What comes to mind when you think of communication skills? You might think of Situation Background Assessment Recommendation handovers, or breaking bad news, with structures reminding us to have difficult conversations in quiet places, and with tissues in reach. These were the first things I used to consider.
Since becoming a cancer patient, I’ve reflected a great deal on clinical communication and how it stretches far beyond the moment I was told, with textbook technique, that unfortunately I had advanced lymphoma. It’s made me realise that low level, less obviously pivotal communication has a high propensity to cause distress, even though these facets are often overlooked. I hadn’t realised that when you’re navigating a significant illness, the difference between an “average” difficult day and a harder one can be due to minor communication pitfalls. I also wasn’t aware how common they are.
The vast majority of my care has been excellent. I have realised though, that the impact of less favourable experiences is exponential and that twenty good exchanges don’t always make up for one poor one. Some of this is organisational—stress and worry quickly mount up when letters go astray, or appointments are double-booked. It’s easy to forget that patients are trying to live their lives, juggling their health with everything else, and that they don’t have endless capacity to change plans with little notice.
We sometimes comment as doctors that patients don’t realise how much work goes on behind the scenes, but I’m not sure we realise as doctors that there is also an organisational cost to being a patient; working out travel, where to park, where to wait, and sometimes when you can eat. During my treatment, letters went astray, instructions forgot that certain hospital entrances were shut on Saturdays, prescriptions were not signed, and crucial results were sent to the incorrect GP practices. All of this caused worry. All of it is communication. It has made me question, as a hospital-based trainee doctor, how we can make the administrative aspect of things easier for our patients, or at least be aware that the capacity for error is significant and be open to acknowledging this risk and impact.
I also learned what it’s like to be a fly-on-the-wall for extended periods in clinical environments. It’s hard to listen to long conversations about hairdos for staff nights out when your own hair fell out spectacularly three days before. It’s frightening when someone criticises how another nurse primed a chemotherapy pump, not realising that implying an error with toxic drugs is quite scary for the person hooked up to them. It’s unsettling when a junior doctor phones their consultant within earshot and anxiously says they’ve never dealt with your acute complication before. It’s hard to know how to feel when a member of staff openly says that haematology is nice to work in as “no one caused their own illnesses,” or you overhear a disparaging comment about someone directly involved in your care. These things were all difficult to hear. I am fiercely proud of the NHS and like to believe we usually get it right. Finding otherwise caused an element of cognitive dissonance, not least because I’m very aware I’ve likely committed similar slip-ups myself, and not realised their significance. It also occurred to me that many of these comments came from tired, frustrated, and stressed out people, and that many of my own mistakes have also happened when I was less than fresh.
In clinical settings, staff are always a little on show and it’s not always obvious what might be hard for patients and relatives to overhear. I perhaps hadn’t realised how important it is that patients feel secure, safe, and that their team is all on the same page. As a patient, you lose a lot of control and have so many things done to you by so many people. Each one of them impacts your experience. They say it takes a village to raise a child, and I’d suggest it also takes one to care for a complex patient, and that everything goes smoother when that village feels safe, collaborative, competent, and efficient.
How do we improve this? Part of this might be how we teach, assess, and give weight to different aspects of communication skills. Part of it might be asking patients what they truly see, or putting ourselves on the other side of the chemotherapy pump, and considering whether a critical comment is likely to build or erode trust. A significant thing however, is about taking care of ourselves and our villages, so that every person has the best chance of being able to give the best care to our patients, is aware of how their own wellbeing might impact their ability to communicate effectively, and has strategies and support to manage this.
Charlotte Squires is an ST3 in acute medicine at the Borders General Hospital in Melrose, Scotland. With thanks to the Nottingham City Haematology Department, where she received her chemotherapy.
Competing interests: None declared