The Communication and Cultural Competence program is based on case studies that give examples of everyday medical practice in Canada. These modules do not focus on diagnosis and treatment. Instead, they focus on communication between health professionals and patients. Please note that the modules are not intended to show the only way to deal with a situation. Instead, they are intended to provide guidance on how to approach and reflect on these different scenarios.
Medical communication skills
Context in medical communication
Selection of a communication technique and our expectations of a conversation depend on our cultural background. There are two major cultural systems at work in medical communication: the medical culture in which we trained and/or practice and the non-medical society in which we were raised and/or now live. The requirements of a Canadian physician with regard to medical communication differ from those needed in other parts of life, such as socializing with friends, shopping, etc. Physicians must consider and process a large amount of information while selecting and interpreting input from patients and colleagues through active listening and observation. This information must then be integrated and summarized in the physician’s mind and in oral and written formats.
Understanding physician-patient communication
The part of medical communication that many physicians, especially international medical graduates (IMGs), tend to find most different from their previous experience is usually the physician-patient encounter. All physicians have learned certain professional behaviours regarding the physician-patient relationship. These behaviours are culturally and historically determined, depending upon where and how the physician was trained.
A brief history of physician-patient communication
Changes in the approach to physician-patient communication in North American medicine over the past 100 years are presented below.
Physician-centred approach pre-World War II
The following is a short listing of some major trends. There have been and continue to be physicians who practice a variety of models of communication.
Pre-World War II
- Physicians were highly regarded, paternalistic and patients trusted them to behave in their best interests
- Physicians were disease oriented (physician-centred)
- There were few effective treatments to offer patients
- Most physicians were generalists and knew their patients well
Physician-centred approach post-World War II (~ 1950-1975)
Physicians became even more overtly disease oriented as:
- More effective therapy became available (e.g., antibiotics)
- There was an explosion of diagnostic and therapeutic technology
- Specialization and research increased, which tended to distance the physician from their patient
The physician-patient relationship was still strongly paternalistic, not because the physician knew the patient well enough to know what was best, but because the physician now had a much larger store of effective knowledge and treatments, resulting in:
- An even greater separation of the physician and patient, in terms of communication
- Increasing dissatisfaction with visits to physicians
- Patients felt they were neither heard nor understood
- Increasing distrust of physicians, who were thought to be more interested in money, and fame in the case of researchers and specialists
- In some societies, a contractual, consumer model of the physician-patient relationship emerged. Physicians would show their wares and patients, with access to more knowledge, could shop around
Medical training reflected the advances in biomedical knowledge, focusing on disease and the increasingly complex technology of medical practice. The dissatisfaction of patients was largely ignored as being irrelevant to patient care. Most physicians who are now practicing were trained in this biomedical focused, physician-centred system. History-taking was the type of patient communication that was taught. In other words, physicians were taught to have a dialogue that was focused on asking questions to find out what kind of disease or abnormality was sitting in the office.
By the mid-1980s, the call for change in physicians’ behaviours was insistent, driven in part by the right’s movement, the consumer movement and the appearance of the field of bioethics, which emphasized patient autonomy as a goal of care. In the last 15-20 years, many medical schools recognized the need to revise their curriculum to include communication skills. They began to look to those whose approach to the physician-patient relationship recognized the importance of the patient’s role in the dialogue. Among them were:
- Balint, who started discussion groups to talk about “difficult” patients
- Engel, whose biopsychosocial model was one of the first models of holistic medicine
- Cassell, who described the difference between disease and illness and language as a critical tool of medicine
- Kleinman, who expanded patient-centred attitudes to all cultures
- Stewart, Levenstein and McWhinney, developers of the Patient-Centred Clinical Method
Full references to these authors can be found in the Bibliography.
The patient-centred model of physician-patient communication
What does the physician do to elicit the patient’s illness experience?