The Scottish Government

Listen

talking matters
developing the communication skills of doctors

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CONTENTS

Foreword
Introduction
What is the problem?
Why is change needed?
What needs to be done?
What happens now?

If you would like further information, or to comment on "Talking Matters", please contact:

Alison Hampton, Programme Manager
Telephone: 0131 244 2377
Email: alison.hampton@scotland.gsi.gov.uk
Address: Scottish Executive
Centre for Change and Innovation
St Andrew's House
Edinburgh EH1 3DG

FOREWORD

The purpose of the Centre for Change and Innovation is to work with people in the NHS in Scotland to make the health service better, both for patients and for staff. In choosing to look at issues around doctors and the way they communicate we are not only concerned for patients. The wellbeing of doctors themselves is dependent on knowing how to demonstrate empathy, without getting damaged in the process. Doctors need to know how to listen, and how to help people to listen to them. It's a clinical technique like any other, and getting it wrong is dangerous.

Over twenty years ago when I first worked in the health service I was sent onto a ward and told to "just talk" to patients. That was very difficult. I have, during the time since, been utterly moved by the skill and experience of doctors who communicate well. However, I have also witnessed verbally abusive exchanges with patients. The question was always there. How did they learn to talk like that? How could doctors know that they might often have to say sorry when they were blameless? How can they listen to patients and relatives being angry, without getting angry and defensive themselves?

This document is part of a discussion about what can be done to make communication easier for doctors. It has been said that it is impossible for people to learn what they think they already know, but there is increasing evidence that doctors want to learn more. It is no longer acceptable to pay the personal cost, and take the risks, that are the direct result of communication problems. Your comments on this are welcome. Please let us know what you think.

June Andrews
Head, Centre for Change & Innovation

INTRODUCTION

Communication looks easy when it is done well. It is anything but. It requires engagement, empathy, an ability to listen and respond, and it requires time.

There is convincing evidence that it is not always done well in the health service. The Centre for Change and Innovation decided to investigate this problem and our inquiry has taken us across Scotland. We have met with a wide variety of people and found out some of what is already happening to improve the way professionals communicate with patients and with other professionals.

What has emerged has been a widespread agreement among practising clinicians, managers and patients that this is an issue that needs to be addressed in a more structured and co-ordinated manner in Scotland. Communication problems exist at all levels in the health service but our focus has been on senior doctors. They need to be effective communicators if the health service is to work effectively.

This report does not seek to apportion blame for perceived failures but to recognise there are issues to address and action that can be taken. Initiatives are already underway in various parts of Scotland to improve the way doctors and other health service staff communicate. We believe there is now a need for this work to be given a national focus.

The purpose of this report is to share our experience so far and to get feedback on our proposals. Good communication has undoubted benefits for patients, for doctors and for the health service as a whole. It is a skill that has been undervalued for too long. We believe it is time that changed.

Dr Lindsay Burley
Alison Hampton

September 2003

What is the problem?

"I was 25 years old and working in an accident and emergency department. A young lad was brought in with severe head injuries following a road traffic accident. We tried to resuscitate him but it was obviously useless. I had to go out and tell his parents. I'd never told anyone before that their child was dead and didn't have a clue what to say. I just blurted it out and the mother starting screaming - I didn't know how to handle the situation. I just said 'sorry' and ran out of the room. I can still hear that woman's screams. That was over 30 years ago and I don't think things are really much better in terms of helping young doctors to learn how to break bad news."¹

Doctors face difficult situations on an almost daily basis. They can be the bearers of the worst imaginable news. They have to turn complex and often uncertain information into something that is understandable. They have to respond to the differing needs of a hugely diverse range of patients and their families. And they have to do much of this when they are busy and under pressure.

It is not surprising that things can go wrong. Although most doctors communicate effectively, there is increasing evidence that large numbers of patients remain unhappy with the amount of information given and the manner of its delivery. ² NHS Quality Improvement Scotland has identified communication with patients as an issue that continues to give rise to concern. ³ Poor communication remains one of the most common reasons for complaints from patients and is an important factor in litigation. As the account above illustrates, many doctors also believe they have been badly prepared for discharging this important and challenging responsibility.

