COMMUNICATION IN MEDICINE Dr Sanjay De Bakshi MS; FRCS.

COMMUNICATION IN MEDICINE

Dr Sanjay De Bakshi MS; FRCS

Plato:

Wise men talk because they have something to say;

fools, because they have to say something.

COMMUNICATION IN MEDICINE

• Communication is extremely important in ALL stages of a doctors life.

Sense of Proportion

99%

0%1%

TOTAL APPLICANTS

MEDICAL SEATS

DENTAL SEATS

• 1225 medical seats (1105 MBBS + 184 BDS)

• Estimated number of candidates this yearMore than 1 lakh

Dis-

Proportional factors

• 1225 medical seats (1105 MBBS + 184 BDS)

• 13000 engineering seats.

• Estimated number of candidates this yearMore than 1 lakh MED

ENGCANDIDATES

1.225%13%

MIS-COMMUNICATING EVEN BEFORE MEDICAL SCHOOL

JOINING THE STREAM

• The VAST majority will however study till they are ready to DROP!!

JEE-IIT

DOCTOR-TO-BE

• The first throes of joining clinical medicine – making sure people see the stethoscope!!

Myself Harsh

Medical student

1st SEMESTER

• ANATOMY• PHYSIOLOGY• BIOCHEMISTRY

• DEAD BODY• BODILY FUNCTION• BODY CHEMISTRY

Some things don't change much..... .. .

2nd SEMESTER

TOPICS• PATHOLOGY

• PSM• FORENSIC

STUDY• BODILY

DYSFUNCTIONS • ENVIRONMENT• UNNATURAL DEATH

3rd SEMESTER

TOPICS• MEDICINE

• SURGERY

• GYNAE & OBS.

NOT ONLY STUDY BUT COMMUNICATE!!!!

• MEDICINE• PATIENTS & PARTY• SURGICAL SCIENCE • PATIENTS & PARTY • G & O• PATIENTS (2) &

PARTY

SYLLABUS• 1st SEMESTER---- Classes on Anatomy;

Physiology and Biochemistry.

• 2nd SEMESTER---- Classes on Pathology;

PSM and FSM.

• 3rd SEMESTER---- Classes on Medicine;

Surgery and Gynaecology.

• WORKING LIFE--- 60% to 80% will work in

Medicine;

Surgery and Gynaecology.

One thing will be common to

ALL DISCIPLINES---------------

• And the number of Formal Classes on Communication during the ENTIRE THREE

SEMESTERS--------0%

FOR A PROFESSION THAT IS SO COMPLETELY DEPENDENT ON COMMUNICATION & TRUST –

IT IS A MAJOR OMISSION!!!

Poor communication is the catalyst for most complaints;

The recognition (especially by medical indemnity organisations) that communication skills can be taught; and

The increasing emphasis now being placed on communication skills in medical training.

MRCS EXAMINATION

MRCS EXAMINATION

COMMUNICATIONSSKILL

CLINICALSKILLS

COMMUNICATION GIVING

COMMUNICATIONGATHERING

TRUNKABDOMEN

HEAD &NECK

VASCULAR

ORTHOPAEDICS


SCENARIO IN MRCS EXAMS.• Allan an overweight 13year old was sent home

after an emergency appendicectomy after 4 post-operative days. His mother, Mrs Green, discovers 3 days after the discharge, that he is draining dark brown fluid from the wound.

• She is very frightened and has brought him back to the hospital. She is very worried and angry. She has the following questions for the young doctor, who is an Senior House Officer to Mr Chorley, the Consultant.


SCENARIO IN MRCS EXAMS.

• Why did this happen to Allan?

• Why have I never seen Mr Chorley after the first two days?

• Is Allan’s life at risk?

CANDIDATE 1

• Well Mrs Green, we all loved Allan, he is such a bright young chap, but as his studies do not leave him enough time for outdoor games he is slightly healthy…… Fat heals very poorly.

• Mr Chorley is a very caring man. He is also very busy and I am sure that he must have been caught up in some emergency, else he would have seen Allan. I will ensure that you both get to see him asap.

• It appears from your history that Allan has some collection in the wound that sometimes unfortunately happens. You have the best person in Mr Chorley to treat this condition. I would trust Mr Chorley’s treatment and care implicitly.


SCENARIO IN MRCS EXAMS.

• Why did this happen to Allan?

• Why have I never seen Mr Chorley after the first two days?

• Is Allan’s life at risk?

