Diabetes and other long term medical conditions make up an increasingly important part of overall health care workload. In the management of such conditions it is clear that the quality of communication between clinicians and patients affects health outcomes.
In order to explore the effectiveness of that communication a research team from the Universities of Otago, Auckland and Victoria has been looking at how health practitioners interact and communicate with patients when they are first diagnosed with diabetes. In this opinion piece, I want to share some of the insights from that study and also suggest that as health care professionals, we can all enhance our communication skills and improve clinical outcomes by paying attention to both what we say, how we say it and the context within which we provide care.
The research team video recorded every interaction that a group of 32 patients had with all the health practitioners they met over the initial six months of their diabetes care after they had been diagnosed with type 2 diabetes. Patients have consultations with a wide range of health providers including doctors and nurses, diabetes specialists, podiatrists and optometrists.
When analysing both the language and the non-verbal features of consultations, one of the most striking observations was the high levels of technical knowledge and communication skills used by all of the different health providers, and also the care and compassion displayed in the consultations. The clinicians we observed also spent significant amounts of time with patients and tried very hard to coordinate the services they provided.
Despite this, we noted a number of ways in which communication can be enhanced.
From the outset, initial consultations are often driven by explanations using very technical biomedical language – sometimes/often out of context from patient experience. Health professionals are very good at talking, when at times listening and allowing the patient to tell a story might be more effective.
As an example, here is the start of a GP consultation in which the patient has been told for the first time they have diabetes. (By coincidence, as one of the doctors taking part in the research, I am the GP in question ……)
GP 1 – “For this I don’t know how much you know or don’t know about diabetes but it’s “…
Having asked the patient what they know, the doctor could wait for an answer. Instead, without pausing for breath, he talks unnecessarily for a minute about what he, the doctor, knows.
GP 1“……. something which at the moment we’re er quite interested and focused on i mean not just in New Zealand but many other countries as well, the amount of diabetes is rising and rising and rising “
Compare this to the beginning of another consultation from the study, with a different and, I might suggest, much wiser and more thoughtful doctor …..
GP2 “I’d like firstly to know roughly what, or er briefly if you like, what you know or understand about diabetes currently and also like you to tell me how that how you feel about that or how you react to that “
When health professionals allowed the patient to tell their own stories, we observed that they already often have their own ideas about causation, management and prognosis, and that their pre-diabetes stories can be helpful.
The system of care and the time allocation can work against good clinical outcomes. While standardised care and checklists ensure that particular topics are covered, they interrupt the natural interactional flow of a conversation and may not fit with the patient context or reality. As a practice nurse in the study said “We have to cover all the stuff in the checklist – sometimes that stops us being able to listen to the patient”
We think that time could be allocated more effectively and efficiently when patients see multiple clinicians. In this study health professionals often duplicated the same (and sometimes unnecessary) information and/or left gaps in terms of what patients really needed to know. Despite the shortage of time in healthcare, we observed total contact time of between two and 11 hours with the patents in our study, enough time for very significant amounts of interaction and health education if the time is planned and agendas agreed. The psychological and emotional implications of diabetes while mentioned were often not explored in any depth.
There were particular challenges in cross cultural consultations and in discussions around sensitive topics such as diabetes and sexual function. One of the most significant things we learned is how easy it is to forget or not appreciate the patient’s social and personal circumstances. It is easy to give advice about ‘good nutrition’, and not ask about the patient’s ability to pay for food, or to acknowledge how ‘shit hard’ many people’s lives are.
e.g. Patient: “but what I’m hearing I’m cooking wrong cos there’s eleven of us, it’s about who I look after and care for but sometimes I’m not eating till about 9.30 after I’ve done, cos nanny’s 89 and the youngest niece I have in my care, she’s two … and we cook bulk and stuff like that”
Health Professional: “okay, that’s alright well what we’ll do today is just have a bit of a chat about your lifestyle and the type of food you typically eat “
We recommend that when clinicians communicate with diabetes patients, they should acknowledge the importance of the patient’s own particular situation and social needs. Our research shows the importance of listening more and possibly talking less in consultations and helps us understand the complex interactions that take place between health professionals and those they care for.
While this research was focused on patients newly-diagnosed with diabetes we feel that many of the insights are applicable to other long term conditions.
Professor Tony Dowell, University of Otago, Wellington
This project was carried out as part of work of the Applied Research on Communication in Health Group (ARCH), a multidisciplinary group of researchers based in the Department of Primary Health Care and General Practice, University of Otago, Wellington. The ARCH group studies all aspects of communication in health care, with a special focus on analysing how people interact in real-life health care interactions. Members of the group and its research associates have a range of clinical and social science backgrounds in the fields of primary health care, public health, sociolinguistics, sociology, psychology and conversation analysis. They would love to hear from anyone who would like to find out more: www.otago.ac.nz/wellington/research/arch/