• When doctors use communication skills effectively, both they and their patients benefit. ⁴ The effect can be that:

• Patients' problems are identified more accurately;

• Patients are more satisfied with their care and can better understand their problems;

• Patients are more likely to comply with treatment or lifestyle advice;

• Patients' distress and the vulnerability to anxiety and depression are lessened;

• The overall quality of care is improved by ensuring that patients' views are taken into account;

• Doctors' own wellbeing is improved;

• Fewer clinical errors are made;

• Patients are less likely to complain;

• There is a reduced likelihood of doctors being sued.

However, different patients require different approaches. So-called expert patients may challenge the information provided by doctors while other patients with the same condition may want only the minimal detail about their illness. There can be language barriers, learning difficulties and physical problems such as sensory impairments to overcome. The problems of communicating effectively have been acknowledged in a report produced by the British Medical Association (BMA). ⁵ It identified both personal and organisational barriers to effective communication.

Personal barriers:

• A lack of skill and understanding - for example the failure to understand the importance of using clear and simple language, giving structured explanations and listening to patients' views and encouraging two-way communication;

• Undervaluing the importance of communicating - for example not appreciating the importance of keeping patients adequately informed;

• Negative attitudes by doctors towards communication and giving it a low priority due to their concern primarily to treat illness rather than focus on patients' other needs which may be psychological or related to social wellbeing;

• A lack of inclination to communicate with patients. This can be due to a lack of time, uncomfortable topics, lack of confidence and concerns relating to confidentiality;

• Human failings, such as tiredness and stress;

• Inconsistency in providing information. One of the biggest complaints from patients is of being given conflicting information by different healthcare providers;

• Language competence. Doctors are required to be competent in the English language to work in the UK but this cannot be guaranteed for some doctors who qualified in European countries. They do not have to take the English language test that is mandatory for other doctors from overseas.

Organisational barriers:

Organisational barriers are usually outside a doctor's direct control and include having a lack of time, pressure of work and being subjected to interruptions. The BMA report notes that doctors may be forced to devote less time to communicating with patients when the organisation they work for places an emphasis on increasing "patient throughput" or similar initiatives.

The General Medical Council (GMC) and other medical professional bodies including the Academy of Royal Medical Colleges, the Royal College of General Practitioners and the Royal College of Physicians have stressed the importance of doctors developing good communication skills. ⁶ That has been taken on board by medical schools which now provide communication skills training for medical students. The main subject areas taught are breaking bad news; consulting patients and relatives; dealing with angry, difficult and reluctant patients; demonstrating empathy; giving and receiving information; explaining and negotiating skills.

However, this still leaves a large cohort of senior doctors who have received no training of any nature in communication skills. Professor Lesley Fallowfield, one of the UK's leading experts in this field, has said this is not good enough. "Too many of our doctors are forced to rely on intuition to guide them as to what to say or how to say things to patients. The skills of hang gliding, painting or playing the cello could not be mastered satisfactorily by merely listening to the odd lecture or reading how to do it or just watching someone else do it but this is how we expect many of our doctors to acquire their communication skills". ⁷

The GMC says there is an obligation on all doctors to review their skills as part of continuing professional development and take part in educational activities as a means of maintaining and further developing their competence.

The big question for doctors in Scotland is - how is that to be done?

Why is change needed?

The most convincing reason to change is the evidence that improving doctors' communication skills can increase patient satisfaction and improve outcomes. It is also what patients want. A survey carried out for a report into the health of older people in Scotland - Adding Life to Years - found they wanted greater personal attention and more time to be spent with individual patients. Although most were satisfied with the care they receive, they did report mixed experiences with staff attitudes in the NHS. "Most health care professionals pride themselves on positive attitudes and good communication skills; where deficiencies are identified, they should be addressed by appropriate encouragement and training," says the report. ⁸

There are also important benefits for doctors in improving job satisfaction and reducing the risk of burnout. The ability to intervene positively to improve people's lives should make medicine one of the most personally rewarding of careers. Instead it is marked by high rates of suicide, emotional exhaustion, depersonalisation (treating people in an unfeeling, impersonal way) and a sense of low personal accomplishment. Ramirez and colleagues found evidence of stress-related psychiatric morbidity in 27% of consultants. They found that burnout was also more prevalent among consultants who felt insufficiently trained in communication and management skills. ⁹ Helping doctors to improve the way they communicate with patients and other staff can contribute to increasing job satisfaction and improving doctors' morale. This benefit should not be under-estimated, particularly at a time of difficulty in recruiting and retaining doctors to work in the NHS.