CANDIDATE 2

• Allan is very very fat. Sometimes these things happen to fat and unhealthy people.

• Mr Chorley is a very busy surgeon. We do not like to bother him with little things like ward rounds. He will of course see Allan when it is convenient for him.

• Mrs Green we all have to die some day, so don’t worry!!

COMMUNICATING WITH COLLEAGUES!

• There was an audit carried out in the British NHS that hospitals with a lounge for doctors worked more efficiently --- simply because of better inter-departmental communication.

Writing a paper!

Suggestions

• Have something worthwhile to say.

• Learn to be brief.

• Write grammatically correct english.

• Get your spellings “WRITE”• AVOID “ABBREVIATIONS”.

ART OF ABBREVATIONS

• Doublespeak supplanted English as the national language at about the time POTUS, FLOTUS and SCOTUS replaced the President, First Lady, and Supreme Court of the United States.

Paul Greenberg

Be Prepared to Sometimes Re-do your Paper Again and Again and

Again!!!• Get your facts right.• Get your References

right and IN THE PROPER FORMAT!

• Read through the Journal you are Targeting and Learn the required Format.

• TRY AND TRY AGAIN

READING A PAPER!!

• PLENTY of papers!!!

• Learning to separate the wheat from the chaff!!!!

• Level I, II or III.(RCTs)!!

A Personal Series of Treating Bilateral Varicose Veins

Dr A Gressive; World J of N Surgery; 2009 Feb ; 215(1):19-26.

Treating Bilateral Varicose Veins with Bilateral Thigh Amputations –

0% recurrence.

COMMUNICATING AT MEETINGS

• The brain is a wonderful organ.

• It begins to work the day we are born and keeps on working-

• Till the time that you get up to speak in public!!!

• IT EITHER DRIES UP OR GOES INTO THE THROES OF VERBAL DIARRHOEA!!

COMMUNICATING AT MEETINGS

• LEARN to handle your CUE CARD smoothly. Write big, bold letters. Never read basics i.e. name of V.I.P/Organisation/Occasion etc. from a CUE CARD.

• SPEECH should be not too long nor too short. If you wish to cut down on the spot : delete one Complete point/paragraph. It is always a good policy to prepare more but speak less.

• NEVER try to recall what you had written & rehearsed. Speak as it comes to you naturally. It will be far superior than the write up.

THE ART AND CRAFT OF TECHNOLOGY

USING THE POWERPOINT PRESENTATION

BASIC RULES

• Keep the slide simple and restrict a slide to about seven lines.

No body has the patience to go through the slide!!

• Ann Surg. 1992 Jan;215(1):19-26.

• Gallbladder sludge and stone formation in relation to contractile function after gastrectomy. A prospective study.

• Inoue K, Fuchigami A, Higashide S, Sumi S, Kogire M, Suzuki T, Tobe T.

• First Department of Surgery, Faculty of Medicine, Kyoto University, Japan.

• In a prospective trial to determine whether gastric surgery induces gallbladder sludge and stone formation, 48 patients with gastric cancer were ultrasonographically examined with simultaneous observation on changes in gallbladder contractile function before and serially for 5 years after gastrectomy. Gallbladder sludge formation was induced with a high frequency of 42% 1 month after gastrectomy, with corresponding significant lowering of gallbladder contractile function. Most of gallbladder sludges, however, disappeared within 12 months in relation to the gradual recovery of gallbladder contractile function. Conversely, gallstone developed in nine patients (18.8%), mostly more than 6 months after gastrectomy. Interestingly, gallstone formation was induced in seven patients who were sludge negative. An evolvement of gallbladder sludge into stone was observed in only two patients, who were, however, treated with intravenous hyperalimentation. This study first provides evidence for the relationship between gastrectomy and a considerably high frequency of incidence of gallbladder sludge and stone in relation to changes in gallbladder kinetics after gastrectomy.

BASIC RULES

• Learn to avoid being too “computer clever”

GALL STONES AFTER GASTRECTOMY

• Surg Gynecol Obstet. 1987 Nov;165(5):413-8.

• Sludge and microlithiasis of the biliary tract after total gastrectomy and postoperative total parenteral nutrition.

• Gafa M, Sarli L, Miselli A, Pietra N, Carreras F, Peracchia A.

• Istituto di Clinica Chirurgica II, Parma University, Italy.

• We have evaluated the incidence and evolution of sludge, microlithiasis and lithiasis formation of the biliary tract in 12 patients who underwent total gastrectomy and postoperative total parenteral nutrition (TPN) beginning immediately after operation.

