On the other side of the (medical) fence

Since retiring from medical practice I’ve exchanged the role of doctor for those of patient and of patient’s wife, and being on the other side of the fence has been an interesting experience. Between the two of us, my husband and I have needed to see a good many different healthcare professionals from various specialties in recent years. Most of them were excellent, but a few were unsatisfactory and this was usually because of their poor “communication skills”.

Following the retirement of the family doctor we had known and trusted for a long time, I saw a GP whose failings included a rude manner, ordering me to take a long-term prescription for a new drug without any discussion of its efficacy and side-effects, and – as I discovered later – referring me to a hospital clinic without telling me. After that I changed to a different practice and am very happy with my doctor there, but my experience with the previous one distressed me for a long time, illustrating the importance of a good therapeutic relationship not only for improving patients’ emotional well-being, but for influencing their compliance with treatment and the outcome of their disease.

I don’t remember having any guidance about how to relate to patients when I was at medical school in the 1960s, nor during my junior doctor posts. Senior role models varied greatly in their approach, ranging from the caring and compassionate to the arrogant and disrespectful. In the later years of my career this aspect of clinical practice began to be taken more seriously, led by specialties such as general practice, oncology and palliative care. Communication skills training is now included in the education of doctors, nurses and other healthcare professionals, though its long-term impact must be difficult to measure, and depend on the student’s personality. The skills may come naturally to those who have chosen their career for humanitarian reasons. Those who are mainly interested in the scientific and technical side, or whose prime objective is making money, may pay little attention to such “soft” subjects in the curriculum.

The basic principles should be obvious, simply involving courtesy, common sense and genuine concern for the patient. Giving a polite and friendly greeting. Meeting in a clean and tidy consulting room free of interruptions. Listening to the patient’s story with genuine interest and empathy. Taking account of the patient’s knowledge and preferences when discussing management of the problem.

Conducting the interview becomes more difficult in the case of a serious condition. The medical literature contains many studies about techniques of “breaking bad news”, usually in relation to a cancer diagnosis, and I won’t attempt to detail them all here. Key points include giving truthful information without destroying hope. And avoiding dogmatic statements about prognosis, because the outcome in individual cases can vary so much from the average. Negative predictions can be self-fulfilling as well as disheartening, whereas except in the most dire situations there is always some help to be offered, and some scope for improvement. Another point highlighted by our recent experiences is that illness can be just as stressful for relatives as for patients themselves.

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