Medical school began with a series of “introduction to medicine” lectures. One of them was on communication, taught by the same professor who introduced us to medical ethics. In the medical ethics class, through a case-discussion, she impressed upon us the need for being non-judgmental when dealing with patients. She did a fantastic job, considering she had just one 45 minute lecture. Her lecture on communications, though, is a blur. In my defense it was 11 years ago and I remember her parting words very well. When we told her after the lecture that there was just one session on communication and this clearly needed more sessions- she said "I've been telling them, but who listens to psychiatrists?" ~~~~~ "Go call nurse Anbu, she is good at TLC, don’t waste your time doing too much of that" TLC, I learned on my first day as an intern, stood for Tender Loving Care and was given to highly emotional patients in the form of hand holding, head nodding and tear-wiping. It was delivered mostly by nurses, unless you had the time (you never did) or it was a special patient (like a young mother who lost a child). While there were those who looked at this derisively, throughout my education and training, it was impressed upon me again and again that patients have needs that cannot be expressed verbally and those too needed to be addressed by the doctor. I was told that I must be courteous and nice to patients. I was to remember that their suffering made them irrational and often angry and sad, and it was my responsibility to rise above the situation and comfort them, and "be nice”. However, throughout the time that I spent there, other than that one lecture, never was I given any further direct teaching about communication. More importantly, never was communication treated as a goal in itself as part of the treatment. All I learned and what I was expected to learn was from watching senior doctors deal with patients. ~~~~~ I came across a set of guidelines on doctor-patient communication the other day. It was structured, had terms like goal setting, expectation setting, addressing health beliefs etc. I remember days as an intern when I saw 30 patients in 5 hours. Let alone addressing their health beliefs, I don’t think I had the time for a thorough examination. Can one set such high standards in communication for doctors and in hospitals in India? Dr. K is a specialist in physical medicine and rehabilitation. When I met her recently, she was working in a PHC a few km from home. She told me that work was hectic, but most days it was peaceful. When I asked how many patients she sees, “150 on a good day”, she said, “I loose count on the bad days. “ 7 hours of work, 150 patients, with no breaks in between give her less than 3 minutes to hear a patient, examine, diagnose and write the prescription. I’ve done this kind of work, once, when I was an intern. This was right after the Tsunami and every month or so a team from the public health department went to hold a camp. Free consultation, cheap medicines was the formula. Everything infectious was treated with Co-trimoxazole or anything else with a combination of Ranitidine, Paracetamol and lots of vitamins. If I had to do more than 2-3 days of such camps, I am sure I would have had a burn-out. There are many thousand doctors working like this every day in India. Many by choice, many because they have to as part of their "bond". Many more, do this because they don’t know of any other way. The flow of patients is un-ending, and India for most parts, even in government service, your income is proportionate to the number of patients you see. ~~~~ "It’s a sham, they learn nothing, this is done just to teach you the difficulties in communicating" a Lecturer of community health told us as we were trying to put up a health education program for women admitted in our community hospital. We spent 20 minutes teaching them about diarrhea. There was no post-test. “Create awareness” is something as commonly seen as "more research is needed" and like the latter, probably deserves to be banned from medical language. Certain stories are told and retold in every medical school in India. One is about how once a doctor visited a woman and her husband at their home and instructed them on how to use condoms, aided by a suggestively shaped vegetable. A few months later, on discovering that this woman was pregnant again, he visits them asks them if they had been using the condom every time they have sex. The man proudly says they had been and runs inside to bring out his collection of latex covered phallic vegetables. Moral of the story, after everyone has finished laughing, is "village people are so simple, you have to very explicit with them" ~~~~~ I learned that communication can be learned and taught because of the Internet. Back in 2003 when I started blogging, blog designs were ugly, pitch black backgrounds with tiny white texts were fashionable and the typical blog posts were more than 800 words, written without images or bullet points. By 2009, when I started serious blogging, things had completely changed. Readability of websites became an important thing, I learned about people’s behavior on the Internet, and how they interacted with content. I learned about short attention spans, to keep blog posts short, use bullet points and lots of images. Not all these rules applied in every situation, but they made me pay attention to how users interact with my writing, as an extension of the quality of my writing. Contrast this with a doctor. An average doctor spends more than half his working time talking and listening, and for this, the only training he receives is the “what to listen for” and “what to elicit" kind. If you were to ask an intern what the components of her consultation were, chances are goal setting and addressing the patients worries and health beliefs are going to be at the very bottom of her priorities, if they you find them there at all. Don’t doctors get good enough with time and start communicating better when the circumstances change? Though it is no meticulously researched study, the popular show Satyamev Jayate might give us a clue. In a recent episode, one of the first issues brought up was how doctors and other hospital employees communicate very poorly with patients. Some of the patients shown went to upscale clinics, could afford good healthcare, yet the communication was not too better than what the poor receive daily. Perhaps we are more polished when dealing with the rich but is that the benchmark of good doctor-patient communication? ~~~~~ Medical information is complex and explaining it and its nuances to ignorant people is next to impossible in the short time we get. Yet, 20 second advertisements on TV get people to make life altering choices. Yet, even in busy OPDs some doctors find time to talk, to smile, to touch, some patients leave better empowered, and are part of the solution. When I started with history-taking and examination classes in my second year in medical school, it took me one and a half hours to cover that one page format. Today, I can do it in a few minutes and make a diagnosis. ~~~~ A lot of things are wrong with medicine in India, but maybe, if instead of focusing on that, we ask ourselves if communication beyond what we do now is important to us, and what we are willing to do achieve it, things will change. This being said, there isn’t much a doctor can do India to learn communication. Self-help books, maybe, some videos on YouTube, but there is no mention of it beyond lip service in the medical curricula. Maybe if there was an alternative more people would subscribe to it? Let me end with a check list I cut-pasted together from various sources. 1. Educating my patient to be part of the team is a part of my consultation. 2. I have addressed all the issues that my patient is worried about in the context of this medical problem. 3. I did not respond to their repeated queries with anger, mirth or condescension. 4. I simplified the directions in my prescription so that even a five year old could understand, and wrote it down in legible handwriting. It is not that I can put a tick mark against each of these points in every consultation, or that this is all communication with patients is about, but it is a start. I know now that I have a long way to go, and in the meantime, I await the Medical council to change curricula and some enterprising folk to start CMEs and workshops in communication for doctors.