• To this end, serial ultrasonographic studies are carried out every 72 hours during TPN and every seven days after oral refeeding and then once a month for three months. Sludge of the gallbladder was demonstrated in five of the 12 patients after a minimum period of nine days after the operation, and in four of these, microlithiasis of the biliary tract was subsequently revealed. In two of these four patients, the stones dissolved spontaneously, while in the remaining two patients, no change occurred in dimension after intervals of six and seven months, respectively. In all instances, sludge and microcalculi were completely "silent." This study was done to underline the high incidence of biliary tract sludge and microlithiasis in the patients examined and to indicate the necessity for preventive measures against

BASIC RULES

Use LIGHT LETTERING on a

DARK BACKGROUND-----

IT IS EASIER ON THE EYES OF THE AUDIENCEPARTICULARLYIF YOUR LETTERING

IS SMALL !!!

BASIC RULES

• Above all know your topic.

• And practice, practice and practice.

I LOVE SPEAKING EXTEMPORE, I PRACTICE DOING SO EVER SO OFTEN!!!

George Bernard Shaw

REMEMBERING THE SPONSORS!!

"We thank Joe's Greasy Spoon Diner for providing the patient for this stomach operation."

COMMUNICATING WITH PATIENTS

MODELS OF

PATIENT-DOCTOR RELATIONSHIP

WEBERIAN

MODEL

VEATCH

MODEL

OZAR’S

MODEL

MAY’S

MODEL


Weberian Models

• The paternalistic model,

• The informative model,

• The interpretive model,

• The deliberative model.

PATERNALISTIC MODEL

• Parental or priestly model, of the provider-patient relationship is the parent-child approach. The provider takes on the role of guardian. In this model, decision-making is taken away from the patient, thus threatening patient autonomy.

THE INFORMATIVE MODEL

• Scientific or engineering model, the physician provides all relevant information, the patient selects the intervention, and the physician executes the interventions. This model lacks physician values, patient values, and judgment.

"Well my records are factually CORRECT...but where's the

PASSION, the MYSTERY, THE REAL ME!..."

THE INTERPRETIVE MODEL• The physician acts as a counselor or advisor.

Conception of patient autonomy is self-understanding pertaining to medical care.

THE DELIBERATIVE MODEL

• The physician's role is one of friend or teacher. The provider helping patients choose the best interventions for their medical care. • ONE NEED NOT

SYMPATHISE –

• BUT SURELY ONE NEEDS TO EMPATHISE!

TO BEFRIEND OR NOT TO BEFRIEND!!

THINK!• A busy lady executive took some quality

time to take her 4 year son to a famous fair for a complete day.

• She was thrilled but very soon the son began whining and wanted to go home.

• Irate she bent down to talk to him and said- “My God!”

• What was going on?

OBSTACLES TO GOOD COMMUNICATION

OBSTACLES

PHYSICAL ENVIRONMENT

DOCTOR-RELATED OBSTACLES

PATIENT-RELATED OBSTACLES

CULTURAL AND SOCIAL DIVERSITY

PHYSICAL ENVIRONMENT

The physical environment may:

• discourage good communication; or

• fail to provide sufficient privacy.

DOCTOR-RELATED OBSTACLESThe doctor may be:

• inadequately trained in communication skills;

• lacking in sensitivity or empathy;

• unwilling to recognise patient autonomy;

DOCTOR-RELATED OBSTACLESThe doctor may be:• inadequately trained

in communication skills;

• lacking in sensitivity or empathy;

• unwilling to recognise patient autonomy;

• face an irritatingly aggressive relative.

DOCTOR-RELATED OBSTACLES

The doctor may be:

• • affected by time pressures; or

• distracted by external or personal factors.

EMERGENCY DOCTOR YOU ARE WANTED ON THE 3RD, 4TH 5TH FLOOR AND ALSO IN TRAUMA

ONE EXPERIENCE----

"Thanks for coming over, doctor, but a bit of antacids fixed me up fine."

The doctor may be:

• influenced by past experiences

OFTEN LEADS TO ANOTHER

Stick to your mother-in-law's remedy and call me in the morning if you survive."

The doctor may be:

• influenced by past experiences

PATIENT RELATED OBSTACLES

• How much is “JUST” right?

• How much to divulge to the patient and how much to the relatives?

• EVERY SINGLE PATIENT WILL REACT DIFFERENTLY.


