"My patient died from this": Doctors and patients about the ability to communicate

The ability to communicate with the patient - the most important skill for the doctor, the absence of which, however, does not prevent to get a diploma and work. Probably, there is no person who is not scared, not offended or left without the necessary information in a medical institution. We asked a few women about positive and negative experiences with doctors, and doctors about how serious this problem is and what to do to solve it.

For twenty-two years my periods stopped for no apparent reason - and I was fortunate enough to get to an excellent gynecologist. She examined me, did not find any hidden problems and calmly explained that all the existing treatment for such situations was intended to get pregnant and give birth to a child. "I suspect that your immediate plans are not included?" - it really was not in my plans, and the doctor said: "Well, then we will just watch. Come, as usual, in a year, and if problems arise, we will solve them as they become available."

Two or two and a half years later my reproductive system suddenly started working normally, the cycle recovered itself, and when my partner and I wanted a child (I was thirty-three), the pregnancy began immediately after the cancellation of contraceptives. Actually, I forgot about this whole story a long time ago - and remembered only when Sonya Borisova addressed me with a story about the treatment of amenorrhea. I understand that if I were allowed to receive a conditional shift in another shift - I could be intimidated or offended, I could hear from the doctor that I was “incomplete” or “who needs such a woman.”

Once I had a dermatitis area on my arm, and the doctor, having tried all the ointments and diets with me, sent me to a psychiatrist, apparently to rule out mental disorders. I waited my turn, I went to the doctor. Inquiries began: how the situation at home, how to work with colleagues? In a nutshell, I explained that everything is fine, and I asked - can there be dermatitis due to stress? The doctor replied: “Oh, anything could happen because of him! There was a young man before you, he and his wife live poorly, she and his child left him for his mother. And he is so worried that he now has constant diarrhea! work barely arrives - by the way, he works with you in the same organization. " The young man who came out of her office, I, by the way, knew that we really worked together and came to this clinic under the working policy of the LCA. The desire to communicate with the doctor further disappeared instantly.

There was another story. During pregnancy, I developed gestational diabetes mellitus, which, unfortunately, did not go away and after - that is, I was left with type 2 diabetes. Unfortunately, the diet and medications did not give sufficiently good results, additional diagnoses such as arterial hypertension began to stick to me. I seriously studied the issue, found another specialist, and eventually the decision was made about the operation (this method is rarely used, but it is effective).

Before the operation, you need to undergo a series of tests, and I went to my endocrinologist for a referral. After my words about the upcoming surgery, the doctor screamed at me: “What are you, absolutely? You can't control yourself? Are you having a bad life with your diabetes? I remembered what kind of operation this is - my patient died after it six months later!” I tried to ask what he died from (maybe from some complications), but she only clutched at her heart and lamented: "He died, after all, he died." I don’t go to this doctor anymore.

During pregnancy, I went on a scheduled ultrasound of the first trimester, went to the clinic in a good mood, prepared to enjoy the process. I was moved by the sensor, the doctor began dictating the parameters to the nurse, and then suddenly he was silent - and in such a voice he said: “The TVP is significantly higher than the norm”. At that moment I didn’t even strain myself, just politely asked me to explain what it means, to which I received the answer: "For example, you have down there." I turned white, they shook salat, the nurse told the doctor that maybe she shouldn’t stand that straight, and the doctor answered something like “well, they want to get answers to their questions.”

I left the office with a piece of paper on which the names and addresses of the star Uzvis were written. She drank water, got ready and boldly went across the whole of Moscow to one of the most famous experts. I paid a large amount for the reception, I spent several hours in the queue, the “star” held a sensor on my stomach, called the parameters of the TVP even worse than the previous ones and wondered why I came. I started explaining something confused, tried to ask some questions, find out what TVP is and what is the norm with its variants, but I was literally pushed out into the corridor with the phrase: "Drop it into genetics."

