Dear Doctor, communication is everything

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COMMUNICATION

Dear Doctor,

We need to talk about communication.  Entering medicine is all about high grades, high intelligence and a mega work ethic to get through those many years of hard training. Right?  Yep, sure, absolutely.  But there are some glaring omissions in medical training.  And one of the most important would be the importance of good communication skills.

You simply cannot be a good doctor if you have poor communication skills. End of story. No exceptions.  If you can’t explain the what, where, when, why and who in simple terms, your patients are not going to be compliant. Largely because they don’t know how to be. 

Whatever you learned at medical school and in your post grad training, it all means NOTHING if you don’t have good communication with your patients.

Whatever your specialty, you probably won’t have time to get to know your patient very well. They’ll come in to see you and at the first consult, you might spend 15 minutes screening them, and asking questions related to their diagnosis.  Then you probably only ever see them every three months, or even less, for another quick consult.  Not conducive to relationship building, which is a huge flaw in the current medical model, because a good relationship with your patient is critical to being an effective practitioner.

But getting to know your patient is essential.  If you treat all patients the same, using the stereotypical ‘average’ patient, you’ll be wrong at least half the time.  For you to diagnose treat them correctly you need to have some understanding of who they are. But that’s another Dear Doctor.

Once you’ve reached your diagnosis, and you have decided to  prescribe a medication, you need to give instructions.  You need to explain what the medication is, and why you are prescribing it.  You need to explain what to expect, how long until the medication starts to help, the common side effects and any possible serious side effects that should not be ignored.  You need to tell the patient what to do if these side effects occur, or if the patient doesn’t like how they feel on this medication.

You need to communicate all of this, in simple terms.  Preferably at the level that suit’s your patient’s education and medical literacy.  Because there’s a vast difference from person to person in the type and amount of information they require.  But when in doubt, keep it simple, but don’t dumb it down.  Treat every patient as if they were a family member.  Don’t condescend.  Don’t rush.  Ask if the patient has any questions, and don’t roll your eyes if they do.

And then, after all of this, after the patient has left your office, you need to be CONTACTABLE.  If your patient has problems or thinks of questions after your consult, they need to be able to contact you, via your staff.

My example is pain management, but it could apply to any medication or treatment plan.

I was prescribed a new pain medication a new opioid.  I am being cross titrated from oxycodone to hydromorphone. First problem:  the reasons for this were unclear.  What’s the benefit of hydromorphone over oxycodone?  I didn’t know.  I asked you but all you said is that I would only have to take one tablet per day, rather than two.  Let me tell you Dear Doctor, I take about 15 tables a day. One more or less pill is NOT my biggest problem.  Not really a big selling point there.

I had to go to my GP to understand your rationale. She explained it to me.  Hydromorphone hits different receptors than oxycodone, so while I have developed a tolerance to oxycodone, that shouldn’t be the case with hydromophone.  In theory I should be able to take a lower dose of hydromorphone for the same level of pain relief. 

Also, hydromorphone is cleared through the liver, rather than the kidneys.  I’m not sure why that is a great benefit, because I’m already on a few liver toxic medications…methotrexate included.  While my kidneys aren’t perfect, they are coping just fine. So, I don’t see this as a benefit, but I don’t get a say.

My GP had to prescribe the medications, because you, Dear Doctor, didn’t even do that much.

It doesn’t impress me one little bit that our consult was less than five minutes long, probably three minutes in fact, and for this I was out of pocket $100.  You didn’t even write the script yourself, so I couldn’t just go to pharmacy and fill the script.  No, I had to make another appointment with my GP.  I had to pay for THAT consult as well, on top of the $100 out of pocket I was from seeing you.  As you know I am in a great deal of pain and driving to my GP is difficult.  It costs me time and adds to my pain burden.  When I questioned why you don’t write the script yourself, you stood and walked me out of the office.  No questions answered.  I left feeling that you have zero understanding of the impact of this pain on my life or its severity and all you did was shuffle deck chairs on the titanic.  I had to wait another few days until I could get a GP consult, pay another $40 on top of the $100 out of pocket I was from seeing you.  And I still needed my GP to explain the ‘whys’ of your treatment plan.

As a long term, medically complicated patient, I expect better.  I expect you to be more thorough.  I expect you to answer my questions. I expect you to write your own scripts.  And I expect to have a voice. 

But here’s the thing, if I disagree with you, I’ll be seen as non-compliant. If I show any attachment to my current pain medications, I’ll be seen as an ‘addict’ with maladaptive behaviours.  You might even decide to take my pain relief away entirely!  So I am super polite at all times.  I stated that I wasn’t sure what the benefit would be, you overruled me with a simple “trust me” and that was that.

