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ART OF COMMUNICATION : BEDSIDE MANNERS - COUNSELLING

CH Asrani

Family Physician, Vakola, Mumbai 400 055.

Ever wondered, various students of the same college, some succeed in practice, others don’t : A Gold medalist not doing well whereas a repeater doing extremely well. Your professor who was such a wonderful surgeon but an awful teacher. Most note cases of students, nurses and wardboys are shown to some particular registrar and not to the boss.

Well, you have just shown the importance of Art of Communication.

What do you mean by Communication?

Communication is sharing of information. It is the art of imparting knowledge or exchanging thoughts, feelings and ideas by speech, writing and gestures. Personal communication is when people make their thoughts and wishes known to each other. People communicate in many ways including talking, moving their hands and even by making faces.

Art of communication is knowing how to succeed in putting your message across.

Communication is of two types verbal and non verbal

Verbal Communication

a)What you say? Always say the truth. It may not help you immediately but over a period of time you will build a reputation and the patients will respect your word. Also how long can you hide the truth, there are enough doctors out there waiting to catch your lie. If your injection has resulted in an injection abscess, admit it and tell the patient that it can happen with anyone.

b)How you say it? This point becomes important when you have to break bad news. You have to be subtle, approach the main point without beating round the bush. Patients are smart and they know something is coming up, suspense is the last thing wanted then. At times you may feel that you are very close to the patient and you can crack jokes at their expense, be careful it may back fire.

c)To whom do you say it? Always tell a responsible person - mostly head of the family. In case the matter concerns him only talk to him directly and if needed/possibly involve the spouse and/or elder child. Never tell important things to neighbours or other relatives even if you feel they are very close.

d)When do you say it? There is always a right time to say something. If you have taken the concerned person away from everyone else, wait for the right occasion. This way you are telling all and sundry that there is something that can’t be told to everyone. If imparting Health Education, give it when the patient need it e.g. if patient has come for treatment of Piles, he will be attentive if you talk of hazards of spicy foods and constipation.

e)What you do not say? As a physician you are bound by professional secrecy. You may not realize but at times you may have to hide things from members of the family. Whenever you go for a visit, invariably people will ask you "Where to?", you may not realize at that time but your patient will not appreciate your telling as after you answer where to next question will be "who is not well?". You may discover that the patient smokes. By not tell ing the parents, you may win over a patient that doesn’t mean you don’t admonish him when alone. At times what you do not say can have detrimental effects on practice i.e. if sending a case of tetanus or acute MI to the hospital you must tell the family about the likelihood or a bad prognosis or even the fact that the patient may not reach the hospital. You may not say it bluntly but can say that "patient is critical, they should hurry and shift him soon as every minute counts".

What are the important aspects of Verbal Communication

1.Language : You should try to learn the languages or at least the medical terms of languages of your target population.

2.Should always talk to your patients in the language they understand, I don’t mean Hindi and English, I mean the type of vocabulary they use. If you ask a patient in anglicised Hindi he is not likely to become comfortable with you. You should not use too many long sentences or medical terms.

Where Verbal Communication is helpful?

a)To get proper history, your patient will not hide anything if he is comfortable with you and trusts you.

b)For you to explain him, his problems and solutions thereof

c)To convince him that this disease is going to take longer to treat and not that your treatment is ineffective. If you can convince your patients about this you won’t have to use steroids and antibiotics indiscriminately.

d)To convince to take treatment for long periods (as in Koch’s) or at times for life (as in HT, IHD, DM etc). If your patient gets convinced and doesn’t default, lesser incidence of relapses and complication.

e)Why is hospitalization essential? If you are able to convince your patient, he will not go for second opinion. Which in most cases will be opposite of yours.

f)Why is particular investigation required? More so if expensive. Advising a patient for an investigation is always difficult. They have still not come to terms with the idea that GP’s also require investigations. They have accepted that a specialist cannot treat without reports but a GP should treat on clinical judgement only. After you have convinced him to get an MRI done, and if it does not show any abnormality you may even be told that you have wasted money. Your art of communication will come handy in such a situation.

Non verbal communication (body language) is much important than verbal communication. It is involuntary and in most cases beyond ones control. It is the reflection of ones inner thoughts, hidden fears etc. of an individual. Patients and more often the relatives accompanying have a powerful antenna and easily pick up your confidence, nervousness, command of situation or lack of knowledge. It is not uncommon to hear a patient say.

"Don’t worry doctor, I am fine"

Non verbal communication can be used in two ways (both by Drs. and Pts)

1.Body and facial movements as an accompaniment to speech

2.Use of gestures, postures, speaking distances or other emotive signals to communicate their feelings; e.g. attending a patient under influence of alcohol.

Examples : your nervousness while handling a pulled elbow. Your reaction while giving IV or taking sutures or interpreting an X-ray/USG.

BEDSIDE MANNERS - Proper way of behaving when dealing with a patient.

ETIQUETTE - Formal rules governing behaviour especially in a profession.

"Proper way of carrying on your profession so as to maintain sufficient dignity for self and pro fession" An ideal admixture of Honesty, Humour, Humility, Modesty and Dignity. How many of us have it and for how long?

Some important aspects of Bedside Manners

1.Manner of Dressing - decent, clean clothes to maintain sufficient decorum. Should not be such that makes a patient uncomfortable. Foot wear also is important.

2.Manner of questioning about intimate problems - at no time should your patient especially of opposite sex feel that this particular question was not warranted. If you feel a particular question may embarrass/annoy the patient, please state that it is not your intention to do so.

3.Manners of examining a patient of opposite sex especially when doing an ECG, examining breasts etc.

4.Manner of examining a private parts PV/PR.

5.Tendency to moralize for their deeds. It is your duty not to moralize. You have to treat and counsel. If someone is sleeping with his neighbour’s wife, you may tell him the hazards of such an action but don’t treat him like a lousy person.

6.Tendency to patronize for status, speech, money and physical characteristics. It is very tempting more so in the beginning of practice where you feel you should be known by the company you keep. If you get a patient from TV/Media/Movies don’t charge because you feel obliged. Resist a temptation.

7.Tendency of amorous relationship with patients.

Counselling - to give advice, to guide

Medical practice is 50%-60% of functional, psychosomatic or pure psychological cases. This doesn’t include frank psychiatric cases. In hospitals the patients you see are proven organic cases. Functional or psychiatric cases are already separated. When you enter medical wards you know for sure that the patient you are going to see is a pure medical case or one with an organic complaint that has defied all attempts at treatment.

It is not so in private practice. You have to decide which is an organic and which is functional, after history and examination with minimum of investigations.

Most patients in practice, will be found to be in grey zone i.e. not frank psychiatric. These patients desist referrals to psychiatrist, as psychiatry is not yet acceptable socially. As a good family physician you have to identify, diagnose, treat and counsel these patients.

Counselling is an integral part of family practice. What your medicines can’t accomplish, your counselling can definitely do. A good doctor has to be a good listening board and a good advisor. Even though the era of a Doctor being friend, philosopher and guide is in past. Good advice is still welcome and is needed. Before counseling you must see that you yourself are convinced of what you are talking. A chronic smoker cannot be good at counseling for hazards of smoking.

Where counselling is helpful and needed

•Anxiety states

•Behavioural problems

•Learning disorders

•Phobias

•Bereavement in family

•Affliction with a poor prognosis disease

•Counselling in HT, DM to avoid target organ damage

•Diet and Nutrition

•Before HIV antibody test

•Marital Counselling

•Family Planning counselling

•Sex education/psychosexual disorder counselling



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