There are other powerful reasons why doctors need to be equipped with highly sophisticated interpersonal skills. The NHS is an increasingly complex environment in which to work where the drive is to establish higher quality, more streamlined and more patient centred services. Technical and clinical competence is essential but these qualities are insufficient to meet the challenges of this changing environment. Doctors also need support to help them respond effectively to these changing conditions.

There are many reasons why this is important:

Complaint handling - a MORI poll commissioned by the Scottish Executive found that 23% of NHS users either have or have wanted to make a complaint about the service they received, although only 5% went on to raise an issue or make a complaint. ¹⁰ This reflects a major culture change within society where many patients and their families are prepared to challenge the way services are provided. This can be difficult for health professionals to manage and requires as much training as other complex activity.

Increasing litigation - just as more people are willing to complain, more people are prepared to sue. The amount paid out in damages by the Scottish health service increased from 3 million in 1999-2000 to 6.5 million in 2002-01 and 7.8 million in 2001-02. However, the figures in Scotland remain much lower than those in England where the health service expects to pay out 5 billion over the next few years. Poor handling of complaints contributes to increasing litigation. A survey carried out by the Association for the Victims of Medical Accidents shows that most patients want an explanation of what went wrong and an apology but many are forced to take legal action when this is not forthcoming. ¹¹ There is work going on in Scotland to introduce mediation services into the NHS to try to prevent disputes reaching litigation. The development of mediation skills could be an important addition to the professional development of NHS consultants in the future.

Improving the patient's journey - there is increasing recognition that the experience of many patients is fragmented as they move from primary to secondary care and within different parts of the hospital service. Managed clinical networks are being created to provide more seamless care. Stabilising and maintaining such networks will require advanced leadership, teamworking and communication skills.

Cultural and organisational change within NHS Scotland - it is important that doctors are in a position to contribute effectively to the clinical leadership of the NHS. Coping with change demands a high level of influencing and negotiating skills if this goal is to be achieved. There is considerable scope for improvement through focusing on helping staff cope better with the daily stresses of working in large, changing and complex organisations.

Chronic disease management - more and more patients and their families are becoming experts in chronic conditions. The focus for the long-term management of conditions such as asthma, diabetes and epilepsy is also shifting to a partnership model - between patients and their doctors and between professionals in different disciplines. This requires a profound change in the traditional role of the doctor and in their relationship with patients and other professionals.

Performance through appraisal - performance appraisal is a well-established process in many organisations and in some parts of the NHS but it is a new concept for consultants. The appraisal process demands a sophisticated level of communication skills if it is to be successful. Many consultants will be both appraisers and appraisees. Each role requires significant preparation and skills in the art of giving feedback, if the process is to be mutually rewarding and effective for the organisation. In addition, appraisal includes an "assessment" of the appraisee's communication skills. How this is done effectively, and how development needs are identified and met, are key challenges for the NHS.

Revalidation - the process of revalidation will require doctors to demonstrate effectiveness not only in what they do but how they do it, including how they interact and communicate with others. This is another reason for support to be provided for doctors who may feel their competencies in this area would benefit from further development.

Communication of risk - awareness and quantification of risk is growing exponentially within the NHS and among the public. The delivery of healthcare is rarely risk free and trade-offs may be made between, for instance, easy access and safety in maternity services. It is essential that clinicians are able to discuss risk with their patients to help them to come to informed decisions.

What needs to be done?

