Later, when the mother was dying, Hawgood was again asked by the team to provide support for the daughter so that hospitalists could care for their patient. “She was so angry, and it was directed at the hospitalists,” recalls Hawgood. “It was just her absolute inability to accept that her mother, who was the center in her life, was going to die. You have to give people credit and respect. You have to understand where they’re coming from and what’s going to work for them.”
Training Adequate?
According to a 2003-2004 survey conducted by the American Association of Medical Colleges, 124 out of 125 medical schools included communication skills as required courses for their medical students.1 However, Dr. Baudendistel points out that there are currently no national standards for proficiency in communications skills and that the field is in relative infancy at this time. Inclusion of interpersonal and communication skills as one of the Accreditation Council for Graduate Medical Education’s (ACGME) core competencies will help focus more attention on how to teach communication skills, he believes.2
“Communication is now one of the six core competencies,” he says. “It’s no longer secondary to being a smart doctor: It’s equally important in the view of the ACGME. So I think that will help.”
Beyond standardization of communication skills curricula, it is also necessary, he emphasizes, to verify providers’ proficiency in those skills. In the California Pacific Medical Center’s residency program residents receive 360-degree evaluations. These go beyond the typical evaluations in the past, wherein residents would be evaluated by supervising attending physicians and interns working under them. Now, evaluations of residents are sought from nurses—and from the patients themselves. Obtaining 360-degree feedback from all those who have interacted with the resident functions as a valuable teaching tool.
Experience: the Best Teacher
While most agree that training and required communications courses should be increased, Dr. Bennett points out that some of the hospitalist’s expertise with family communications will simply evolve with time and experience.
“I’ve learned a lot from situations in group meetings with a social worker or a patient ombudsperson, just watching how they manage the situation,” she says. At Newton Wellesley Hospital, social workers and chaplains were sometimes better able to find the right way to phrase something so it came across in a way the family could accept, recalls Dr. Bennett. She raises the a case of a 50-year-old man who came in with cardiac arrest and whom they needed to withdraw from life support. He had been born and raised Catholic, but had converted to Judaism, which was his ex-wife’s religion as well as that of his children. He had an extensive family (he was one of 10 children), who were concerned about his ability to receive Catholic last rites. The chaplain understood the implications for both religions and was able to negotiate a compromise that satisfied both sides and allowed life support to be withdrawn.
Dr. Weber, who completed her residency at DeVos Children’s Hospital in Grand Rapids, Mich., praised the training she received in doctor-patient communications while in medical school. However, once she arrived in Anchorage, she discovered that the cultural norms of Alaska native people required some on-the-job learning.
She once asked an adolescent girl with Crohn’s disease whether she had any belly pain. “She wasn’t answering me, and I thought, ‘Oh great—just another typical teenage girl’” remembers Dr. Weber. “Well, I thought she wasn’t answering me, but she was lifting her eyebrows, which means ‘yes.’ But I didn’t know that.”
Dr. Weber has found nurses and other long-time hospital staff to be very helpful in learning how to communicate with her patient population.