September 2003

Dear Readers: Here's the Article for this Month:

Name of article:

Do we really care about Doctor-Patient communication or is it just talk?   Editorial

Author(s): Robert M. Arnold

Reference: Journal of Palliative Medicine 2003; 6/2: 189-192

Abstract: 

Most of the clinicians working in the Palliative Care (PC) setting, as well as patients and families, believe and affirm the importance of the doctor-patient communication. This is a topic widely considered and discussed at the scientific and clinical meetings, and in the PC books. In reality, how, and how much, do we actually communicate with our patients in the daily clinical practice? If we communicate, are we sure that we are doing it in the right way? Who taught us to communicate? What kind of training did we have? Who evaluates what and how we communicate in verbal and non-verbal ways? How much do we actually listen to the patient before, and while, we are speaking to him/her?

Data of literature show that effective communication is correlated with improved patient satisfaction, understanding, clinical outcomes and decreased malpractice claims.

Some studies show that a 3-day, interactive course on communication skills produces changes in physician behavior that positively influences patient satisfaction, compliance and clinical results.

Various scientific and professional societies (the American Association for Medical Colleges, the Accreditation Council for Graduate Medical Education, the American Board of Internal Medicine, the American Academy of Hospice and Palliative Medicine) declare, and stress, the importance of competent communication skills of clinicians, medical residents and students as well as the importance of adequate and specific training of them.

Notwithstanding this emergent awareness, few schools spend time on the basic science of communication and thus few medical students spend time learning about the language that they should use in their clinical practice in order to communicate a diagnosis or prognosis; to "educate" patients and their families; to negotiate priorities and aims of clinical investigations and therapies with the patients.

Oncology fellowships require very little training in communication, even though it is recognized that this is a difficult area for oncologists to deal with.

According to Robert Arnold, adequate training on the science of communication would not only be helpful for physicians to improve their verbal and non-verbal communication with patients, but, it may also help them when they speak with other clinicians and hospital administrators.

Arnold goes further emphasizing the need "to practice listening" more effectively. He suggests a book by Eric Cassell entitled "Talking with patients" (2 vols. Cambridge, MA: The MIT Press, 1985, pp196), which carefully describes how the "way of speaking" by a patient tells us a lot about the patient himself and what he or she really wants to tell us. Cassell describes the clinical implications of the tone, and timbre, of the voice, the speech rate, the articulation and the choice of words by the patient. These are important communication elements that allow us to better understand the patient, his/her world, and so to communicate in a personalized way.

In Arnold’s opinion, teaching how to listen and to communicate must have a specific and precise methodology. The students have "to be observed" while communicating and listening, giving bad news, discussing and negotiating a plan of cure.

With the exceptions of Family Medicine and Psychiatry, programmes are rare where the residents are observed by the trainer and receive feedback about their communication skills with the patient.

PC is an area of medicine where the importance of the doctor-patient communication is very often discussed. However, no one knows what the effects are of asking patients about their spirituality, or what is done, or is said, when giving hope to a patient.

Arnold believes that the certification of "Palliative Physician or Palliative Nurse" should include training, with observation by the trainer, in communication. Otherwise, the risk is that the term communication is used "just for talking".

Why I chose this article.

I found that Dr. Arnold has made a critical analysis of communication skills based on reality, scientific data, mind and heart. He has shaken our convictions about our presumed communication skills in the medical field in general, and in PC in particular. Our pedestals are shaken now. At least it should be so.

This Editorial is an invitation to listen and to communicate more and better, it is an invitation to learn how to do this in the right way. Thanks Dr. Arnold. Well done!

Regards,

Carla Ripamonti, MD
Member of the Board of Directors, IAHPC