Interpersonal and Communication Skills
4.1: Communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds
4.7: Demonstrate insight and understanding about emotions and human responses to emotions that allow one to develop and manage interpersonal interactions
(From: Physician Competency Reference Set)___________________________________________________
“I hate doctors,” my patient’s mother said as she eyed each of the three doctors and two medical students in the exam room. She was sitting in bed with her son, arms crossed, exhausted from a near sleepless night following his admission to the hospital.
This was one of my first interactions with the patient and his mother, who arrived from West Virginia late one night. The 4-year-old patient had developed pain and a worsening limp in his left leg until his symptoms became so bad he could no longer bear weight on the affected limb, prompting his mother to bring him to the hospital. He’d had similar symptoms 6 months before with positive lyme disease serologies, but he’d only had 7 days of amoxicillin—an inappropriate antibiotic regimen for late disseminated lyme, which was the suspected cause of his symptoms. He’d been admitted to the infectious disease floor to rule out septic joint from other causes and start empiric treatment while awaiting lyme laboratory studies.
Though boy’s mother had brought him in hoping for medical help, she voiced a longstanding and unequivocal skepticism for the medical establishment. She described multiple herbal remedies that she’d tried at home initially for her son’s pain: oregano oil, moss extract, and other treatments that she’d read relieved inflammation. She also reported that her son was incompletely vaccinated due to her concerns about the MMR vaccine causing developmental delay.
The attending explained that we would be starting intravenous antibiotics and exited the patient room. Once outside, he voiced frustration about the mother’s aggressive stance toward the team and her mistrust of evidence based medicine. He also brought up concerns that the patient’s mother might not be compliant with our recommendations for treatment. It seemed a worthwhile consideration, and I returned to see the patient after rounds in order to further assess the mother’s attitude toward her son’s care.
When I arrived, it was clear she was anxious and upset. She told me she felt like she’d been interrupted during rounds when she tried to ask questions and had a poor understanding of the team’s plan for her son. I apologized and walked through what we had talked about on rounds carefully with time for questions. I also told her she had done the best possible thing for her son by bringing him to the hospital and that he was fortunate to have such a caring and observant parent. Our longer conversation seemed to break down much of the initial mistrust that the patient’s mother had for me, and it taught me more about her perspectives.
For example, she explained that her mistrust of the medical establishment stemmed from a chain of negative interactions with medical staff at other facilities. She also explained that her hesitancy to give her son the MMR vaccine was due to her belief that it had been the cause of her daughter’s developmental delay, which was formally diagnosed just weeks after she received the MMR vaccine. While it was likely a coincidence, I could see where a combination on misinformation readily available online combined with the timing of her daughter’s diagnosis could bring her to this conclusion.
We parted for the evening on good terms, and the patient’s mother reported feeling better informed about her son’s care plan. For the duration of the patient’s stay, I made sure to continue stopping by after rounds with updates and time to answer questions. When a diagnosis of lyme was confirmed and the patient was ready to go home on oral antibiotics, I stopped in one last time to deliver home-going instructions.
The patient’s mother listened and participated in teach-back regarding instructions for follow-up, return precautions, and specifics about the timing and duration of her son’s antibiotic treatment. I paused and asked her how she felt about his taking antibiotics for an entire month. She nodded, “I know he needs to take them,” she said, “and I feel like I get what’s going on.” She smiled “I’m going to make sure he eats extra green vegetables to treat his inflammation, but he’s also going to take all of those antibiotic pills.” As I said my goodbyes to the patient and his mother, I was happy to see contentment on the mom’s face as her son ran around the room with barely a limp.
As I considered my interactions with this patient and his mother in the days that followed, I thought about the ways in which my communication skills with patients have developed over the past few years. Looking back on one of my early patient interactions in LP, I noted that it was difficult for me to focus on the patient perspective when I couldn’t understand the patient’s health behaviors or attitudes. In these circumstances, it was often easier to jump to judgements about the patient than to empathize.
For example, during my first year, I wrote about a patient with HIV and Hepatitis B who engaged in high-risk behaviors and was non-compliant with his medications, putting his wife and other sexual partners at risk for infection. I was frustrated with his nonchalant attitude toward his own health and the health of those around him, and I initially found myself passing judgement on his behaviors. Upon reflection, I recognized this judgmental stance and realized that this failed to take into account the complex personal history and experiences that contributed to his health behaviors. At the time, I wrote the following as I reflected on the experience:
“I want to commit to showing unconditional compassion to the patients who are hardest to sympathize with, but who often are the most overlooked. I want to recognize the ways in which I accidentally commit small acts of bias through my behavior during the patient encounter. As part of this commitment, I plan to continue learning about social disparities so that I can more easily recognize the factors that shape the people I am trying to treat. I plan to use this knowledge to reframe the way I look at complex patients: with empathy rather than judgment (hopefully!) so that my body language and questions during patient interactions give every patient the opportunity to seek treatment from a compassionate and empathetic provider.”
Since then, I have worked to gain insight into the wide range of factors that affect a patient’s attitude toward the medical establishment. These include prior interactions with the health care community, cultural background, and personal beliefs. Working to understand social determinants of health more clearly has helped me become more empathetic in my conversations with patients and has helped me provide better patient care. The following evaluation from my third year clerkship demonstrated progress I made in this area:
A second area in which I’ve made progress is in my own confidence as a student doctor. Gaining confidence has helped me take ownership of difficult situations and face challenging communication without becoming intimidated. This, in turn, has opened up new learning opportunities by giving me a chance to practice navigating scenarios such complex social situations or parents declining important care for their children.
Moving forward, I hope to develop critical skills in interpersonal communication by continuing to learn how to build rapport with families under challenging circumstances. I aim to continue working on my understanding of how peoples’ backgrounds affect their views on medical care, and I want to continue building my confidence as a caregiver in such situations. I also want to continue making time to listen to the stories of patients and their families, which I have learned contain valuable information about what underlies the emotions present in these situations.