Why do doctors struggle to communicate with their patients?

Many doctors turn their nose up at the art of communication, viewing it as potentially soft medicine.

Last month, the GMC reported that the number of complaints regarding doctors have increased by 23 per cent with complaints received focusing primarily on how doctors interact with their patients. Allegations about communication in particular have increased by 69 per cent with a lack of respect rising to 45 per cent. Dr Niall Dickson, Chief Executive of the GMC, commented that:

"the rise in complaints did not necessarily mean worse care and that the evidence was actually about rising levels of satisfaction with medical care across the country."

Katherine Murphy, Chief Executive of the Patients Association, reported that

"the huge rise in complaints in relation to communication and a lack of respect are of particular concern. Patients are not receiving the compassion, dignity and respect which they deserve."

For several years, medical schools across the UK have taken steps to help train future doctors enhance their communication skills. Throughout their training, students are expected to undertake role play sessions to help simulate situations they may face in the future either on the wards or in the GP setting. These can include anything from breaking bad news to communicating with an angry patient or explaining a procedure such as endoscopy. At the time, I can admit to doubting its relevance. However, looking back, those sessions certainly helped me to improve my patient interaction and appreciate what being a patient may actually feel like.

And of course don’t just take my word as gospel. A study by Dr Debra Nestel and Dr Tanya Tierney at Imperial College looked at the merit of role play during students’ first year at medical school. The scenario utilised centered on a "patient" who had come to see their GP following sustaining a wound to their hand in the garden. The patient is instructed to act worried about the wound using non verbal and verbal clues. And as the wound occurred following contact with a nail, the patient may as a result need a tetanus injection, and is instructed to act frightened of injections. Students are then assessed on their overall ability to assess why the patient has come to the GP and their ability to assess the patient’s ideas, concerns and expectations (ICE). The results of their research found that role play was an effective means of learning communication skills with over 96 per cent of students reporting it as helpful.

Of course role play is just one example of improving one’s communication skills. Dr Alan McDevitt, chair of the BMA Scottish GP committee, recently reported that his mother’s influence in persuading him to get his first job selling cream door to door aged 11 helped him to learn a lot of communication skills.

However despite some success stories, the current evidence suggests that doctors on the whole are failing to demonstrate their bravura in real life.

Dr Clare Gerada, chair of the Royal College of General Practitioners commented that:

"a number of factors could be responsible for the increase in complaints including over-worked and stressed doctors failing to communicate well and a growing culture of complaining."

She went on to say that:

"‘We must always be kind and compassionate. In the end, being kind and compassionate is what is important about being a doctor and what patients want."

Many doctors turn their nose up at the art of communication, viewing it as potentially soft medicine. And speaking with colleagues the general consensus is that patients surely want a doctor who simply knows their stuff, regardless of how they communicate. It seems however the inability of doctors to communicate well is not only being discussed among adults – its transition to the animated world surely serves to emphasise Oliver Goldsmith’s mind set: "People seldom improve when they have no other model but themselves to copy."

Neel Sharma is a medical doctor and Honorary Clinical Lecturer at the Centre for Medical Education, Barts and the London School of Medicine and Dentistry

 

A doctor examines a patient. Photograph: Getty Images
Photo: Getty
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The Prevent strategy needs a rethink, not a rebrand

A bad policy by any other name is still a bad policy.

Yesterday the Home Affairs Select Committee published its report on radicalization in the UK. While the focus of the coverage has been on its claim that social media companies like Facebook, Twitter and YouTube are “consciously failing” to combat the promotion of terrorism and extremism, it also reported on Prevent. The report rightly engages with criticism of Prevent, acknowledging how it has affected the Muslim community and calling for it to become more transparent:

“The concerns about Prevent amongst the communities most affected by it must be addressed. Otherwise it will continue to be viewed with suspicion by many, and by some as “toxic”… The government must be more transparent about what it is doing on the Prevent strategy, including by publicising its engagement activities, and providing updates on outcomes, through an easily accessible online portal.”

While this acknowledgement is good news, it is hard to see how real change will occur. As I have written previously, as Prevent has become more entrenched in British society, it has also become more secretive. For example, in August 2013, I lodged FOI requests to designated Prevent priority areas, asking for the most up-to-date Prevent funding information, including what projects received funding and details of any project engaging specifically with far-right extremism. I lodged almost identical requests between 2008 and 2009, all of which were successful. All but one of the 2013 requests were denied.

This denial is significant. Before the 2011 review, the Prevent strategy distributed money to help local authorities fight violent extremism and in doing so identified priority areas based solely on demographics. Any local authority with a Muslim population of at least five per cent was automatically given Prevent funding. The 2011 review pledged to end this. It further promised to expand Prevent to include far-right extremism and stop its use in community cohesion projects. Through these FOI requests I was trying to find out whether or not the 2011 pledges had been met. But with the blanket denial of information, I was left in the dark.

It is telling that the report’s concerns with Prevent are not new and have in fact been highlighted in several reports by the same Home Affairs Select Committee, as well as numerous reports by NGOs. But nothing has changed. In fact, the only change proposed by the report is to give Prevent a new name: Engage. But the problem was never the name. Prevent relies on the premise that terrorism and extremism are inherently connected with Islam, and until this is changed, it will continue to be at best counter-productive, and at worst, deeply discriminatory.

In his evidence to the committee, David Anderson, the independent ombudsman of terrorism legislation, has called for an independent review of the Prevent strategy. This would be a start. However, more is required. What is needed is a radical new approach to counter-terrorism and counter-extremism, one that targets all forms of extremism and that does not stigmatise or stereotype those affected.

Such an approach has been pioneered in the Danish town of Aarhus. Faced with increased numbers of youngsters leaving Aarhus for Syria, police officers made it clear that those who had travelled to Syria were welcome to come home, where they would receive help with going back to school, finding a place to live and whatever else was necessary for them to find their way back to Danish society.  Known as the ‘Aarhus model’, this approach focuses on inclusion, mentorship and non-criminalisation. It is the opposite of Prevent, which has from its very start framed British Muslims as a particularly deviant suspect community.

We need to change the narrative of counter-terrorism in the UK, but a narrative is not changed by a new title. Just as a rose by any other name would smell as sweet, a bad policy by any other name is still a bad policy. While the Home Affairs Select Committee concern about Prevent is welcomed, real action is needed. This will involve actually engaging with the Muslim community, listening to their concerns and not dismissing them as misunderstandings. It will require serious investigation of the damages caused by new Prevent statutory duty, something which the report does acknowledge as a concern.  Finally, real action on Prevent in particular, but extremism in general, will require developing a wide-ranging counter-extremism strategy that directly engages with far-right extremism. This has been notably absent from today’s report, even though far-right extremism is on the rise. After all, far-right extremists make up half of all counter-radicalization referrals in Yorkshire, and 30 per cent of the caseload in the east Midlands.

It will also require changing the way we think about those who are radicalized. The Aarhus model proves that such a change is possible. Radicalization is indeed a real problem, one imagines it will be even more so considering the country’s flagship counter-radicalization strategy remains problematic and ineffective. In the end, Prevent may be renamed a thousand times, but unless real effort is put in actually changing the strategy, it will remain toxic. 

Dr Maria Norris works at London School of Economics and Political Science. She tweets as @MariaWNorris.