Consultations – patient’s opening chat is interrupted by their doctor after mean 18 secs. Patient talk for 40% of total consultation time, estimated by doctor at 60%.
Wayne et al 2011 – less info given to poorer and minorities, more dialogue and more informative with better educated, more literate patients
Neumann 2011 – decline in medical empathy: significant through medical school, further declines through residency. “Hidden” curriculum? Hardening/cynicism?
Rosenthal 2011 – humanism and professionalism student module, no decline in 3rd year student empathy.
Chen 2012 empathy associated with women, non-technological specialty preference, high debt!
Roter and Hall 2006 – doctors like to retain authority but poor at managing confrontation eg eye contact, picking up emotional cues of distress
Psychodynamic approach – counter transference (disgust, judgemental), counter resistance (non-compliance)
Narrative as diagnosis! William Osler – the diagnosis is in the story.
Communication and teamwork “skills” underestimates complexity, the affective component. Only learned if valued, rather than as something to be acquired.
Heroic individualism valued in medicine, cf dialogue
Students struggle to make conversation with patients! Fear of intrusiveness, failure to connect medical issues with psychosocial elements.
Best – learn through active reflection on work based learning (cf how artificial PBL etc are). Think about values, how they shape communication. Modelling of democratic values. Appreciation of complexity of communication.
[ Alan Bleakley, Peninsula medical school – Homer as evidence of honour/shame/face directed behaviours, cf feminine, guilt directed behaviours etc]
“We teach good communication skills because we accept not everyone has them. But we also need to teach professionalism… We’re happier to challenge poor clinical skills, or to point out a gap in knowledge, than to have a conversation about behaviour or attitudes.”
“We expect learners to improve and progress. So, by implication, they’re not perfect professionals: they can make mistakes. It gives people permission to say, “That doesn’t look professional”.”
“We need to work on accepting constructive feedback for unprofessional behaviours… We want a positive culture, where we teach people to speak up to promote professionalism.”
[Sheona MacLeod, BMJ 2020;368:m768]
Outside of the consultation, doctor-patient communication becomes a mixture of formal and informal, but both tend to be one sided. Formal letters are an essentially one sided message from the doctor to the patient. Informal communication includes requests or questions from the patient to the doctor but again, often one sided as it does not usually lead to a meaningful exchange.
See Participatory medicine.