вільний доступ

рецензована стаття

Анотація

Актуальність: Ефективність медичної допомоги у великій мірі визначається якістю контакту між лікарем та пацієнтом. Володіння комунікативними навичками та знання дієвих засобів медичного спілкування дозволяє лікарю будь-якої спеціальності більш ефективно вирішувати складні завдання, які виникають в лікувально-діагностичному процесі.

Методи: Даний огляд базується на матеріалах статей про рекомендації доказової медицини стосовно спілкування лікарів та пацієнтів в онкологічних, акушерських і гінекологічних та педіатричних клініках.

Результати: В результаті ми очікуємо, що цей огляд сприятиме поширенню знань про методи доказової медицини для покращення спілкування в акушерстві-гінекології, педіатрії та онкології.  

Висновки: Здатність лікарів до ефективної комунікації є ключем до успішних відносин між пацієнтом і лікарем. Сучасний стан системи охорони здоров'я вимагає збільшення клінічної продуктивності та меншого часу для кожного пацієнта, що може перешкоджати якісному спілкуванню між пацієнтом і лікарем. Використання пацієнт-центрованого підходу, емпатії, спільного прийняття рішень покращує зв'язок між пацієнтом і лікарем, ефективність терапії та збільшує прихильність до призначеного лікування у клініці онкології, акушерства-гінекології та педіатрії.

Background

The quality and effectiveness of health care is largely determined by the quality of contact between doctor and patient. Possessing communicative skills and knowledge of effective means of medical communication allows a doctor of any specialty to solve more effectively complex tasks that arise in the medical-diagnostic process.

The review will provide recommendations for evidence-based medicine on communication between a doctor and patient in a clinic of oncology, obstetrics, gynecology and pediatrics, since communicating with these contingent patients is a challenging task and requires considerable attention and communicative competence of doctors.

Oncology

Communication between clinicians and patients is a multidimensional concept and involves the content of dialogue, the affective component (i.e., what happens emotionally to the physician and patient during the encounter), and nonverbal behaviors.

In oncology, communication skills are a key to achieving the important goals of the clinical encounter. These goals include the following [1]:

  • Establishing trust and rapport.
  • Gathering information from the patient and the patient’s family.
  • Giving bad news and other information about the illness.
  • Addressing patient emotions.
  • Eliciting concerns.

Cancer patients, either in treatment or survivors, compose a vulnerable population with increased information needs. [2, 3] They depend heavily on their clinicians in regard to coping with physical, emotional, and social burdens, which affect their quality of life. [4]

Cancer patients typically have a long period where they are under treatment and control, and consequently the care involves a number of different clinicians and institutions (specialist hospital, general hospital, GP, etc). This poses another challenge to the communication with cancer patients, as they meet new clinicians numerous times. Although clinicians have reported communication to be a challenging task, it is the foundation of caring for cancer patients. [5]

Effective communication skills enable physicians to improve patients' understanding of their illnesses, improve patient adherence to treatment regimens, use time efficiently, avoid burnout, and increase professional fulfillment. [6]

Evidence-based recommendations on the patient-oncologist relationships: [7, 8]

  1. Use patient-centred interview approach. The definition of patient centered communication was a communication style in which the patient’s perspective is the foundation for the dialogue, and social, psychological, and emotional aspects are acknowledged as equally important as somatic aspects. It is communication that invites and encourages the patient to participate and negotiate in decision-making regarding own care. [8, 9, 10]
  2. Ask patients what level of involvement they want in medical decision making. This can be done with a couple of questions: “Are you the kind of person who wants to hear all the information, both good and bad, about this illness? People vary in how they want to make medical decisions. Some people want to make the decisions themselves, some people want to share decision making with the doctor, and some people want the doctor to make the decisions. Where do you stand?” [6]
  3. Develop a caring attitude toward the adjustment patients must make to living with cancer. Offer information about quality-of-life issues as well as anticancer therapy.
  4. Ask patients what types of information and level of detail they wish to have.

Describe treatment options and confirm understanding. Most patients say that they want all available information, and many clinicians say that they observe patients becoming overwhelmed during the course of a visit about treatment options. It is useful to give information in small chunks (a useful rule of thumb is to give no more than three pieces of information at a time) and check patient understanding: “Are you following me?” or “Did that make sense to you?” This allows the physician to titrate the amount of information that can be covered in a particular visit. Confirming understanding can also enable the physician to correct misperceptions or inaccuracies. Since emotions can shape perceptions and decision making, it is useful to respond empathetically to the patient's emotions: “It sounds like this information is different from what you expected, and I think it would be upsetting for anyone.”

