“Technical progress is useless without better communication.”
Interview: Urs Hafner
Sabina Hunziker teaches prospective physicians how to communicate with their patients effectively. As the professor of medicine explains, if someone talks a lot, the most important thing often goes unsaid.
UNI NOVA: Professor Hunziker, imagine that a patient is sitting in front of you and endlessly pouring out their sorrows. Do you ﬁnd it irritating when patients ramble on in this way?
SABINA HUNZIKER: My students ask me the same thing … It’s important for patients to be able to express their problems to us in their own words. This has the advantage that we learn a lot about them and they get things off their chest. It allows us to form an initial impression of what’s causing their troubles. The disadvantage is that patients sometimes talk about things we don’t need to know for our diagnosis, thereby wasting a great deal of precious time.
UNI NOVA: In other words, you have to interrupt them?
HUNZIKER: Yes, we structure the conversation. As well as waiting to hear what they have to say, we probe speciﬁc points and also provide concrete information. Ideally, the physician begins the conversation by focusing on the patient – in other words, by actively listening to them. They should allow the patient to talk and pause for thought, as well as reassuring them that they have their full attention by giving short verbal responses such as “I see,” “right,” “good,” and so on. It’s also important for the physician to lead the conversation, especially once it’s clear where the problem lies. At this point, the expert takes over and homes in on the problem. Depending on the situation, we alternate between these two types of conversation – patient-centered and physician-centered.
UNI NOVA: Isn’t listening just part of normal, non-pathological communication? If you’re talking and I sit in rigid silence, it’ll put you off and eventually reduce you to silence as well.
HUNZIKER: Of course, but that’s something you have to realize for yourself, especially if you’re studying medicine. For example, we practice situations such as this using video footage of simulated patients. The patient who talks a lot and is going around in circles may have concerns they are unaware of or unable to articulate. Something is on their mind – but what? The physician needs to get to the bottom of what the patient is saying, as it might just be the tip of the iceberg.
UNI NOVA: When exactly do you interrupt the patient?
HUNZIKER: When I have the impression that I need to know more about the medical history in order to make a diagnosis, I ask targeted questions to test the hypothesis I’ve formed based on the data available to me and while listening to the patient – how long have they been aware of the pain, does it radiate outward, what symptoms accompany it, and so on. I’m looking for answers that are as precise as possible, because these are just as important as listening to the patient completely openly. At ﬁrst, many students think that listening is all that matters, but really a conversation is between two partners, who should take turns to speak.
UNI NOVA: Physicians often seem rushed and don’t listen to patients properly during consultations in the office or at the bedside.
HUNZIKER: Studies show that, on average, a physician waits just 90 seconds before interrupting their patient for the ﬁrst time. This means we miss out on valuable information that could help us form a hypothesis as to the causes and rationale behind their complaints. But this isn’t simply a question of impatience on our part. Mounting ﬁnancial pressure and time constraints leave us with less time to talk to the patient. For example, we know that medical residents spend most of their working hours on admin and reports. On the other hand, it’s also true that if a patient talks a lot, the most important thing often goes unsaid, and that you can have a useful conversation in a short time. Our students learn how best to structure a conversational situation – that is, how to communicate professionally. Appropriate techniques exist for doing this. You just have to know how and when to use them.
UNI NOVA: You are a professor and Deputy Head of Psychosomatic Medicine and Communication. How does a surgeon respond when you tell them what you do – do they take it seriously? Do they even listen to you?
HUNZIKER: Naturally, I sometimes encounter a degree of skepticism, but I’ve witnessed a growing acceptance of the signiﬁcance of communication in medicine over the last few years. In the 1970s, the topic was still seen as something exotic. Today, the medical profession is more receptive to and interested in the idea of structuring conversations professionally, and there’s growing awareness that a good physician should not only have sound medical knowledge but also good communication skills. Our patients have come to expect this. That’s why I don’t like to see communication described as a “soft skill.”
UNI NOVA: Skills have to be strengthened based on empirical evidence.
HUNZIKER: We’re striving for what is known as evidence-based communication. In other words, our research is based on randomized studies. We demonstrate causalities: If the physician uses technique X, this results in Y for the patient. For example, research is currently underway into whether it’s better for patients if we ﬁrst discuss the case outside the room and then give a patient-friendly version inside – or if the medical rounds are conducted entirely at patients’ bedsides. The rationale for this is that we devote a lot of time to the patient that they aren’t actually aware of. On the other hand, they might ﬁnd the academic discussion intimidating or unnerving, or they might notice mistakes on the part of the medical resident and wrongly conclude that they’re incompetent. This is a key question that still needs to be answered.
