Unfortunately, human beings are not born with communication skills manuals. Nor do children typically learn the skills in school. Not until adulthood are people taught how to connect well with others—in chapters like this. Instead we fumble along through life and learn to communicate by default—for better or worse, from society, culture, and role models—parents, teachers, professors—who learned from their own role models—and not always to great effect. These chains can be broken, however, and new skills learned.

Medicine Is a Stressful Profession

Effective communication is a major component of any personal, emotional, and physical wellness program, as great stress occurs when relationships don’t go well. The system of medicine itself compounds the problem further.

Therefore, in addition to learning better communication skills, stress management is also critical. Physicians should do their best, even if done in smaller time snippets, to exercise; rest sufficiently; meditate; eat healthily; use support in friends, family, therapists, and clergy persons; go on vacation; and so on, to increase their resilience, keep calm, and foster communication.

Keeping Up With the Changing Culture in Medicine

Traditional culture in medicine promotes the individual physician as the “in-charge” professional of patient care. It also fosters a strong, distinct hierarchy between levels of professionals starting with doctors, followed by nurses, technicians, secretaries, and so on, and finally by patients and families. The culture is now changing to one of more teamwork, with a physician leader, but where all members are seen as equally vital to the team regardless of status, and collaboration is more the guiding concept. Effective July 1, 2013, the ACGME will make public its new Next Accreditation System, with revised Common Program Requirements. In Section VI.F. on Teamwork, a core requirement, it stresses, “Residents must care for patients in an environment that maximizes effective communication. This must include the opportunity to work as a member of effective interprofessional teams that are appropriate to the delivery of care in the specialty” (4). Good communication within medicine is thus now more important than ever.

A Personal Resistance to Change

Changes in the profession require those in the profession to change. But many people lack insight about themselves, and when made aware of their communication shortcomings, become resistant to change and self-reflection. They may also believe they already communicate well and even that the conflicts they get into are due to the poor communication skills of others. This is often seen in medicine, where, for example, a doctor may blame a nurse, physical therapist, or social worker for the difficult conversations he or she has with them. A good rule of thumb to remember: “We take ourselves with us wherever we go.” If one finds oneself having communication problems in several relationships, including personal ones, the conclusion should be: “I must be part of the problem, as I’m the common denominator in all these relationships.”

Ingrained Beliefs That Impede Change

Another typically overlooked block to personal change is deeply ingrained—often subconscious—attitudes and beliefs, in this case about communication, which may need to be altered. If they don’t align with skills being taught, the skills won’t “stick,” as what’s in the subconscious mind will “win out.” The following are a few examples:

Certain factors, some uncontrollable, inhibit communication: too short appointment visits—a tough problem to address—cultural and language differences, unclear accents, and medical jargon. Pragmatic solutions for these issues include:

  Age-appropriate lay language and printed materials should be used with patients.

Other issues during a visit are anxious or upset patients, or those afraid to ask questions, as “the doctor is always right.” In addition, doctors who don’t involve patients and families in their care, who have a poor “bedside manner,” or who lack empathy create more barriers.

The impact from all these problems on patient care is high. Patients unclear about treatment plans can’t follow them. Results are poor resolution of physical symptoms, function, pain control, and physiological measures such as blood pressure, as well as poor emotional health outcomes. Frustration ensues for all. Patients may not return to these physicians and may sully their reputations. And the ultimate injury is lawsuits.

Issues Between Physicians, Colleagues, Nurses, and Other Staff

In Physical and Rehabilitation Medicine, patients’ disabilities affect many parts of their lives, making a well-functioning team critical. Physiatrists, nurses, social workers, dieticians, psychologists, occupational and physical therapists, speech therapists, case managers, and the patient and family are all involved (5).

Often team members won’t speak up, especially in risky, controversial, and emotional conversations. The one thing skilled people do is find a way to get all relevant information from themselves and others out into the open. “At the core of every successful conversation lies the free flow of relevant information. People openly and honestly express their opinions, share their feelings, and articulate their theories. They willingly and capably share their views, even when their ideas are controversial or unpopular” (6).

Team communication can fail on many levels. Many physicians won’t confront and resolve concerns with each other. When peers fail to—or are incompetent to—do their share, for example, resentments build up. Doctors may stay silent and allow resentments to simmer for years, thinking they’re avoiding stress by avoiding these conversations—when in fact they’re magnifying it. In fact, doctors who more quickly and effectively confront performance problems with peers experience improved quality of work life and relationships (7).

Conflicts also exist between professions; these are commonly seen between doctors and nurses. Medical culture also fosters those of higher status to poorly treat those below. Rebelling ensues. A nurse who cowered from a screaming doctor now yells back. Worse, he or she may watch that physician commit a grave patient error and say nothing out of fear or revenge—a passive–aggressive move, clearly not for the good of the patient. In addition, patients who see staff argue may lose confidence in their providers or facility, and leave.

