Lecture
Chulkova V.A., Pestereva E.V., Demin E.V., Rogachev M.V. Psychological aspects of the physician's interaction with the oncological patient / Manual for oncologists – St. Petersburg: N.N. Petrov Research Institute of Oncology. – 2015. – 40 p.
The medical profession includes communicative activity. However, over the course of all 6 years of study at a medical university, students are taught to diagnose and treat disease, yet not a single hour is devoted to teaching and developing their communication skills.
Thus, in our study of students at St. Petersburg State Pediatric Medical University, only 36.4% of students, and only in their 6th year, indicated that a physician needs to have communication skills for interacting with the patient: «the doctor should also talk with the patient», «the patient will not follow recommendations if not properly informed».
In contrast to students, practicing physicians much more often acknowledge the need for interaction and dialogue with the patient – 97.1% of oncologists. A physician's use of professional communication skills affects patients' satisfaction with the quality of the medical care provided to them: patients more fully realize their existing problems, understand the necessity and meaning of diagnostic and therapeutic measures, and as a result they are more adherent to therapy and take a more conscious and active part in the treatment of their disease. Along with this, the use of professional communication skills helps to improve the physician's own quality of life: it increases his stress resilience and professional self-respect.
A physician's lack of professional communication skills can lead to «compensatory» behavior in the form of denial
of the need for psychologically competent communication with patients, a tendency toward passive disregard of the social and psychological needs of patients, as well as a striving to fulfill one's own authoritarian attitudes.
Thus, a physician needs to possess certain professional skills, among which we single out, first and foremost, the following: presence, empathy, sharing of feelings, active listening, and the setting of temporal and spatial boundaries.
Presence
Perhaps no one would deny that in order to interact with a patient, contact with him is necessary. The most important condition for contact is presence, which includes not only physical presence (nearby, in the same room) but also psychological presence – which implies being engaged in the patient's situation at the present moment.
One can often observe how a physician, inviting a patient to talk about the disease, its symptoms and how he feels, seemingly listens to the patient while at the same time filling out the medical record of the previous patient, which does not foster contact between the physician and the patient. This example illustrates the psychological absence (non-presence) of the physician in the situation of interaction with the patient, even though physically he is right beside him. As a rule, physicians explain such behavior to themselves and to others by the lack of time allotted to a particular person. This is true. Indeed, in our view, too little time is set aside, according to the medical standards adopted in our country, for the physician's communication with the patient. This is one side; on the other hand, the quality of communication in situations of limited time is of even greater importance: in the short time,
that the physician does nonetheless devote to the patient, he must be psychologically fully focused on the specific patient, not
being distracted by any external (phone calls, colleagues approaching about other matters, etc.) or internal (thoughts about unresolved personal problems) factors.
Empathy
By the nature of his professional activity, the physician faces a psychological task – to build a relationship with a suffering person. The physician must strive for a psychological understanding of the patient. This becomes possible when he has empathy (from the Greek empatheia – feeling into, compassion). Empathy can be defined as the ability to «put oneself in another person's place». It is believed that every person possesses empathy to one degree or another, even if it is very weakly expressed. It has also been established that a person's capacity for empathy can develop over the course of his life.
Unlike sympathy and antipathy, which are evaluative judgments toward another person (like – dislike), empathy is a non-evaluative judgment: the physician sees and understands the emotions and reactions of the patient in the situation of illness, but does not evaluate whether they are good or bad, whether he likes them or not. Empathy allows the physician not only to better understand the sick person, his thoughts, feelings and desires, but also to show him that the physician understands and sympathizes with him. Empathy allows the physician to see and understand not only the patient's outwardly manifested behavior, but also his inner state, which is not overtly expressed.
