Communication And Counselling Notes

Communication And Counselling

Changing Scenario And The Need For Counselling

• Health care has been witnessing phenomenal changes in recent years. In the past, the doctors planned and administered the treatment, the outcome of which was willingly accepted by the patients; a paternalistic attitude was prevalent among the doctors. In choosing the doctors and the hospitals, the patients had very few options. Illiteracy was rampant and patients were generally ignorant about the diseases.
• This scenario has been progressively changing in the last few decades. People have become more educated; the media has played its role in mass health education; the common man has some general knowledge about common diseases. Doctors, corporate hospitals and nursing homes have proliferated and patients have the option of selecting the doctors and hospitals of their choice.

Read And Learn More: Basic Principles Of Surgery Notes

• Doctors have retracted from the paternalistic roles; patients have to participate in the decision-making process. The phenomenal growth of medical science, astounding technological advances, increasing health care costs, improving awareness, rising expectations of the patients, and most importantly the Consumer Protection Act have brought into sharp focus the importance of communication and counselling in the medical practice.
• Counselling means exchange of ideas to reach a conclusion (Webster). There is hardly any place for counselling while eliciting patients’ history; formal consent is required for physical examination, especially the internal examination, viz. digital rectal examination and per vaginal examination. It is at the end of physical examination that counselling skills become increasingly important in explaining the diagnostic dilemma, accuracy of lab reports, treatment options, outcome, complications and costs.

Explain Medical Details Of The Disease

Diagnostic Dilemma:

The patients often expect that every disease should be accurately diagnosed in the first visit; in simple disease it is possible, but not in complicated ones and if this is made known to them, their mind is prepared to accept subsequent changes in the diagnosis.

• When the final diagnosis is less serious than the first, the patients are happy to accept it; but if it is more serious, the patients are unhappy and tend to lose faith in the doctor.
• The intensity of these undesirable effects of change in the diagnosis can be minimized by proper counselling, e.g. benign-looking breast lump turns out to be malignant in the histopathological report.

Accuracy Of Investigation And Their Complications:

• Many patients believe that it is possible to prove the diagnosis by lab tests and that more expensive tests are more accurate; counselling should remove this misconception; lab tests are not 100% sensitive and specific.
• Patients with simple curable diseases do not pose much problem, but those with serious and life-threatening or incurable diseases often demand foolproof lab diagnosis and such proof is not always possible to secure.
• In the absence of such proof and when the lab test reports are conflicting, counselling becomes increasingly difficult, e.g. disagreement between the pathologists about the presence or absence of cancer in the specimen.
• Counselling should also include a brief mention about the anticipated complications of investigations, e.g. allergic reaction to 4 contrast agent.

Diagnostic dilemma Treatment options and their complications:

• That the patient has to participate in the planning and execution of the treatment has become an accepted norm.
• The doctor has to offer treatment options, discuss the merits and demerits of each of them and then decide to administer it.
• Possible complications and their approximate incidence should be discussed, e.g. recurrent laryngeal nerve palsy in thyroid surgery.

Diagnostic dilemma Outcome:

It is a fond desire of many patients that every disease is completely curable. Many diseases, disabilities and deaths are not totally preventable by the most modern medicine.

• Discussion about the outcome of treatment is especially important in surgical patients because operation is an event which has no parallel in non-surgical branches of medicine, and any adverse postoperative outcome is almost always attributed to surgery.
• In search of cure for incurable diseases, the patients keep changing doctors and hospitals spending their resources until they are told and convinced that the cure is unachievable.
• Patients’ ability to cope with the disease and accept the outcome of treatment improves if it is told to them before executing the treatment what is the anticipated outcome—palliation or cure.

Diagnostic dilemma Cost:

It is better to overestimate the cost than to underestimate it and to express it as a range than as a finite unless it is a package.

Address psychosocial, emotional and spiritual issues:

• Anxiety, fear, worry, shyness, embarrassment, religious and cultural issues, and patients’ preferences are addressed on individual basis.
• Patients’ mental make-up and willpower have significant bearing on the management of the patients.

Methods of Counselling

• There is no single best method suitable for all patients on all occasions. Counselling is individualized and personalized.
• Verbal counselling is the most common method. Showing charts and diagrams is an easy and effective way of convincing.
• Giving patient education material for reading or showing videos are other methods. Showing other patients being treated for similar disease is quite helpful.
• The patients’ family physician can be used for counselling because he has a better rapport with the patient than the specialist.
• If there are a number of patients with the same/similar condition/disease (e.g. maternity hospitals or cancer hospitals), group counselling is useful.
• Complex situations (e.g. living donor liver transplantations) need the services of counselling experts. Speaking the patients’ language and having good vocabulary and communication skills makes the job easier.