Change can occur. A hospital’s pilot program to build physician–nurse leadership partnerships led to breakthrough improvements in patient safety and quality, and forged better physician–nurse collaboration and job satisfaction, after which they came to appreciate each other’s pressures and challenges (8).

Electronic Communication Erodes Connection

Texts and e-mails are eliminating in-person conversations. Daniel Moore, MD, PMR Chairman at the Brody School of Medicine, says, “Electronic media is king. The tweet, text, email, twitter, and Facebook page are all popular with billions of dollars being consumed. But, face to face communication is still the ultimate way to communicate. Electronic communication is efficient, but often the reader inserts their own context and emotion into the message” (9). Feelings can get hurt. Emotional e-mails or texts should be avoided, and discussion of those issues should occur by phone or in person where tone and body language are clearer. Many people purposely use electronic means to avoid confrontation. Avoid this—it creates more problems than it solves. Also avoid texting and phone use in meetings. It signals no interest in the group, and is disrespectful to the speaker and attendees.

COMPONENTS OF COMMUNICATION: INTRODUCTION

There are various components of communication that will be discussed in the following four sections. Part I includes basic ground rules, attitudes, and beliefs that maximize the effectiveness of communication. Part II covers concepts that are “internal” and not necessarily consciously thought about such as emotions, needs, and empathy, or behaviors that are more “ingrained” or based on personality, such as communication styles and preferences. Part III addresses practical areas in which behaviors are obvious to others and can be changed by the learning of new skills. These are body language, listening, and speaking. Here, examples will be given that apply to communication with colleagues, patients, and families. Part IV offers additional skills to be used specifically with patients.

COMPONENTS OF COMMUNICATION—PART I: GROUND RULES

COMPONENTS OF COMMUNICATION—PART II: EMOTIONS, NEEDS, EMPATHY, COMMUNICATION STYLES, AND COMMUNICATION PREFERENCES

Emotions

Emotions are the life blood of human existence. They let us feel fully alive. On a continuum, they go from expansive and freeing (e.g., joy, love, and bliss) to constricting (e.g., sadness, fear, and anger). Humans can feel a full range of emotions, and doing so greatly enhances their lives.

Emotions are simply expressed with the words “I feel” plus an emotion: “I feel sad,” “I feel angry,” “I feel elated.” This may seem ridiculously obvious, but it’s one of the hardest things to do—to feel and identify a specific emotion felt in a given moment, and to say it simply without superfluous words.

It’s best to fully feel emotions—when done, they come and pass. But often, due to past painful experiences and wanting to avoid that pain and vulnerability again, people deaden their feelings—with compulsive behaviors like drinking or overeating, busyness, or intellectualizing emotions. This just buries the feelings, which have an uncanny way of surfacing sideways later—in illness, anger outbursts, and self-destruction.

Understandable to a degree, medical schools promote suppressing emotions. Emotional attachment to patients is undesirable, and emotions are inconvenient if a patient dies but there’s no time to cry. But those emotions won’t just disappear, and should be expressed at some point soon after. Physicians might thus “retrain” themselves to feel their feelings, and “compartmentalize” them, or feel and express them when appropriate. So if a patient dies, having dinner with a friend that evening and discussing it and crying is much better than, say, getting drunk. Getting it out of one’s body is a much healthier alternative.

Remember, good communication necessitates one to feel and express emotions. Compassion for patients, others, and oneself also requires being able to feel. Yes, doctors may not want to “fall apart” in front of patients. But they can do it behind closed doors, or away from work. This will do wonders to maintain their humanity, a major push in medicine today. It will also enhance their personal relationships, because numbing out in medicine will spill over into nonprofessional relationships and cause problems there.

Needs

Humans have different levels of needs. Basic needs, for example, are food, clothing, and shelter. Higher-level needs are for time off from work, time with family, good health, and so on. Even deeper needs are to be heard, loved, respected, or connected to others (10). A problem is that many people don’t know their own needs, though they know the needs of others, especially if they’re caretakers like doctors or nurses.

Empathy

Empathy is listening with one’s heart. It’s “the power of understanding and imaginatively entering into another person’s feelings” (11). It’s critical in communication, especially for physicians and professionals who deal with patients. It goes beyond compassion, letting one put oneself into another’s shoes to sense his or her emotions and needs. Empathy also helps people genuinely connect with the human race, and gets people out of themselves. Because it lets one separate from the other, it allows one to also stay aware of one’s own emotions and needs as well as those of others, even in situations that are difficult to handle.

