Objectives: Upon completion of this activity the participant will be able to
differentiate between male and female processing issues, and demonstrate
techniques for various medical specific communication needs.
INTRODUCTION
The importance of effective communication in medicine often is overlooked. For female patients, this is a particular concern, especially for women with obstetrical and/or gynecologic health problems. A large body of literature exists that discusses the different communication styles of men and women. Because of these differences, discussing obstetrical and/or gynecologic health problems, particularly with a male health care provider, is likely to be problematic for many women. This issue takes on even more importance in an emergency setting, in which continuity, engagement, and educational opportunities are often limited. Formal medical education provides few opportunities to acquire and improve basic communication skills. Consequently, communicating sensitive medical issues with women in an emergency situation is a skill that often is obtained by experience, sometimes negative experience.
While the problems of gender gap and setting are real, they are not insurmountable. Some thought given to this subject is amply rewarded with improved personal comfort as well as patient satisfaction and compliance.
PROCESS ISSUES The process by which sensitive information is communicated is very
important, and communication is smoother if the physician considers some
basic issues to be addressed. The first important issue is who conveys
information. If sensitive information is to be communicated, it usually is
better for the physician, rather than a nurse or a technician, to discuss
it with the patient. This demonstrates respect for the patient, the
seriousness of the situation, and also bypasses the “I want to speak to
the doctor” scenario. Many physicians consciously or unconsciously avoid
difficult or sensitive communication scenarios because they may be
time-consuming or because health care providers recognize their own
inadequacies in communicating. Ultimately, both the health care provider
and the patient are better served by a deliberate effort to learn
satisfactory communication skills than by the provider simply abdicating
communication responsibilities.
Having some support personnel in the room with the physician also is
helpful, if possible. A social worker or nurse may be able to provide
support once the physician has left, and making a connection with the
patient while the unwanted news is delivered may be helpful. Also, this
helps the patient to see that the support personnel have a relationship
with the physician. Support personnel also may be able to provide the
physician helpful insight that allows further communication skills
refinement. At times, having the physician be the communicator of
sensitive news is impossible or impractical, but direct physician-patient
communication should be the ideal.
After deciding who relays sensitive information to the patient, the
setting needs attention. Standing in the middle of the hallway to inform a
woman that she has a sexually transmitted disease (STD) is not optimal.
The preferred setting would be a room (not a curtained cubicle) that is
not a high traffic area where the patient and physician can sit. The
physician needs to be at eye level with the patient, preferably sitting.
Eye contact is important when talking with a patient, and this is a skill
that can be formally rehearsed to improve performance.
Physicians also need to communicate to the staff that uninterrupted
time is needed with the patient/family. Attempting to discuss sensitive
information while being interrupted by staff or by a pager beeping may
increase the patient’s anxiety as well as inspire anger. Uninterrupted
time in an appropriate setting is more likely to convey care and concern
on the part of the physician.
Physicians also need to be conscious of their communication style,
including such issues as speed of delivery. Speaking at a slower speed and
in a lower tone helps to reduce anxiety. While the physician may be
feeling enormous pressure to complete the conversation and move on to
other tasks, very little time is lost by techniques such as sitting down,
pacing the delivery of news, and maintaining appropriate tone and speed of
speech. Indeed, time may be saved if patients comprehend information more
clearly on the first transmission.
Timing also is important. A good time to present bad news does not
exist; however, bad times to present bad news do occur, such as when the
patient and/or family have been awake all night and are fatigued or when a
large family group has just arrived and emotions are very intense. While
one cannot always wait for the optimal time, consideration of this issue
is important. Less urgent tasks, such as acquiring consent for autopsy,
may be deferred until the family has had a chance to recover from the
initial emotional blow.
Providing the patient with an opportunity for follow-up questions and
clarification of issues also is very important. If the physician cannot
provide this opportunity, having the patient and/or family contact someone
who can answer any questions is imperative. This allows closure to the
current event and allows patients and/or families to know that someone
will be able to help when they are ready to deal with some of the
emotional issues of the situation. Many support groups exist to provide
patients with information and assistance beyond what the doctor can
provide. Some useful numbers for national agencies are listed in Table 1.
