Communication between doctors, nurses & patients

Monday May 6, 2013 -

This week, let’s talk about communication; the communication between doctors, nurses and their patients.

I have two questions: why is it so difficult for doctors to tell their patients what is wrong with them and what they are doing to cure them? Why the silence, the sarcasm or even insults when a patient wants to know what you have found after asking all those “weird” questions and probing and prodding him/her in all sorts of private places?

A patient once asked, “Is it not easier on everyone for a straight, honest answer than the diatribe about the fact that you are the doctor, and I am not a doctor? Of course I know that and that is why I am sitting in front of you!”

The arrogance and condescension is sometimes absolutely unbelievable.

Apart from the fact that an informed patient is more inclined to be compliant with the prescribed treatment, a respectable communication between a doctor and his/her patient builds trust, allays anxiety and prevents blame later on. Most importantly it is the patient’s right.

Again, the rationale for the arrogance and the condescending attitude is lost on me. What is the gain for a doctor to refuse to communicate or even be rude? Power play? What power? The power we wield is the power that comes out of the respect patients have for us. We do not gain that respect through arrogance.

And do nurses really lose anything if they answer patients’ questions directly, truthfully, respectfully and nicely. Adding a smile will not hurt!

Some reasons have been given for the rudeness: 1. that doctors and nurses are overworked and working conditions (including pay and benefits) are bad. 2. The worst reason that I have come across is that, sometimes, patients are rude. My question for any nurse who has used the second reason is this, “in your experience has being rude to a rude patient ever made the patient less rude”. No, it makes matters worse.

I am not holding brief for a rude patient; I have met a few in my day. They can be irritating, disruptive and a nuisance. The good news is they are few and far between. They are rare. The best way to deal with them is to be nice to them, it disarms them. Being nice to them is not a weakness. Indeed it is great strength. That is the strength that our profession should portray.

This lack of communication and arrogance breeds mistrust and anger. It is the stuff that leads to malpractices suits. The research data is there. I know that it is uncommon for patients to take doctors in Ghana to court for malpractice but I can assure everyone, as much as we will not like to hear it, that it is coming. With all the negativity going on about healthcare, drowning out the good and great things that most healthcare workers are doing, I will not be surprised if malpractice suits become part of our lives sooner rather than later. If the unfortunate day comes, I believe that one of the reasons for it will be the poor communication between doctors/nurses and their patients.

Question is: are there really any legitimate reasons for the poor, sometimes rude, communication between doctors, nurses and their patients? What can we do to improve the discourse between doctors, nurses and their patients?

Dr. Joseph Boateng

About Dr. Joseph Boateng

Dr. Joseph Boateng is a Physician Specialist. He has practiced medicine for over 31 years. He has extensive medical management and leadership experience as Medical Director or Deputy Medical Director for several hospitals in the US, Ghana and Nigeria, and as the managing partner of a medical practice he founded in the US.

20 comments on “Communication between doctors, nurses & patients

  1. Well said Dr. Boateng. The doctors who have commanded my respect the most are those that have been nice, open, and honest in my conversation with them. To gain power by being rude and/or arrogance will backfire except perhaps from the vulnerable.

    I wish all doctors and other health practitioners have such mentality as yours. But more so all of us human beings. Also great to have chanced upon your blog and this piece in particular. I am a fan of yours.

    Thanks,

    Joe

    • Joe, thanks for the sentiment. It is for all of us to talk openly about these things so that we can help improve the status quo. It will be good for us, individually, as patients, and even as doctors, and, collectively, for us as a society aspiring to become a modern nation.

  2. I think doctors and nurses have been quite patronising in our approach to patients especially when practicing at home, the syndrome of “doctor knows whats best” still afflicts both doctor and patient in many scenarios.
    I still have family members who are hospitalised at length at home and are forbidden any discussion on their investigations and treatments let alone the diagnosis and prognosis.
    A close relation had surgery, chemo and radiotherapy for an aggressive tumor and is still none the wiser about the prognosis and salient details of her treatment. ” Fa ma Nyame” is our eternal plea, that seems to banish all enquiries as to what is actually being done to our bodies by our learned friends in white coats.