An example of this is an empathetic physician who sees an emotional patient, and realizes he or she simply needs to be heard and reassured. If the doctor feels overwhelmed, as he or she focuses on the patient’s needs, he or she will become calmer and listen vs. telling the patient to calm down. The more empathy is practiced, the more rational and caring “responses” one will have vs. knee-jerk “reactions” that may worsen the situation.

Communication Styles

There are basic communication styles that people use, each implying a certain level of underlying self-esteem. They tend to be more “automatic” than “chosen” ways of communicating. While no one always uses only one style, most people can categorize themselves as primarily being one of the following:

Passive—Passive people are quieter and don’t say much, though they may if asked, and have lower self-esteem. They may be “people pleasers” who avoid rocking the boat. They may not think highly of themselves or of what they have to say, or that it will matter. Others’ opinions matter more. They may not want to bother others. But quietness isn’t always from passivity. It could be a person who has good self-esteem who won’t speak up in that moment, or whose culture fosters not speaking up to elders, but whose self-esteem is fine.

Aggressive—Aggressive people are some combination of loud, pushy, angry, a bully, domineering, demanding, threatening, condescending, uses foul language, ans so on. They may not listen well. They engender fear and dislike. Contrary to popular belief, their self-esteem is low, not high. They may really dislike themselves, and use aggression to cover this up and to compensate for their low self-esteem.

Passive-Aggressive—Passive-aggressive people have low self-esteem, and express their anger through vengeful behaviors rather than directly stating their anger. This typically occurs unexpectedly, making it particularly virulent. For example, they may act pleasantly toward someone in person, but then get back at the person by not relaying an important message out of anger. Or they might agree to be on a committee but dislike the chairman, and then not attend the meetings. Passive-aggressive people also use sarcasm—a nasty mix of humor and anger that can be very hurtful.

Assertive—Assertive people speak up and are clear, direct, and to the point. They listen well. People often confuse assertiveness and aggressiveness. Assertive people “assert” themselves and pull no punches, but aren’t pushy. They have high self-esteem. They value what they feel and say—and value what others feel and say. They set boundaries. Though some find it intimidating, assertiveness is the style to strive for.

Communication Preferences

People also have preferred ways of communicating, and one aspect of this is how they prefer to give and receive information. One might see generalizations of this with certain specialties of physicians, or simply among individuals in various specialties. It is helpful to learn about how one’s “audience” prefers to share information, and to calibrate a message to that person’s or group’s preferences. Those preferences may reflect personality traits of a physician, how they best learn, who they were trained by, how much time they have or typically allot for conversations, and so on.

To learn the preferences of colleagues, physicians can observe them as they work—at rounds, meetings, when leading a seminar, and so on, or when interacting with themselves or with others, such as a nurse or a family member. Physicians can also ask their colleagues directly what type of information they want at various times and in what format; then, after giving them the information, they can ask for feedback as to whether they gave what the colleague needed.

Some physicians, especially when faced with challenging cases, use a “group thinking” approach and prefer to seek opinions and input from other doctors they trust while making decisions. They have colleagues they’ve worked with over the years, in the same specialty or not, with whom they regularly cross-consult. Others may exhibit a more independent approach to their work.

Personality may motivate some physicians to go through conversations slowly, while others exchange information and get to the point quickly. The amount and type of information shared also varies among physicians. Some are detail oriented and want specific facts about a case. Others may be more bigger-picture oriented and prefer a general synopsis. Some may want only current medical facts, whereas others want to know the context and circumstances behind a situation as well. Some physicians want to know the social aspects of a patient—how involved family members are and if they function well together. Others focus on a patient’s personal emotional situation when looking at the causes of their illness or injury. Teaching and training styles may also reflect a more lecture-type style when information is more likely to be given, or a more interactive approach where trainees are expected to provide much of the information.

COMPONENTS OF COMMUNICATION—PART III: BODY LANGUAGE, LISTENING, AND SPEAKING

Body Language

Body language can speak volumes without a word being said, and is an important aspect of communication. During communication, how people act, how they express emotion, how close they stand to each other, the tone of their voice, where they focus their gaze, how relaxed or tense they are, how well they speak and listen, and other things they do all reflect their cultural norms, how interested they are, how connected they feel, how well they handle conflicts, how comfortable or confident they feel, and much more.

Body language incongruent with other aspects of communication can also be revealing. Someone avoiding eye contact may be withholding information or lying. A big smile but a lack of warmth and distancing demeanor may indicate that a person looks happy but isn’t and won’t say why. An angry person may cross his or her arms and look defensive but when asked about this, he or she may say, “No, I’m not mad!” Astute listeners and observers pick up on these miscues. It’s important that body language matches how one speaks and listens.