In the course of a career spanning 40 years, a hospital doctor is likely to conduct around 150,000-200,000 interviews with patients and their families. ¹³ They talk to people more often than they perform any other medical procedure yet very few receive any formal training. Too many doctors are ill prepared to meet the challenges of developing an open, negotiating and partnership style of communication with patients. ¹⁴

There is strong support for change. Reviews into health service failures have chronicled how breakdowns in relationships and subsequent poor communications have contributed to problems. The Bristol inquiry concluded: "Education in communication skills must be an essential part of the education of all healthcare professionals. Communication skills include the ability to engage with patients on an emotional level, to listen, to assess how much information a patient wants to know and to convey information with clarity and sympathy." ¹⁵

That view is echoed by NHS Quality Improvement Scotland. Its review of progress against generic standards of care stated: "All Trusts should continue to work to ensure all staff have participated in communication skills training and are aware of the availability and potential benefits of advocacy services for patients." ¹⁶

The British Medical Association report says that efforts should be made to raise the profile of communication skills training among professionals. "Simply recognising the need for good communications skills is not enough; healthcare professionals must actively strive to achieve good communication skills by evaluating their own abilities." It recommends that such training should be available to all medical students and doctors in practice and that communication skills training programmes should be developed at a postgraduate level. ¹⁷

There are particular areas that need to be addressed to support the work of doctors in the increasingly complex circumstances facing them:

Dealing with difficult patients effectively and with confidence - doctors and other health professionals are sometimes faced with patients who are angry, hostile or even aggressive. These are obviously very difficult situations but the way they are managed can influence the outcome. Staff can be taught ways of managing difficult situations and relationships.

Communicating with people with differing needs - this includes people who both use and work in the health service and have particular needs, such as sensory impairments, mental health problems, learning disabilities and language barriers. There is a need to support doctors by providing interpreting, advocacy and other services.

Improving clinical effectiveness and reducing errors - doctors have a key role to play in increasing the focus of clinical teams on the need to review mistakes and near misses. These need to be seen as opportunities to redesign systems to prevent recurrences rather than blaming individuals once problems have emerged.

Teaching a wide range of health professionals - consultants play a vital role in coaching and educating medical students, postgraduate doctors and staff from other disciplines. It is important that their needs are recognised and supported to help them discharge their responsibility as effective role models.

Influencing the way their service and/or wider organisation is developing - for many years doctors had real power in the health service. It arose form their position, expertise and, for some, their personalities. This is changing and today getting things to change requires a much greater level of negotiating and influencing skills.

These needs can be met by providing access to a wide and diverse range of support. Some of this will be built into an organisation's overall development programme. Some may be in the form of special programmes delivered by a team or an individual. Training programmes have been developed and have been demonstrated to be effective. ^18,19 These have dispelled the myth that communication skills cannot be taught. It is not some natural ability that people either possess or they do not. It is a skill that can be taught. However, there is concern at the relative ineffectiveness of bought-in products in a long-term programme aimed at changing behaviour. Much of what may be needed is already available, though not necessarily in Scotland.

It appears there is wide acceptance that this is an issue that needs to be addressed. The next step includes identifying how the development needs can best be met and establishing relevant programmes.

What happens now?

We propose the development of a programme for NHSScotland that will incorporate a menu of diagnostic tools and development opportunities that can be accessed by doctors, reflecting individual differences in terms of need, learning styles and working arrangements. The initial target group would be consultants. However, in the longer term, it is anticipated that the most successful development initiatives could be made available to all NHS staff who work with patients and the public.

We envisage the development programme will comprise a range of different components and approaches, as agreed with representatives from key interest groups. Possibilities that have been explored to date include:

• Diagnostic instruments to help consultants reflect on their own practice, and acquire robust feedback from patients and peers - for example a 360 degree feedback tool, or the CARE (Consultation & Relational Empathy) measure developed by Dr Stewart Mercer and colleagues

• High quality, experiential training courses such as those developed by Peter MacGuire or Lesley Fallowfield, which are currently being used by NHS Education for Scotland and the South East Scotland Cancer Network

• Therapeutic skills development programmes, such as that devised by Dr David Reilly of the Glasgow Homeopathic Hospital

