Dr Alexander Thomas, President, Association of Healthcare Providers – India (AHPI) and Divya Alexander, Research Consultant, in a first of a series provide detailed insights on healthcare communication that explores its different aspects in an Indian context
Let us trace the journey of a patient visiting a hospital as an outpatient. As the patient walks into the hospital, the first person that he or she comes into contact with is usually the security staff and the front desk or reception desk. Thereafter, he or she is directed to go to the registration section to register his or her file. After consultation with the doctor, the patient is referred to the laboratory or the radiology department for diagnostic tests. Prior to actually getting the tests done, the patient comes into contact with the cash and billing staff to pay for the investigations. Once the investigations are complete, the patient goes back to the concerned physician for a follow-up and prescription. The medication is procured from the pharmacy and then the patient leaves the healthcare facility.
The dynamics are quite different for the patients when they are admitted as inpatients. Once admitted, they must visit the cash and billing section to pay an advance prior to admission, and if health insurance, too, is involved, then meeting the administrative office is also mandatory. The patients then get in touch with the support staff – including customer service and security – who guide them to their respective wards. During the course of the hospital stay, numerous visits by allied health professionals and dieticians are inevitable. Finally, at the time of discharge, a second visit must be made to the cash and billing counter to settle the final bill, and to the pharmacy to claim refunds for returned medication and to purchase medication prescribed at discharge.
As one can see, there are numerous ways for patients to lose their way and run from pillar to post if hospital systems do not work properly. The very thought of having to do this while physically unwell is distressing.
The low global ranking of the Indian healthcare system re-emphasises the need to assess and strengthen the way healthcare services are delivered. The approach is important since healthcare services, more than any other, depends on the human touch. On one hand, the communication that doctors, nurses, and other healthcare personnel establish with patients is crucial in aiding the patients to adopt life-changing healthcare practices. On the other hand, communication among the members of the healthcare team plays an important role in ensuring a smooth and error-free approach to healthcare. Errors can easily be prevented by adopting small changes in the system.
Communication affects the foundation of quality care with its direct bearing on the accuracy of diagnosis, the patient’s acceptance of treatment, patient safety, patient satisfaction, and the healthcare team. Communication in a hospital setting can be grouped into several strands. The patient interacts with healthcare providers, that is, doctors, nurses, physiotherapists, dieticians, etc. He or she will also, inevitably, interact with the supporting staff such as those involved in billing, customer care, food services, housekeeping, and others. Communication of healthcare providers with other healthcare providers, supporting staff, administration, and external agencies is common. Effective communication among each of these subgroups is essential for sharing information accurately and in a timely manner.
With the increasing emphasis on quality in healthcare, doctors and all other healthcare professionals are expected to demonstrate competency in communication. But in the Indian context, the resources required to equip healthcare providers in communication are few and far between. For decades, communication had not been given enough importance in medical, nursing and allied health training, as it was assumed that students would simply imbibe these essential skills through observation and without the need for structured training. Until recently, medical colleges in India did not have a formal curriculum for teaching and learning communication, imparting ethics, or inculcating the right attitude in students. The lack of formal training in these skills and the resulting inability of medical students to communicate effectively cause a large amount of stress, frustration, anger, resentment, misunderstanding, and disappointment. This is one of the contributing factors to the increased amount of distrust in healthcare.
The Medical Council of India has revised its curriculum for the academic year beginning in 2019, with the introduction of the Attitude, Ethics, and Communication Module (AETCOM), which is now being implemented across the country. This module is intended to prepare medical graduates for the role of a clinician, communicator, leader, lifelong learner, and professional. This module is a welcome step towards better communication by healthcare professionals, but there is a long road ahead in implementing competency-based medical training and ensuring sustainability, the principal responsibility of which lies on the shoulders of medical school leaders. Since the competency-based training programme and assessment methods differ in many ways from the traditional curriculum, it is crucial to sensitise and prepare the faculty for this change. The next important challenge is to change the student’s attitude towards medical education: moving from the mere internalisation of knowledge and scoring marks towards adopting the finer AETCOM skills in order to deliver quality medical care. It is a tremendous task to attempt to change the behaviour of medical students in the 4.5-year tenure of the medical course.
Medical errors, inaccurate diagnoses, inaccurate treatment, compromised patient safety, and patient non-compliance are some of the immediate results of poor communication. Integrating effective communication skills with the regular medical education curriculum through AETCOM is an important milestone in the journey of reducing medical errors, improving patient compliance, and creating greater patient satisfaction.
The doctor-patient conversation must take place with the understanding that the patient is an equal partner in the interaction, with the doctor leading the interaction through his or her knowledge and understanding of the subject. Medical students need to acquire skills to quickly build the initial rapport, make patients comfortable, ask open-ended questions to facilitate the patient’s narration of the problem, and identify the reason for the visit. They also need to learn how to gain a patient’s trust by exhibiting empathy and using the appropriate verbal and non-verbal communication such as greeting the patient, making eye contact, using the correct body language, smiling whenever appropriate, and demonstrating effective and active listening skills. The patient’s concerns may be completely different from his or her existing health issues, and these need to be addressed during the consultation. The medical student has to learn how to establish the patient’s priorities in the list of problems, state his or her clinical goals, and negotiate a mutually agreeable agenda for the consultation. This requires an understanding of the patient’s perspective without losing the sight of important clinical goals and the ability to help the patient understand the clinician’s point of view.
All these skills can be learnt through role-play and practice. In western countries, the students are assessed on these skills with standardised/simulated patients. These skills need to be inculcated meticulously as they are a very important part of any clinician’s career. For example, in the US, the communication and interpersonal skills of the physician-in-training are no longer viewed as personal styles that emerge during residency but are seen as a set of measurable and modifiable behaviours that can evolve. Medical students and postgraduates are increasingly instructed on techniques for listening, explaining, questioning, counselling, and motivating.
What is crucial in meeting patient expectations, therefore, is adherence to basic communication courtesies and etiquette by all members of the healthcare team. A common misconception among healthcare providers is that the responsibility for effective communication lies only with doctors and nurses. In actual fact, what makes the overall patient experience memorable is the quality of communication not just with the doctors and nurses but also with less-recognised but equally important members of the healthcare team. These include the paramedical staff (the laboratory and radiology departments) and the support staff (at the reception, registration, admissions, cashier and billing desks; in the dietary department, the pharmacy; and at the security cabin).
Ineffective communication in healthcare, where accuracy and timeliness regarding patient information are vital, is dangerous. Poor healthcare communication has far-reaching effects on the economics of healthcare service organisations. A study published in the Journal of Healthcare Management (Jul-Aug 2010, 55 (4): 265-281) indicated that US hospitals suffer a $12 billion loss annually and that a 500-bed hospital may need to bear a loss of $4 million annually. Patient compliance can also be affected adversely, resulting in distrust, distress, misunderstanding, and misinterpretations. Unfortunately, in some instances, this leads to litigation against the institution or the care provider.
Fostering a culture of effective communication in these complex settings, therefore, has various benefits – increased trust between patients and doctors, greater comfort for the patient, ease in the disclosure of important information, a better understanding of patient expectations, and the prevention of medical errors. The remaining columns in this series will address different aspects of communication in the healthcare setting.
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