Having a similar list of local resources available (preferably in a pocket
card format) for all care providers in a particular institution is
helpful.
Do not provide too much information too soon. If the patient and/or
family does not appear to comprehend the situation, back up and repeat the
information in even smaller segments. Physicians may find themselves
repeating the same news a number of times or in several different ways.
Open-ended questions such as "What do you know about herpes?" are
time-consuming but can provide great insight into what information needs
repeating or reframing.
The literature indicates that one of the most important issues in
communicating unwanted news is that the physician be honest and direct.
More often than not, the patient and/or family has an idea that a
potential for bad news exists and needs to begin to deal with it on an
emotional level. Providing hope, but not false hope, is important.
Sometimes physicians can be vague when communicating sensitive news. This
may be due to their own discomfort and generally is not what the patient
wants or needs. One way to compromise between withholding information and
overwhelming the patient is to let the patient guide the conversation with
questions such as "What would you like to be told about this problem?" or
"Do you have concerns about how this might affect you?"
Many physicians are uncomfortable with their own emotions. When
discussing a sensitive medical issue with a patient and/or family, the
physician often attempts to remain emotionally detached. A number of
studies indicate that a physician who demonstrates some emotion comforts
patients and/or families more than a physician who does not. This allows
the family to feel that the physician is engaged in their situation and
cares about them. Even having the physician express sorrow can be very
helpful to the patient and/or family; expressing sorrow can change the
tone of the statement "we did everything we could" from a defensive
comment to one of shared loss and frustration.
Some physicians are very uncomfortable when the patient and/or family
has very intense emotions. The physician may attempt either to squelch the
expression of the emotions or to remove him or herself from the emotional
environment. Allowing the patient and/or family freedom of expression is
important. Becoming comfortable with the emotions of others requires
practice but allows the provider a much broader scope of healing than
otherwise would be possible.
The most important skill that a physician can acquire in dealing with
sensitive news is the ability to listen. The ability to listen
communicates respect, caring, and empathy. In addition, it provides the
physician with guidance as to the direction the conversation needs to
take. Most people complain more about not being listened to than any other
single issue in their medical care. In addition to physicians being aware of their own personality issues
and belief systems, understanding that each patient’s personality affects
communication is important. Not all women express their emotions in the
same manner, and if a physician waits until the patient expresses her
emotion in the manner that is expected, discomfort and misunderstanding
may exist for all parties involved. Some patients are prone to anxiety
that may be expressed in several different ways, such as crying, anger, or
pacing. While a provider cannot possibly know all patients equally well,
some attempt to identify the patient’s personality type and needs is
rewarded with greatly enhanced communication patterns.
Another factor that needs to be considered is the patient’s social
environment. Having some information as to what is going on in the
patient’s life may facilitate the communication that occurs. For example,
if a woman has been attempting to have children for several years and has
experienced a fetal death, her reaction may be much different from a woman
who was not aware that she was pregnant and has experienced a spontaneous
abortion. If a woman is going through a conflictual divorce, her reaction
to any bad news may be compounded by her already fragile emotional state.
The level of support that an individual has from other sources, such as
family, clergy, and friends, also greatly impacts her ability to receive
sensitive communication. While the physician cannot know all these things,
simply remembering that a social context is affecting the transmission and
interpretation of information is helpful.
Patients may have mental health issues in addition to their presenting
symptoms, and the mental health issues sometimes can overshadow the
physical ones. Two categories of mental illness are of particular concern
to physicians caring for women. The first is schizophrenia. Patients with
this diagnosis often have difficulty establishing ongoing relationships
and, thus, may receive most or all of their health care in an emergency
setting. These patients can be extremely frustrating because of
noncompliance with prescribed care regimens and their disordered and often
disruptive thought processes. Obviously, every effort should be made to
establish a connection with a mental health professional. These patients
require a great deal of time and energy, but this investment may be
rewarded with improved compliance as the patient musters the trust
necessary to continue the care regimen.
