Tuesday, 5 May 2009

Theory and Practice

At 11am I was close to having an argument with a patient's granddaughter. At that point my registrar deflected the conversation, and I realised just how far I have to go in my communication skills.

Since I started university, for some reason I have considered myself to be an excellent face-to-face communicator. I knew I wasn't as good at writing, or at confrontation, but when it came to day-to-day interactions, it seemed to go more smoothly for me than for others. Now, I'm no charmer. I will never say anything just because it's what someone wants to hear. But by that token, people get to know that when I say something, I mean it. When I was young, I read a book about conflict resolution and active listening*, and so I try really hard to listen and understand people in return. And combined with the fact that I have a nice smile and (I thought) a good attentive manner, and my eagerness to say things in a way people will understand ...

... well, it seems to work. People like me. People smile at me when I smile at them. I have gone up to people and made bald-faced unusual requests, and had them granted out of the goodness of their hearts (in a good cause). And patients and their families love me.

Actually one of the positive thinking slogans I made for myself when I was down, was related to this: "The world smiles at me when I get things done and go out!" I really do have all the luck sometimes. I used that as my screensaver, so that when I got paralysed in front of a computer I might think about moving.

Being a doctor ... well, I certainly had a lot of skills to learn when I started - case presentation, handover, ward rounding, informed consent, explaining things to patients and their families. But it's been two years now, and these days I feel pretty confident, especially with the last one: explanations. I really put some thought into finding a simple way to explain what's happening and why we need to do certain things. But maybe I'm over-confident. It's come to the point where I do interrupt my registrar and at times even my consultant, in order to clarify things for the listener. Maybe I'm backing them up, or maybe I'm getting in the way and being inappropriate. I don't know how to tell.

Anyway, today ... we got a call to say the patient's granddaughter was upset and wanted to speak to us. Now, we hadn't met her before, but we were already having problems dealing with the patient's medical issues - mainly pain and agitation - and her son's distress. So on the way in we caught up with the nurse, who said the granddaughter's main concern was that the family hadn't been informed when the patient was moved into a windowless single room overnight. (Ahh, treatment rooms. Another story for another time.) And that the reason for this was that the patient had been agitated overnight, but now she was quite settled in the new room.

Now, we hadn't been informed either. Actually, we'd come in that morning and gone "where's the patient?" "Oh, she's on [a ward on another floor]". So I was all set up to go in and sympathise - after all, we would have preferred her not to be removed from her familiar environment either. But boy, did that conversation take a turn in the opposite direction.

She started by expressing her severe disappointment with the system, and her wish to speak to someone senior. Fair enough. We talked about the bed move, and the fact that yesterday she had specifically asked that the family be informed about any changes in treatment. Obviously that message and its scope (including 2am phone calls about bed moves) hadn't got through to us. Anyway, she thought her grandmother would have been further agitated by the move, and the language barrier wouldn't have helped, as her grandmother now didn't know where she was. I tried to explain that people had tried to speak to her in two of her native languages last night with no success - because she had been confused. She didn't agree.

But then she took a completely unexpected direction. She was concerned that her grandmother was drowsy, and expressed her opinion that she was on too much medication. At this point, I'm not sure, but I think I did no more than frown, I don't think I said anything. The response: "Don't question me." (I was standing facing her with my registrar between us half-facing her, so he couldn't see my face.) So I said nothing further, and she continued along her line - her grandmother was drowsy and not herself. Obviously this was true even if I didn't agree with her over the cause, and my facial expression at that point was (or should have been) of "concern". Suddenly her tone changed, and she looked like she was going to get angry with me. My registrar sensed it too, and quickly changed the subject slightly.

(As I later did manage to explain to her, we had cut her medications by two-thirds the day before, and she had had hardly any that night.)

Later in the conversation there was another flashpoint, where she had questioned the prescription of a medication a couple of nights before - the nurse had needed to tell the doctor a medication he was about to write had already been given. I tried to point out that the doctor was on the evening shift and wouldn't have known the full situation. She didn't respond well to that - she told me not to defend something that was wrong. (Later we pointed out that he had already asked for advice from a senior doctor before making that decision.) Anyway, I guess I scored myself another aggravation point with that one.

My registrar is a very experienced doctor, who worked in Palliative Care last term, and it's to his credit that he was able to defuse the whole situation. He acted swiftly to protect me from becoming a focus for her anger. Later, he explained that he could see her misinterpreting what I was saying, and he was afraid that she and I would get into a proper argument. Overall, his competence with the situation made me feel I should just keep my mouth shut and learn from the way he dealt with it. He did give me a few tips afterwards - on what parts of a conversation I should actively let go, and how to emphasize just the necessary facts.

It's funny, I always thought I was good with families. Now I realise that there are two categories I've learned to deal with. Anxious and worried people, I'm good at - I can give them enough information, and reassure them that I believe in what I'm doing. People who are just upset for no good reason and don't listen - I learned long ago that they're a lost cause. But there's at least one type that I don't respond to adequately - the angry argumentative person who listens to what I'm saying in the wrong way, and throws it back in my face. I get defensive, just like I tried to defend the intern from the other night. Those sorts of things, I need to learn to actively listen to, acknowledge, and then let go, and wait for the right time to provide correct information. And despite my reading, I've never practiced active listening and it's not in my skillset. More practice needed.

And there are probably myriad other situations I haven't yet come across or learned to deal with ...

Oh, and we did manage to explain everything to her in the end, and she agreed with the plan, and we encouraged her to take some of her concerns to a higher level. Later that afternoon, though, we were told she was planning legal action against the hospital.

*bibliography: I'm almost sure the book I read was We Can Work It Out, but it's way too recently printed... I've been trying to find which book I actually read. Any suggestions?

1 comment:

  1. I also thought I was a relatively empathetic and transparent communicator, but there are some people who (through grief or otherwise) unconsciously look for someone to blame, and nothing will ever be done to satisfy their level of expectations.

    AND, I also respectfully defend staff if a family member starts attacking when I think they have no right to. And I get very hardline if I hear any patient or family member get personally insulting or verbally abusive.

    They need to be politely told to go home and simmer down before they do something they regret. Their behaviour will only compound an already difficult situation.


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the angel Jean