  1. Reinforce accurate understanding: “I agree that Option 1 would be the roughest in terms of side effects.” If necessary, add further information as relevant to ensure that patient's thinking is medically accurate and expectations are reasonable. [6]
  2. In transitions to hospice care, avoid using phrases such as “there is nothing more that can be done”
  3. The skills required for a clinician to deal effectively with patient emotions, especially distress, involve detecting and identifying patient emotion, responding to the emotion with empathy, and in some cases, further medical assessment or intervention for distress or mood disorders.

Obstetrics and gynecology

Effective communication and strong patient–physician relationships, while central to all fields of medicine, are of particular importance in obstetrics and gynecology given the sensitive and intimate nature of commonly addressed clinical concerns. While some women feel comfortable discussing the menstrual cycle, genital concerns, contraception, sexuality, or abuse, others may find discussions on these topics inappropriate or embarrassing. Therefore, an obstetrician-gynecologist must establish a comfortable environment and welcoming interviewing technique to facilitate the care of their patients.

Ideally, a gynecologic history should be obtained in a relaxed, private setting with a patient fully clothed. Under usual circumstances, the interview should occur alone. However, patients may request the presence of parent, spouse or loved one for the interview. This accommodation should be made after verifying that she is comfortable addressing personal questions with an observer in the room. Otherwise, a loved one may be present for part of the interview and, subsequently, a provider may request to speak with the patient alone for a brief period of time before the physical exam to address more personal questions or concerns.

During the interview, providers must continually assess the patient’s comfort level and make adjustments to their questioning and technique to facilitate the history. For example, a reserved patient who may be uncomfortable answering a direct question about sexual activity may respond to an open-ended question about contraception. Other topics in the gynecologic history, such as vulvar or vaginal symptoms, pelvic relaxation, and pregnancy history may also serve as transitions for exploring the sexual history further with patients. Occasionally, a complete gynecologic history will only be obtained over multiple visits, as some patients will provide more detailed information about their emotional, social, or sexual history only as they become more comfortable with their provider.

Additionally, remaining non-judgmental during the interview process is imperative; making assumptions regarding a patient’s sexual orientation or sexual activity represents unethical behavior that may have a substantial negative impact on outcomes (such as failing to perform sexually transmitted infection testing and missing the opportunity to diagnose HIV). Ultimately, providers must always remember the sensitive and intimate nature of the gynecologic history. Therefore, the adoption of a comfortable, patient, tolerant, and accommodating interview technique and style is particularly important. [11]

The obstetrician–gynecologist can take the following steps to improve communication:

  • Use patient-centered interviewing and caring communication skills in daily practice.
  • Encourage patients to write down their questions in preparation for appointments. A form for writing down questions can be given to patients on their arrival at the office. An organized list of questions can facilitate conversation on topics important to the patient.
  • Advocate for sustainable practice models that increase the duration of visits to provide the opportunity to address multiple patient concerns. Increased time for visits is crucial in efforts to improve patient-centered interviewing, shared decision making, and improved patient–physician communication. [12, 13, 14]

Obstetricians are generally associated with caring for expectant parents who are looking forward to the birth of a healthy baby. However, they also have to report bad news. The sensitivity of how news was broken to parents was recalled as part of the overall memory of experience. Parents appreciated when clinicians spent time with them in an empathic way, clearly but with compassion. They also want to get information as soon as possible, because keeping them from them creates a sense of mistrust and tension. Clinicians cannot change the news they must convey but they can change how it is communicated and how they express care. [15]

Pediatric

Effective communication between the physician and the child and / or her parents is an important milestone in the management of each pediatric pathology and can be much more complex than in the case of adult patients. According to the American Academy of Pediatrics, effective communication is a cornerstone of care, an answer to the needs of the patient and the dynamics of the family. [16]

In pediatrics, therapeutic interaction is characterized by increased complexity due to the inclusion of three subjects: a doctor, parents and a child. The relationship between the parent-child doctor consists of three elements: informativeness, that is, the quantity and quality of medical information provided by the pediatrician; interpersonal sensitivity, which refers to the doctor's attention and interest in the patient's feelings and cares; and the creation of a partnership is how the doctor invites parents to express their fears, perspectives and suggestions during the consultation. [17, 18, 19]

For pediatricians, communicative skills have their own peculiarities and include [20, 21]:

  1. the ability to talk with parents of patients, as with equal partners;
  2. the ability to communicate well with the child and her parents in order to understand their concerns, problems and beliefs, as well as the collection of relevant information. Communication for children should be age-appropriate and child-friendly. Use child-appropriate language, characters, stories and humour;
  3. the ability to explain to the infant his illness and the need for treatment. The explanation should be clear, complete and easy for the child and her parents. The treatment options should be clearly and fully described so that they can make decisions about the treatment;
  4. the ability to persuade parents to follow the treatment plan. This is especially important in long, complicated, painful or expensive procedures for the treatment of a child;
  5. the ability to establish relationships with parents and their children, based on mutual respect and trust;
  6. softskills, the ability to get in touch easily, to bring trust and comfort to communicating with children and their parents.

Factors predictive of effective communication between physicians and patients/parents are the perception of interest, caring, warmth, responsiveness and empathy. [22]

Empathy is the ability to put oneself in another’s place, including the ability to feel and experience the situation that person faces. An empathic reaction conveys three main messages to a child: “I care how you feel,” “I am trying to understand how you feel,” and “It is all right to feel as you do.” This approach focuses on the child’s feelings, as well as the physician’s attentiveness. [23]

Patients undergoing surgery and their parents often want answers to seemingly “minor” questions. [24]

The expected duration of the surgery, the amount of hair to be removed, the location and length of the incision and bandages, location and purpose of intravenous lines and other assorted tubes, and the child's likely appearance after the procedure are sources of concern that, although routine for practitioners, should be prospectively addressed.

Parents consistently state that they need more and clearer information about their children's health status, particularly in the setting of chronic or terminal illness. Parents of chronically ill children want more information about the child's condition, its treatment, and its long-term implications; they want that information to be shared with them as soon as it is known.

Parents want advice about their child's behavior and development, genetic implications of the child's condition, and social contact with families in similar situations. They would like someone, preferably the physician, to provide oversight of the long-term care plan, including an opportunity for advance care planning and execution of advance directives. They want their views and concerns factored into the care plan and to be treated like partners (and often experts) in their child's care. [18]

At its core, child health decision making is family-centered decision making. Parents and children themselves are more satisfied and adherence to the treatment regimen is enhanced when the child is addressed in information gathering and in the creation of the treatment plan. However, parents want to be involved in the decision regarding how their children are informed about their health conditions. It is, therefore, important to understand the preexisting parent-child relationship, the family's cultural and idiosyncratic values, and the developmental needs of the child, including the desire to participate in his or her own care plan. Simultaneously, determination of the parents' perspectives on providing information to the child is imperative. It is important for parents to understand that research demonstrates improved adherence to the plan and resultant health outcomes when the child is treated as a partner. [18]

Strategies for improving communication 25

  1. Check what the parents know.
  2. Assess what the parents want to know: Some parents want to know every little fact and detail about their child’s condition. Others simply want a prescription and an assurance that all will be well. It is important to assess the parents’ desires, and communicate accordingly.
  3. Assess understanding: Understanding can be improved by giving time to absorb, and by repetition. At the end of the consultation, the parents can be asked to repeat some information, to ensure it has been understood.
  4. Listening skills: A quiet room, lack of interruptions, provision of chairs for the parents, sitting at an appropriate distance, good eye contact etc., are helpful to enhance listening and learning from the parents.
  5. Build confidence and tell the truth: accept what the parents say, without judging it. Some suggestions for future care improve their confidence that they will be able to manage the situation. Giving false hope is wrong, but we can give information in a positive manner.
  6. Speak simple and clear: Explaining things in simple, clear, and direct language is very important. Clarity and directness are particularly important with parents of low comprehension abilities.
  7. Demonstrate empathy.

Conclusions

The physicians’ ability to communicate effectively is the key to a successful relationship between a patient and a doctor. The current state of the health care system requires increased clinical efficacy and less time for each patient, which may impede the quality of communication between the patient and the physician. The use of a patient-centered approach, empathy, shared decision-making improves the relationship between patient and physician, the effectiveness of therapy and increased adherence to prescribed treatment in oncology, obstetrics, gynecology and pediatrics.