The second mental health disorder of particular significance to women’s
caregivers is borderline personality disorder. Less room for optimism
exists in this situation. This axis II disorder is 3 times more common in
women than in men and often goes undiagnosed. It is not highly amenable to
treatment, but the highly disruptive effects of a borderline "acting out"
can be contained if the provider is alert to the possibility of the
diagnosis. Women with borderline personality disorder are extremely
seductive, although this may not be enacted as sexual behavior. They may
be victims, ceaseless caregivers, lost newcomers, or any other role
calculated to win sympathy and special treatment. They often are
excessively flattering regarding their current care situation, while being
vituperative in their denunciation of the previous caregiver who somehow
failed them.
Underlying all the actions of a patient with borderline personality
disorder is the insatiable need for attention. While initial interactions
may be quite gratifying to providers, such as being told by the patient
that they are marvelous, the patient with borderline personality disorder
inevitably becomes disillusioned when the interaction fails to escalate to
what her fantasies lead her to expect. At this point, she may become
angry, vengeful, and abusive. At this stage, the special efforts her
physicians may have exerted on her behalf inevitably are used against
them.
Physicians should not be discouraged from providing genuine care to
particularly needy patients. Certainly, patients exist with extraordinary
problems worthy of extraordinary care measures. The provider should be
alert to patients dressed seductively, those who describe outrageously
inappropriate behavior on the part of previous caregivers, or those who
actively campaign to elicit sympathy. Providers are cautioned particularly
to pay attention to their interaction style and how that may change from
patient to patient.
If the physician begins taking extraordinary measures on behalf of a
patient whose needs at face value do not merit such effort, disengaging
quickly is best. Such patients are best managed by a team approach with
active involvement of a mental health professional, and physicians should
never allow patients to manipulate them into being alone for any portion
of a physical examination. Once a patient with borderline personality
disorder has been identified, having a chaperonage, even for interviews,
helps contain inappropriate self-disclosures or solicitations.
Unfortunately, the seductive behavior patterns of patients with
borderline personality disorder, along with their explosive interaction
patterns, tend to put them at high risk for rape, domestic violence, and
battery. Awareness of the patient’s underlying personality disorder in no
way lessens the tragic nature of these situations, nor does it diminish
the need for provider concern and compassionate care. However, providers
must protect their interests as well as those of the patient.
Emotional response to a fetal death may be influenced by several
factors. Gestational age of the fetus is highly likely to play a role.
Generally, the more advanced the pregnancy, the more intense the grief
reaction. This is true not only because of the expectancy of a live birth
but also because of the amount of planning the mother and/or family has
carried out to welcome a new baby. The more preparation that has been
made, the more difficult recovering emotionally is.
Life experiences of the parents also may play a part. Young parents who
have experienced very little grief in their lives are likely to respond
with greater difficulty to a fetal death than older parents who have had
other grief experiences. On the other hand, a woman who has undergone an
extensive infertility workup in order to get pregnant is more apt to
experience an intense grief response than a woman whose pregnancy was
unintended.
Social support is quite important in helping a mother deal with a fetal
loss. Women who have a high degree of social support are more likely to be
able to handle the situation better than women who are socially isolated.
The most difficult area to evaluate in regard to grief experience is
the importance of the pregnancy to the mother. The issue of planned versus
unplanned pregnancy may have an effect on the emotional response. If the
pregnancy was unplanned and termination of the pregnancy was considered,
feelings of intense guilt may result. If the mother felt somewhat
ambivalent toward the baby, feelings of guilt may result. If the pregnancy
was planned and looked forward to with anticipation, the emotional
response to the loss is likely to be significant.
Each individual woman is different, and her grief is acknowledged,
felt, and expressed in a unique way. Providers should be aware that a
broad spectrum of emotional responses may occur and that many full-blown
grief reactions occur after the patient is sent home with the diagnosis of
miscarriage. Every effort should be made to ensure both adequate medical
follow-up care and availability of appropriate emotional support. Most
communities have fetal loss support groups, and every patient should be
provided this information for possible future reference.
Sexually transmitted disease
Communicating the presence of an STD should be straightforward and
matter-of-fact, without expressing judgment. Most patients accept this
information without significant emotional reaction, particularly in an
urban medical environment. However, for some patients, notification of an
STD, such as herpes, is devastating. All patients should be approached
with some consideration that they may have an intense emotional reaction
to the news.
