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
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What happens when a president refuses to step down?

An approaching constitutional crisis has triggered deep political unrest in the Congo.

Franck Diongo reached his party’s headquarters shortly after 10am and stepped out of a Range Rover. Staff and hangers-on rose from plastic chairs to greet the president of the Mouvement Lumumbiste Progressiste (MLP), named after the first elected leader of the Democratic Republic of Congo.

Diongo, a compact and powerfully built man, was so tightly wound that his teeth ground as he talked. When agitated, he slammed his palms on the table and his speech became shrill. “We live under a dictatorial regime, so it used the security forces to kill us with live rounds to prevent our demonstration,” he said.

The MLP is part of a coalition of opposition parties known as the Rassemblement. Its aim is to ensure that the Congolese president, Joseph Kabila, who has been president since 2001, leaves office on 19 December, at the end of his second and supposedly final term.

Yet the elections that were meant to take place late last month have not been organised. The government has blamed logistical and financial difficulties, but Kabila’s opponents claim that the president has hamstrung the electoral commission in the hope that he can use his extended mandate to change the rules. “Mr Kabila doesn’t want to quit power,” said Diongo, expressing a widespread belief here.

On 19 September, the Rassemblement planned a march in Kinshasa, the capital, to protest the failure to deliver elections and to remind the president that his departure from office was imminent. But the demonstration never took place. At sunrise, clashes broke out between police and protesters in opposition strongholds. The military was deployed. By the time peace was restored 36 hours later, dozens had died. Kabila’s interior minister, claiming that the government had faced down an insurrection, acknowledged the deaths of 32 people but said that they were killed by criminals during looting.

Subsequent inquiries by the United Nations and Human Rights Watch (HRW) told a different story. They recorded more fatalities – at least 53 and 56, respectively – and said that the state had been responsible for most of the deaths. They claimed that the Congolese authorities had obstructed the investigators, and the true number of casualties was likely higher. According to HRW, security forces had seized and removed bodies “in an apparent effort to hide the evidence”.

The UN found that the lethal response was directed from a “central command centre. . . jointly managed” by officials from the police, army, presidential bodyguard and intelligence agency that “authorised the use of force, including firearms”.

The reports validated claims made by the Rassemblement that it was soldiers who had set fire to several opposition parties’ headquarters on 20 September. Six men were killed when the compound of the UDPS party was attacked.

On 1 November, their funerals took place where they fell. White coffins, each draped in a UDPS flag, were shielded from the midday sun by a gazebo, while mourners found shade inside the charred building. Pierrot Tshibangu lost his younger sibling, Evariste, in the attack. “When we arrived, we found my brother’s body covered in stab marks and bullet wounds,” he recalled.

Once the government had suppressed the demonstration, the attorney general compiled a list of influential figures in the Rassemblement – including Diongo – and forbade them from leaving the capital. Kinshasa’s governor then outlawed all political protest.

It was easy to understand why Diongo felt embattled, even paranoid. Midway through our conversation, his staff apprehended a man loitering in the courtyard. Several minutes of mayhem ensued before he was restrained and confined under suspicion of spying for the government.

Kabila is seldom seen in public and almost never addresses the nation. His long-term intentions are unclear, but the president’s chief diplomatic adviser maintains that his boss has no designs on altering the constitution or securing a third term. He insists that Kabila will happily step down once the country is ready for the polls.

Most refuse to believe such assurances. On 18 October, Kabila’s ruling alliance struck a deal with a different, smaller opposition faction. It allows Kabila to stay in office until the next election, which has been postponed until April 2018. A rickety government of national unity is being put in place but discord is already rife.

Jean-Lucien Bussa of the CDER party helped to negotiate the deal and is now a front-runner for a ministerial portfolio. At a corner table in the national assembly’s restaurant, he told me that the Rassemblement was guilty of “a lack of realism”, and that its fears were misplaced because Kabila won’t be able to prolong his presidency any further.

“On 29 April 2018, the Congolese will go to the ballot box to vote for their next president,” he said. “There is no other alternative for democrats than to find a negotiated solution, and this accord has given us one.”

Diongo was scathing of the pact (he called it “a farce intended to deceive”) and he excommunicated its adherents from his faction. “They are Mr Kabila’s collaborators, who came to divide the opposition,” he told me. “What kind of oppositionist can give Mr Kabila the power to violate the constitution beyond 19 December?”

Diongo is convinced that the president has no intention of walking away from power in April 2018. “Kabila will never organise elections if he cannot change the constitution,” he warned.

Diongo’s anger peaked at the suggestion that it will be an uphill struggle to dislodge a head of state who has control of the security forces. “What you need to consider,” he said, “is that no army can defy a people determined to take control of their destiny . . . The Congolese people will have the last word!”

A recent poll suggested that the president would win less than 8 per cent of the vote if an election were held this year. One can only assume that Kabila is hoping that the population will have no say at all.

This article first appeared in the 01 December 2016 issue of the New Statesman, Age of outrage