Abstract
Junior perspective: Gianluca Pellino
Effective and empathic communication with patients is an important skill that surgeons in training need to master, before regarding themselves as “consultants”. This is particularly true in colorectal surgery. Surgery for colorectal conditions might involve complex procedures, and could require formation of a stoma – sometimes more than one. Anxiety ahead of surgery can be therefore anticipated in most patients, and it is justified. Several studies on patients who needed major GI surgery, suggested that anxiety (as measured by validated tools) tends to be higher early after elective procedures, but it takes several weeks to get back to normal. Irrespective of the mean by which the level of anxiety is measured, I would suggest that – should these findings apply to our patients – we are losing an opportunity to make the perioperative experience less stressful, at least in those patients for whom surgery can be planned.
Certainly, it is not possible to reply in a reassuring and exhaustive way to the questions of the patients, without adequate knowledge of the condition, as well as of the surgical techniques and phases of the procedure. Young surgeons would struggle to sustain a discussion with patients and their families if not adequately trained, and patients would feel disoriented. Anticipating questions requires experience and a specific training.
Just as learning surgery requires a structured and gradual path, the art of listening and communicating with patients needs to be acquired with the supervision and support of trainers and mentors. Effective communication starts in the outpatient clinic. It is important to involve the patient in the decision making process, which means providing a balanced and honest view of the treatment possibilities for the specific condition, with associated benefits and shortcomings. Scientific societies are now including patients and representative in guidelines development and trials planning, meaning that in a near future it would be easier to discuss with the patients the outcomes that they would value more.
A good doctor is the one who listens to the patients. We live in the era of Social Media, which offer a precious opportunity to meet people with similar interests, and to expand our cultural and social boundaries. Social Media have been used effectively by colorectal surgeons, to conduct research and to access scientific data more efficiently – e.g. by means of direct interaction with peers who authored the researches they are interested in. For patients, Social Media represent a mean to connect with those who underwent the same operation, or to know more about their condition by other patients. More importantly, Social Media have now become a platform to facilitate interactions between doctors, surgeons, researchers, and patients. However, the patient-doctor interaction ahead of surgery cannot be replaced by any other means than a quiet discussion in an adequately prepared environment. Being asked about the most important innovation of the recent years, Gregorio Marañón – a Spanish doctor, philosopher and writer – replied, after a short pause of reflection: “The chair”. He meant, the chair allows the doctor to sit next to the patient, to explore and to listen to him/her. Along with a perfect knowledge of the disease treated, adequate training in communication skills and continued interaction with the patients will contribute to create a solid basis for the colorectal trainees to deal with patient anxieties. The art of communication will then be perfectioned with experience, by conversating with the patients in the outpatient clinic, by attending the wards after surgery, and by following up patients afterwards, with a true interest in understanding their perspective and feelings.
Senior perspective: Janindra Warusavitarne
Seeing a clinician let alone seeing a surgeon is a very stressful experience for a patient. Understanding the issues that drive anxiety will form the basis for effective communication and reducing the stress of surgery. Many of these anxieties can be driven by the disease and its consequences and this can be accounted for in any conversation with a patient. What can be more difficult is when we as clinicians have to overcome anxieties that are driven by friends and relatives, the media, social media and the ubiquitous Dr. Google. The following points may provide a framework for a successful consultation.
Understanding the issues
One of the main ways in trying to diffuse any anxiety in a consultation is ensuring that the patient feels that they can trust you with their thoughts and feelings. While this may sound corny what one has to take into account is that each patient has different expectations of how a consultation should proceed. On this basis, the questions they ask can be related to issues that may not seem as important to the clinician. There are several potential themes that a clinician can predict based on the presenting diagnosis or complaint. For example, a patient with a diagnosis of cancer is more likely to worry about the fear of dying from the cancer while those with inflammatory bowel disease may be concerned about the possibility of having a stoma after surgery.
Listening to the patient
One of the main criticisms that clinicians receive is that they did not listen in a consultation. In this day and age where we have limited time between consultations and very full waiting rooms there is a huge risk of dismissing some of the concerns of a patient in order to keep to time. This can result in some difficulty for the patient in understanding the surgery or the condition. If it is not possible to discuss all aspects of a patients care then it may be prudent to set another time and also involve the many nursing and allied health professionals to also counsel the patient. This has a significant ability to add value to any consultation, as the patient will always feel that they have been listened to and that they have had the ability to discuss their innermost feelings. Another handy hint is to allow the patient to talk uninterrupted for a few minutes at the beginning of a consultation followed by building on the consultation based on what the patient says. This also helps to further establish understanding anxieties that are unique to a particular patient. A tailored and empathic approach is far more successful than a clinical approach to the problem.
Dealing with physical examination
Physical examination particularly in colorectal surgery can be quite intimidating to a patient. Understanding what is about to happen can often put a patient some ease. While it is important to also have a chaperone present at these sensitive examinations it is also important for the patient to understand the nature of the examination and when the process will occur. This gives the patient the ability to relax as far as possible. In particular where anal examination is concerned, explaining the examination, why it is important and how it will occur can often ease any anxiety. Allowing the patient the option to say no or stop even mid examination is vital to ensure that they are in control.
Dealing with external influences and research
The ubiquitous Dr. Google and social media such as Twitter and other support groups can play a big part in how patients gain information before a consultation. In addition, discussions with those who have similar diagnoses to them can significantly influence the direction of a conversation. The challenge to the clinician is to give confidence to the patient while addressing the information or misinformation as it may be. A calm rational and systematic approach to the situation with clear reasons for agreeing and disagreeing with a patients ‘research’ can be useful. Instant dismissal can result in a negative view of the consultation and may deter from instilling confidence. It is also important to realise that sometimes the patient may come up with an approach that the clinician may not have thought of.
It is important to understand that each individual is different and have anxieties, preconceptions and expectations that are unique. It is the clinician’s responsibility to understand these and address them in a manner that puts the patient at ease. For a patient understanding the road map and the potential twists and turns can allow for a smoother journey even if they are presented with a fork in the road.