• A 66 year old man presents with disseminated cancer of the stomach. On being informed about his condition, he wanted it to be kept a secret from his family members.

• His reason- being intelligent he realized that chemotherapy would at best grant him 6 months of life but would wreck his plans for his daughter’s impending marriage.

• After his death his family are very irate and want to litigate for suppression of facts.


• An 80 year lady presents with disseminated cancer of the colon.

• On being informed about the disease, she stops eating, becomes severely depressed and wastes away.

• The family is irate that the patient was told about the news.


• A 40 year old executive has a massive myocardial infarction and is left with an aneurysmal dilatation of the left ventricle and an ejection fraction of 20%.

• His family insists on his NOT being told about his prognosis as they would like to protect him from bad news.

• What do you do?


• How much is “JUST” right?

• How much to divulge to the patient and how much to the relatives?

• EVERY SINGLE PATIENT WILL REACT DIFFERENTLY.

EVERY SINGLE PATIENT WILL REACT DIFFERENTLY.

• REACTION 1 TO THE NEWS ABOUT CANCER!!

EVERY SINGLE PATIENT WILL REACT DIFFERENTLY.

• REACTION 2 TO THE NEWS ABOUT CANCER!!

DON’T “BLEAT” AROUND THE BUSH!!!


BUREAUCRATIC WAY OF SAYING NO!!!

COMMUNICATING WITH THE “PRESS” ABOUT A PATIENT

• The Medical Council of India stipulates that a registered medical practitioner shall not disclose the secrets of a patient that have been learnt in the exercise of his profession except in a court of law under orders of the presiding judge.

• The police had summoned three doctors of INDRAPRASTHA APOLLO

• Prasad Rao, who headed the team that treated Rahul,

• Medical director Anupam Sibal and

• Senior doctor Mukund Pandey - for questioning .

WHO’S RIGHT TO INFORMATION?

• RTI Act, meant for 'promoting transparency and accountability in the working of public authority' is most commonly used in our hospital for obtaining case sheets, wound certificates and post-mortem reports by advocates toexpedite settlement of their cases.

A Hospital Manager from Chennai

THEREFORE----

• Ensure that the “Bed Head Ticket” is filled up diligently.

• While ensuring that it documents all that has happened diligently do not allow yourself the liberty of documenting your personal thoughts and angst!!

• “Tried to

contact Dr

------- and

could

not!!!”

• Make sure that all informed consent is signed AN APPROPIATE TIME BEFORE the actual Procedure!!

• YOU MUST GET A CONSENT FROM AN ADULT PATIENT DIRECTLY– It is not medico-legally justified to get a CONSENT from a relative of an adult patient who is mentally sound.

THEREFORE----

• CORRECT THE DISCHARGE and get the CORRECTED DISCHARGE RE-TYPED!!

• Don’t send out a Discharge with Corrections and Deletions done by Hand.

THEREFORE----

• Your adult balanced patient has the PRIMARY RIGHT to his own information according to the Supreme Court not the relatives.

• One must learn however, how to break a bad news gently.

THEREFORE----

ALSO-YOU LIVE AND SLEEP AND DREAM THIS PROFESSION

• A PART OF YOU BLEEDS WHEN YOUR PATIENTS DO BADLY!

• BUT, LIKE ANY OTHER PROFESSION YOU DO HAVE YOUR LIGHT MOMENTS---

YOU LIVE AND SLEEP AND DREAM THIS PROFESSION

FIRST LESSON--WE DOCTORS LIVE IN

INCREDIBLY CLEAR GLASS HOUSES---

“SO DON’T THROW STONES”

SO WHAT IS THE ANSWER-

SO WHILE IT “IS” VERY IMPORTANT TO

DOCUMENT ALL ONE’S DEALINGS—

TO SAVE YOURSELF----

SPREAD A BIT OF RESPECT ALL AROUND!!!

IN RESPECTING YOUR PATIENT,

YOU RESPECT YOURSELF,YOU RESPECT YOURSELF,

AND, YOU RESPECT THE NOBLE AND, YOU RESPECT THE NOBLE PROFESSION THAT WE HAVE ALL PROFESSION THAT WE HAVE ALL CHOSEN TO PRACTICE!!CHOSEN TO PRACTICE!!

COMMUNICATION IN MEDICINE Dr Sanjay De Bakshi MS; FRCS.

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Transcript of COMMUNICATION IN MEDICINE Dr Sanjay De Bakshi MS; FRCS.