A dramatic increase has occurred in the diagnosis of pelvic
inflammatory disease (PID). Women who are diagnosed with PID often are not
told that it is the consequence of an untreated STD. This leads to social
embarrassment as well as high likelihood of reinfection if sexual partners
or behaviors are not modified. Because of social and medical consequences,
the diagnosis should not be made without careful consideration of a
differential diagnosis, and the patient should be informed of the etiology
of PID so she can make informed decisions regarding her lifestyle habits.
Domestic violence
Domestic violence is more prevalent today than many would like to
acknowledge. The most likely medical arena in which domestic violence is
discovered is the emergency department. When discussing the possibility of
domestic violence with a woman, the spouse/partner should not be in the
room. Most women who have experienced domestic violence are unlikely to
acknowledge the problem without some probing. This is a situation where
the ability to communicate sensitively is very important.
One of the convenient ways many providers have a conversation with a
woman privately is to have a standing policy that no family members are
present in the examination room when a pelvic examination is being
conducted on an adult. This allows for an opportunity to talk with the
woman without creating suspicion in her partner. If the partner is
reluctant to leave the room, this may be a warning sign.
Questions regarding abuse should be frank and explicit. Many abused
women do not consider being slapped or punched by a partner to be
abnormal, so specific questions should be asked about the etiology of
injuries. Many women also collude to hide abuse, either because of fear of
retaliation or because of a genuine desire not to see the partner harmed.
If a high index of suspicion exists that domestic violence is occurring
but the patient refuses to acknowledge it, information regarding shelters
and victim services should be made available in such a way that she can
secure it for future use. Consider having this information available in
the waiting room or in women’s bathrooms. Some women use this information
later, even if they are not prepared to do so at the time of presentation.
Additionally, each state has specific laws regarding suspicion or
knowledge of domestic violence. Providers should be aware of the laws in
their state.
Rape
Rape or attempted rape is one of the most difficult situations that a
woman may experience. The reaction is often far more severe than even that
of aggravated assault, in part because rape threatens the deepest sense of
self and personal control that most women possess. Upon the arrival of law
enforcement officials, the patient often is drawn back into what feels
much like a second assault, first by having to repeat her story in detail
and then by submitting to the most meticulous and invasive medical
examination imaginable. Being able to communicate with a woman who has
been raped in an empathic and sensitive manner is of vital importance.
In some cases, the patient believes litigation is not under
consideration and the patient just wants a medical evaluation that is
briefer and much easier on the patient and the staff. However, some
patients subsequently change their minds, and the best time to collect
evidence is immediately after the assault. If any potential for litigation
exists, evidence should be collected immediately and following the
standard protocol. The patient may be very poorly suited to make this
decision immediately following an assault. The job of the provider in this
case is to be the patient advocate in assessing opportunity for improving
litigation outcome versus immediate cost to the patient.
Careful communication with the patient is vital. As with any severe
emotional trauma, patients who have been raped may not be able to hear or
understand information and/or instructions. All information should be
presented often and in many different ways so that the patient can absorb
it. The patient should be informed of what is to happen at each phase of
the examination and, whenever possible, should be allowed choices about
her examination and treatment. This begins to restore some sense of
control. If the protocol involves plucking hair or scraping nails, the
patient should be allowed to collect these samples herself rather than
having medical providers reenact her assault. Psychomotor retardation is
very common in women who have been sexually assaulted and can be maddening
to busy providers, but the patient must be allowed to move at her own
pace.
Law enforcement officials often have their own agendas regarding
reporting of sexual assault. They may push for access to the patient
before she has been fully evaluated or before she is emotionally able to
communicate with them. Again, the provider may need to serve as the
patient advocate in controlling access to her.
Potentially serious diseases
In her book, On Death and Dying, Elizabeth Kübler-Ross
discusses the 5 stages of grief (ie, anger, denial, depression,
bargaining, acceptance) and notes that patients may move often and at
varying speeds back and forth through each of these. Expect patients who
are informed of having a serious disease to begin to traverse these stages
almost immediately. The physician is unlikely to know where a particular
patient is in her grief process unless extended previous contact has
occurred.
