One of the first activities undertaken by all 330 First Year students at the University of Melbourne is to ponder the question: “what is a good doctor?” In fact, this problem is the main focus of their first week in medical school in early February, which culminates in them developing and reporting back their own definitions of ‘the good doctor’. When grouped and analysed, these definitions reveal some interesting trends about what these brand new students think is important in their chosen career.
One word usually stands out. This year, the most frequently used word in defining ‘the good doctor’ was ‘communicator’. It was closely followed by ‘compassionate’ and ‘empathetic’, which are similarly reassuring of the values these students are bringing with them. But the single most important requirement for being a good doctor was seen to be good communication. The challenge for any medical school is to keep those qualities in the forefront of students’ minds throughout their studies.
Those who have been involved in healthcare for much longer than these neophytes will recognise the importance of good communication in ensuring that healthcare is safe, effective and efficient. We are frequently told that poor communication is at the root of many adverse events and that clumsy handling of the interpersonal issues often worsens the consequences of these events. But one area where even very experienced clinicians can fall down as communicators is during the consent process, when they can become ‘locked-on transmitters’. Being barraged with buckets of information is a disempowering experience, unless the clinician is sensitive to the client’s health literacy and specific information needs.
Effective communication is a two way process and this is rarely better demonstrated than when ‘consenting’ patients before a therapeutic or diagnostic intervention. Even the hideous use of the term ‘consenting’ as a transitive verb suggests that it is actively done to the patient, rather than being the outcome of an informative conversation. The decision to proceed with a particular procedure is one undertaken in a partnership, to which the proceduralist brings their expert knowledge of healthcare and the patient brings their expert knowledge of themselves. The responsibility for the decision is shared between the two – the clinician in recommending the most appropriate course of action based on what they know and what they’ve learnt from their client, and the client in deciding how that recommendation fits with their needs and preferences. The client has a variety of different sources of information available to them, and the clinician’s role is to help them assemble that information into a meaningful understanding of the choices they have.
There is no question that the increasing accessibility of health information has made healthcare consumers more informed about their choices, but are they better informed? A recent paper in the British Journal of Medical Ethics created a link between gaining informed consent and the ‘routinisation’ of that process to become largely meaningless1. Although the authors were referring to consent for the exchange of patient information via the Internet, the same principle of loss of patient autonomy due to the reduction of the pre-operative ‘consent conversation’ to an algorithmic routine holds firm. It’s perhaps a little ironic that having a personally tailored conversation with a clinician can be more enabling than independently accessing web-based information without support; the key is in who directs the conversation, and whose agenda is paramount. In a good consent conversation the patient asks a lot of questions, preferably with the clinician’s responses backed up by high quality written material.
This communication partnership is clearly expressed within Standard 2 of the Australian Commission on Safety and Quality in Health Care’s national standards for health services, which talks about making a health service that is responsive to patient, carer and consumer needs2. Apart from high-level issues such as consumer inclusion in governance and policy frameworks, the Standard specifies that consumers should be consulted on patient information distributed by the organisation and their feedback incorporated into revisions of those materials (Standard 2.4, page 24).
It must be recognised that sometimes those who are most expert in a topic are least able to communicate it at a level that a consumer can assimilate, even though it is their responsibility to ensure that their message has been understood; a phone call to an IT helpdesk often reinforces this truism. Consumer partnerships are vital in ensuring that patient information is accessible, meaningful and comprehensible by all those accessing the health service.
Documents that relate to healthcare can be surprisingly difficult to read. It is widely recommended that patient information sheets be pitched at upper primary school reading age. By contrast, simple analysis by Microsoft Word’s in-built grammar tool (using the Flesch-Kincaid method) shows that the NSQHS Standards themselves have a reading ease score of 33% and that they would probably be understood by a student about to enter Year 10 at secondary school. The ‘EasyRead’ summary of last year’s British publication about involving consumers in decisions about their health: “Liberating the NHS: no decision about me without me”3 scores 77% on readability with an appropriate grade level of 6.2. Shamefully, comprehension of the article you are reading now requires the highest reading grade of 12; unnecessary semicolons and gerund phrases like these not helping.
Health service leaders have long understood the importance of consumer partnerships. Increased emphasis on involving consumers in the development and improvement of patient information materials is just one more way of ensuring excellence amongst health services.
Author: Professor Stephen Trumble Chair, Editorial Board Specialist Management Services
References 1 Ploug T, Holm S. Informed consent and routinisation. J Med Ethics. 2012 Dec 5. Epub ahead of print] 2 Australian Commission on Safety and Quality in Health Care (ACSQHC) (September 2011), National Safety and Quality Health Service Standards, ACSQHC, Sydney 3 http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_134221 (accessed 10 February 2013)