By DR. V. N. JINDAL

THE MOST COMMON complaint of the patients against doctors is not regarding the treatment given to them, but is about the way doctors talk to them. As medical professionals, we have rigorous curriculum of 10 to 12 years in medical schools, where all sorts of scientific data is fed to us day and night. However, there is absolutely no attention paid to the communication skills that a doctor must develop. After all, the doctor is a public man, in the sense that he has to deal with human beings all the time and that also with those who are sick and miserable and who look upon the doctor not only for medical treatment, but also for psychological relief. We are all very well trained in physical examination of the patient, in diagnostic skills and various therapeutic modalities, but we spend very little time on communicating with the patient, regarding his physical as well as psychological problems. There are many reasons for this.

Very often, the reason for lack of communication is on the part of the patient also. Patients think that the doctor is too busy. They feel that they are more interested in their physical care. They believe they don't want to know about any emotional problems. They are frightened that they may break down while narrating their personal problems. They are terrified of revealing the truth at times. On the other hand, doctors find it difficult to communicate bad news for many reasons. They feel incompetent, as they have had no formal training. They are worried that they may be blamed for the condition of the patient. They at times feel awkward or embarrassed. Sometimes they may want to protect the patient from the harmful effects of bad news. Finally many feel they have very little time.

It is very easy to convey good news, e.g. a healthy baby is born or a tumour that was operated turned out to be not cancerous. It is difficult to break bad news. Moreover, there are two viewpoints about revealing bad news to the patient. One feels that bad news should not be given to the patient. Ignorance is bliss. They feel the patient should be left alone. Knowing about his illness, especially if it is not curable, will make the patient miserable and may expedite his end. The other school believes in telling everything to the patient. They believe there are many reasons for this. One is the credibility of the doctor. If the patient comes to know about his sickness from someone else, he will lose faith in the doctor. He will feel the doctor lied to him. Also the uncertainty is harmful. It is better to tell the patient the facts, so that he can be prepared for the worst. Sometimes, it is important to tell the truth because the patient may have to prepare for the family- especially if he is the provider of the family. It may also be important for settling certain financial matters or preparing a will.

Then the question is, is there a method for breaking bad news? Well, though difficult, it is possible. One has to first take the family into confidence and first inform the family members. Also one should find out from the family as to how the patient normally reacts to the bad news. While breaking the bad news to the family as well as the patient, the doctor must keep in mind two factors i.e. faith and hope. Very often attendants or the patient has full faith in the doctor and they feel that the doctor knows what is best for the patient. Similarly, hope is essential for man to cope up with the trials and tribulations of life and this could be best maintained through silence and avoiding information, especially that which is too detailed or unsafe. First, one should determine how much the patient knows about his condition. Many a times the patient would have guessed the outcome. Determine if more information is wanted. Let the patient lead the conversation. Sometimes, a warning shot can be given, without giving all the details. Allow the patient to express his reaction. Further explanation can then be given if required. Listen to the concerns of the patient and encourage him to vent his feelings.

Secondly, keep in mind the social, cultural and psychological make up of the patient and his family. Some patients and their families take things boldly; others break down and may not be able to sustain the emotional trauma. Finally, keep in mind that bad news can never be made good news. The impact of bad news can be minimized. It will depend on the doctor as to how he conveys the bad news to the patient.

To illustrate an example, I will relate how I handle such situations- In an advanced case of malignant brain tumour, I tell the family and or the patient as follows : “If there are hundred patients with this kind of tumour, five of them die soon after the operation. About sixty percent survive for two years. Twenty percent can survive for three years and five percent may live for more than five years. I don't know in which category your patient / you will fall.” This way, I feel I have conveyed to them the truth i.e. worst the patient may die within a few weeks of surgery and at the same time give them hope that he may be one of the lucky one who survives for five years. The human mind always believes that there is high probability of getting the one in thousand chance of a lottery prize, but does not believe there is a reasonable probability of getting the one in ten chance of a road traffic accident while driving above the speed limit. I do not claim this is the best method, but it seems to work.

Lastly, can this technique be learnt? Should it be taught or does it come naturally to every doctor? I feel, though presently this is not a part of the medical curriculum, but it can be learnt and should be taught to doctors early in their education.

Another important shortcoming of medical personnel is the lack of administrative skills. Very often a competent clinician is elevated to an administrative position due to his seniority. Though he is an excellent doctor for the patients, yet it does not guarantee that he will also be a good administrator. In fact many a times such a person proves to be a total failure and disaster for the institution that he heads. Again the reason for this is that the doctors are never taught the art of administration during their medical curriculum or even in the job. This makes them bad administrators. Of late many doctors do get into hospital administration by joining these specialized courses. However, this specialty has not yet picked up very well in our country. In the interest of the institution, it is important that the government should organize some administrative training for the person who is tipped to be the Chief Executive of the institution by sending him to an administrative staff college or any other similar institution. This will make a lot of difference in the working of the person as well as the results that he will show for the institution.

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