Factors Influencing Counselling

• There are many factors influencing the counselling. Patients’ background, literacy, level of understanding and trust in the doctor are the most important factors. Suspicious and indecisive mind of the patient is an obstacle.
• Patients’ perceptions of doctor’s honesty, trustworthiness, dependability and intentions have their own measure of impact on counselling.
• Nature of illness, whether simple to diagnose and treat with assured successful outcome, or a complex disease, difficult to diagnose and treat with a guarded prognosis, or a fatal, incurable disease have an important bearing on counselling.

Patients’ Rights

• Patients’ rights are supreme and should be respected; right to refuse the plan of treatment, right to information, to have second opinion, and to change the doctor and the hospital in the middle of treatment.
• The doctor need not feel embarrassed. The Consumer Protection Act has given another right—right to file a suit in the consumer forum.
• Many consumer cases against doctors are avoidable, if every patient is counselled properly and more importantly the counselling notes are documented and authenticated by the doctor, patient/patient’s relative and a witness.
• Some hospitals have adopted video recording of the counselling as a foolproof method of documenting.

Counselling and the percentage:

In medicine, nothing is 100%. This should be used liberally while counselling, e.g. 10% conversion rate in laparoscopic cholecystectomy; 50–60% 5-year survival in cancer patient; 90–95% cure rate in hernia repair; 5–10% recurrence rate after fistulectomy; 50–60% chance of saving a diabetic foot.

Truth and counselling:

• In a hurry/enthusiasm to convince the patient, one is often tempted to overstep and overstate the positives and understate the negatives.
• It is always better to tell the truth because truth is constant, consistent and durable, and hence truth need not be remembered.

Patients’ Rights Do’s and don’ts:

Do repeat, reinforce counselling at the appropriate time. Don’t argue, confront, quarrel, give false assurances, guarantee 100% results, make adverse remarks about other doctors, give opinions or sensitive information on phone.

Quality of Counselling and Its Effects:

• Patients are in a state of physical, psychological, financial and emotional distress. Counselling should more or less address all these issues; it should be cautious, careful, convincing, reassuring and consoling.
• It strengthens the faith and improves reputation of the doctors and hospitals; establishes rapport, builds relationship, reduces complaints, consumer cases, assaults and vandalism.
• Substandard counselling is done carelessly, is indifferent, confusing and intimidating; it results in loss of faith and reputation of the doctors and hospitals, suspicion in doctor’s intentions, arguments and quarrels, assaults, ransacking, complaints and consumer cases.

Patients’ Rights Counselling triangle:

While counselling, the doctor should be acutely aware of the presence of others and place himself in three different places—his own place, in the patient’s place and the place of the relatives and look and listen to himself.

Patients’ Rights Consent:

• Consent form is an important documentary evidence in the consumer forum. Printed consent form which is usually signed by the patient/relative at the time of admission, giving blanket consent for all tests and treatment is a weak evidence.
• Consent taken after counselling notes are documented is strong evidence and can save the doctors from many consumer cases.

Communication and counselling skills are put to acid test by worst situation such as when the treatment results in a severe adverse outcome due to most unanticipated rare complication, e.g. death due to drug reaction. Successful counselling will convince, console and calm the agitated and aggrieved relatives who understand the human limitations of the doctors and the uncertainties of medical science.

• Conversely, unsuccessful counselling can result in an extremely unhappy patient even if the treatment of a complicated disease was successful and the team of doctors were extremely happy about the outcome. Counselling is an art more than science.
• As much, share of success of a doctor in the practice of medicine goes to communication and counselling skills as his medical knowledge and technical skills.

Competency:

• Describe the steps of obtaining informed consent for laparoscopic hernioplasty in a simulated environment. For medical simulation, a healthy person is trained and asked to act as a patient. He is trained to mention a few symptoms and signs.
• In a similar manner, he will be told about a surgical procedure and its complications, etc. Simulation helps in educating trainees/undergraduates so that their communication skills/performance will improve when they see the real patient.
• I have given one example of informed consent for a patient undergoing laparoscopic hernioplasty. Every surgery should have separate consent form. Remember that the relevant procedure has to be explained in patient’s own language or in a language that the patient understands.
• The patient should not only sign the consent form but also consent for HIV testing, blood transfusion and anaesthesia.

The Steps Of Obtaining Informed Consent Are As Follows:

1. The consultant surgeon will explain the disease, why surgery is needed what type of surgery is planned (open or laparoscopic) and its complications.
2. He/she will allow the patient to ask any questions and clarify his/her doublts, if any.
3. The patient, once satisfied, will need to sign the consent form for surgery. One witness will also need to sign the consent form.
4. The consent form is then counter-signed by the surgical consultant and indicate his name, date and time.
5. Consultant anaesthetist explains the type of anaesthesia (regional or general anaesthesia) and possible complications related to anaesthesia. The patient will then need to consent for administration of anaesthesia. This form also needs a witness signature and the consultant anaesthetist’s signature, name, date and time.