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THE MISSING CHEMISTRY, Doctor – Patient communication

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Last year local newspapers reported a strong case against a team of doctors at a public hospital in Islamabad. According to the reports, Mohammad Farooq, a father of five daughters, lodged a complaint that the doctors stole his twin babies. During an initial ultrasound the doctor had informed the mother she was going to have two boys. But it came as utter shock when a baby girl was delivered after c-section. Concerned doctors on the other hand, were firm there was just one girl delivered. Ultrasound reports can be incorrect therefore cannot be relied on completely. And this is what the doctors failed to inform the complainant. A senior official at the hospital admitted that it was a mere communication gap issue. “It is the senior doctors’ job to tell the mother and family of a birth or any problem after birth. They should also have warned the family of possible errors in the ultrasound.”
No doubt, it is just one of the cases of doctor-patient communication gap which are many. Problems that this gap can create include incorrect assessment, generalized treatment, misunderstanding, patient dissatisfaction, distrust and suspicion on prescribed treatment and unawareness about the prevention. It is one of the reasons behind self-medication.
32-year-old Naz Jabeen is one such who prefers self-treatment. “Consultation with a doctor is usually my last option now. They do not pay attention and give time.” The resident of Multan also thinks most doctors are insensitive and do not listen to the patient carefully, which leaves her dissatisfied.

Gap or no gap?
Dr Nadeem Naeem a doctor at Baqai Institute of Endocrinology and Diabetology Karachi thinks otherwise. “I do not think there is much gap from the doctors’ side. Illiteracy is high in our country therefore it becomes difficult to explain something to patients.” They have no awareness or understanding about diseases, important symptoms and preventive measures.
“With tough schedules we are unable to give patients that much time,” he adds.
Shedding light on the issue, Dr Imad Bashir, a psychiatrist at Peshawar Institute of Medical Sciences, Hayatabad says that communication gap can only occur when communication actually exists between a physician and patient. “In Pakistan, sadly there is no communication at all between them.” Most doctors do not understand that it is demand of their profession to ensure good interaction with patients.
Dr Somu G, professor & HOD of hospital administration, KMC Manipal, Manipal University India, while commenting on the topic, believes this gap has widened significantly over the past few years. The older concept of considering the doctor as God has now become obsolete. “Loss of concept of family doctor has led to the loss of bonding between the patient family and the doctor.”

When it is the doctor’s fault
Language barrier is one of the reasons for the gap. Doctors use medical terms that patients usually cannot understand completely. “They should use easy and simple language instead of expecting patients to guess what they say,” explains Naveed Sultan, a psychologist at District Headquarter Hospital, Lower Dir, KP.
The relationship is usually formal as many doctors prefer keeping a distance from patients. According to Dr Somu, in the past decade, clinical grand rounds were an elaborate affair with a team of doctors spending significant amount of time at the patients bedside. “But doctors now rely more on investigations for making treatment decisions and spend less time with patients.”
That is probably why patients become hesitant when it comes to asking something. Nevertheless, cultural barriers create a distance too. For instance, most female patients in our country do not feel comfortable communicating openly with male doctors and vice versa.
“At times, poor appearance of the patient can also make a physician feel uncomfortable. A patient with untidy hair, shabby dress and poor hygiene can put them off,” comments Naveed. Patients come from all walks of life, have different socio-economic statuses and can feel miserable due to their medical condition. It is highly inappropriate of doctors to discriminate patients according to their appearance.
Moreover, some doctors avoid offering detailed checkups knowing their hospital or centre has limited resources or facilities. “Maintaining a gap prevents ‘unnecessary’ questioning of the patient,” says Naveed.

Not just the doctors
A disturbing fact is that Pakistan’s disease burden is on the rise. Physicians have to cater to a huge population that can also be responsible for the communication gap. According to WHO’s recent report, one fourth of the population over 40 years suffers from a cardiovascular disease and one third from high cholesterol. Disability due to blindness or other causes is also high, while services for patients are limited. To treat these issues efficiently, physician density in the country per 1000 population is 0.8, which is highly insufficient.
Experts interviewed believe with huge number of patients in the clinic, it becomes difficult to do justice to patients by providing enough time and listening carefully to all of them.
Explaining the demand-supply gap, Dr Adeel Qamar,a gastroenterologist at Mayo Hospital, Lahore says that he has to check around 40 patients in the ward, 100 in the clinic and around 200 in the emergency daily. “How can one expect us to give proper time to a patient in such a situation,” he asks.
Doctors, yet again
Of course, this may not be true for all. According to Dr Hayat Yousefzai, a psychologist at Ziauddin Hospital, Karachi, some doctors “deliberately” overload themselves for money.
Missionary spirit of doctors has been replaced by a more business perspective,” explains Dr Somu. Consequently, busy schedules of doctors have added to the communication gaps. “Doctors rarely find sufficient time to console the patients and explain the disease condition properly. This has also resulted in increase in the incidence of violence against medical staff.”
This tends to increase the chances of misdiagnosis. A number of diseases have overlapping symptoms. “Fatigue can occur due to overwork, sickness, anemia, hyperthyroidism, arthritis, diabetes or even depression,” highlights Dr Imad.
The standard time according to US National Institute of Health that needs to be given to each patient is 15 to 17 minutes. “However, doctors in Pakistan do not follow this standard. They should at least try to give five to seven minutes to each patient,” adds Naveed.

The patient’s responsibility
Communication is a two way process. So, it is not always the doctor’s fault. Most patients do not ask questions from their doctors. “A patient should demand for clarifications and inquire about treatment even if the doctor does not like it. It is his right to know all the answers,” mentions Dr Imad. In many developed countries, patients can even ask for summary about their treatment. There are patient advocates and many organizations that ensure protection of patient rights. It is deplorable that Pakistani patients are not even aware about their basic rights as patients. “Especially, patients from rural areas usually do not probe their doctors as compared to the patients living in urban regions of Pakistan,” he informs.

Bridging the gap
There is considerable healing power in the doctor-patient relationship. Working together offers the opportunity to significantly improve the patient’s quality of life and health status. This therapeutic association cannot be possible without mutual understanding feeling the pain of the patient.
According to mental health experts, good understanding of patient’s psychology is a must for a doctor. “Patient tends to feel lighter and better when they find a doctor who is a good listener. And all they need is reassurance, compassion, respect, attention and empathy necessary for their satisfaction, treatment and quick recovery,” explains Naveed.
Most doctors interrupt when a patient tries to explain his condition. “It is unethical and should be avoided,” informs Dr Hayat.
Trust is built when a physician builds rapport with the patient. Patients feel satisfied when they are heard and the doctor is open and friendly to them. “For the sake of clarity, he can repeat what the patient says during assessment,” mentions Naveed. Careful listening at least for the first time is a must for building good relationships.
Doctors are a sign of hope for the patients so they should try to see the situation through the patient’s perspective. “Make eye contact and avoid focusing on writing the prescription,” suggests Dr Hayat.

Dr Somu believes it to be a dire need to bridge this gap by “sensitivity training among the senior doctors and consultants in inculcating patient communication in their daily practice and also become a role model to young medical graduates during their formative years in the field of medicine.”
A patient should also focus on explaining the disease. Be concise, clear in interaction and ask questions if required.

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