Communication: The Critical Accompaniment to Clinical Skills

Jorgen McLeman/123RF.com

You have been trained to examine patients, obtain medical histories, order and perform diagnostic tests, interpret tests, and treat illnesses. You also counsel patients on how to take preventive measures and live healthy lifestyles. These clinical skills help you to “do no harm.” In fact, about a decade ago, the National Board of Medical Examiners (NBME) added a step 2 Clinical Skills (CS) component that students must pass before applying for a medical license. The step 2 CS testing takes place in a testing center, where students assess 12 standardized patients, with 15 minutes for each patient encounter. They are also given some time to record their findings (about 10 minutes). While testing can be done during one's fourth year in medical school, international medical graduates are required to complete this step, regardless of how long they have been practicing medicine outside of the United States. Basically, medical students and graduates are tested on their ability to gather information from patients, perform physical examinations, and communicate their findings to patients and colleagues. This underscores the importance of communication in patient care.

So what is communication? Simply put, communication is a combination of many things. It involves listening to others, as when the patient tells you the reason for their visit and what is bothering them. It involves understanding your patients, what they are telling you, and what they are not telling you. It means understanding the non-verbal message - their feelings, their emotions, and their body language. Then, there is verbal communication, as in spoken words, while giving directions or counsel about one's diet and lifestyle. Make sure they understand your message. This is especially important for foreign doctors who are not English-natives. Even some English speaking foreign doctors are not easily understood, because of the their accents  and/or the tendency to speak too fast. Among the thousands of international medical graduates who apply for ECFMG certification and medical license, there are brilliant clinicians who struggle with the Spoken English Proficiency sub-component of the step 2 CS.

That part of the testing is based upon the frequency of pronunciation or word choice errors that affect comprehension and the amount of listener effort required to understand the examinee's questions and responses. How do you impact the amount of listener effort required to understand you? Often times when a person with a non-American accent is speaking to us, we tend to focus on the accent instead of the message. When asked how an appointment went, one of the first responses I usually get is, “She is from country so-and-so,” and then they will go on answering the question. When you enter the patient's room, after the usual greeting, start by assuring your patient that you have time for him/her, and that she is free to ask questions if she wants something clarified. This will also put the patient at ease, knowing that you will not take it personally. Regardless of how thick your accent is, if you ask short questions and speak slowly, they are more likely to understand you. Practicing these scenarios and speaking English at every occasion (yes, even at home) will boost your confidence.

Listen. A vital aspect of communication is listening. In fact, you must be listening most of the time (more than 70% of the time) for communication to be effective. If there is something important that you really want the patient to understand, ask him or her to repeat it back to you. Communication is a two-way process. Likely, you may not understand all of what the patient is saying. Not all Americans speak proper English. If you are a foreign doctor who has successfully completed the certification process, you are likely to serve in under-privileged areas (a separate blog will explain some reasons for this). In such areas, you will have a share of patients who are not well educated, and some may be immigrants. When in doubt, always restate what the patient said.

Write it down. I have lived and observed the cultures of different countries. One thing I can say with certainty is that America is a litigious society. Medical malpractice is a booming business in the US, and for good reason. Medical negligence is the third leading cause of death in the US, right in the same category as heart disease and cancer (diseases you are trying to treat). The first line of defense is not deviating from the standard of care. Stay current with the industry. Another protection is writing things down. As stated earlier, students and graduates taking the standardized testing are given 10 minutes to record their findings. This is good clinical practice.

In summary, regardless of how busy you are, take time to actively listen to your patients. Be alert for non-verbal messages in your patients’ body language. Make sure they understand you. Take good records.