How to speak so that patients listen to us and how to listen so that patients speak to us?

antonina doroszewska

The key to successful therapy is good communication. And anyone can learn it, there is evidence of it shown in many studies. At our university, we train not only future doctors, but also future nurses, midwives, paramedics and nutritionists - all medical staff. This distinguishes us from other universities - says Antonina Doroszewska, PhD from the Medical Communication Department of the Medical University of Warsaw.

Since when are communication classes conducted at the Medical University of Warsaw?
Antonina Doroszewska, PhD: The Medical Communication Study has existed since 2018. We conduct obligatory classes from the 2018/2019 academic year. It was then that we implemented a comprehensive curriculum. Of course, this does not mean that nothing was done in this area before. The subject of communication was introduced at the Second Faculty of Medicine a few years earlier. On the other hand, in the remaining faculties, knowledge in the field of communication was transferred within other subjects or optional classes. Currently, we conduct classes at various faculties: medicine, health sciences, medicine and dentistry. We have classes for students of medicine, medicine and dentistry, obstetrics, nursing, dietetics, emergency medical services, dental techniques and dental hygiene. Compared to other medical universities that only train future doctors in communication, we are doing very well. I even think that we are in the lead in this regard. We strive to implement at least a basic but comprehensive communication curriculum in all of the aforementioned faculties. Comprehensive, i.e. one that allows students to form and develop key communication competencies. It is a program that takes into account both the development of knowledge about communication and the acquisition of the skill of communicating with the patient, his relatives and colleagues.

There are people who are more and less empathetic. Can everyone be taught good communication?
A.D.: My own research shows that the level of empathy among students varies. It is easier for those who have a higher level to understand the perspective of patients and to talk to those who are sick. But we also know from research that communication skills can be developed. An appropriate curriculum enables students to acquire communication skills and be able to apply them in real clinical situations.
During the classes, we try to develop communication skills both with patients and with colleagues. It is worth remembering about the latter aspect. It is important both from the point of view of people working together and from the point of view of the patient, who feels much safer when looked after by a well-coordinated team.

What is the most important for good communication?
A.D.: It is very difficult to specify one aspect that would be the most important. Because is it more important that medical personnel should be able to listen or that they should be able to convey information well? Both are equally important. Without good listening, it is difficult to make a good diagnosis and refer to tests or treatment adequate to the patient's condition. On the other hand, even a well-collected interview and a correct diagnosis are not enough if the staff is not able to convey information in a clear and understandable way taking into account the patient's perspective. The ability to cope with various stressful situations, especially emotional ones, is also very important. To sum up - communication competences are a certain set of knowledge, attitudes and skills. They are based on values such as trust, autonomy, respect and empathy. And this is exactly how we want to shape communicative competences in a comprehensive way.

How do you teach these skills?
A.D.: We start with lectures, so the transfer of knowledge. In this way, we show that there are certain methods that are rooted in research results. They can be described and students can just learn them. At the next stage, we aim to practice our skills. These are workshop activities where students discuss, exchange opinions, play roles and participate in simulations. Simulations are a key element of our classes.

What are these simulations?
A.D.: These are conversations with simulated patients, i.e. actors. We recreate situations that may happen to our students every day during classes in the clinic and later, when they start practicing in a hospital, clinic or other institutions. In order to accurately reflect such situations, we create their detailed scenarios. We characterize the patient's situation in both medical and psychosocial aspects. This information is primarily needed by our simulated patients to know how to prepare for the role. In the scenario, we also describe the context very precisely: where the conversation takes place, what preceded it, what tests or procedures were performed on the patient, what are the recommendations for the patient, etc. The student is to find himself in this situation and conduct a conversation with the patient focused on the implementation of specific didactic goals related to the improvement of conversation skills. After the conversation, we discuss what happened. All this is done in accordance with the methodology of conducting this type of classes, so that, on the one hand, students can get the most out of them, and on the other, to ensure the standardization of the education process. We also make sure that communication classes are conducted by experts in this field. Each one of us communicates daily, but not everyone does it according to the rules. Every healthcare professional talks to patients every day, but numerous experiences of patients show that not all do it professionally. Even more so, not everyone is qualified to conduct communication classes. We attach great importance to the fact that these classes are conducted by specialists in the field of medical communication. This is what the team at the Medical Communication Center is all about.

