Parang N Mehta

From Mehta Hospital, Surat, Gujarat, India.

Correspondence to: Dr. Parang N Mehta, Consultant Pediatrician, Mehta Hospital, Opposite Putli,
Sagrampura, Surat 395 002, Gujarat, India. E-mail: [email protected]

Once upon a time, parents would bring their sick child to a doctor, and be happy to leave with a prescription. Explanations, empathy, and politeness were never expected of doctors.

Times have changed, however, and so have our patients and their parents. In today’s scenario, patients are health care consumers, we are providers, and the traditional doctor-patient relationship has changed. Patients and parents today demand information, courtesy and time. Arrogance, taciturnity, and a generalised lack of communication skills are no longer acceptable to health care consumers.

Apart from the demands of patients, good communication is good medicine. It enhances patients’ understanding and adherence to therapy, and has a therapeutic effect. If the parents do not understand the disease and treatment issues well, they may not adhere to therapy, resulting in poor outcome. It is important for doctors to be good communicators, and most medical colleges in USA now teach and assess communication skills. In our country, however, this essential component of a doctor’s skill set is largely neglected.

These are, quite simply, the skills that allow human beings to communicate with each other in an effective way. For pediatricians, communication skills consist of:

(i) The ability to talk with parents. Not to parents, not at parents, but with them. Listening is an essential part; communication must be a two-way process.

(ii) The ability to communicate sufficiently well with patients and parents so as to understand their concerns, problems, and beliefs, and to elicit relevant information.

(iii) The ability to explain the child’s illness and its treatment. The explanation should be clear, complete, and in a language that the parents can easily understand. The treatment options should be explained clearly and completely, so that they can make informed decisions about treatment.

(iv) The ability to convince parents to follow a treatment plan. This is especially important when embarking on prolonged, expensive, difficult, or culturally unacceptable treatment for a child.

(v) The ability to establish a relationship with the parents and child, based on mutual respect and trust.

(vi) "Soft skills" like being able to put all classes of parents at their ease, being able to generate confidence, and being comfortable holding conversations on non-medical subjects with parents and patients. In days of old, these were the components of a "good bedside manner", which was considered an important attribute of a successful practitioner.

There are several advantages to possessing good communication skills (Table I). In general, a doctor with these skills is more likely to have happy, satisfied patients, than an equally technically competent doctor who does not bother about communication(1). Even if a pediatrician’s diagnosis and treatment are accurate, thoroughly rational and successful, poor communication leaves parents unhappy and resentful. On the other hand, answering all questions without hesitation enhances patients’ and parents’ belief in a doctor’s expertise. This is especially so with chronic or incurable diseases, which are associated with anxiety, stress, and uncertainty for the whole family. A doctor who offers support, empathy, and clear and complete explanations at every step can help alleviate these to a significant extent. Good communication also enhances adherence to long term therapy(2). On the other hand, lack of communication can lead to treatment discontinuation and therapeutic failure. This can extend to depression and despair, or to anger and complaints.

Most complaints in health care systems, both public and private, arise from poor communication(3). Very few people can judge the quality of a doctor’s examination, diagnosis, or prescription. Obviously, relatively few complaints originate in poor performance in these areas. Parents are angered by the doctor’s refusal to spend time with them, refusal to give complete and clear explanations, a casual or callous approach to the child’s problems, and a lack of courtesy and care. When all these are followed by a poor treatment outcome, complaints, quarrels, and legal action are likely. On the other hand, good communication can play a significant part in avoiding complaints and malpractice claims(4,5).

Traditionally, we have not paid much attention to communicating well. Even today, few of us appreciate the importance of communication skills, and hardly any make a concerted effort to learn and apply such skills. This is perhaps the single biggest barrier to good communication. Unless we accept the contribution of good communication to patient outcomes and parent satisfaction, poor communi-cation is likely to remain the norm in the medical field.

Even doctors who realise the importance of good communication are not always successful at implementing it. Many of us do not realise what patients want from us (Table II). Some other barriers to good communication are:

Lack of time: Most pediatricians see a large number of patients every working day. This is true of both government and private hospitals. History taking, physical examination, and prescription writing are of course, essential parts of a clinical encounter. When time is short, it is the communication with parents that is sacrificed(6). We can overcome this, partially, by deputing some explanations to paramedical staff.

Arrogance: Arrogance is deeply ingrained into doctors. We expect our patients and their parents to follow our commands unquestioningly. We do not understand the need for explanations, and often give none.

Shyness: The parents may be very shy and not ask the questions they have in their minds. On the other hand, the doctor may be shy, and either ignore questions, or give minimal and incomplete answers. Shyness on either side stands in the way of adequate information being imparted.

Language and jargon: In any major city of India, there is likely to be a large population of people from other states and linguistic groups. Communication with them can be a problem, and needs a special effort.