Then, in another clinic, where familiar doctors worked, I urgently had a chorionic biopsy done. There I was sent to a new uzist - and with it I went through the whole pregnancy. At the first meeting, she told me everything about the measurements of the TVP, whether it was necessary to have a biopsy urgently or not, about various other types of diagnostics - well, I was very upset that I had not met her from the very beginning.

It seems to me that the doctor has three mortal sins: stupidity, cowardice and inability to communicate with the patient. Recently, I often come across the fact that colleagues make the correct diagnosis, choose the right tactics and make the right appointments - but then they destroy and devalue their own work by gross defects in communication with the patient.

For example, recently there was such a case: the dermatologist made the correct diagnosis, prescribed topical steroids (hormonal ointment) and said to the mother: "You can smear, but you can not smear it as you wish; it will still pass." I understand what was meant: the child had a non-dangerous self-propelled disease, in which hormones sometimes speed up recovery, but more often not, and given the fairness and price of such treatment, the game is not worth the candle. But it was necessary to clarify this better - after all, the mother perceived the situation as if the doctor did not care about the problem, and the doctor does not know how to solve this problem and hopes that "somehow she will pass."

And this happens often - the essence of the appointments remains the same, but after detailed explanations the parents remain calm and are ready to implement these recommendations. And after consultation in the style of "you are many, and I am one," the list of appointments is likely to be torn behind the office door.

At the same time, doctors, who make such gross mistakes in communication, are hardly aware of their own blunders - this is evident from the outside, but it is very difficult to notice and recognize in oneself. For certain, I also overestimate my communication skills and do not notice defects: a patient recently sent a link to a discussion of my medical skills - I was convinced that patients often hear something different from what I say or write, and this is partly my fault - lack of skills communications.

You need to learn to communicate - although this will not solve all the problems, it will definitely increase the satisfaction of the doctors with their work and the patients' desire to follow the recommendations.

In gynecology, the problem of intimidating patients is very acute. It should be borne in mind that in the gynecologist's office, the patient is in a vulnerable position in principle: they need to undress in front of an unfamiliar or unfamiliar person, talk about the details of their lives that are not customary to share, and even experience not the most pleasant sensations. All this creates an atmosphere in which to hurt a person is not difficult, and gynecologists, in my deep conviction, should be especially sensitive.

According to the stories of patients, most often medical ethics are violated in matters related to infections, infertility and pregnancy. In Russia, an orgy is happening around sexually transmitted infections. Many doctors do not know the difference between true STIs and components of the flora, which normally live on the mucous membrane of the female genitals. This creates a huge problem: finding any microorganism on the mucous membrane of the vagina or cervix, doctors tend to interpret the result of the analysis as the discovery of an STI and tell the woman that she was nagging - and if not she, then her husband. It is difficult to imagine what a blow it is for a woman who knows that she is faithful to her partner. Most of these conversations occur from scratch, that is, against the background of complete health, due to overdiagnosis and the appointment of unnecessary tests and treatment - and it turns out that such consultations are only harmful.

Infertility is a diagnosis that should be made after unsuccessful attempts of a couple to conceive a child (there are rare exceptions - when, for example, a woman has no uterus). In Russia, the often innocuous findings on ultrasound (indirect signs of adhesions or endometriosis) for some reason allow doctors to judge whether a woman can become pregnant in the future. Patients often hear that they will definitely have problems with pregnancy, although there is no sufficient reason for this. Such statements can be frightening and offensive: many women, even those who are not planning a pregnancy in the near future, are nevertheless important to realize her possibility in the future. Another option - recommendations to become pregnant as soon as possible, because "then it may not work." If a woman does not have a regular partner, she finds herself in an incredibly difficult situation: either giving birth now from someone, spitting on a career and other plans, or never. It is a very difficult choice - and in most cases it’s really not necessary to do it, and it’s worth planning your life the way a woman wants and is comfortable, and not a doctor.