UNI NOVA: Which option do you prefer?
HUNZIKER: Our patients are confronted with a huge amount of new and unfamiliar information. This may be exacerbated by academic discussions at the bedside if they don’t understand all of the terminology, leading to potential misunderstandings. That’s why I prefer to have a discussion outside the room and then give a patient-friendly version. I’ll know more once we’ve ﬁnished the study.
UNI NOVA: We often hear that physicians don’t explain ﬁndings to patients in a way they can understand – that the wording is too dense and littered with technical jargon.
HUNZIKER: When it comes to professional communication, explaining our knowledge to patients calmly and clearly is just as important as being able to deal with strong emotional responses, such as anger, disappointment, and sadness. Studies show that many physicians rely on providing information as a way to distract attention away from emotions – including their own – or to prevent them from rising to the surface. We’re trained to communicate using facts. But if the patient cannot express themselves and the physician overloads them with information, communication breaks down. The problem – the disease or illness – is not addressed. Research has shown that it’s virtually impossible to make amends for serious communication errors over the course of the physician–patient relationship, and that these errors have a major impact on patients’ health and well-being.
UNI NOVA: If the patient breaks down in tears after receiving a cancer diagnosis, for example, do you use physical contact to comfort them?
HUNZIKER: There’s no hard and fast rule in this situation. Some physicians place their hand on the patient’s arm, but others ﬁnd that too intimate. The key thing is that the response should be authentic. When delivering bad news, physicians are addressing serious and often life-changing issues. As well as providing the medical information, it’s vital that they have a capacity for empathy. Being diagnosed with an incurable cancer, for example, has an enormous impact on the patient’s quality of life. Their outlook on life and future prospects change from one moment to the next, and so what we communicate – and how we communicate it – is particularly important. In a recent study, we found that the family’s communication with the treatment team was a key factor in determining how often the patients who had suffered a cardiac arrest and required resuscitation developed post-traumatic stress disorder, depression or anxiety disorders.
UNI NOVA: What do you teach your students to do in cases such as this?
HUNZIKER: You have to prepare for the conversation thoroughly so that you’re aware of all the ﬁndings and have an idea of how much the relatives and patients know. You should communicate the information brieﬂy and clearly, and it’s essential that you address any emotions and give patients space to deal with them.
UNI NOVA: Studying medicine involves a lot of cramming – if you don’t learn enough of the material off by heart, you won’t even be accepted onto a degree course. But there’s no test of patience or social skills. Does the selection process miss the mark?
HUNZIKER: It’s not easy to identify good candidates. In Switzerland, the numerus clausus tests above all intellectual abilities as part of the admission criteria but ignores social and communication skills, unlike in the USA. I can see communication skills being tested as well in the future. On the other hand, a medical degree – and indeed the medical profession – is very challenging from an intellectual perspective. It takes considerable hard work and ambition to pass. Later, as physicians, the students will need to cope with stress factors – and so it’s important that they learn to do so from an early stage. At the University of Basel, we have a course of studies that teaches communication and social skills for the duration of the degree and is therefore unique throughout Switzerland.
UNI NOVA: The “End of Life” National Research Programme discovered that communication between physicians from different departments in hospitals is often ineffective – for example, when it comes to deciding where dying patients should be cared for.
HUNZIKER: That’s another key point: Professional communication in medicine also means communication between physicians. Studies of emergency responses show that correct conduct by physicians signiﬁcantly improves the performance of their teams. Good leadership communication allows the response to proceed with fewer interruptions and the resuscitation of the patient to begin sooner, for example.
UNI NOVA: Modern medicine is heavily inﬂuenced by technology – by computer-controlled instruments and large volumes of data relating to diseases or patients. During consultations, some physicians therefore spend more time looking at their screen than at the patient’s face. Is technology the enemy of communication?
HUNZIKER: No, on the contrary. The technical advances that help us treat many diseases also require us to become better communicators, otherwise it’s useless. Technology creates greater communication challenges for physicians than ever before – and we’re working on rising to those challenges.
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