There are two types of a person's outward behavior: nonverbal and verbal:
Nonverbal behavior includes posture, gestures, facial expressions, gaze, nods of the head, etc., that is, the «language» of the body. It must be taken into account that nonverbal behavior is less consciously controlled, and therefore it is more truthful: we glean 70% of the information about a person's state from his nonverbal behavior. Thus, the physician, during the conversation, by observing the
patient, can obtain information about his state. It should be emphasized that interaction is always two-sided: the patient can also «read» information from the physician's nonverbal reactions. A gaze averted to the side, gloomy intonations in the voice, which may be caused by fatigue, the aftermath of a conversation with another patient, or the physician's personal problems, can disrupt contact with the patient. Oncological patients are very sensitive to the physician's nonverbal behavior: a sad gaze, surprised eyes during the examination of the patient, or an expressive glance toward colleagues or relatives
– all of this is not infrequently perceived by patients as a «verdict».
Verbal behavior implies verbal communication: questions, answers, that is, talk, conversation, in which active listening skills may be used.
Outward behavior is what can be observed. However, outward behavior does not always correspond to a person's inner state, his feelings, thoughts and intentions.
For example, a patient may not put into words his fears and anxieties about what he saw while observing the physician's behavior, but he has interpreted (inwardly) what he saw as information frightening to himself. In doing so, naturally, his fear and anxiety increased.
Also, not all the questions that the patient asks should be taken by the physician at face value; sometimes the patient «encodes» them. Thus,
when asking the question: «How long do I have left to live?» – the patient is expecting to hear not the specific length of his life, but that he has a chance to recover.
Sometimes one may hear: «Doctor, I have pneumonia, I will surely recover». At the same time, one can see how the patient's eyes «say»: «I know everything, I have no chance of recovering, I am tired, I do not want anything».
Or a patient says to the physician and to his loved ones: «Thank you, everything is fine with me», while remaining alone one on one with his agonizing
distress. It is important for the physician to hear what stands behind the patient's nonverbal and verbal messages. It is precisely the physician's possession of empathy that allows him to build an adequate relationship with the patient and to provide him with psychological support.
Sharing of Feelings
The oncologist is in the same situation as the patient, which is filled with the patient's extremely intense experiences, and he is involuntarily drawn into these experiences. While empathically understanding the patient's feelings and expressing sympathy to him, the physician also needs to be aware of his own feelings and experiences arising in the process of interaction with the patient, especially if this is an oncological patient.
It is important for the physician not only to be aware of his feelings, but also to be able to express them constructively. A situation often arises in which the physician, in conversation with the patient, experiencing emotional tension caused by various external and internal reasons, cannot contain this tension and expresses it unconstructively.
For example, he raises his voice at the patient, abruptly ends the conversation, or shows the inappropriateness of the patient's feelings, thoughts and questions, and so on. After this, as a rule, the physician develops a not always conscious feeling of guilt, which he tries to rationalize (to explain his lack of restraint in a way acceptable to himself): «A doctor is a human being too». Of course, a physician as a human being has the most varied feelings, and they accompany his professional activity. The problem lies not in the fact that the physician does not have the right to have feelings, but in the fact that he must be able to express them constructively when interacting with the patient.
When communicating with an oncological patient, it is important for the physician to be able to separate his own feelings from the patient's feelings. Thus, a feeling that the physician is aware of within himself (for example, a feeling of guilt) – is it his own feeling or is it
the patient's experience of a feeling of guilt? Of course, the process of sharing feelings is not simple, and it is necessary to have certain skills and experience.
The sharing of feelings is preceded by their awareness and understanding. The awareness of feelings is directly connected with a person's capacity for reflection (from the Latin reflexio – a turning back, reflection). It should be noted that the capacity for reflection is present differently in different people. There are people inclined to live life reflectively, being aware of their thoughts and feelings and coming into contact with the emotional pain that accompanies human life. Another category of people has a strong unconscious psychological defense that protects them from awareness of the psychologically traumatic circumstances of life and the mental suffering associated with them.
Education at a medical university (all the humanities disciplines, the importance of which, unfortunately, is insufficiently realized by junior-year students) is aimed at developing the future physician's ability to reflect on his existence, including in the professional space. The physician's further professional self-determination requires him to develop this ability (reflection).
The physician's awareness and understanding of his own existence, his experiences and his feelings allows him not to identify with the patient's feelings, but to separate his own feelings from the patient's feelings, which is a condition for effective psychological support of the patient.
