A common misconception is equating communications technology with communications. It is certainly easier to reach out and send information to people than ever before, but is this the same as communication? If this were just semantics, it would not be worth considering, but it is one of the main challenges facing medical practice today.
Kjell Benson recently posted an article arguing for measures designed to improve medical quality while avoiding the negative aspects of “the quality paradox.” His first step is to choose strong clinician leaders. “Only practicing providers understand the difficult balancing act of the patient relationship, with its ethical duties, inherent subjectivity, and inevitable stresses.” His second step was to “define an ongoing consensus in your group regarding why you are providing medical care.” He notes this is not the same as a mission statement, rather “a team that understands that they are in it for the patients first will be a team that coalesces around the need for quality.” These first two steps clearly require effective communication.
Nurok and associates have also focused on communications as the key to taking care of patients with complex medical problems. They noted “the traditional focus on who captains the ship is misguided. In many complex clinical scenarios, there is often no single right way to do things. Having many different physicians bring their attention to a difficult problem can minimize the chance that something will be missed.” Of course, realizing true team-based care requires intensive communications. “The trick is to understand that intensive communication is needed, not because anyone’s skills or judgment is in question, but because a fellow specialist is equally invested in the patient and does not want to be surprised.”
They note communicating effectively requires both time and effort.
“Good communication requires both push and pull: stating one’s opinion, and at the same time, being open to others’ views. Skilled clinicians create conditions that make their colleagues feel valued and good about themselves—the fertile soil of collaboration. This work starts with the humility to accept, on occasion, someone else’s care plan that is different from one’s own. Contrast this approach with the physician who becomes surly and more insistent when his perspective is challenged, which in turn hardens others’ willingness to accept an alternative point of view…
Cultivating communication skills takes investment, repetition, and mentorship. Indeed, it is the third, and equally important, element of a clinical triad that includes technical skills and judgment. While many young physicians see their careers as a journey to becoming captain of the ship, we believe clinicians and leaders need to focus instead on working together to become the ship’s ballast: that which keeps the vessel upright in troubled waters.”
As the volume of business and the documentation requirements have increased, I have noted that in our practices we rely more often on a “message,” either a secure text message or a note in the chart, rather than on face to face discussion. After all, the message is quick, and the conversation will take longer, and there will be some push and pull. On the other hand, I find effective communication with colleagues can help me get on the same page, or the same care plan, much more quickly. My input is then able to stay focused on helping achieve the goals outlined in that brief conversation.
As I was thinking about the decline in true dialogue, I read an op-ed piece by David Brooks in The New York Times. He was musing about being “moderate” in his political stance. As he noted: “Like most of you, I dislike the word moderate. It is too milquetoast. But I’ve been inspired by Aurelian Craiutu’s great book ‘Faces of Moderation’ to stick with this word, at least until a better one comes along.” He argues that moderates tend to embrace certain ideas including, among others, “the truth is plural,” “creativity is syncretistic,” and “humility is the fundamental virtue.”
“Humility is a radical self-awareness from a position outside yourself — a form of radical honesty. The more the moderate grapples with reality the more she understands how much is beyond our understanding. Moderation requires courage. Moderates don’t operate from the safety of their ideologically pure galleons. They are unafraid to face the cross currents, detached from clan, acknowledging how little they know.”
Brooks was commenting on our current political scene, which certainly does not evidence much moderation, but it seems to me that moderation is what is required for effective communication among those providing care for patients. All of us may have a piece of the truth, but it is unlikely any of us have a complete grasp of a whole truth. Maybe we need to find a way to restructure our care so that real dialogue happens as often as needed to optimize the care of our patients. Without a billing code for this, or replacement of fee for service payment, I am skeptical of dramatic changes in current practice—and that is too bad.
28 August 2017
 Benson K. 5 Steps to Create Medical Quality Without Trying. 25 July 2017. Accessed 27 July 2017 at http://www.kevinmd.com/blog/2017/07/5-steps-create-medical-quality-without-trying..
 Nurok M, Sadovnikoff N, Gewertz B. Leadership for Complex Care: The Ship’s Ballast in Troubled Waters. 20 July 2017. Accessed 27 July 2017 at http://catalyst.nejm.org/leadership-complex-care-ships-ballast/?utm_cam.
 Brooks D. What Moderates Believe. 22 August 2017. https://nyti.ms/2vkh1J0. Accessed 22 August 2017.
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