  3. I am able to defend myself against rude doctors and nurses but I really pity those who cannot stand up for themselves and are afraid of those in positions of authority. When I knew my daughter was ill and the doctor would not listen, I had the confidence to ask for a second opinion and eventually go elsewhere.

    Some time ago a female night doctor at Lister completely dismissed us when we came to them around 4am with our baby, who was vomiting, had diarrhoea and an extremely high temp. We had been at Lister earlier in the day to see the paediatrician but at that time our daughter was less ill and they dismissed it as a cold and refused to do a lab test. The night doctor, under pressure from us, did a lab test and sent us away saying there was nothing wrong and haughtily questioned why did we not wait until Thursday to come back for a check-up as the paediatrician had instructed. Angry, upset and worried, we went home.

    Our daughter became weaker and sicker in a matter of hours so we went to Omni Clinic in Dzorwulu where the doctor showed the due concern and urgency our daughter required. The doctor immediately detected malaria as well as an ear infection and a secondary infection. Our daughter received immediate treatment but worsened in the evening and since Omni Clinic does not have 24-hour facilities we had to drive around in the pouring rain to find another hospital, which we did and thankfully, she was fine after being admitted to hospital for five days.

    But, did we need to go through all of that? Did we need to fight to have our daughter treated, even at a private hospital? Did we have to visit three health facilities to get her well again? I cannot even imagine what less privileged members of our society have to go through when even the supposed ‘best’ in the country cannot do their jobs.

    Dr Boateng, this blog is a crucial step in shaking up the healthcare system in Ghana. People aren’t just patients when they visit hospitals; they are customers and must be treated as such, regardless of whether they are attending La Polyclinic or the best private hospital in the city.

    • Christina, the reason for this blog is to bring awareness to this hidden “cancer” in healthcare delivery in Ghana which I suspect is causing the death and suffering of countless patients.
      Your advocacy for your child and your assertiveness, most likely, saved your child’s life. My hope is that we will have more of that advocacy and assertiveness. I believe that that will strengthen the medical profession because it will improve quality and induce accountability.
      I am not advocating for unnecessary confrontation and discord between patients and doctors. I am advocating for openness, respect and accountability.
      Patients are human beings (let me repeat that: human beings) with health problems who come to us because they have hope and trust in us as doctors, clinics, and hospitals. The least we can do for the honor they have shown by believing we can help them, is to do our best and help them the best way we can, with respect and dignity. Is this too much to ask for?

  4. First of all, I want to commend this initiative as an additional effort at improving the quality of health services delivery.

    As a contribution to the question I wish to share that, there are very intangible reasons for which poor communication between doctors/nurses and patients occur, although its negative effects are well acknowledged.

    There are what I call “training etiquette”, however crude, that some doctors/nurses use as a barrier of communication, and in most instance affect negatively oral communication with their clients. For example, I once asked a doctor, why he cannot write clearly in a patient folder and the response was “We don’t want anyone to understand what we know”. He agreed with me that scribble same as a medical student he would not have been certified.

    I also share the view that our social upbringing also contributes to the low level of confidence during communication with persons from whom “help” is sought. It said literary that if your hand is in somebody’s mouth you don’t hit on his head. Some heath professionals do take advantage of this.

    The social definition of doctor, and the way it manifest also create a problem in communication. The “ordinary” Ghanaian perceive a doctor to be rich, respected, have a car, a house, etc. Of course deservedly so, but I am afraid some doctors consider clients below such status as “nobody” and do not address them in same manner as they would address persons of known high status in society. Many exit interviews have demonstrated this trend.

    A doctor/nurse must demonstrate confidence in the line of duty, but for some who are ill-prepared for some cases, this important attribute is applied wrongly to the peril of the patient. Whereas it is honourable for a practitioner to simply admit his limitation and making the necessary referral, an intimidating attitude is rather used as a defense mechanism.

    These notwithstanding, there are very difficult challenges that most health workers face which affect the way they would ideally communicate. I mean, there are many doctors, nurses and other professional who are very welcoming and accommodating, yet due to circumstances of stress (social and work), they are unable to communicate as professionally dictated. Are we not asking too much a smile from a doctor/nurse who has over-worked a consequence of which he/she cannot attend to his family or have little or no social life to deal with the stress. Can call them “super humans” or force them to work within their professional ethics all time without addressing the many distress? I think this is a management issue.

