One of the ways medicine plays games with itself is in the provision of names for modes and models of care. Names are used to brand modes of care and perhaps in an unnecessary manner.

Some examples that come to mind include the distinction between palliative care and supportive care. Respectively these terms have come to mean palliation at the end-of-life and palliation through the rest of an illness. At the end of the day the aim is to effectively manage physical, psychosocial and existential issues and symptoms related to an illness regardless of the phase of the illness. The different terms serve to support different political and economic agendas.

Another potential example is the concept of the medical home. The medical home is a model of care designed to provide high quality care through a primary care practice, arguably, as opposed to fragmented care in a specialist system. An alternate way of thinking of the medical home is that it is about having a family doctor. Yes, I’ll acknowledge that the concept is expanded to include team-based care coordination, etc, but the bottomline is that the concept is about good primary care.

Recently in the oncology world the concept of survivorship has become fashionable for research and service delivery. Interestingly a lot of the interventions that are being demonstrated to potentially be of benefit for cancer survivors overlap with those which are of interest to preventive medicine. These include managing diet and weight, activity levels and fitness, and mindfulness. In otherwords both survivorship and preventive medicine are about wellness.

Holistic medicine, the bio-psycho-social model of healthcare and the whole person movement are another example of word-games in medical care.

There are two themes that underpin these comparisons. The first is an emphasis on delivering quality care for the unwell regardless the context of the illness, both in terms of physical setting and the phase of the illness. The second is wellness or being healthy, underpinned by personal empowerment around healthcare decisions. If we can focus on these principles rather than specific silos of thinking that they might support then perhaps we can start to see the forest through the trees. Lets talk about quality of care and wellness.

Possibly more confronting that being called by a nurse to actually go and review the person who has just died and having to check for vital signs in front of a family is then needing to go and complete the certificate of death documentation. Nobody taught me this in medical school and like all good forms often the fields don’t make sense.

As this post, Quantified Death, in the Health Care Blog points out, because doctors aren’t trained to fill out death certificates a lot of the data about why people died is nonsense. ‘Brain failure’, ‘full body organ failure’, ‘old age’ really don’t count as a cause of death.

Doctors need to be taught how to complete death certificates but it is also not just a matter of completing the form correctly for the sake of data collection. Perhaps underpinning the problem is our own failure to really understand why and how people die. This needs to be discussed more at medical school. A case in point when I discuss Not for Resuscitation orders with patients and their families I no longer refer to attempting resuscitation when their heart and lungs stop working – I simply refer to the person dying.

In the last fortnight the new registrars started and they have been thrown into being ‘On Call’. This means fielding calls from doctors in the emergency department about patients who might need admission to hospital.

This is something I do all the time and it is interesting to reflect that nobody actually taught me what to do – one day I was on a roster. I guess the expectation was that I’d been on the other side of the phone making calls to consultants so of course I knew what to do. But actually taking the calls is different from making the calls. For starters you might be asleep when the call comes in.

@cancersolutions (Matthew Links) & I have been pondering the question of what needs to be taught in medical school about being on call.

Some of the key competencies for oncology on call that we’ve identified include:

1. Assessing the reliability of the information obtained over the phone and the competence of the person making the call.
2. Prioritizing problems and anticipating other problems that the caller may not have thought of
3. Determining the appropriate location of care for a patient – does the patient need to go to a high dependency unit or even transfer to a different institution?
4. Appropriately involving or referring to other medical teams
5. Addressing supportive care and symptom management needs
6. Actively considering end-of-life issues and advanced directives
7. Communicating with other teams
8. Using the call as a teachable moment
9. Using the call as an opportunity for reflection – what would I have done differently next time?
10. Managing the caller – sometimes one gets a long-winded story that totally misses the problem….it can help to recalibrate the call e.g by returning to ask what was the reason the patient came to the ED?

Being on call can be stressful especially if there are a lot of calls. Learning how to do it properly can certainly make life easier.

If you’re interested in the topic of being on call my next post will be on how remote presence technology could be a disruptive innovation for the on call doctor.

