Why communication more important now than ever

TAUREEF MOHAMMED

AS DOCTORS-IN-TRAINING, we all had an imaginary list of “Things to master to be a good doctor.” In medical school the list included things like memorising Latin and Greek names of body parts, taking a history (Could you tell me more about the chest pain?), examining a patient (May I listen to your heart?), interpreting lab results (Why is the sodium level so low?), reading radiographic images (What is that strange thing there?), performing simple procedures.

As we progressed through training, the list changed – things got ticked off, added, and, when they became outdated and obsolete, crossed out. In the end, we hoped that the core skills we needed to be good doctors would eventually become second nature through practice and repetition.

Communication was never on the list – at least for me. I knew communication was an essential skill for a doctor and, during training, everyone took courses on communication, learned how to break bad news and how to counsel patients on various medical issues, practised for the purpose of passing simulated exams, but I did not give it the same priority as, say, knowing how to diagnose a stroke or heart attack.

This was not unreasonable. Does a patient want a doctor who could communicate well or one who would not screw up? Ideally, both. But as a trainee, for the most part, you are more focused on learning how to not screw up. The aim was to be an expert in diagnosing and treating – not an expert in communication. Communication – particularly navigating difficult conversations – was not the goal.

In this prioritising of the science over the art, the practice of medicine became mechanical and tedious. It was a phase of training that we all had to go through.

Did we kick ourselves out of it, though? Or were we indoctrinated from the start to practise a mechanical kind of medicine that was just very 21st-century? Are we limited by the overburdened healthcare system that pushes patients along like a production line? Or is that we just don’t feel comfortable having a difficult conversation – it was not on the list – so we do not prioritise it?

Whatever it is, something is amiss.

According to a 2023 Health Canada report, 70 per cent of people with a serious illness do not understand that their illness is incurable and will progress over time, and only ten per cent of clinician recommendations are guided by patients’ values and goals. Doctors and patients are not on the same page – something in the doctor-patient relationship needs to be fixed, and that something is communication.

In 2012, Atul Gawande – surgeon, writer and researcher – co-founded Ariadne Labs at Harvard University. “We are named for Ariadne, the Greek goddess who showed the way out of the Minotaur’s labyrinth with a simple thread – for we are trying to provide simple solutions to navigating the maze of healthcare complexity,” the website says.

One of their innovations was the serious illness conversation guide, “a structured communication tool based on best practices in person-centred communication.”

It is a tool that guides clinicians, step-by-step, on how to have a conversation with a patient with a serious illness.

A couple months ago, the geriatric medicine and oncology departments at the hospital where I work conducted a workshop on how to implement the guide in daily clinical practice.

“If you ask yourself the question, ‘Would I be surprised if this patient dies within the next two years?’ and the answer is ‘No,’ then you need to have a serious illness conversation with the patient,” one of the instructors, a geriatrician, explained.

We divided into groups – my group included an oncology resident, an oncology nurse practitioner, and a palliative care nurse practitioner – practised having serious illness conversations.

“It would feel clunky the first few times,” another instructor added, “but stick with the guide.” Like trying to suture a wound for the first time, it was clunky.

We role-played patients with heart failure, COPD, Parkinson’s disease, dementia, all incurable diseases that progressed with time and were becoming more prevalent as the ageing population increased.

These conversations, research showed, led to decreased distress among patients, improved work satisfaction among clinicians, and decreased healthcare costs.

Navigating a difficult conversation well is a win-win for everybody, it seems. But, like everything else in medicine, it’s a skill that needs to be honed.

Taureef Mohammed is a graduate of UWI and a geriatric medicine fellow at Western University, Canada