    To overcome, the use of TV and radio to educate people on some medical conditions has to be expanded. This would allay the barrier of “fear” of probing doctor/nurses about some basic information about a patient’s condition.

    We need to advocate for the institution of stress management sessions in health institutions as a comprehensive component for the promotion of a healthy occupational working environment.

    There are Quality Assurance units that continuously address patient concerns in seeking health care; yet little effort is seen regarding efforts at improving attitudes of culprits. Do we name and shame, or continue to hope that culprits would by themselves change to improve on the situation?

    Out training component, especially during housemanship/internships should find a way of independently measuring or evaluating traits of poor attitude of communication of trainees; and have modules to rectify gaps identified.

    Finally a continuous plea on health workers to improve on patient communication can be a excellent reinforcer.

    • I completely share the expressions of Kofi Boateng. He has captured the situation so well. I don’t know if he is a health worker but he seems to be very closed to the happenings in our health institutions. It’s a two way affair. The bigger responsibility to correct this behaviour is on the health worker (Doctor/Nurse) more than the patient. After all we are the professionals and our basic knowledge of psychology should be brought to bear when we are faced with ‘a difficult patient’
      There must be a continues process to improve our communication but often customer care related trainings/activities have not been sustained. We assumed that our staff know how to communicate. This is the challenge that the managers of our health institutions have to resolve to enhance patient trust and confidence in us and ultimately earn the respect of patients.

      • I agree with Dr. Baffoe that Kofi has captured the complexity of the communication problem very well.
        In terms of solutions, I agree with Kofi that we should name and shame. As we make this problem public, health professionals who insult, are rude, and disrespectful to their patients will know that someone may be watching. If their behavior becomes the focus of Quality Assurance activity in the ambience of public outcry, I believe we can improve things.
        A second line of action is to encourage patient assertiveness and intolerance for abuse. This is not gong to happen overnight, partly because of cultural reasons, some of which Kofi has identified, but will definitely increase with public discussion and awareness of this problem.
        In the long run I believe that this initiative, that I am hoping will catch on, i.e. the effort to improve the experience of patients with health care delivery, will also help to improve the overall quality of medical care in this country.

  5. I want to thank Dr. Boateng for starting this blog and creating the plat for a lively discourse on topical issues bothering on health care delivery in Ghana. I have read all the previous blogs, but that on communication caught my greatest attention. The issue of poor Dr./ nurse/patient communication is sometimes, but not always, due to over work. I will cite a few cases to buttress my point.

    1. Working over capacity. Unlike in other well-developed economies, very few hospitals in the country will turn away patients because the capacity to admit and/or care for patients vis-a-vis reaching their ward capacity to admit. For this reason, nurses and Drs are compelled to handle more than they can manage in the name of trying to sacrifice. This often cause communication hiccups.
    2. High patient volume. As a young Dr, I used to be in-change of running the diabetes clinic in one of the teaching hospitals on Tuesdays and Thursdays. On such days, I see a minimum of 80 patients (I kid you not). And with this high patient volume, I often found myself having to leave most important aspects of patient education and information to the nurse, who was equally overwhelmed by the situation. My audit regarding a solution to the problem yielded no favorable results. We found out that most patients lived far away and our clinic days coincided with major market days for most of the patients who could only find means of transport to our facility only on such days. And guess what, there was nothing like closing at 5pm or 6pm etc. you only close after you see the last patient and this often means around 9pm or beyond. Under such circumstances, the health professional may inadvertently miss having some really important communication with the patient.