• Development of a coaching culture, supported by a coaching and facilitation development programme, modelled on the work of Sarah Goldsworthy and Judith Ward (NHS Argyll & Clyde) for cancer lead clinicians

• Context-bound development using simulated patients, similar to the work of Paul Kinnersley with NHS Wales/ University of Wales

• Counselling skills development, such as COSCA/BACP recognised courses

• Peer support through Buddying Schemes, Mentoring Programmes and/ or Action Learning Sets

• E-learning facilities through, for example, the Cyber Medical College or goodpractice.net

• Video training programmes

• Values in Healthcare, and Spiritual Skills development programmes such as those offered by health care charity The Janki Foundation

• A doctors' support line and/or network, for those who are struggling most - similar to those sponsored by the DoH in England, and the BMA

Such a programme will need to be evaluated to ensure that it is robust and delivers the desired objectives. As such, we propose that the programme itself is developed as a research project with clear endpoints, some of which may take several years to assess. This needs to be seen as a long-term programme to help foster long-term change. It will need investment in development time and in support and training.

Doctors are highly educated and highly skilled individuals. However, most have not been supported properly to meet the challenges posed by today's consumer- driven society where, increasingly, individuals are prepared to challenge the views of professionals. This project has found overwhelming support from within NHSScotland for doctors to be provided with greater support to develop the kind of communication skills that are required to help create a truly patient-centred health service.

Good communication is good for patients, good for doctors and good for the health service. The better doctors can be supported, the better prepared they will be to respond to the challenges before them.

The Centre for Change and Innovation was set up on 1 November 2002 to work with Scottish Ministers, the Health Department and all health bodies in Scotland to spread good practice in service redesign. This translates into five aims:

• To drive change in specific priorities

• To spread good practice

• To address weak practice

• To support improvement in practice

• To research good practice

For further information, please contact:

Centre for Change and Innovation
Scottish Executive Health Department
St Andrew's House
Regent Road
Edinburgh EH1 3DG
Telephone: 0131 244 3027

Footnotes

1 Fallowfield L J. Giving sad and bad news. The Lancet 1993;341:476-478

2 Audit Commission. What seems to be the matter? Communication between hospitals and patients. London. Stationery Office, 1993.

3 Safe and Effective Patient Care: Generic Clinical Governance Standards. NHS Quality Improvement Scotland 2003.

4 Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ 2002; 325: 697-700.

5 British Medical Association. Communication skills education for doctors. 2002.

6 The General Medical Council. Good Medical Practice. 2001.

7 Fallowfield LJ. Things to consider when teaching doctors how to deliver good, bad and sad news. Medical Teacher 1996; 18 27-30.

8 Adding Life to Years. Report of the Expert Group on Health Care of Older People, Scottish Executive 2002.

9 Ramirez AJ et al. Mental health of hospital consultants: the effects of stress and satisfaction at work. The Lancet 1996; 347: 724-28.

10 Scottish Executive. Our National Health: a plan for action, a plan for change. 2000.

11 www.icmresearch.co.uk/reviews/2002/patients-redress-survey.htm

12 Johnson D. How the Atlantic barons learnt teamwork. BMJ 2001; 322:563

13 Fallowfield LJ et al. Efficacy of a Cancer Research UK communication skills training model for oncologists: a randomised controlled trial. The Lancet 2002; 359: 650-56.

14 Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ 2002; 325: 697-700.

15 www.bristol-inquiry.org.uk/final report

16 Safe and Effective Patient Care: Generic Clinical Governance Standards. NHS Quality Improvement Scotland 2003.

17 British Medical Association. Communication skills education for doctors. 2002.

18 Fallowfield LJ et al. Efficacy of a Cancer Research UK communication skills training model for oncologists: a randomised controlled trial. The Lancet 2002; 359: 650-56.

19 Kinnersley P, Butler C. Context bound communication skills training: development of a new method. Medical Education 2002; 36:377-83.

20 Ford S, Fallowfield L, Lewis S. Doctor-patient interaction in oncology. Soc Sci Med 1996, 11, 1511-1519.