At medical school, we were taught a lot about communication, to the point it almost felt like the course was a communication degree with a medicine module thrown in. We would have (at least) weekly sessions, particularly during the early years or “phase 1” where we learned the basic science and anatomy that underpins modern medicine. It would form an integral part of our objective structured clinical examination (OSCE) assessments, which were our practical exams.
During this time, I had always felt confident with communication skills and considered myself to be au fait with managing most clinical scenarios. However, as soon as I started foundation training, I really began to appreciate the nuances of communication, especially during my oncology placement where breaking bad news and communicating effectively with emotionally charged and grieving families formed the mainstay of the day job. It was as clear as day when poor communication was at play and the disputes that ensued were certainly never any less awkward to witness.
More recently though, I observed a challenging situation which warranted the utmost skill with respect to effective communication (all clinical details herein are fictional bar the nature of the circumstances). A patient had been readmitted for the umpteenth time with a purulent discharging wound. The wound had previously undergone several washouts and was improving clinically, as well as biochemically. This time, the incremental improvement was visible, despite the persistent purulent leakage; the wound appeared clean and dry, with no surrounding erythema.
The real hurdle arrived in the form of the patient’s close relative. They were furious at the repeated admissions and were under the impression that this reflected a failure of medical management. Initial attempts by the consultant to pacify the relative were futile, who progressively became more and more irate to the point they walked out of the consultation. This unpleasantry left everyone present feeling palpably shaken and we retired to apply the proverbial balm to soothe our wounds. It then transpired that another relative would visit to resume the original conversation so we proceeded to await their arrival.
“Bleep”
The substitute relative had arrived. My consultant and I made our way back to the ward, apprehensive of the ordeal that potentially lay in wait. The conversation immediately commenced on the offensive, with the relative demanding to know our names, which they promptly recorded in a notebook, why we were objecting to them recording the conversation and what, therefore, were we hiding (no objection had actually been made to them recording the conversation, it was actually encouraged), and why we wanted the patient to die. Pretty gnarly stuff for introductions. The subsequent conversation played out like a record on repeat until eventually a satisfactory decision was reached for the relative (which was unfortunately not the ideal clinical decision).
In summary, this was not the best situation to be in, both from a clinical and a personal perspective. This conflict inevitably left us feeling rather raw and added an element of distaste to the rest of the on call shift. There is evidence to show the reduction in staff morale following conflict, along with increased levels of emotional friability, can negatively impact patient care (1). However, when I took a moment to reflect on the discussion, I uncovered a lot of clues which, with the power of hindsight, revealed a great deal about the origin of the conflict. I also identified things that I feel could have helped ameliorate the various obstacles. See below:
1. Names and the conversation which ensued were recorded in a notepad.
This immediately highlighted distrust. For someone to feel as though they wish to record everything that is being said indicates they feel vulnerable to the party with which they are having the conflict. This relative clearly thought we were out to get them and were hiding something. The prior series of events leading up to this point had not matched their expectations and they were therefore defending themselves. The distrust was in fact proven during the discussion itself when the relative alluded to previous “bad experiences” which had left them feeling let down by the healthcare services. This now provides a panoramic view of the backdrop to this conversation, where it is clear the relative was weighed down by a history of perceived negative healthcare encounters.
Fix: Next time this occurs, I will remember that there is likely to be some history involved with this type of behaviour. It may be worth spending some time to unpick the patient/relative’s views and experiences, and to empathise with them in order to improve rapport. This may help to build a better foundation for the remainder of the conversation.
2. “Why do you want (patient) to die?”
Any healthcare professionals will know that this statement is utterly unfounded. Extremely rare situations have occurred where there has been a healthcare professional with malignant intentions. However, the ethical code of conduct with which we are correctly indoctrinated holds fast throughout every aspect of our practice. The patient’s relative was nonetheless absolutely convinced that the events up until now had reflected medical negligence and therefore translated into intention to kill. It is compellingly evident therefore that somewhere along the line, they have not understood what is occurring with this patient’s care plan. When it came to the underlying pathology itself of the original problem, this was an incorrect belief as multiple washouts and antibiotic courses are not uncommon. But they clearly did not anticipate this, nor were they expecting the sequelae involved in the healing process of the wound. Their expectations had been misaligned seemingly from the beginning, and repeated admissions therefore simply reinforced the belief that the healthcare system had failed to manage a problem that, to them, should have managed the first and only time.
Fix: This seems to be a longer term problem, so I think the ideal solution would have been to set up their expectations more firmly from the beginning. However, in the more acute setting, I feel it may be helpful to firstly provide express reassurance that our intentions are benevolent, and then to provide full details on the clinical sequalae involved with and the care necessitated by the original pathology. Effectively, retrospectively resetting their expectations.
3. Broken record.
The repetitive nature of the retorts and accusations made by the patient’s relative reflected something interesting. Firstly, it was highly likely that their stressed, vulnerable and defensive state rendered them unable to hear and comprehend what was conveyed to them. Another explanation would be that they could not understand what was being said to them, as it wasn’t communicated in suitable language for their level of lay understanding. Secondly, there’s a possibility that they felt as though their concerns had not been satisfactorily acknowledged. Thirdly, they may have had this bottled up inside and needed to vent. Lastly, they may not have been reaching the answer they wanted and so kept repeating the same thing. All in all, it was a clear sign of an error state somewhere in the spectrum of communication.
Fix: I feel there is often an assumption that the patient understands everything we say. However, the use of language which appears too simple risks the patient/relative feeling patronised. It’s a fine balance, which I am assuredly no master of, but I imagine the recognition that the above reasons could be causing the repetitive statements may help guide the explanation process. For example, a patient/relative could be repetitively stating that the wound infection is in fact a “body” infection. This suggests they haven’t fully understood the nature of wound infection and the fact that it can not only involve the skin but also the underlying layers of muscle and subcutaneous fat. A simple explanation +/- diagram could most probably fix this instantaneously.
4. Future planning.
I strongly feel this helps close the encounter with some empowerment and reassurance for the patient/relative. Understandably, the last thing they would want, particularly after a discussion like this, is to be left in the dark once again. Oftentimes, the option to come back to A&E if things get worse heavily places the onus on the patient/relative themselves, which can cause a great deal of anxiety.
An additional point I feel is important to reflect on is that despite discharge summaries, some patients/relatives may still not understand what is occurring. This is because they may not be able to understand the language utilised in the summary. It also may be because they cannot read. In communities where there are either higher proportions of non-English speaking ethnic minorities or low levels of literacy, this can be a major confounding factor in routine healthcare communication. This is an aspect I have learned and appreciated more fully following this encounter.
The only real way to concisely summarise this situation is to say it was a difficult yet not uncommon situation which necessitated a whole host of communication skills. Unfortunately, with the widespread dissemination of distrust through media outlets, patients have an even harder time believing what is told to them. Understandably, therefore, if they don’t understand something, it is perceived as a threat and the defences fly up. Unpicking this and collaboratively formulating a strategy with them could be a route to patient/relative empowerment and consequential re-establishment of trust.
References:
- Civility Saves Lives, 2020, Incivility: The Facts (Infographic). https://www.civilitysaveslives.com/infographics?lightbox=dataItem-j9wmt66l [Accessed 23 Oct 2020]
Vasudev Zaver 