“Much of the art of general practice lies in the ability to communicate”
So writes John Murtagh, grandfather of Australian general practice, in his ubiquitous self-titled textbook (1).
Being able to communicate effectively defines the good doctor. Effective communication builds rapport and the therapeutic relationship, it facilitates trust, it contributes to positive health outcomes, it enhances doctor and patient satisfaction, and it reduces error. Communication skills development is a fundamental plank of GP training in Australia. Good communication is good general practice.
The prism through which general practice has traditionally viewed communication has been the time honoured face-to-face consultation, the doctor sitting at a desk with the patient opposite. But over time, with advances in technology and understanding and pragmatism, we have refined the way we communicate. Patients have moved location to now sit alongside us, not across from us. And their changed position is not just geographic, but also authoritative - they are now equal partners in the decision-making process. Use of interpreter services is mainstream. We have embraced electronic records, FitBit data, patient education YouTube videos, and smart phone images (sadly over-represented by photos of discoloured baby poo). These changes have thus far been adaptive, gradual, non-threatening.
But the prism has been smashed.
The COVID-19 pandemic has led to a massive, and almost overnight, transformation in Australian general practice, most notably with the rapid rise in telehealth. Our patients now consult us from another suburb. And, depending on the technological platform and the vagaries of the internet, the non-verbal cues that we have thus far relied on in our face-to-face interactions (body language and gesticulations and which footy jersey they are wearing) may be invisible.
So, what does effective communication via telehealth look like? Unfortunately, the literature doesn’t help us much. A 2017 Cochrane review (2) found there was no evidence available to guide an effective approach to training clinicians in telephone consultation skills. The authors concluded that such skill development has therefore to be guided by face-to-face communication models.
Thus, it’s back to basics. Suddenly all that jargon we learnt in ‘Communications Skills 101’ from medical school – active listening, reflecting, use of silence, chunking, summarising – is meaningful again. Speak a wee bit more slowly. Use open-ended questions. Remember that you get most bang for your buck from history-taking, so spend a little longer here. Summarise back to the patient – ‘so what I have heard is…’. Ask the patient to repeat key aspects of management back to you to ensure they have understood it.
But perhaps also be innovative and use the new telehealth medium to your and your patient’s (communicative) advantage. Ask the patient what the problem is and then switch to ‘mute’ (you can’t interrupt them when you’re muted!). Ensure that they have nothing else to ask before you hang up – there’s no scope for a doorhandle ‘Oh, and there’s one other thing doctor…’ in telehealth. And if you want to close your eyes to concentrate, you can, without giving the impression that you have drifted off.
The ‘art of communication’ has been described as effectively adapting core communication skills to suit the patient and their context (3). As GPs, we already have these skills. And the patients are no different. So, while telehealth may a new context, by applying old tricks to a new dog we can continue to successfully communicate with our patients.
1. Murtagh’s General Practice
2. Vaona A, Pappas Y, Grewal RS, Ajaz M, Majeed A, Car J. Training interventions for improving telephone consultation skills in clinicians. Cochrane Database of Systematic Reviews 2017, Issue 1.
3. Warnecke E. The art of communication. Aust Fam Physician. 43: 3; 156-158.