Communications and emotions

Anyone who wants to be regarded as a good doctor needs to possess effective communication skills. Everyone expects that of us, but the truth is that good communication is often quite difficult and training for it is still developing.

Communication skills make an appreciable difference to clinical management. We take for granted our own communication abilities in history taking, but further training can enhance our ability to diagnose and treat conditions, including depression.¹ Communication is often a major component of the medical management in chronic and palliative care: sometimes it is all we have to offer. Compared with most medications, communication skills have undoubted palliative efficacy (often reducing symptoms significantly), a wide therapeutic index (overdose is rare), and the commonest problem in practice is suboptimal dosing. At a more mercenary level, poor communication skills have been shown to be a predictor of medicolegal vulnerability and also of burnout.²,³

Yet, although the clinical value of these skills has been known for many years, it has traditionally been difficult for many doctors to accept the idea that something as supposedly intuitive as communication could or should be influenced by teaching or training. It was a commonly held belief that communication skills could not be taught: they were natural talents—inborn attributes of the “good doctor”—and a young doctor was either endowed with them or not. For decades it was debated whether these techniques could be taught and learnt, and whether anything could be done to bring the more awkward communicators to a reasonable, or at least average, level. Mounting evidence has shown clearly that these goals are achievable and that these skills can be taught, do change patient satisfaction, and can be retained over time.⁴ In this edition of the BMJ, Maguire and Pitceathly present an overview, detailing those tasks that should be considered as key communication skills and surveying the research, teaching, and retention of those skills.⁵

All of this makes the task of handling emotions—the patient's and the doctor's—even more important. Emotions are notoriously difficult to deal with in clinical practice: a recent survey of oncologists showed that this was by far the most difficult element in breaking bad news.⁶ Many factors are involved. Although much of a patient's distress may be triggered by the medical reality, often nobody is around to blame for the message but the messenger. We may also bring our own emotional mixture to the interview: feelings in sympathy with the patient, feelings of transference, our own frustration, anger, and so on. As Maguire and Pitceathly highlight in their article, the emotional atmosphere may be so intense that we use blocking behaviours to protect ourselves.

The actual process of acknowledging and addressing emotions is not impenetrable or esoteric. The central techniques are straightforward. The empathic response, for example, is a technique that consists of three steps: (1) identifying the emotion, (2) identifying the source of the emotion, and (3) responding in a way that shows you have made the connection between the first two steps. The belief that the clinician is supposed to experience what the patient is feeling is incorrect and may actually be unhelpful in acknowledging and addressing the patient's reactions. As the saying goes, “You do not need to have pain in your own right iliac fossa in order to diagnose a patient's appendicitis.”

Teaching techniques are evolving rapidly and becoming much more accessible and intelligible. Communication teaching methods in many centres currently involve the use of standardised patients. A paper by Luck and colleagues in this issue (p 679) shows that they are a valid measure of the quality of doctors' care.⁷ Recording the interview with feedback on video is also effective.⁸ Specific tasks, including breaking bad news, can be approached by using relatively straightforward strategies that can alter the professional's sense of competence.⁸,⁹ In terms of wider availability of teaching materials, videos and CD Roms can show how complex situations may be approached by using basic strategies and relatively simple techniques.¹⁰

Expectations of the general public and of our patients are high. Based on what they see on television and read, most people have high expectations of our medical prowess and our communications. We will never meet everyone's expectations, but the skill and effort that we put into our clinical communication does make an indelible impression on our patients, their families, and their friends. If we do it badly, they may never forgive us; if we do it well, they may never forget us.

Papers p 679Clinical review p 697