Artykuł ukazał się w Medical Maestro Magazine, Vol. 1, s./p. 001-148
A Modern Day Tragedy
Dr Abraham Verghese tells the story1 of a 40-year-old woman who is brought to the emergency room in a critical state. She is diagnosed with advanced bilateral breast cancer, which has spread throughout her body. In the previous two years she had been to see around five doctors and none of them had been able to diagnose her. The chance to intervene much earlier when the cancer was treatable had been lost. The health system, medicine and doctors had failed her. In these modern times this is a real tragedy, but unfortunately it is not an isolated story and happens all the time. According to one study2, as many as one in six patients in the UK are currently being misdiagnosed.
If this woman had been given more time to explain, or even if one doctor had just listened better or a little longer, then maybe things would have turned out differently. It is suggested that some doctors are too quick to judge patients’ symptoms and are therefore unable to communicate and diagnose effectively. So have doctors lost the art of communication? Has the ability to obtain vital pieces of information that could make all the difference been lost to a world of prescription writing, complicated tests and high-tech scans? Dr Verghese believes, „the most important innovation in medicine to come in the next 10 years: the power of the human hand”.
The Code of Conduct
All doctors who wish to practice in the United Kingdom must register with the General Medical Council (GMC). The GMC issues each successful applicant with a professional code of conduct entitled ‘The Good Medical Practice’3. This advisory document contains a set of guidelines that every doctor must adhere to throughout their professional lives. It lists the key duties and standards that are expected and is divided into four main categories or domains. One of those domains is entitled ‘Communication, partnership and teamwork’ and highlights the fact that a huge part of being a doctor is being able to communicate effectively. It states that doctors should “treat patients politely and considerately”. This may go without saying, but for whatever reason this can sometimes be neglected. Research has shown4 how the clinical environment, including how a doctor behaves, the words used and even the tone in which they are said, can have a massive placebo type effect on a patient’s response to treatment.
The code goes on to advise doctors to always “Give patients the information they want or need in a way they can understand”. Medicine is awash with medical jargon and medical professionals can’t help themselves from using it. But when talking to a patient it is clearly more beneficial if everyone is singing from the same hymnbook. If a patient requires the removal of their gallbladder then it is better to say that instead of having them scratch their heads in confusion when told, „well Mr Smith, it looks like you need a cholycystectomy”. Some patients who have a sore throat may be shocked to find out that what they actually have is pharyngitis. It can be a complicated business.
The code also implores doctors to „Listen to and respond to their (patients’) concerns and preferences”. It has often been said that listening is an underrated and difficult skill; we were given two ears but only one mouth after all. It’s important to remember that communication is a two-way game and usually works best when there is a balance of interaction from both parties. Some studies suggest that after a doctor asks a patient to explain why they have attended, they will only listen for around 20 seconds and then interrupt the patient. Not only will this leave the patient feeling disrespected, insulted and not taken seriously but can also result in missed opportunities to collect vital information.
So be polite, speak in simple terms and use your ears. The clinical encounter process or time spent interacting with a patient can vary depending on a patient’s needs. But whether it takes seven minutes or seven weeks the interaction will usually follow five key stages.
- Welcoming the patient and the Presenting Complaint (PC) 
- Taking a History – Past Medical History (PMH), Drug History (DH), Family History (FH) & Social History (SH) 
- Examination – Giving Instructions 
- Investigations & Treatment
Each stage requires specific language and the use of open and closed-ended questions. For example after welcoming the patient a doctor can ask about the presenting complaint (why the patient has attended) with an open-ended question such as „so how can I help you?” or „so what brings you here today?” This will allow the patient to answer in his or her own way and perhaps more importantly make them feel valued. Remember that they should be allowed to finish and never interrupted. To show active listening (that you have been listening) and that you have indeed understood the patient then it is a good idea to repeat a summary of what they have just said, „so you’ve had pain in your stomach for three days now, which is not relieved by medication…it comes and goes and is worse after food…”.
It’s never too late to learn good communication skills and as we have seen doctors are required to do it in order to be doctors. Communicating better makes you a better doctor. If you communicate well then the chances are that you might discover some vital information that will make all the difference to your ability to make a good diagnosis. A difference that could be a matter of life or death for one person.
- bilateral – (adj.) having two sides; mutual
- vital – (adj.) essential; very important
- advisory document – (adj.) suggested/recommended information/guidance;
- adhere to – (v.) keep to; obey; stick to
- mumbo jumbo – (n.) something that makes no sense
- awash – (adj.) everywhere
- both parties – (n.) both sides/groups; two people
- follow-up – (n.) check-up appointment
- emergency room (ER) – (n.) casualty department; accident & emergency (A&E)
- beneficial – (adj.) of benefit/useful
- all ears – (adj.) to listen carefully; to pay attention
- relieved by medication – (v.) eased/helped by medication
References [access: 14.01.2014]