Active Listening
Active listening consists in providing the patient with support in the conversation in order to activate his speech, help him express and become aware of his feelings, and acknowledge their naturalness and normalcy in the situation of illness.
Active listening is a tool that allows the physician to steer the conversation with the patient in the direction necessary both for himself and for the patient, as a result of which it becomes more constructive and
the goal of the conversation is achieved more quickly, while the time spent on it is reduced. In the process of active listening, the physician's empathy is manifested.
Active listening consists in the physician's ability to briefly summarize (paraphrase) what the patient has said, to verify the correctness of his own understanding of the essence of what is happening with the patient. In doing so, the physician asks the patient not only closed questions, requiring a «yes» or «no» answer, but also open ones, which allow the patient to speak about his existing fears and anxieties. At present, the skills and techniques of active listening are widely applied in many fields of professional activity in which interaction between people takes place.
Spatial and Temporal Boundaries
The physician's examination of the patient and conversation with him always take place in some room, so it is important for the physician to consider whether the chosen place is appropriate to the goals of the conversation.
It is necessary to take into account the observance of privacy: not all conversations with the physician does the patient wish to conduct in the presence of other people, even those close to him, and this especially concerns oncological patients. In turn, a designated space for interaction with the patient allows the physician to be more engaged in this interaction. The physician's neglect of the organization of the setting not infrequently leads to unregulated and informal conversations with the patient, as a result of which the physician may become an object of manipulation on the part of the patient.
Practicing physicians complain about the lack of time for conversations with the patient. Behind this may lie the physician's apprehension of being drawn into a long, unstructured conversation with the patient, which often happens. In doing so, the physician experiences natural irritation, since his workday routine is disrupted: at that moment he has no time, and he is not ready to talk about the topic that concerns the patient. Defining the temporal boundaries of the interaction with the patient can help the physician cope with this
problem. Here a realistic assessment and the physician's voicing of his time possibilities are appropriate: «I have 5 minutes right now. Will this time suit you?». And at times the patient himself declines to discuss what concerns him at a rushed pace. The patient understands that the question troubling him cannot be discussed in a short amount of time; moreover, he begins to realize that the physician, by declining to discuss the question concerning the patient in a hurry, shows respect toward him and his problem. The further step in this dialogue will be an agreement on a conversation time convenient for both of them.
Another common problem encountered in the physician's interaction with the patient is the difficulty of ending the conversation with the patient, even if it takes place within the time set aside for it. In doing so, the physician's tension may increase and, as a consequence, irritation, against the background of which his engagement in the patient's situation decreases.
In this case, the physician is confronted with the problem of the inability to refuse another person, especially if this is a gravely ill person, and to say «no» to him. At the root of the physician's difficulties lie certain psychological problems of his own. This may be indicative of the physician's personal insecurity. We emphasize that we are talking not about his professional insecurity, but precisely about personal insecurity, which manifests itself in professional interaction. This may also be connected with the problem of establishing one's personal boundaries. A person himself determines to what degree another may intrude into his personal space without thereby violating his personal boundaries, including temporal ones. These processes, as a rule, are not consciously realized by the person, but are painfully experienced in the form of a sensation of being «used».
The development of reflection allows the physician to be aware of the features of such interaction and to manage it.
Atpresent, a topical phenomenon of human behavior
insociety is the phenomenon called assertiveness (English: assertiveness). In the Great Encyclopedic Dictionary of B. Meshcheryakov and V. Zinchenko, assertiveness is defined as «a person's ability to confidently and with dignity defend his rights without thereby trampling on the rights of others». In our view, the physician's development of his assertiveness, manifested in behavior, allows him to interact more successfully with other people, including patients, and to preserve his own mental health.
It is not enough to know about the necessity of using communication skills, as well as to be informed about what these skills are and how they are applied. This is just as it is impossible to become a surgeon by studying only books on surgery. Communication skills are formed only in the process of psychological training. In our view, in the education of medical students it is necessary to use such a form of their professional preparation as psychological training, which enables them subsequently to avoid the psychological difficulties that are inevitably present in a physician's work.
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