Three researchers on patient dialogue

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Research shows that the doctor-patient meeting is highly significant for the patient's prognosis. But what happens if you speak past each other? Three researchers share their experiences of communication problems in health care and how they can be solved.

"The key is an empathetic approach"

Carl Johan Fürst, Professor of Palliative Medicine at Lund University and affiliated with the Department of Oncology-Pathology, Karolinska Institutet.

"Telling someone that he or she has a serious illness can be difficult. But often there is a treatment that can be offered and the vast majority of patients choose to have treatment. This makes the conversation a little easier. Later, if the treatment proves to be ineffective, there is a risk that the situation will become more charged. At the same time, it is extremely important at this stage for there to be reciprocity and for a dialogue to be established with the patient about, for example, the risk of side effects and a likely prognosis.

For a while now we have arranged courses for future doctors that focus on difficult conversations. A good foundation that we teach is the importance of the doctor leading the conversation. This may involve setting a clear agenda together with the patient at the beginning of the conversation. In addition, we practice responding to different emotions, but also the absence of reactions. Tears or angry words can sometimes be easier to handle than silence. Some of our exercises are as concrete as daring to take certain charged words, such as cancer or death, and speak them aloud. Through practice, it becomes easier for both the patient and the doctor.

There are guidelines on how to proceed when communicating bad news, but they lack scientific evaluation. In our research we have just begun to take an interest in what is required for these conversations to be handled successfully. I believe that the key is an empathic approach. If the patient feels seen and understood, the dialogue works much better.

I have always thought that the actual contact with patients is very exciting and have seen the difficult conversations as a challenge. But getting good at conversations takes practice, and this is something that I consider to be sorely lacking in the training of medical students today. It is extremely important for the patient that it works well, and also for the doctor's professional self-confidence."

"The interpreter can't solve everything"

Elisabet Tiselius, Director of Studies at the Institute for Interpreting and Translation Studies, Stockholm University, and researcher at the Department of Women’s and Children’s Health, Karolinska Institutet.

"When a child becomes seriously ill, the parents always become very involved in the care. But in a family where the parents have difficulty understanding Swedish, the child is often forced to handle a lot of the communication with heath care services. This puts double the burden on the child. Today there are 170 different languages spoken in Sweden. At the same time there is a great shortage of available interpreters. To gain a better overview of where, how and when these shortcomings arise, we are currently mapping the use of interpreters within highly specialised paediatric care.

Not being able to speak the language also affects the ability to orient yourself in ways you might not think of. If, for example, you can't read medical staff’s name badges, you don't know if the person you are meeting with is a doctor or nurse's assistant. Communication problems are often blamed on the lack of an interpreter or the low quality of the interpreter. But the interpreter can’t solve everything. Some of the problems that arise when patients and health care professionals have different backgrounds are the result of cultural differences. You may have different background knowledge on how the disease occurs and whether you can trust the care being offered; then it doesn’t matter if you speak the same language.

The waiting time for an interpreter at present is on average two weeks. One consequence of this is of course that many conversations have to be had without an interpreter. In an interview study, we are now examining how patients and their parents resolve this situation in other ways, such as through using translation services online, using sign language, doing charades or calling a relative. We are also holding in-depth interviews with interpreters experienced in children's cancer care in order to include their perspective. My hope is that our research will lead to improved use of interpreters and increased support for families in need of an interpreter in the future."

"I am going to insult you now – OK?"

Brian Hodges, Psychiatrist and Professor at the University of Toronto, Canada.

Awarded Karolinska Institutet’s prize for research in medical education 2016

"My newly-appointed colleague felt nervous about meeting an aggressive patient at the department. Then I took her aside in a room and said: Now I am going to insult you – is that OK? I wanted to give her the opportunity to prepare for what she could possibly encounter and how she should tackle it.

Listening to personal and insulting attacks from an aggressive patient or relative without reacting angrily yourself can be very difficult, but necessary for those of us who work within the health care sector. We need strategies to encounter strong emotions like intense grief, strong concern or confusion, such as that experienced by an Alzheimer’s patient. 

Our research group was first in the world to simulate difficult emotional patient meetings by using medical students as actors. We saw that it provided the students with greater awareness of their reaction pattern and the opportunity to practice professional treatment. We have been able to demonstrate in our research that it makes them better at conversing when similar situations occur later in medical care. As a result, for a long time communication skills have been included in the final examination of medical students in my home country Canada and in many other countries. I think that it would be good if this also comprised an even greater part of the education of Swedish students.

I believe that the communicative part of the doctor-patient meeting will become increasingly important. Medical knowledge, diagnostics and technical skills are assets which will be possible for robots to handle in the near future. Our potential ability to show sympathy will remain. Medical care is void without it."

As told to Cecilia Odlind, first published in the magazine "Medicinsk Vetenskap", no 4, 2016