    Despite the aforementioned somewhat valid contributing reasons for poor Dr./nurse and patient communication, some Drs fail to communicate properly with their patients out of sheer arrogance and ruddiness. The fact that a patient shows up for an opinion regarding his/her malady does not give any Dr. or nurse any right to take them for granted or treat them with less courtesy and/or with disrespect. As a medical student, I shadowed a senior colleague and was utterly disgusted by his attitude towards a woman we were both seeing. My “boss” as we used to call them, literally smacks her face with her hospital card. I was shocked! The patient’s crime was her response to the Drs question regarding her chief compliant. The woman had said she had malaria and this was enough to attract such a barbaric behavior. His defense was that the woman could not possibly know what was wrong with her since she was not a Dr. (I wonder how my boss could also possibly tell that sitting before her was not a cardiothoracic surgeon or a medical epidemiologist or yet still a very wildly read home keeper).

    Drs. must take or leave it, that gone forever were the days when even the most basic of medical knowledge (such as the ability to infer that ones symptoms of headache, fever, poor appetite etc. could as well be malaria) was the solely the preserve of medical personnel. With the current unstoppable (even if you wanted to) print and electronic information explosion, many people are now becoming very well informed and well aware of their symptoms much to the benefit of medicine as a whole.

    Mu two cents regarding the solution is as follows:
    1. Drs. and nurses and other ally health personnel must eschew arrogance and disrespect. In fact they should see themselves are waiters and waitresses in a restaurants and their patients their costumers. You must treat your clients nice enough to want to come back and eat there again. By so doing, even if you the waiter/waitress inadvertently vomit on their food while they are eating, they will still come back to eat in your restaurant.

    2. I am one person who advocates for malpractice lawsuits in Ghana, please do not get me wrong. However, before we get there, there must be a system wide overall so that Drs. and for that matter hospitals can, with a very clear conscience, say no to patients when they think their admission capacity has been reached or capped.

    3. Health workers should be paid well and paid what is due them very timely. It is no excuse for government to not pay the arrears of Drs nurses and other health workers under the pretext of having no money. Government must prioritize his needs. It is ridiculous to hear that legislators were paid their end of service benefits in one big lump sum yet the same government cannot find the money to appropriately remunerate Drs.

    4. I am a big fun of privatization and it is about time many of the nation’s leading health facilities including KTH and KATH to go private. As stated earlier in this blog by Dr. Boating, Drs. must also seriously consider going into private practice. A private practitioner who treats their patient disrespectfully will go hungry.

    5. Finally, There is the need to re-emphasize that respect for patients is the cardinal rule of engagement for the practice of medicine. Medical school curriculum must strongly revisit and hammer this point with great seriousness. Communication with patients, like costumer service in any enterprises, should be given greater weight in medical school curriculum and in the exam s for board certification.

    • Chief, thank you for a fantastic contribution.I really hope and pray that we can use this platform and other public platforms to openly discuss and share ideas on how we can improve the patient’s experience of the health delivery process. This will involve the identification of the problems such as the large numbers of patients that doctors see and the overwork which can be detrimental to quality and the physician-patient relationship.
      From my own experience, private practice is a viable and a very legitimate option to help solve some of the ills that plague our profession including physician dissatisfaction and independence.

  6. Dr Boateng’s May 6 epistle to the medical profession on communication has reminded me of great doctors like the late Dr S.A. Banful, formerly of the Legon Hospital who after retirement from the University of Ghana worked in a once famous clinic next to or on where the Canadian High Commission now stands.
    Then there are Doctors like Reverend William Baeta at Baeta’s Clinic at Dzorwulu. I am told of one young doctor in their gendre at the District Hospital at Edweso (Ejisu) in Ashanti.
    The distinguishing character of these genre of doctors is that they love what they do and put their heart in what they do. They communicate by words, with their eyes and by gentle respectful touch and tell you what you may have and what the causes are and what you must do must to get it out of your system or at least not to add any more to it. And they do all this in a conversational manner, with respect, cracking jokes which emphasizes the point of their communication.
    And I have come across the others who were not called but who came by themselves. I walked into his office. He doesn’t even look up. He is writing. He stops and without lifting his eyes to see who it was sitting in front of him, indicates through a mmhh? that i should not be wasting his time but tell him what ails me.
    I stutter to tell him what ails me and before I am halfway through, he has written some prescription and handed over to me without lifting his eyes to see which of God’s creation has shared his space over the 3 minutes it took. Next patient please? I kid you not. This was right at Osu here in the capital city.
    Dr. Boateng is right. Indeed, the days are coming and the days are already upon us when not only will doctors be dragged to court and jailed, but also the Ghana Medical Council may find itself dragged before the world body of which it is a member to explain why it should not be expelled or suspended or shamed for its failures to censure members who kill , maim or otherwise harm patients by their failure to observe professional conduct.

