unable to even start compassionate and meaningful discussions, and seldom fulfil the needs and growing expectations of patients and their families. We see patients who have no understanding of the burdens of their treatment, have not been offered the opportunity or encouragement to consider their preferences, do not understand that they can make choices, or regret expending their limited time and energy on the pursuit of dreams. Admittedly, sometimes these sentiments are expressed with the benefit of hindsight, or because the patient or their family has bought into the idea of treatment being a battle against death. However, too often, it is because their clinicians do not seem to understand that their role is to care for the whole patient, not just treat their disease, and to help them make wise choices, not just brave choices. If we do not communicate, we run the risk of simply being technicians.

The delivery of 21st century health care technologies is a hugely complex process for everyone involved. At times, the things we do can prolong a life with great quality; at other times, even in the one patient, the same intervention may cause harm or simply prolong dying. The extension of complex treatments to patients who are more and more likely to be frail or elderly demands that we be able to translate what we are offering into language and concepts that our patients can understand. Our community is starting to expect that clinicians will help their patients to make wise choices.

Over my years as a GP, I referred many patients to Dennis Campbell because I knew that he would always work with his patient to try to make wise decisions about what to do and what not to do. For me, that is the core of the practice and art of medicine.

I am not sure why it is that while the ongoing demonstration of most clinical competencies is mandatory (eg, operations for surgeons or delivering chemotherapy for oncologists), rigorous assessment does not seem to be applied to the essential art of communication. If the ongoing employment of a mattress sales consultant is contingent upon her ability to communicate effectively, why is it not also the case for health workers? Perhaps, like the competencies of airline pilots, such skills should be assessed regularly.

Having just this week taken delivery of our new mattress, my wife and I are sleeping like logs, which proves that at the end of our consultation in the mattress shop we made an informed choice that best suited our needs. I hope that I will be able to say the same when the time inevitably comes for complex discussions about my health care.

Associate Professor Will Cairns is a palliative medicine specialist based at the Townsville Hospital and author of the eBook Death rules – how death shapes life on earth, and what it means for us.

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