There is an exhaustive general literature devoted to communicative skills, and in the corporate world – certainly in politics- and in most endeavors in which management of people is important, the achievement of this basic social asset is usually 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, and furthermore, it’s not a stretch to say that an ability to communicate is the key ingredient to people skills. It follows, therefore, that in the very important human endeavor of medical practice (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.
Communicative and leadership matters have always interested me, and I have written and published on both*. In particular, I want to emphasize that the doctor’s communicative ability with patient and family – when the cancer is discovered – that required after treatment with the looming chance for cure – and that unpleasant communication when treatment failure becomes obvious – are all critically important. In the last of these circumstances, a death and dying discussion with patient and often family tests the compassion as well as the leadership skills of the physician.
Fundamental to all of this is the notion that communication is a two way thing, and no matter how detailed or how much time and energy the doctor devotes to explanation, if the patient and/or family does (do) not understand what they’ve been told, then there has not been real communication. In reality, such a conversation is nothing more than the doctor’s monolog. By definition, communication is both talking and understanding. This is what I meant in the first paragraph when I referred to “duality”. Furthermore, I strongly contend that achieving this ideal standard is mainly the responsibility of the doctor, not the patient. 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 else might be needed.
The emotional issues related to good communication aside, the legal part of this problem is paramount, and patients who are given a piece of paper, euphemistically called an Informed Consent, usually 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 maximum anxiety. Aside from this document being scary in its potential list of complications, it is a bit much for the average patient to read, assimilate, and sign in the bright light 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, questions 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 just before being taken to the operating room; bottom line, 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 today’s patients and caregivers. In today’s economic climate, the old method is inefficient and unaffordable, no matter how comforting. 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 operation, and so on. Essentially, during this tense time just before the operation, a surgeon should avoid talking details about the operation or referring to any potential problems. Better, an optimistic surgeon, a hand on the arm, reassurance that they will be protected – better for the patient to have quiet visitation with family or friends and 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. This 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 in play. Reader, take note – I said dialog, not monolog.
In future essays, I plan to write more on physician’s communicative skills, or lack thereof, but as it pertains to the above point in question, it’s 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.
I am making such a big deal out of all of this 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.
Roy B. Sessions, MD, FACS
Seabrook Island, SC
References: Sessions, Roy B; The Cancer Experience: the doctor, the patient, the journey; publisher, Roman Littlefield, 2012