Communication skills,patient voices and the art of listening

Increasingly, medical colleges and other academic institutions, healthcare organisations and health policy makers seek directly to incorporate the voices of patients and the views of community members when designing policy and curricula, developing services and accreditation processes, defining research questions and priorities, and on occasion, assessing individual clinician performance. Many observers describe the purpose of incorporating the voices of patients into these healthcare systems or processes as a means of incorporating the perspective of patients into decision making. However, it is also acknowledged that the perspectives, experiences and outcomes of patients are as heterogeneous as the conditions for which they require treatment, and the particular circumstances of their care.

We propose that the purpose of incorporating the voices of patients or consumer representatives into any function of a medical college or other healthcare teaching, training or service provider, or decision making organisation is to support and promote effective listening. The Victorian government has specifically described the role of patients and patient stories at board level to help ‘build a culture of listening’. ¹ We commend the Victorian government’s approach, and we also suggest that listening and learning from bad outcomes is necessary but not sufficient for a world class health system. Sustained listening, at every level, and from everywhere within and adjacent to the system is essential to the creation of a ‘continuously improving, compassionate healthcare environment’. ²

Teaching and training in communication skills is now fundamental to all undergraduate and postgraduate medical disciplines in Australia. ³ However, much of this training has focused on doctors as successful information providers—the doctor ‘explains the procedure’, ‘informs the patient and carers’ and ‘communicates decisions’. The Australian Medical Council (AMC) which accredits medical colleges expects that college training will produce graduates who are ‘fit for purpose’ and who possess the ‘knowledge, skills and professional qualities that are not only expected as a practitioner within the specialty but also by consumers and the community’. ⁴ Effective communication is more than the successful transmission of complex information. One commonly used definition of communication is ‘the creation of shared meaning’. ⁵ To enable this creation of shared meaning, effective communication is by necessity a ‘two-way street’. This process requires (typically) the physician to impart technical information and describe options, and the patient or carer to define their understanding, perspective and values which will influence the therapeutic choices to be made. To co-produce shared meaning and truly understand what is most important to patients, doctors require advanced listening skills—to hear not only what is said, but also what may remain unsaid or assumed. High quality listening has been found to contribute to enhanced diagnosis, healing and doctor-patient relationships. ⁶

The Australian community has high expectations of both the technical and non-technical skills of its medical workforce, including high-quality communication skills. For the most part these expectations are met. When expectations are not met, a significant number of complaints and disputes involving medical care have been attributed at least in part to deficiencies in communication, including clinician ‘attitude and manner’. ⁷ There is an increasing expectation that doctors’ communication with patients should be ‘collaborative’, and that listening should be ‘attentive’. ⁸ In its most recent multipurpose household survey, the Australian Bureau of Statistics (ABS) reports that fewer than 65% of people agreed that hospital emergency department doctors and specialists ‘always listened carefully’. ⁹

In order best to recruit, select, support and empower patients and community representatives to use their voices to enhance listening most effectively and to avoid a ‘box ticking exercise’ requires evidence and resources, intention and commitment. Australian health systems and organisations can potentially learn much from the UK experience. Since 2003 Patient Voices® (UK) has developed robust methodologies to extract and process patient stories as a means of bringing about transformational change, improving communication and care and, importantly, also improving staff morale. ¹⁰ A patient and public voice partners policy has been developed, which describes the defined roles, support provided (including financial support, training and ongoing development where needed) and outcomes expected from partners.

We suggest that a more strategic approach to harnessing patient and community voices at all levels from organisational to broader system levels in Australian healthcare will result in better skills for doctors and better outcomes for patients and communities.