Most such people will bring an interpreter with them when coming to us. However, we must use such a person well. It is necessary to give the interpreter the information in small chunks, and have him translate it for the parents as you go along. This is especially important with the prescription – explain one drug at a time and have him translate.

A major problem occurs when the parents speak English. As soon as we meet an English speaking parent, we start speaking in technical/medical language. This leaves the parents confused and uninformed. When talking in English, it is essential to make an effort to talk in language that a non-medical person can understand.

Deafness: Deafness is a major cause of poor communication(7), and is a special concern when our patients are accompanied by their grandparents. When we suspect a hearing impairment, we must speak loudly, slowly and distinctly. Other useful measures are: voice amplification, if a device is available; a quiet room, to improve signal to voice ratio; use of written communication; and asking the family, at the end of the consultation, if they have understood everything, and if they have any questions.

An important measure is to have the relatives repeat the prescription instructions, to ascertain they have been understood. This ensures that the child will receive the medication as it has been prescribed.

Phones: Earlier, a telephone would buzz discreetly on a receptionist’s desk, and a consultation would not be interrupted. Today, there’s a phone in everyone’s pocket or hand, and calls can interrupt and hinder communication terribly.

When faced with a chronic/permanent condition, most parents want to know:

The last point is especially important. Complementary and alternative medicine is a growing business, and their remedies are often advertised and promoted aggressively. Dismissing them offhand does not convince parents. It is necessary to explain treatment goals, explain how our treatment works, and convey to them the unscientific basis and unreliability of advertised "magic remedies".

Check what the parents know: With intelligent and knowledgeable parents, the discussion can begin at a higher level. However, assessing the parents’ knowledge is important, because some of their knowledge or understanding may be faulty. Many parents get their knowledge from magazines, lay books, and websites. Most of these sources have no system of review or control of the information published.

Assess what the parents want to know: Some parents want to know every little fact and detail about their child’s condition. Others simply want a prescription and an assurance that all will be well. It is important to assess the parents’ desires, and communicate accordingly.

Assess understanding: The parents may not fully understand what is being told to them. They are upset about the child being sick, they have poor comprehension skills, they have language problems – there could be many reasons. If the parents indicate that they are not fully understanding what is being told to them, stopping the explanations for that session might be appropriate and take it up next time. Understanding can be improved by giving time to absorb, and by repetition. At the end of the consultation, the parents can be asked to repeat some information, to ensure it has been under- stood.

Listening skills: Most of us hardly allow the parents to speak. As soon as they start their description of the child’s problem, we start asking questions, and attempt to keep the consultation focussed. However, this often leads to an incomplete description of the child’s problems.

Listening well is an essential part of communication. This requires the provision of adequate time and patience, and the willingness to listen to parents’ concern. A quiet room, lack of interruptions, provision of chairs for the parents, sitting at an appropriate distance, good eye contact, etc., are helpful to enhance listening and learning from the parents.

Build confidence: The parents’ confidence must be bolstered. We need to accept what the parents say, without judging it. A little specific praise for the parents’ efforts so far helps significantly in building confidence and helping parents to cope. Some suggestions for future care improve their confidence that they will be able to manage the situation. Giving false hope is wrong, but we can give information in a positive manner.

Truth: Parents like to know the truth, but the bald truth can be harsh and shocking. Parents deserve to know the truth, but its delivery should be tempered with common sense and empathy. If the facts are particularly unpleasant, they can be delivered in small parts spread out over two or more visits. However, if parents express a desire to know everything, it must be told to them. Withholding information leads to distrust.

Simplicity and clarity: Not all parents have a good educational and intelligence level. Explaining things in simple, clear, and direct language is very important. Clarity and directness are particularly important with parents of low comprehension abilities. Many people do not comprehend words like "growth" and "tumor", for example. "Cancer" sounds shocking, but may be necessary to drive home the problem to parents.

Be tolerant: Parents react in various ways, and we should be prepared. Blame, anger, a sudden outpouring of grief – all these are common reactions. We should be ready to deal with these emotions with understanding and support.

Empathy: Parents of sick children are going through a difficult experience. They appreciate the fact that their doctor understands their situation and their difficulties. While sympathy has overtones of pity and is likely to be resented, empathy is simply an understanding of the parents’ plight.

Apart from these broad principles, many small factors affect communication positively or negatively (Table III).

Good communication is an art that is so far acquired, developed and improved by experience. However, it can also be taught, and assessed, by means of structured programs(8,9). Medical students will gradually have increasing levels of training in this essential aspect of medicine. Though formal training is not easily available to doctors in jobs or practice, we can improve our communication skills with some personal efforts. This will lead to better patient/parent satisfaction and perhaps better clinical outcomes. Compassion, explanation, and reassurance are valued by our patients and their families as much as a diagnosis, treatment, and cure.

Competing interest: None stated.