Can you give an example of a scenario realized during the simulation?
A.D.: In a moment I have classes during which we will rehearse and analyze the following scenario: An 85-year-old patient came to the ER with his son. The patient had impaired consciousness. He has been at the ER with his son for many hours now. Numerous tests and procedures were done on him. They are both very tired and the son is also nervous. He is worried about his father. The task of the student who will act as the doctor will be to inform that the patient will be discharged home and to give appropriate recommendations. How the conversation unfolds depends on whether it will be an exercise in communicating information or in dealing with the expectations of the patient's family. The information about the discharge is very often unacceptable for the family - in this case for our patient's son. He believes that the hospital wants to get rid of the elderly patient and that the doctors have not looked after his father well enough. If we imagine fatigue, stress, fears, it is easy to predict that the response to what the doctor says can be very different.

Dealing with a patient's emotions, conveying unfavorable information, is a difficult task. Can students count on detailed instructions on how to do this?
A.D.: We teach methods developed on the basis of well-established knowledge and the results of many studies. We show that there are protocols that help to conduct such conversations. For example, giving bad news. Here we have two protocols that we tell students about: SPIKES and EMPATHY. The latter was created by professor Aldona Katarzyna Jankowska from the Collegium Medicum UMK and the president of the Polish Society of Medical Communication. We include the most important tips there. We start with making a plan for such a difficult conversation. We are looking for a suitable, quiet place where it can be carried out. We show the patient interest and engagement (e.g. we ask what they think about the situation in which they find themselves). We deliver the message directly and simply. Finally, we show empathy - which is a key element in such a conversation. However, I would like to strongly emphasize here that we cannot view communication methods as rigid procedures that must be followed by medical personnel. It needs a degree of flexibility.  

What does this mean in practice?
A.D.: This means that the patient's perspective must be taken into account every time. We want our students to be able to notice and identify what is going to be crucial in contact with a given person. There are patients for whom the most important thing is medical knowledge and precise communication of all information. They need a professional doctor. But there are also many people for whom the most important thing is that the doctor shows them concern and empathy. Such patients are looking for a doctor-caretaker. When we are conducting classes in communication, we want students to be able to quickly recognize what the patient's expectations are, and at the same time have a whole range of skills to deal with the situation at hand. In communication classes, we always take these two plains into account - i.e. we teach specific skills and the ability to use them depending on the context.

It is now emphasized that good communication with the patient means better recovery rates. Research proves this. How does communication translate into more effective therapy?
A.D.: Let's start with the diagnosis. In order to correctly make a diagnosis and order appropriate tests, you need to do a good interview. Adequate questions should be asked, and space for the patients to say what is of key importance to them. Sometimes encouragement is needed to bring out embarrassing information or information that the patient does not necessarily want to talk about right away. Another issue is the way of providing information about what is wrong with the patient, what it entails, and what treatment is possible. Whether or not the patients follow the instructions depends on their ability to understand this. Communication skills also help motivate the patient to, for example, stick to a diet or be physically active. It is worth emphasizing that communication is also an important trust-building tool. If the patient trusts their doctor, they are more likely to ask a question, talk about their difficulty in complying with the prescription, or that they are afraid to go to a test. Usually, patients' decisions depend on such often unspoken doubts: I will go get tested / I do not go get tested, I will follow a diet / I will not stick to it, I will take medications consistently / I will do it my own way. Good relationships based on trust and understanding with healthcare professionals are of paramount importance for the decisions patients will make about their health.

Interviewed by: Iwona Kołakowska
Photo: Michał Teperek
Communication and Promotion Office MUW