When breaking the news of a serious and/or life-threatening disease,
the following issues should be considered. First, never lie. Physicians
should acknowledge that they may have a limited knowledge base about the
problem, and they should provide enough information to get the patient to
the next level of care.
Second, do not overstep the knowledge base even though the patient or
family may press to do so. For example, if a gynecologic patient has been
told that she has pancreatic cancer, do not tell her that she only has 6
months to live. The information may or may not be true and will not be
helpful regardless. As much optimism should be expressed as the situation
allows, along with the repeated emphasis that prompt treatment by the
best-qualified specialist is vital to the patient’s emotional, as well as
physical, well-being. If possible, connect the patient to the next level
of care prior to her leaving the office or emergency department. This
connection is potentially the most important thing that the physician can
do for the patient.
Thirdly, and in keeping with earlier sections in this chapter, be
prepared to repeat and rephrase information frequently. Do not expect a
patient to understand phrases such as "radiation therapy" or "exploratory
laparotomy." Patience with what seems like endless repetition will be
rewarded with increased patient trust and, ultimately, a smoother
transition through Kübler-Ross’ grief stages. Open-ended questions are an
effective way to measure the degree of comprehension on the part of the
patient and may provide valuable insight for the sensitive provider.
REFERENCES
MEDCEU
Continuing Education Courses CEU for Nurses and Healthcare Professional
Men and women communicate
differently. Men tend to be more focused on factual issues and tend to be
action oriented, asking “What are the facts and what needs to be done?”
Women tend to focus more on emotional issues and working out solutions
through dealing with emotional aspects. Although these are generalizations
and significant overlap exists in communication styles between genders,
the stereotypes are nonetheless well supported by research. In order to
optimize communication with female patients, consciously identifying a
communication style that is more emotionally oriented than one might
embrace with male patients may be helpful.
Content issues might seem more
straightforward than process, but they may in fact be equally difficult
when communicating sensitive news. Using terminology that the patient can
understand is important. Remember that the patient receiving unwanted news
may hear only a small portion of what is being said and may not understand
the implications of certain medical terms. A tendency also exists for
patients to nod as though in understanding, thus leading the provider to
believe communication has been successful. The words used by the provider
need to be simple and basic in order to increase understanding.
PERSONALITY ISSUES
Each individual involved in a
communication situation brings aspects of his or her personality to the
interaction. Physicians need to be aware of their personality type as well
as the personality type of the patient with whom they are communicating
sensitive information. The physician, like any other person, has a
particular way of looking at such things as death, the role of the
physician in the treatment process, and appropriate ways of expressing and
coping with intense emotion. The physician’s perspective affects the
communication interaction. For example, if physicians believe that they
represent health and wellness when serious illness or death has to be
communicated, they may have a sense of failure. If physicians believe that
they are facilitators working with the patient to obtain optimal health,
the view of illness or death may differ.
Fetal death
Attention to global aspects of patient care
rather than the chief complaint is essential in order to assure
compliance, continuity, and patient satisfaction. The skills necessary to
accomplish this may not be intuitive and almost certainly were not taught
or emphasized in medical school; however, they can be learned if the
caregiver values them. Many sources are available from which to learn
these skills, including textbooks, the references below, and good
mentoring from clinicians respected for their ability to communicate. Such
effort will be amply rewarded by generally shorter, less conflictual
patient interactions and by better compliance with prescribed therapy.
Resources are available for patient support and should be used
liberally.
SUPPORT SERVICES
Table 1. National
Agency Support Services
Support Service
Phone Number
American Cancer Society
800-ACS (227)-2345
National Child Abuse Hotline
800-422-4453
Sudden Infant Death Syndrome Alliance
800-221-SIDS (7437)
AIDS Hotline
800-342-AIDS (2437)
AIDS (SIDA) Hotline (Spanish)
800-344-SIDA (7432)
National STD Hotline
800-227-8922
Hepatitis Hotline
800-223-0179
Sickle Cell Disease Association of America
800-421-8453
National Mental Health Association
800-969-6642
National Headache Foundation
800-843-2256
National Stroke Association
800-787-6537
Endometriosis Association
800-992-ENDO (3636)