And, of course, pregnancy - this is where you can roam, if you want to belittle and intimidate the patient. The most terrible, in my opinion, the accusation of the patient in the loss of pregnancy. About 30% of pregnancies end badly, and each such case is a huge stress for a woman and her family. In this situation, the main task of the doctor is to help survive the loss and tune in to a future pregnancy. In Russia, I encounter situations where a doctor is trying with all his might to find out what a woman could have provoked an abortion to declare: “Well, of course! What do you want?” The reasons are sex, sport, stress, air flight, hot bath - anything that does not actually lead to abortion. Unfortunately, many who have miscarried are intimidated so much that in the next pregnancy they deny themselves all the joys of life.

This is far from everything that I have to face at the reception and after that I need to console the patient for a long time; such situations occur literally every day. “Thanks to” such actions by the doctors, part of my consultations are long conversations with the patient, aimed at explaining to her that she is doing well, she is not seriously ill, and her moral condition (her and her partner) is also okay. It's nice when a partner is also present at such consultations - then you can calm down and “justify” two.

I believe that it is just as important to enter into trusting contact with a patient as making a diagnosis and prescribing a treatment. If there is no contact, the person will not tell you everything (and then you risk making the wrong diagnosis) or with distrust and carelessly react to appointments (and then treatment will not help).

There are doctors of different ages in our team, most of them have gone through the old school, and it can be difficult to teach them that it is important for patients not only to talk and explain their actions and assignments to them (which is a breakthrough for many adult colleagues), but also to look for everyone individual approach. With someone you need to communicate in a friendly way, someone better perceives a parting tone. If you do not find this key - the patient may simply not hear and not understand your explanations.

And of course, under no circumstances should you intimidate patients and tell them that if they do not listen to you, something terrible will happen. First, no one knows for sure. Secondly, intimidating the patient, you provoke a defensive reaction and make him nervous, afraid and try not to think about the problem at all. I think you should not say phrases like "let's try such and such treatment." Even if the doctor doubts the success, why start at all? Of course, we cannot guarantee the patient anything, but phrases like "everything should work out" and "we will try" sound much more optimistic.

I was lucky to receive medical education from two schools at once: the classical European and the traditional eastern. The doctor-patient relationship is very different. In the medical school, of course, there is the subject of “medical ethics,” but it’s rather about how to inform a person about the terminal stage of the disease and questions that are similar to it. Contact with the patient is not taught there, although it is very important.

Eastern medicine is based on the understanding that the patient comes to the doctor because he suffers, he is uncomfortable. Suffering people may be capricious, rude, stubborn, but they are because they need help, and our task is to hear them in order to be able to help. That is why Tibetan doctors play the role of someone like a mentor and often become doctors for the whole family.

The Eastern approach helps me and my colleagues a lot, because people who have tried all conservative methods often turn to non-traditional clinics like ours. Such patients are closed, mistrustful, do not want to cooperate, communicate from the position: "Come on, try to cure me. We'll see how you fail." Another common type is people who have diagnosed themselves on the Internet. I am all for curiosity, but often the symptoms are the result of completely different reasons than those thought of by people. With such patients, it is important not to argue or persuade them: they did not come for your advice, but for confirmation of their conjectures. If you give a person a talk and just make the right appointments, delicately persuading to try, then at the next reception he will be more open, because he will see the result.

In general, I want to say that in a doctor-patient relationship we still have a long way to go towards each other. It is important for doctors to learn to talk with patients, establish contact with them and explain their actions, and it is also important for patients to be able to talk with doctors. In our country, doctors don’t like to go to doctors and treat them with caution, and it is often almost impossible to collect a correct history: a person simply does not consider these or other symptoms to be important. It seems to me that only enlightenment can solve both problems. And this material is a great start to talking about its importance.

Unfortunately, the subject iatrogenii(deterioration caused by a medical professional. - Approx. Ed.) due to the incorrect, rude, and non-empathic behavior of Russian doctors remains extremely relevant. For some reason, an incredibly tenacious idea is that if a doctor knows a "materiel", that is, he is competent in medical matters, then he can behave somehow. As if the psychological part of the interaction with the patient is not included in professionalism at all.