References

  1. Baile WF. Communication competency in oncology: legal, ethical and humanistic imperatives. Psycho-Oncology. 2006; 15(2):S6. DOI
  2. Rawl S, Given B, Given C, Champion V, Kozachik S, Barton D, et al. Intervention to Improve Psychological Functioning for Newly Diagnosed Patients With Cancer. Oncol Nurs Forum. 2002; 29(6):967-75. DOI | PubMed
  3. Jefford M, Tattersall MH. Informing and involving cancer patients in their own care. The Lancet Oncology. 2002; 3(10):629-37. PubMed
  4. Heyn L, Finset A, Eide H, Ruland CM. Effects of an interactive tailored patient assessment on communication between cancer patients and physicians and nurses. Psycho-Oncology. 2011; 22(1)Publisher Full Text | DOI
  5. Epstein RM, Street J. Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. National Cancer Institute, NIH Publication No 07-6225. Publisher Full Text
  6. Back AL, Arnold RM, Baile WF, Tulsky JA, Fryer-Edwards K. Approaching Difficult Communication Tasks in Oncology. CA Cancer J for Clin. 2005; 55(3):164-177. Publisher Full Text | DOI | PubMed
  7. Fallowfield L, Ratcliffe D, Jenkins V, Saul J. Psychiatric morbidity and its recognition by doctors in patients with cancer. Br J Cancer. 2001; 84(8):1011-5. DOI | PubMed
  8. Back A. Patient-physician communication in oncology: what does the evidence show. Oncology. 2006; 20(1):67-74. PubMed
  9. Graugaard PK, Finset A. Trait anxiety and reactions to patient-centered and doctorcentered styles of communication: an experimental study. Psychosomatic Medicine. 2000; 62(1):33-9. PubMed
  10. Zachariae R, Pedersen CG, Jensen AB, et al. Association of perceived physician communication style with patient satisfaction, distress, cancer-related self-efficacy, and perceived control over the disease. Br J Cancer. 2003; 88(5):658-65. DOI | PubMed
  11. Lappen JR. History-Taking and Interview Techniques and the Physician-Patient Relationship. Glob libr women's med. 2011. Publisher Full Text | DOI
  12. American College of Obstetricians and Gynecologists Committee. ACOG opinion No 587: Effective patient–physician communication. Obstet Gynecol. 2014; 123(2):389-93. Publisher Full Text | DOI | PubMed
  13. American College of Obstetricians and Gynecologists Committee. ACOG opinion No 447: Patient safety in obstetrics and gynecology. Obstet Gynecol. 2009; 114(6):1424-7. DOI | PubMed
  14. Simpson A, Hodges R, Higgins M. Improving Communication in Obstetrics Practice. J Obstet Gynaecol Can. 2016; 38(10):961-964. DOI | PubMed
  15. Nuzum D, Meaney S, O'Donohue K. Communication skills in obstetrics: the impact on bereaved parents. Ir Med J. 2017; 110(2):512. PubMed
  16. Medical Home Initiatives for Children With Special Needs Project Advisory Committee, American Academy of Pediatrics. The medical home. Pediatrics . 2002; 110(1):184-6. PubMed
  17. Street RL Jr. Physicians’ communication and parents’ evaluations of pediatric consultations. Med Care. 1991; 29:1146-52. PubMed
  18. Levetown M and American Academy of Pediatrics Committee on Bioethics. Communicating with children and families: from everyday interactions to skill in conveying distressing information. Pediatrics. 2008; 121(5):e1441-60. Publisher Full Text | DOI | PubMed
  19. Kolucki B, Lemish D. Communicating with Children. Principles and Practices to Nurture, Inspire, Excite, Educate and Heal. New York: UNICEF; 2011.
  20. Mărginean CO, Meliţ LE, Chinceşan M, et al. Communication skills in pediatrics – the relationship between pediatrician and child. Medicine. 2017; 96(43):e8399. DOI
  21. Bagiyrova FA, Kurbanova АО. Problems of forming communicative skills in pediatric practice. Scientific-Practical Journal of Medicine "Vestnik KazNMU". 2014; 3(2):10-13. Publisher Full Text
  22. Simonian SJ, Tarnowski KJ, Park A, Bekeny P. Child, parent, and physician perceived satisfaction with pediatric outpatient visits. J Dev Behav Pediatr. 1993; 14(1):8-12. PubMed
  23. Sarnat H, Arad P, Hanauer D, Shohami E. Communication strategies used during pediatric dental treatment: a pilot study. Pediatr Dent. 2001; 23(4):337-342. Publisher Full Text | PubMed
  24. Shiminski-Maher T. Physician-parent communication problems. Pediatr Neurosurg. 1993; 19(2):104-108. DOI
  25. Mehta PN. Communication Skills – Talking to Parents. Indian Pediatr. 2008; 45(4):300-4. Publisher Full Text | PubMed