THE WANTING COMMUNICATION SKILLS IN MEDICINE

Every time a patient seeking a second opinion sits in front of me asks, “Why didn’t he/she just say so?” I smile patiently and say it is alright. In my work, I have been blessed to work with some of the most brilliant minds in medicine, learnt from them and I owe my professional achievements to my interactions with them. This remains true for both institutional learning and in the course of practice.

However, it is quite something to note that most patients hardly ever get a chance to appreciate this brilliance because of lack of a very important skillset, communication. Despite communication skills being taught in the medical school curriculum, it is either not given due attention or its importance is not stressed enough. Once the doctor is out in the field practising, various factors contribute to quickly losing even the little that was taught.

All doctors undergo a year of internship immediately upon completion of their undergraduate training. It is a memorable year everyone. The work hours are outrageous, the workload is almost inhuman and aside from work, they are also testing the waters as independent caregivers in the practice. The supervisors, who are specialist doctors, demand perfection, dedication and utmost commitment. This is a key cornerstone in the polishing off of a doctor before they are fully independent to care for the public.

My own internship in the national referral hospital was no less busy. In the paediatrics department, the intern doctor on call had to see all babies admitted to the ward, review them and take notes, a long process called clerking, that ensures that all medical details of the patient are fully documented for reference throughout their stay in the ward. This department generally admits the highest number of patients in all hospitals because of the nature of children.

On a particularly bad night, we ended up with sixty four very sick babies coming for admission. The ward was chaotic. Everyone was on their feet trying to stabilize the unstable ones. The nurses were moving all over the ward settling the babies, giving due medication, setting up infusions and oxygen masks and measuring out special feeds for the malnourished babies. We were calling the intensive care unit incessantly trying to get space to transfer our very sick ones in vain. The unit was packed with patients who had undergone open heart surgery as a special medical camp was going on that week. The senior doctors in the team for the night, including the senior specialist on call that day were all in the ward working hard.

All the communication skills training flew out of the window. After the first 30 or so clerkings, I was out on auto-pilot. The questions asked of the mother after establishing the main reason why the baby was in the ward are pretty standard, including the baby’s nutrition, immunization status developmental milestones and social environment. Asking the same questions to the mothers 64 times on a cold rainy night leaves one numb. It is impossible to take adequate time to empathize with the mother and reassure her about her baby. In the midst of it all, the nurses would still frantically call for me to help with resuscitating the some of the babies who were quickly deteriorating. We’d have to stoically mask our emotions when we lost the battle and the little angels left us, to face the distraught mother and break the sorrowful news.

Days such as these are replicated across the doctor’s profession most especially in the early days of their career. Attending to 70 patients a day in an outpatient diabetic clinic in Nyeri means that by your 40^th patient you are no longer an effective communicator. You are a starving tired doctor who is driven to ensure all the patients are seen, prescriptions refilled, infections picked out and addressed and the very sick are sent to the ward for admission. The skills fade in the background of overwork and desperation to attend to all.

Effective communication, especially in a field dealing with life and death everyday requires time and patience. None of these are availed especially in the public hospitals where the doctor to patient ratios are abominable. Over time, the requisite qualities required are eroded under an overlooked state of overwork, frustration at not being able to provide what the patient needs due to systemic issues in the sector that are beyond the control of the doctor and lack of a supportive system to promote good communication between providers and their clients the patients. The doctor is reduced to a series of nods, grunts and monosyllabic responses.

The effects of the problem are myriad and affect the patient and the doctor directly. Lack of adequate communication results in a patient who is not fully aware of their health issues hence are unable to effectively participate in their care, cannot make informed decisions, is poorly compliant with the laid care plans resulting in bad outcomes and is overall very unsatisfied. The doctor lacks fulfilment derived from a job well done, may miss out on critical information that could alter patient outcomes and forms bad habits that persist throughout their career as providers.

In the new face of medical malpractice litigation, which is on the rise in Kenya, more than half of the cases presented to court or to the regulatory body disciplinary committees are deeply rooted in communication deficiencies between the care provider and the patient.

There is urgent need to bridge this gap and for better health outcomes. The barriers raised must be addressed sufficiently to create an environment where good communication thrives effortlessly. There is no patient who cannot comprehend issues surrounding their care, unless they have severe mental impairment. It is every patient’s right to be informed of their medical issues in a language they understand, broken down to their level of understanding. As one of my professors always emphasizes, there is no such thing as a difficult patient, but rather a patient in difficult circumstances!