Chapter 13. Art of communication and counselling

Dr. Yeshwanth K. Amdekar, DCH, MD (Pediatrics), FIAP

He that won’t be counselled can’t be helped

                                                            Benjamin Franklin

He was a patient with a diagnosis that he could not understand

                                                            Maggie Stiefwater

Introduction

Communication and counselling are essential skills that every doctor must learn. It is a key to success as it instils confidence in the mind of a patient and improves compliance andthereby also recovery. Communication and counselling arenot the same. Communication refers to meaningful information while counselling goes much beyond it.Good communication skills are a prerequisite for effective counselling. Counselling is not mere information but should provide professional help, assistance and guidance to resolve problems and difficulties that would make it easy for patients to face the situation.

Basics revisited

Communication and counselling should be accurate, brief and clear, preferably documented, relevant to individual situation and needs, must avoid complexity by using simple language that lay person can understand, ideally by giving simple examples of day-to-day experiences. Courteous behavior and empathy are most essential components of counselling. It is important to read the mind of a patient and his relatives and address their concerns. Every patient would like to know about the disease – what is it, why did it happen, which tests are necessary, how would it be confirmed, how would it be treated, options available for treatment, safety of drugs and their side-effects, expected outcome, suffering and disability, time frame and cost of treatment. Communication offers relevant information and counselling takes care of hidden factors such as anxiety, worry, uncertainty,frustration, self-pity, self-blame etc by empathetic approach, giving support and confidence. Patient must feel that his doctor is with him to guide and help to face the situation.

 

\Varied situations requiring counselling

Every patient must be counselled relevant to his needs. However, physician is faced with many situations in practice that requires counselling at different levels. Rational practice during routine outpatient service, chronic diseases requiring good compliance, chronic functional disorders, disabilities with permanent handicaps, worsening conditions are some of the situations that need relevant counselling. But, most challenging situation for counselling is uncontrolled outbursts of anger and agitation by the relatives of patients that may lead to violence.

Counselling in office practice to ensure rationality

It is often not possible to arrive at a provisional diagnosis on first visit. Rationality demands that patient is advised to “wait and watch” without specific therapy till diagnosis evolves. It is necessary to ensure and convey safety of “wait and watch”by giving proper instructions to monitor danger symptoms and if observed, report immediately. We may have to explain dangers of empirical therapy and futility of ordering investigations at random. It is most important to document short summary of the problem along with advice given that ensures legal safety. Most appropriate action taken by a physician but if not documented, is not accepted as evidence in the court of justice.

Counselling for chronic conditions to ensure compliance

Many chronic diseases remain incurable but can be controlled to an extent to maintain reasonable quality of life. However, it is possible only with patient’s compliance to follow advice given by the doctor and for which adequate counselling is required. Most patients default on advice once symptoms disappear, wrongly considering it as control of disease and fearing side effects of drugs. Besides, there are often “well-wishers” who advice to stop medications on feeling better. We need to emphasise on safety of long-term use of drugs and also dangers of non-compliance that may end up with worsening condition necessitatinga greater number of drugs for longer duration. We must discuss periodic monitoring strategies and of course document the same.

 

Counselling for chronic functional disorders

Functional disorders are on the rise even in children. It is important to realize that symptoms of such disorders are genuine even in absence of organic disease and are triggered by multiple factors such as home / school environment, stress and individual personality. The disorder presents with varied symptoms mediated through the mind. Abdominal pain is a common presentation of such a disorder as a result of gut-brain functional axis. We need special skills to convince the patient / parents of a child about the nature of the disease, lack of laboratory proof, diagnosis based on circumstantial evidence and management depending not much on drugs but participation from entire family and not the patient alone. Counselling should start with a discussion about organic disorders responsible for the symptoms and rule them out one by one before suggesting the role of mind over the body.  We often meet denial to accept such a diagnosis from patients and parents and hence counselling in such situations becomes a challenge. We should be careful not to suggest malingering that is different than functional disorder. Patience and empathy are the key factors in counselling of such disorders and multiple counselling sessions may be necessary as improvement may be slow.

