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Communication skills: I know ‘em when I see ‘em

The people who know me, know that teaching doctor-patient communication is my jam. As an author of the Communication Skills Role in both CanMeds 2015 and CanMeds FM 2017, I have thought long and hard about what makes a good communicator in medicine and how to teach it.

I have an obsession with direct observation and I insist that the learners explain themselves with both clarity and compassion. I believe that this skill can be taught. It is not some magical intrinsic quality that you either have or don’t. If you can learn to put in a central line, or remember the differential diagnoses for hypercalcemia, you should be able to remember to wait two minutes before interrupting the patient all the while nodding and saying “yes” and “can you tell me more about that?”, or learning to occasionally say, “this seems to have been very hard on you.” These are techniques like any others and should be taught and can be learned.

I will concede, however, that some people do have a natural talent for communication.  Like long fingers on an Ob/Gyn or good haptic and stereoscopic senses in a surgeon, it makes their job easier.

One July, when I was a young teacher, I watched a new resident, Rob, with one of his first patients. Sitting in the dark, watching through the one-way mirror, I was blown away by his instant ability to connect. He teased out the patient’s story and made sense of its complexity. He made the patient feel understood. I turned to the psychologist sitting next to me in the teaching room. “He’s really got it, doesn’t he?” I said.

Over the next two years, I watched Rob blossom into an excellent family doctor. On graduation he went to work in the great north. Later he returned to Toronto to care for AIDS patients. He developed a reputation as an exceptionally able and compassionate advocate for patients with the deadly virus. I invited him to give a talk to my residents and he walked them through the basics of HIV care. Then he told them they would have the chance to practice interviewing an AIDS patient. He invited a resident to start the interview. “Where’s the patient?” asked the resident. “Here,” said Rob, sitting down in the patient’s chair. He then guided the resident through an enquiry into his own struggles with AIDS and his precarious health. It was a moving moment. He taught them so much about being a physician and about being a patient in that one hour. In those early days of the epidemic, his fate was sealed. A few years later, he died, much mourned by his partner, family, friends, patients, and me.

At this, the end of my career, I still get a thrill when I see young docs who are talented communicators. I am blessed this year with a collection of excellent and dedicated residents. Last week I was watching Hana deal with one of her complicated patients. She has a lot of complex patients. A colleague of mine once said, “Looking at the patient roster is a good way to differentiate strong and weak residents. The good communicators always have more patients and their patients are more complex. The poor residents have patients leaving them in droves!” I watched Hana navigate a difficult situation. The man had many unresolved medical issues, interacting with a terrible psycho-social situation. Her communication with the patient just flowed. It was both clinically effective and palpably compassionate. It was impressive!   She had the whole package. “I should videotape Hana,” I told some of the R1’s. “She is a role model for you guys.”

Sometimes the clue that a learner is an excellent communicator comes not from watching them interact with patients but from seeing their interactions with staff. For example, I was on call last week in L&D with a young R1. He was hardworking and practical but what struck me was that everyone knew his name! In the Case Room, the learners come and go, often ignored, sometimes pushed out. Yet after one month, wherever we went that day, people greeted him.

 “Hi Nigel, can you come and assess your patient?”

“Good Morning, Nigel. Are you on today? Good.”

“Hey, Nigel, my man!”

Nurses, receptionists, even the orderlies and cleaners had a warm greeting for this young man. Towards the end of the shift, I asked him as we were debriefing after a nice delivery. “So Nigel, how come everyone knows you?”

He looked at me a bit shocked, “Oh, you noticed,” he said with a slight blush. “I always make it my business to tell people my name and remember theirs. That way, I feel that we work better as a team.”

Neil Gaimon, the brilliant science fiction author, talked about how to survive as a freelancer. There are three important qualities: being good at your work, being nice and being available. And you don’t even need all three! Two out of three is fine.

The same is roughly true of working in medicine. The truly brilliant and very available do well even if they are difficult. The pleasant and hardworking will be helped, but if you are not good and not pleasant, particularly if you don’t show up, you are in deep trouble! Since you may not have complete control over being brilliant, concentrating on being nice seems like a good strategy.

Having taught these outstanding communicators, I remain heartened about the future of medicine. We may be harassed by governments, exploited by health care institutions and often deal with less than loveable patients. Yet, we continue to see people working with kindness and the ability to make the world a little bit better.