Interpersonal and Communication Skills: Breaking down barriers

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:

Evaluation from UPSMN General Medicine (December 2020)

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.

Interprofessional Collaboration: Working with a community of caregivers

Interprofessional Collaboration:

Objective 7.2: Use the knowledge of one’s own role and the roles of other health professionals to appropriately assess and address the health care needs of the patients and populations served.

Objective 7.3: Communicate with other health professionals in a responsive and responsible manner that supports the maintenance of health and the treatment of disease in individual patients and populations.

(From: Physician Competency Reference Set)___________________________________________________

One of the most rewarding experiences I’ve had as a student took place with a patient who I cared for on my mini-internship experience on the infectious disease service. I had the privilege of working with her and her family from admission to discharge as they navigated a complex hospital experience over almost three weeks.

My first encounter with this patient and her family took place during night call during my third day on service. She was 16 years old and initially presented with weight loss and a very large pleural effusion of subacute onset. She and her family were Nepali, and her parents spoke a limited amount of English. With the help of an interpreter, we learned that she also had a history of previously treated latent tuberculosis as well as a BMI less than the first percentile for her age due to restrictive eating behaviors. We were concerned for active pleural tuberculosis, and we began an infectious workup for this and other organisms.

However, her hospital course quickly became complicated for a variety of reasons. On her second day in the hospital, the team placed a chest tube to relieve her large effusion. This resulted in post-obstructive pulmonary edema that required several days of high flow nasal cannula oxygen in the PICU. Though she recovered from this in several days, she was weak and malnourished at baseline, which worsened with her acute illness. To further complicate matters, her previous history of latent TB made it difficult to interpret her TB quantiferon gold test, which was positive. We ordered a variety of PCRs and cultures of her blood and pleural fluid instead, but though the fluid was exudative they were all negative for organisms. It soon became clear that we were going to need other teams on board to help make a diagnosis.

Our initial thought was to get a biopsy of her lung pleura as this was where the disease process seemed to be localized. I consulted the general surgery team; however, they were concerned about her post-operative recovery given her poor nutritional status and worried she would develop a pleural leak that would compromise her respiratory function. I then reached out to pulmonology to get broncho-alveolar lavage samples for microscopy, PCR, and culture. They were able to safely complete this procedure, but it again yielded no answers. With so many negative infectious studies, we began to consider additional causes for her presentation. I consulted rheumatology and ophthalmology who evaluated her for autoimmune causes, which were also negative.

Throughout the patient’s hospital stay, I worked with other teams to address additional health and social issues. Hematology helped evaluate and treat a severe iron-deficiency anemia present on admission. Adolescent medicine and nutrition both worked with the patient to further investigate her restrictive eating behaviors and optimize her nutrition. Social work helped her parents fill out lengthy paperwork to secure a leave of absence from work during her admission. Child life worked with the patient to help fill the long days with interesting activities. Psychology was consulted to help her process her illness and lengthy hospital stay.

Ultimately, weeks went by without answers, and though we were unable to confirm TB with lab tests, it was deemed most likely based upon her clinical presentation, risk factors, and failures on trials of several empiric antibiotics. She was started on empiric four-drug therapy just over two weeks into her admission, and within 24 hours, she had her first day fever free since arriving to the hospital. Her clinical status continued to improve on TB treatment, and we moved forward with this presumptive diagnosis. I called the Ohio Department of Health to coordinate direct observed treatment and worked with the patient’s family to clarify home- going instructions and follow-up.

Throughout this patient’s stay, I spent many hours communicating with the multiple interprofessional teams involved in her care. I then communicated the information I learned to my team as well as to the patient’s parents and nursing staff. As I worked with many different specialties, I found it particularly challenging to communicate the patient’s complicated hospital problems in a concise manner that emphasized the points relevant to specific consultant teams.

As I’ve reflected on my experience caring for this patient and her family, I have considered the ways in which my skills in communicating with interprofessional teams have developed over the past three years. During my first two years of medial school and into the first part of my third year, I felt like much of my progress in communicating with different providers involved learning the basic language necessary to have discussions about patient care such as rounding and basic note writing. Initially, as I worked on developing these basic communication skills, I sometimes struggled to “take ownership” of patient care by contributing to interprofessional care:

Evaluation from UPWP GI rotation; June 2020

As I’ve gotten further along in my training, not only have I learned how to provide more comprehensive care for my patients by communicating with consultants— I’ve also learned more about which specific details of such communications that are valuable to certain care teams: For example, a general surgery consultant, a rheumatologist, and a social worker may all be interested in different aspects of the same patient’s history. Working as a part of some of these teams myself and interacting with different members of the interprofessional care team have helped me become more adept at developing this skill. Some of these skills began developing during my third year as I starting interacting more often with interprofessional teams and asking them to teach me more about their roles in patient care:

Evaluation from UPWP Pediatric Ambulatory rotation; September 2020

As I became more comfortable interacting with interprofessional team members and consultants, I gained confidence in reaching out to them to facilitate more comprehensive care for my patients. During this most recent experience on pediatric infectious disease, I was proud of the hard work I put in to follow up with consultants regarding my patient’s care needs and of the long hours I spent with the patient and her family explaining various aspects of her care. I felt as though I had made the effort to take ownership over my patient’s care as the designated caregiver from her primary team. When I got feedback from the ring, it was gratifying to see that physicians I worked with noticed this effort, too:

Evaluation from AMHBC: Mini-internship in Pediatric Infectious Disease

Continuing into my final year of medical school, I hope to keep working toward improving my ability to collaborate with members of an interprofessional team. As I get closer to becoming an intern, I plan to take ownership such conversations for my patients whenever possible and to be intentional about touching base regularly with teams such as nursing and PT/OT who carry key knowledge about important aspects of patient care. In this way, I hope to both gain knowledge as a student doctor and become a better caregiver for my patients.