I left feeling dismissed, ignored, unheard, unimportant and completely misunderstood.  You even saw the ‘spinal stimulator’ flyer that I picked up in your waiting room, because having had multiple cortisone injections, and a couple of radiofrequency ablations, I know a spinal stimulator is the next logical step.  You saw that flyer and my discomfort with your treatment plan and you said “Yes I see you’re interested in a spinal stimulator, that is an appropriate next step and we’ll discuss it next time.  Make an appointment for three months.”

THREE MONTHS.  I came to you because I was at absolute wits end with this pain. I wasn’t coping any more.  There is only so long you can live in agony (pain that is an “8” or higher every single day qualifies as ‘agony’).  I can’t stand it anymore.  And you?  You just fiddled around the edges and despite my explaining the spinal pain was by far the worst pain, you worked on my general pain levels, which, are not that bad.  Ignoring the severe pain, and potential treatments for that pain specifically.  Likely because you know there isn’t a whole lot that can be done about severe spinal pain with definite neural compromise and resultant nerve pain and paralysis.  You further showed your hand by telling me to keep on seeing my psychologist and to work on my PTSD and once that’s ‘solved’, my pain will improve.

That’s bullshit, Dear Doctor. My severe spinal pain preceded the PTSD.  They are separate things.  Sure, a bad PTSD day means I suffer more pain on that day.  The long-term trend would show that it has very little impact.  You need to trust me.  That trust thing?  It works both ways.

Anyway, fast forward a week, and I’m in massive pain because this regime isn’t working well.  I called your rooms and spoke to a receptionist. She told me to send in an email stating the problem and she would pass it onto you, Dear Doctor.

Two days later I called again and was asked to again email.  It is unclear whether the receptionist dropped the ball, or you did. But from my point of view, it doesn’t matter. I was left in agony for two days and I received no response, no help.  Even if the receptionist failed, and not you Dear Doctor, it is still your failure even if indirectly.  Communication within your office is after all, still your responsibility.

After the second email, a day and a half later, I received your reply. Succinct and helpful. Empathetic even.  Thankyou.  I was very grateful for the response, it’s just unfortunate that I had to wait so long for that reply. And endure a week of suffering and severe pain in the meantime.

Unfortunately, you’re not alone Dear Doctor.  Just yesterday I had to cancel my Immunologist appointment.  I was genuinely in too much pain to get there and wait the hour and a half that he is ALWAYS late.  I couldn’t drive and a cab would have cost upwards of $60. Each way. 

So I rang his rooms and asked if he could instead phone me at the designated appointment time.  My situation is unchanged since last appointment, there are no labs or test results to discuss, in fact he is waiting for me to get sicker as I taper prednisone. I am out of ‘instructions’ for how to continue the taper, so all I need to know is how to continue that taper.  I have Adrenal Insufficiency, so it’s pretty important that I get this right.  I also have recently discovered I have a pituitary tumour – a microadenoma – and this may be something my immunologist needs to know.

The receptionist said “No.”  As in, ‘No, we don’t do that’.  I asked her why not. She just repeated more firmly that they did not do that. And “that’s what appointments are for”.  I explained again that I am unable to get there, I’m actually TOO SICK to get there.  In my head I’m thinking:  of all the people who should understand that sometimes people are too sick, it’s the person who specialises in complicated cases, but clearly saying that would not have helped the situation.

I then asked if I could email the doctor a question and would he respond to that?

She said “I can’t be sure”.

I explained that I just needed instructions for how to continue my prednisone taper, for the next three months.  Simple question, but essential that I get the correct information.

She then told me that she would ensure that he received the message, but she couldn’t guarantee a response.

I gave up and she gave me the next available appointment (which is almost three months away). I had no choice. I could not physically attend the appointment.  I sent the email, I received a read receipt, but no response has arrived. 

If my immunologist does not respond, he is being negligent, so Dear Doctor, poor communication is rife in your profession.  Which is a terrible shame.  For patients, as well as doctors.  Good communication is the basis of any good relationship. And wouldn’t practicing medicine be more enjoyable and satisfying, and arguably achieve better outcomes, with engaged patients with whom you had a quality, working relationship? A partnership?

Communication is EVERYTHING. Your personal communication skills, and the communication between your staff, yourself and your patients.  You’re a doctor. Sometimes your patients have emergencies. You need to be available to handle those, or you need to have someone available.  Sometimes your patients will be too sick to make it to your appointment.  A phone consult with a long-term patient you know well should not be an unreasonable request.  Or answering questions via email in a timely matter.  Your staff need to recognise the seriousness of those situations and escalate appropriately.  The message needs to get to you quickly and the return message has to get back to the patient quickly.

Dear Doctor, Your years of medical education, your vast clinical experience, all of it means nothing without good communication.

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