In thinking about my question – about what I wasn’t taught (or maybe didn’t learn) in medical school – I’ve been trying to come up with a way of summarising the themes and chanced upon a book about life skills needed for the 21st Century. I thought it encapsulated the needs of the modern doctor in training nicely. Whilst modern curricula do address some of these issues they certainly don’t give them enough prominence.

Trilling and Fadel describe in their book 21st Century Skills: Learning for Life in Our Times, 7 C’s that constitute the 21st Century skill-set when combined with the tradiational 3 R’s (reading, writing & arithmetic). The 7 C’s are:

Critical thinking and problem solving
Communications, information, and media literacy
Collaboration, teamwork, and leadership
Creativity and innovation
Computing and ICT literacy
Career and learning self-reliance
Cross-cultural understanding

Looking through the 7 C’s one can see the importance of each of these skills for a doctor working in a health system dominated by team-based healthcare, electronic connectivity, mHealth, social media, and patient empowerment. These skills also subserve the doctors of the future as more and more digital natives or Millennials pursue non-traditional, portfolio-style careers. Practising doctors and medical students can evaluate themselves against these 7 C’s.

As I was going though medical school and especially when I was doing speciality training as a medical oncologist there was a growing trend to teaching communication skills. Generally this focused on communicating with patients and in particular this focused on breaking bad news. Although this was useful and now it is something that I pride myself on doing well it wasn’t really enough to address my communication needs.

Doctors need to be able to communicate with patients but also with their colleagues including other doctors, nursing and allied health professionals, junior staff and students. Although rough frameworks are taught in communication skills training what isn’t taught is how any of these interactions requires dramatic skill and the ability to improvise.

An example I use is from a tutorial I run with medical students about malignant spinal cord compression. As we work through the case I get the students to pretend that they are the doctor in the emergency department in the middle of the night who has to call the radiologist, the neurosurgical fellow and the radiation oncologist about the patient. Any doctor who has worked in an ED on an overtime shift can tell you of the joys of having to make these calls and ‘sell’ the case to another doctor. The job of the junior doctor is to do stuff for other peope and to get people to do stuff for you. This process continues on through one’s career as you move from making your case to one other doctor to groups of doctors in multi-disciplinary meetings.

When dealing with patients the communication skills we are dealth with at medical school really only covers the basics. I like to think of it as jazz. There are a set of chords and melodic themes to work with but then you have to adapt to the occasion. In any given clinic the doctor might move from needing to break bad news to the patient he or she has known for years and whom there is an established rapport to the totally new patient whom one has to assess in a matter of minutes and then play one’s spiel to the tempo of the occasion. Discussing end-of-life with somebody who you met 15 minutes earlier requires a lot of improvisation and a great deal of practice: one size doesn’t fit all.

Now I guess you can argue it is hard to teach these skills and that some are more naturally gifted than others. Well that it true but I think one can learn. The first step is to realise that you can’t simply say the same things in the same way to every person. The worst communicators I’ve met follow the same pattern every time.

For me the most important components of learning to improv in medical communication are:
– actually know what you are talking about – it is hard to be an expert if you aren’t actually an expert
– if you don’t know what you are talking about then admit it openly
– establish what the patient and their family expect from the consultation
– find out what people know first – sometimes I ask if they just want to ask questions or would they like me to do the talking
– start with the most simple explanations and then make them more complex as needed
– use non-medical analogies to help people understand
– compare and contrast – for example – when I explain chemotherapy I explain what happens with and what happens without treatment
– practice a lot and remember what works
– be repetititive so you are thorough but don’t follow a strict script
– when there are treatment options offer clear choices that are genuinely different and don’t offer too many
– recap and check understanding

One particular way to improve communication improv skills is to explain the same concept to different audiences, expert and non-expert, – this way you learn to move the explanations along the complexity spectrum. With the experts you have to use the right jargon – with the non-experts you can’t.

It seems, as time goes on, there is less time for junior doctors to watch senior doctors explain things to patients and also less time for senior doctors to watch junior doctors make explanations. In the era of mHealth this needs to change. Medical schools need to move beyond the limited communication skills currently taught and train star performers.