Counselling in case of permanent handicap

Many chronic disorders end up with some permanent disability. Patient or parents often feel guilty, blame others or curse destiny. We need to remove such feelings and induce positive thinking to focus on retained functions with best of the efforts. Proper explanation of real situation is necessary but without undue hopes or despair. It is important to emphasise that every handicap can be overcome by compensatory mechanisms. For example, if a right-handed person loses his right hand, he can learn to work effectively. with left hand and if one loses both the hands, there are persons who could learn to use toes as fingers. Such things are possible only with determination and best efforts by the handicapped individual under the guidance of an expert. We must encourage and support rehabilitative measures and not forget that for such individuals, we are the last hopes. We need to be empathetic to do our best.

Counselling when faced with a dying patient

This is the most difficult part of counselling. We need to prepare the relatives for the inevitable but the process should be slow and smooth not to give them a sudden shock. They do sense the grave situation but still harbor a hope. We must inform them real situation of poor response to treatment but add that one has seen improvement even at such a worsening stage and assure them that everything possible is being done. It is ideal to allow within limits two or three close relatives in rotation to witness efforts being put in. We must communicate with relatives every half an hour and answer all questions that may be asked repeatedly. During counselling sessions, we must be careful to phrase statements in a way that they are not misinterpreted and it is best that only one person counsels them. Patience and empathy are the key factors for successful handling of such a crisis. It is best done by senior-most doctor in charge of the patient and not left to juniors.

Counselling when faced with angry and agitating relatives

This is a tricky situation that calls for remaining calm avoiding arguments and allowing the relatives to vent out their feelings without interruption. Patient hearing of their complaints is likely to reduce the tension a bit. We must not vehemently refute their allegations but must be tactful. We must say that we do understand their concern but explain them the correct view of the situation. We should not try to appear defensive but demonstrate confidence in handling the situation without instigating them. Don’t forget, such a situation often results from lack of communication and counselling and should be mostly avoidable.

Personal notes

I learnt the counselling skills during my training by observing how my teachers talked to patients and their relatives. I realise that it is possible to explain most complex disease in simple lay language. I give examples of real-lifesituations which are similar to their own medical problem. I was counselling the parent of a child with neurodegenerative disorder. I told them that as one gets older, many functions such as hearing, memory, body balance, speech etc. start getting impaired, this is called degeneration. It occurs in adults anytime from 60 years onwards but may also start occasionally bit early. However unfortunately, such degeneration started in their young child at an early age. But as degenerative impairment cannot be corrected with medicines, one has to adapt to such situations with relevant help from gadgets and supports. Explaining with such similarities, lay persons understand even the most complicated medical problem such as neurodegeneration. It is the art that each doctor must develop. I recall mother of an infant who was instilling oral anti-cold medicine into nostrils. When she found it difficult, she phoned her doctor, who advised her to instill the same with dilution with water, to which she reported it was impossible. At that time, doctor realized that she was instilling oral medicine into nostrils. When reprimanded, doctor was blamed for unclear instructions as he had not mentioned it was for oral use. Even simple facts should not be taken for granted and clear instructions must be documented. Patients often make mistakes about formulation in drops and syrups as concentration is so different and may be harmful if one is mistaken for the other. I have known rectal suppository for constipation being swallowed orally. Other issue is poor handwriting of most of us. I know about a pharmacist giving Ascabiol (anti-scabies medicine for local application) instead of Ascoril (oral cough remedy). It may be ideal to write name of drugs in capitals or better is a digital print-out.

Take home message

Counselling is an art that is not taught in medical school but must be learnt by observing a role model and improved by experience. Communication and counselling are as important in practice as knowledge and competence. It is equally

Important to document every action that serves as evidence. Problems arise when we don’t follow these norms.

 

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