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Tuesday Mar 14, 2017

Mastering the Art of Communication Takes Compassion

Communication is the key to success in many professions, but there are few for which the stakes are as a high as they are for physicians.

How we wield our ability to express thoughts and ideas can deeply impact how well we perform. For us, miscommunication can sometimes have serious consequences. Thankfully, we have years of training and many resources to help us bridge communication gaps and maximize the transmission of clear and accurate information.

As physicians, we can use the whole communication toolkit -- from social media platforms and educational campaigns to gadgets (such as flash drives and iPods), informational handouts, reminder cards, visit summaries, and patient portals. We have everything we need to get the job done. In fact, physicians have led the way in some communication techniques. For instance, who can deny that long before emojis became trendy we were using smiley and frowny faces in the Wong-Baker FACES pain scale to help children tell us about their pain?

However, we must not minimize the importance of having clear one-to-one conversations with our patients to accurately gather diagnostic information and to effectively communicate the workup and treatment plan. Despite our best efforts, many obstacles can stand in the way of good communication.

Having started my medical training in Guadalajara, Mexico, and completing medical school and residency in the diverse community of the Bronx, N.Y., I can attest to the difficulties of communicating vital medical information when confronted with language barriers. In one way or another, all of us have faced such communication challenges. It is because of this reality that the United States Medical Licensing Examination Step 2 CS (Clinical Skills) Exam puts such a premium on the importance of clear, effective communication during patient encounters and in clinical documentation.

I experienced this firsthand during medical school and residency when I helped teach a CS preparatory course that was geared toward international medical students. From my unique vantage point as both a standardized patient and a teaching assistant, I was impressed by the fact the most difficult challenge these students faced was the ability to gather and share information in a second language.

I now work in a rural community where I care for a variety of patients with their own unique sets of ideas, traditions, misconceptions and regional language characteristics. These patients range from farmers and closed-community Mennonites and Amish to students, academics, ministers, business people, and transplanted urbanites.

Each patient encounter is unique and requires a slight variation in how communication is approached. For patients who do not use modern technology, communication can be more difficult, but this is easily remedied by scheduling followup visits to review labs and imaging studies at the time they are ordered. This is a habit I have tried to employ for all results so I am sure to have thoroughly addressed them, and decisions regarding followup studies or treatment can be made on the spot with the patient's involvement and consent.

Between medical school, residency and life as practicing physicians, we all have countless stories of communication mishaps we can tell. For instance, I can recall using "Spanglish" when trying to provide infant care education and anticipatory guidance to Hispanic couples who were more familiar with rearing children than I was. This happened on a number of occasions, and I distinctly remember the feelings of awkwardness and insecurity when fumbling through my canned text of things I was supposed to say while the couple politely nodded with looks of amusement on their faces.

Like many of you, I have faced the difficult task of delivering a terminal diagnosis or poor prognosis to a patient and/or the patient's family while facing their shocked and disbelieving stares.

There also have been many instances when I have had to tactfully educate and encourage resistant patients to agree to be vaccinated or receive a routine screening (a colonoscopy, for example) or to consider completing an advance directive.

I have had to calm angry, tearful and anxious patients and even talk a suicidal patient down from the proverbial ledge. I have also had to inform patients that I no longer felt comfortable providing them with prescriptions for narcotics or other controlled medications because of their failed drug screens or other evidence of aberrant behavior -- then faced their wrath as they stormed out or later launched a complaint.

I am still learning how to communicate effectively, and I know I have a long way to go. Fortunately (or unfortunately, depending on your perspective), we have patient satisfaction surveys and other performance metrics to track our progress and help us right our course. I find the processes and procedures of quality control measures and improvement initiatives to be tedious and cumbersome, but they can be useful to some degree.

The crux of the matter is that we are experts at juggling and processing piles of data, inputting and outputting information at dizzying rates, yet we have varying degrees of skill and are all at different levels of experience. Despite this, our patients and staff look to us to perform at the same level as the most seasoned and tech-savvy medical professionals. Unfortunately, seasoned and tech-savvy are two traits rarely found in the same person. Thankfully, family physicians are some of the most patient, resourceful and adaptable people on the planet, so one way or another, we get the job done.

I may not have all the answers, but I know where to find them. When it comes to relaying information, I am getting better at being clear and concise. I may be part of a medical community where consensus guidelines and algorithms rule the day, but when I am sequestered in an exam room with a patient giving me the quizzical eye or breaking down in tears, I realize that in that moment, I stand alone.

Ultimately, I have found that the key to bridging the language gap between providers and patients is to show how much you care. This can be done through attentive listening, empathetic feedback and positive reinforcement. One thing is certain: From hieroglyphics to hashtags, communication is still an art.

Kurt Bravata, M.D., is a family physician who practices primary care, geriatric medicine and addiction recovery medicine in rural southwest Missouri.

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