This idea is supported by the medical system itself, and patients - still, it is necessary to somehow work out the traumatic experience. And the fact that it is traumatic, no doubt. Thousands of people, having survived the only meeting with domestic medicine, are desperately avoiding repeated ones. They are afraid of doctors and suffer symptoms, even if everything is already serious. Many of them need psychotherapeutic help, since they develop the whole set of symptoms of post-traumatic stress disorder - especially for women who are traumatized by the way obstetricians and gynecologists communicate.

When I wrote the brochure "Medical system of Russia and how to survive in it," I first did a survey on the LiveJournal platform about people's personal experience. The number of responses and their content exceeded all possible expectations. But this is only the tip of the iceberg - those who can talk about it. In general, the situation is frankly deplorable and quite hopeless for patients, while doctors continue to train in the same model.

The problem of communication skills with patients exists everywhere, and there is no such country that could state that it has been completely solved - after all, we are talking about the interaction of living people, not robots, and the human factor can always lead to deviations from the desired standard. Communication fundamentally affects the quality of care. Now they have begun to realize this too - literally in the last year or two they have recognized this and at the state level, important decisions have been taken; however, it is not clear what they will lead to.

In particular, it is planned that the accreditation of doctors - in the coming years, this will affect graduates, and then all levels of retraining - will include an assessment of communication skills. Universities understand that they will have to teach, because students cannot take an exam for which they are not ready. But this raises the question of resources, including teaching hours and teacher rates. In general, this is such a very crucial moment, and many mistakes will probably be made - I would like them to be correctable.

I never planned to teach, I was going to be a medical practitioner, and I was always interested in palliative medicine. When I worked at the First Moscow Hospice, I was lucky to receive funding from the Give Life Foundation - and I went to Cardiff University for two years. Я училась паллиативной медицине и тогда глубже познакомилась с дисциплиной навыков коммуникации; мне очень понравился формат обучения. Потом в какой-то момент я участвовала в развитии команды, помогающей людям с боковым амиотрофическим склерозом, и при обсуждении навыков общения поняла, что не знаю, как передать свои знания.

Then I began to look for courses for teachers, “trainings for trainers,” and found the European Association for Health Communication (EACH). I completed an internship at this organization in Cambridge, saw how they teach students, and continue to work actively with them. About four years ago, I decided to start applying their method - and then a school appeared. Training is built on working with so-called simulated patients - these are the actors who play patients. Beverly Dean, an actress who works as a simulated patient in Cambridge, helped me a lot. She was interested in Russia, and we started a project: gathered interested people through Facebook, held a casting and she taught them two full days.

Today we have three absolutely professional, proven EACH, simulated patients. This is a very difficult job: a person has to perform many tasks simultaneously. First, they reproduce the situation as close as possible to life: they may be embarrassed, they are afraid to kill the doctor, they talk about what is easier to say. Secondly, they should constantly monitor their feelings, then to give feedback, answer questions like "what did you feel at the moment when the doctor said ..." Finally, the simulated patient should be able to quickly get out of the heat of emotions and give feedback kindly calm and simple language. Now medical universities are asking us to record some video to let their management understand how difficult the work of a simulated patient is - many people think that this is a matter that any student can handle.

We definitely have where to develop. In the same England, students for three or four years regularly learn communication skills, and then pass the exam. We still have short courses at school - two working days, and about two hundred people have been trained. Most of them came to study at their own expense, including from other cities, and only in recent months did doctors appear for whom the employer pays. Of course, it would be great if some grants or scholarships were allocated for teaching communication skills; In some countries, doctors receive a certain amount of training and decide for themselves exactly what to spend it. We have big plans: an important textbook on communication skills will soon be translated into Russian, there will be an online manual with an illustration of these skills on video. We want to create longer programs, including annual or biennial, separately for students and for practicing doctors, and we plan to work closely with foundations, because many people cannot afford to study.

Photo:Ocskay Mark - stock.adobe.com, 1stdibs

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