  7. Dr Boateng, the answer to your question is short and simple: NO. There are no, I repeat NO, legitimate reasons for the poor, sometimes rude, communication between doctors, nurses and their patients.

    Patients need to be educated on how to assert themselves in their communication and not hold back because the doctor or nurse is better educated than them.
    That said, patients get rude out of powerlessness. This powerlessness is a direct result of the lack of understanding or simple arrogance they are received with and talked to by doctors and nurses. Any patient who comes to a hospital is already 1-0 behind: they are in need and are already in a weak position. Being arrogant and disrespectful only adds insult to their injury.

    In respect to doctor/nurse communication: same here. The nurse is in a weaker position because the doctor is more qualified and better educated than her/him. So barking commands at their nurses doesn’t add any more power or authority to doctors, it just shows their inability do conduct themselves professionally – as their education and profession would require.

    The heart of your question boils down to our inability to provide service in a professional and self-respecting way. As a nation – starting from our education system and going to all corners of our society’s fabric – we have to do better. Healthcare would be one service to start with: give meaning to the caring for the health of somebody who in need.

    • Ampofoaa, you have added another facet to this debate about communication which I overlooked in my initial entry: the doctor nurse communication.
      You are absolutely right that it is as unconscionable for a doctor to be rude, disrespectful or be unprofessional to a nurse. It is wrong and must be condemned. Nurses should resist any disrespect.
      There is really nothing to gain by arrogance and disrespect in the work place.

  8. Dr Boateng,
    As a chronically ill patient, I’ve witnessed too many doctors in Ghana who don’t know how to communicate with their colleagues including nurses and trainees. Perhaps an authority like yourself could advice the nation’s medical schools to add ‘communication skills’ to their curriculum. I’m sure that would be of great value to not only themselves and their colleagues, but to patients as well.

    • Ampofoaa, your idea is a great one and I will mention it and push it to the medical school Deans that I get the opportunity to interact with.

      There are several new areas in the training of doctors that need to be incorporated or emphasised. This includes coomunication as you rightly noted. Communication with patients, healthcare colleagues especially nurses and non doctors, patient’s family members etc.
      I also believe that we should be interested in how an applicant for medical school does on questions about ethics, empathy, responsibility and equity during the interview process.

  9. Effective communication is very important in resolving all the setbacks.I would hope it is taught in the various schools.There is the verbal/non-verbal cue that we as healthcare workers portray to pts.It is all about empowering these pts with knowledge on their ailment.Shame on these healthworkers who have flunked the basics;effective communication/listening/human dignity…..without these pts you guys would not have a job!THE PATIENT IS ALWAYS RIGHT.

  10. Dr Boating, I must recommend you for this blog. Communication is very important in health care profession, it establishes some sort of reassurance to the patient no matter how bad the situation may be. And nurses should try as much as possible to communicate well with their clients.

  11. Good communication needs time. I have a personal maxim which is “see more, do less”. Having worked both in Ghana and the UK, i have come to question the benefit of high patient volume “clinics” such as the Diabetes Clinic mentioned by the contributor Chief. Even when you look at guidelines by medical societies for review and monitoring of chronic conditions, there is very little evidence to back them. The key issue is good patient education and communication. I would advise any patient who has a chronic condition to empower themselves by getting reliable and up-to-date information about their condition. Most doctors welcome this, except those who are not adequately informed about the condition. The honest doctor will admit that he does not know about the new info and refer you if he is not sure. Another doctor may get angry with you for questioning his training and competence. Unfortunately many patients have no choice about where to go due to financial issues or the urgency of the situation

  12. I really do go along with all of the ideas you might have made available to your post. They can be pretty convincing and can absolutely perform. Still, this posts have become quick for starters. May just you desire expand all of them just a little via next time? Appreciation for your write-up.