Sunny Deo

You would think that communication skills come easy to healthcare professionals. After all, they are dealing with people on a daily basis—whether patients, patients’ relatives, other members of the healthcare teams or their peers—in situations where lives, quality of lives, livelihoods and general wellbeing are in imminent or potential danger. Although dealing with people in these situations is going to be stressful, healthcare professionals are highly trained, and their training is built on the foundations of good, kind communication, that allows them to transfer their knowledge in a manner appropriate for each patient they see.

Unfortunately, however, this isn’t always the case. While there has been a significant increase in the amount of time spent on good communication skills, awareness of personality types, situational judgement, neurodiversity and diversity training, I still observe, hear or see written evidence of poor or inadequate communication. I hope to delve briefly into the reasons for this lack of progress despite changes to training and resources, and introduce the ‘compass’ of clinical consultation.

Who has been on the receiving end or witnessed unhelpful comments like these?

“There’s nothing wrong with you.”
“This condition is awful. There is no way it can improve.”
“There’s nothing wrong with your knee [or other body part]; the X ray/scan/investigation is normal.”
“The evidence states this is the best option.”
“The evidence is…”
“You’re too fat/your body mass index is too high.”
“You’re too young/old to have this treatment.”
“You need this operation [or treatment].”
“There is no point considering that [other treatment option].”

Some of these statements will produce the following feelings:

• That you are being fobbed off.
• Your symptoms and emotions are being ignored.
• You are railroaded into one type of treatment, perhaps against your better judgement.
• You feel disempowered.
• You may feel humiliated.
• You may feel confused, especially if you’ve done some research and the healthcare professional has a differing view.
• Usually, later on or occasionally at the time, you may feel anger.

But that’s not all. In addition, other consulting problems may arise:

• Over focus on one diagnosis when several might be in play.
• Mistaking an underlying condition as the principal cause of a given problem rather than a contributor or co-factor or vice versa.
• Loose use of statistical terms, such as “this will make you significantly better” or “this treatment statistically has the best track record”. The use of the word ‘will’ is potentially dangerous as it implies a presumption of success that is over-ambitious. Similarly to ‘need’ a given treatment is a highly specific term that effectively excludes all others.
• Confusion with the type of diagnoses being outlined—definitive, working, differential.
• Likelihoods versus the balance of probability.

Why do people speak the way they do?

This is a question that would fill a reasonable-sized text book. However, briefly,  the way people speak is:

• Personality type.
• Emotional state.
• Cultural norms and differences, including differing power distance indices—i.e., the degree of structured hierarchy between individuals.
• Subject knowledge.
• Environmental stresses.

These factors interact and have enhancing effects on each other to produce a consultation where the communication quality can range from fantastic to terrible and unhelpful.

Environmental stresses

The key environmental stressor facing most healthcare professionals, most of the time, is time.  In the modern healthcare environment, time is at a premium and this has an impact on the clinician–patient interaction .

Here is an example of some of the key elements of a clinical consultation:

1. Discussing the patient’s medical history.
2. A physical examination.
3. Special tests—e.g. X rays, scans, blood tests (if available), then interpreting them in the context of the history and examination.
4. Review of test results, producing a diagnosis, working diagnosis or differential diagnosis.
5. Explanation of the diagnosis, particularly the prognosis concerning symptoms and any loss of function. Folding in the interactions of relevant concomitant diagnoses.
6. Outline treatment options, including the success and complication rates of each, ideally tailored to the individual’s diagnosis, symptom severity, functional loss and other relevant conditions.
7. Confirming a mutually agreed management plan.
8. Allowing time for the patient to ask additional questions.

Reducing consultation time can be a mark of a highly experienced clinician who has seen many such cases before, having a set of well-tried shortcuts to establishing a diagnosis and management plan. However, it could also be a clinician in a hurry simply shaving off key elements of the consultation. For any given clinician–patient interaction, it could be both.

Time pressure or impatience can lead the clinician to rush a consultation and increases the likelihood of them using unhelpful language.

For many conditions, this may have little or no effect on the successful outcome of the consultation; however, this isn’t always the case. It is particularly relevant if something goes awry with the diagnosis or the treatment.

Complexity science

There is another reason too, and that is how practitioners and the wider healthcare community deals with complexity.[1][2][3] In my opinion, traditional experiential wisdom has been replaced by data-driven knowledge, which for many practitioners is the bedrock on which decisions are made. However, there are flaws in the over-reliance on evidence[4] and, if this is combined with heuristics and confirmation biases, this may lead to over-confidence from some clinicians. I use the term hubris (“excessive pride or self-confidence”) for this type of behaviour. If we go back to the start of this article and look at some of the unhelpful comments, they can be recognised or defined as hubristic.

In order to visualise this a little more easily, I think of a consultation along two axes to create a ‘compass’ of clinical consultation (see diagram below): humility and hubris on one axis, and data and wisdom on the other axis. Ideally the ’good‘ clinician should be aiming for the top right corner.