|
My first impression was how poor were the facilities in many wards.
Some wards of special units had been renovated and were quite pleasant
and well appointed. Other wards, notably those in the general medical
and surgical units, with their high turnover and sick patients, were
old and run-down with dingy paintwork and corridors cluttered with
equipment. My sense from talking to the staff is that the stresses of
working in these wards are considerable, and I could not escape the
feeling that patients and staff deserve better in a rich country like
ours.
The next step was obtaining permission to visit patients. The medical
students I have taught have complained from time to time of being
refused permission by ward clerks and nursing staff to visit
patients. I now have first-hand experience of this -- one ward clerk
insisted on asking each patient if they wanted to be visited by a
chaplain (access to the patients was easier on the days she was away).
However, in most wards, access to patients was easier, particularly
when I became known to the staff. It was particularly rewarding when a
nurse would say, "Mr X is looking forward to seeing you" or "Mrs Y has
some problems at home she might want to tell you about".
My contact with patients was very enjoyable. I was surprised and
delighted at how often and how readily patients would begin to tell me
their life story. In my surgical practice, I prided myself on my
ability to form a good relationship with my patients, but in this new
role communication was on a much deeper level. There may be several
explanations. A visit to a specialist, as I then was, can be quite
daunting and, despite my best efforts, patients may have felt
inhibited from talking openly. Alternatively, they may have
believed (quite reasonably) that the detail was irrelevant to the
purpose of the visit. Family doctors may have a different
perspective, although I would be surprised if the interaction in a
standard consultation is as deep as I experienced as a chaplain. I
think a third explanation is most likely: in these visits, in contrast
to most encounters with medical, nursing or ancillary staff, the
patient was much more in control of the situation. There was no agenda
(apart from my need to prepare a report for my supervisor), and
patients could talk or not talk as they wished. The result was that
almost all were happy to talk freely.
Two insights caused me concern because they reflect poorly on our
profession. The first was the frequency with which patients would
tell me that they did not know what was going on with their treatment. I
know the difficulty of communicating with sick patients and their
families, particularly in the environment of a teaching hospital,
and I know that patients have denied having had detailed explanations
of planned procedures even when I have explained them myself. In
practical terms, this highlights the need for reinforcement of what
patients have been told and for testing of their understanding. It is
not always easy to find opportunities for senior staff to talk to
patients. It was my habit during the preoperative visit to ask
patients if they had any further questions about their procedures. I
was generally reassured by a negative response. However, this may
have been false comfort if the patient did not understand what was to
happen or was afraid to ask. Frequent use of written material given to
the patient helped, but I think it would have been better had I directly
tested the patient's understanding and provided additional
information as needed. Nevertheless, there is another side: many
patients take the view that the decision has been made, and the sooner
the procedure is carried out the better; it may not be helpful to remind
them that the carotid endarterectomy they are about to undergo
carries a risk of stroke of about 2%, provided the information has been
provided previously.
The second issue, which disturbed me at times, was the frequency with
which some chaplains expressed negative views of the medical
profession. This may have been part of the syndrome "doctors are
bastards, but my doctor is good". However, at times I heard sufficient
detail of patients who had been hurt emotionally by their encounters
with doctors to cause me concern about both our image and the way some of
our colleagues appear to function. Although the patients seen by
chaplains often have complex and difficult interactions of
physical, emotional and spiritual factors, and are clearly not a
random sample of the population, if these "difficult" patients are
not being dealt with adequately by the medical profession, then we
need to look to ways of improving the situation.
During most of my time in the hospital, my background was unknown to the
staff and patients. An exception, and a highlight of my time in the
hospital, was when I took part in the teaching session to introduce a
new group of medical students to the work of the chaplaincy. The object
of the session was to point out the importance of spiritual factors in
healing ("making whole"), and to claim on behalf of the chaplains to be
the specialists in this area. My ability to talk to the students in
familiar language may have enhanced their appreciation of this point
of view.
The program of training that I undertook is called Clinical
Pastoral Education (CPE). Its aim is to allow non-ordained hospital
chaplains and ordination candidates to "develop new
awareness of their own humanity and of the needs of those to whom they
minister".1 This is now an
internationally recognised discipline, which began in the United
States in the 1920s. The links with medical teaching go back to its
originators, one of whom, Dr Richard Cabot, developed the case-study
conference at the Massachusetts General Hospital (S Ames, Clinical
Pastoral Educator, Anglican Centre for Clinical Pastoral
Education, Melbourne, VIC, personal communication). As currently
practised, the major element in CPE is the "verbatim" report, which
purports to be a literal report of part of a clinical chaplain-patient
encounter. This is written from memory and presented either to the
supervisor or to the group, which typically comprises four to six
students and two to three supervisors. This report is analysed and
discussed in detail, often in a way which confronts students with
their own feelings and inadequacies. As far as I can determine, this
process has no parallels in medical education, either undergraduate
or postgraduate.
At least one aspect of the CPE program might be helpful in medical
education and practice. I believe many doctors would be helped by
greater understanding and awareness of the emotional responses of
doctor and patient, which occur in almost every clinical encounter.
As doctors, we are trained to act in a detached, "objective" manner
with our patients. This may be a necessary part of clinical
decision-making, but I suspect that doctors do respond emotionally
to patients, often in ways we do not recognise or admit. Explicit
acknowledgment of this would enable greater rapport with patients
and their families, especially in times of stress. In addition,
greater awareness of, and sensitivity to, the patient's feelings and
emotions would probably help improve patients' perceptions of
doctors.
There are important lessons from this CPE program for all clinicians
concerning communication with patients and families. The first is
the need for reinforcement and testing of understanding in
situations such as obtaining consent for procedures. The second is
the recognition of emotional responses of patients and doctors to
clinical encounters. A greater appreciation of these issues would
improve the quality of our communication and enhance our image.
Irwin B Faris
MD, FRACS, Deacon, formerly Professor
of Surgery
The University of Melbourne
The Geelong Hospital,
Geelong, VIC
ifarisATozemail.com.au
Reprints will not be available from the author.
Correspondence:
Irwin B Faris, 1 Brendan Court, Highton, VIC 3216.
- Association for Supervised Pastoral Education in Australia.
Standards for clinical pastoral education, 1995: 2.
©MJA 2000
Make a
comment
Readers may print a single copy for personal use. No further
reproduction or distribution of the articles
should proceed without the permission of the publisher. For
permission, contact the
Australasian Medical Publishing Company.
Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>".
<URL: http://www.mja.com.au/>
© 2000 Medical Journal of Australia.
We appreciate
your comments.
|
