# Introduction

ommunication with the patient must be important skills for a doctor or medical practitioner in practising field. Without good communication with the patient it is difficult to help that patient properly.

In most developed and developing countries in the world health system is changing; political and economic forces are behind the growth of profit driven medicine, managed care and increasingly technological focus.

Good communication skills improve the doctor -patient relationship and decrease the dissatisfaction by the patient and relatives. It offers numerous benefits to the patient.

Communication skills is an interactive process, patient will also need knowledge to take part in decision making and can raised question about the quality of life.

Doctors have a moral and social responsibility towards the community as well as medical responsibility and must preserve their patients' trust.

Communication skills influence the quality of interactions between the doctor and the patients as well as compliance, patient education and health outcomes.


# Improvement of communication skills between doctors and the patient:

Communication difficulties between doctors and the patients have been looked at by researchers from time to time in several disciplines who have tried to explore why these occur.

In many researches it was shown that doctors talk with the patient in different voice. Sometimes doctors do not want to listen what patient want to say and this is a big barrier for doctors -patient's relationship.

To improve the communication between the doctor and the patients we need also to understand the nature of the decision making that taking place in the consultation. There were studies in United Kingdom found that misunderstanding between doctor and the patient is very common, because of lack of active participation in decision making either by the patient or by the doctor.

Unvoiced agenda items led to specific problems such as unwanted prescription and nonadherence. That's why it is good to provide enough information to the patient during consultation about the decision making especially for the management plan.

Information exchange helps the doctor understands the patient and ensures that the patient is informed of their treatment options; risks and benefits. It also allows patient to assess whether they feel they can build a relationship of trust with their doctor.

Also, as a doctor we have to explore how much patient knows about his/her illness and the prognosis of the disease as well.

There are few important criteria need to consider for good communication skills are as follow:
? Patient centred. ? Active listening.
? Clarify the patient knowledge.

? Identify the goals care.

? Identify patient resources.

? Explore fear and feeling.

? Offer support.

? Help patient with sustain hope.


# For effective counselling to a patient we have to established good communication bond or relationship. For these following things we should always keep in our mind as below:

? Valuing respect to the patient.

? Connecting to the patient. ? Empowering knowledge.

? Finding meaning.

? Genuineness.

? Empowerment and self responsibility.

? Confidentiality.

? Unconditional positive regards.


# Breaking bad news to a patient:

? To break the bad news to a patient proper preparation is important, e.g. need to sit with the patient in a consulting room and make sure that she is comfortable with the environment inside the room. ? Need to find out from the patient that 'how much she knows about her/his illness including the prognosis of the disease?' ? Need to listen attentively to her all the current concern.

? Try to get more information from the patient by asking open ended questions. ? Need to find out more that 'How patient will cope present ailments. ? Ensure that patient should get enough support both mental and physical from the loved one or close relatives, as well as from the health care worker. ? Need to involve the multi-disciplinary team problem and concern; such as social welfare officer. ? Need to make sure patient should be free from all the stress and pain. ? If patient need spiritual support e.g. from her/his church or priest, I will make sure or arrange that kind of support as well for her/his. ? Finally, there is a need to discuss with the patient about the hospice and palliative care facilities. If patient wants that service, try to organize that as well.


# Patient background:

Patient is a 66 years old lady and retired from job as a school secretary. She is known to have metastasis carcinoma of the breast and had mastectomy 2 years ago.

6 months later from the date of her operation, her husband died of cerebral metastasis from the previously undiagnosed carcinoma of the lung.

Her only daughter living in Canada and works as a receptionist at a doctor's clinic over there. Also, the daughter has got her third baby, who was born recently in Canada. Apparently, the patient is staying alone at home and there is no close is nearby to give her support.


# Communication between doctor and in this particular patient (barrier from both side):

This patient is living alone at home, because her husband died 6 months ago, and the only daughter is not around as well. Therefore, we need to explore from the patient what really, she wants us to do at this moment! Information about the palliative hospice care facility in South Africa and after discussion if she wants to get that service, then doctor can organize for her.

She could have a fear of suffering alone at the end stage of her life, because she has already seen the suffering of her husband who died of undiagnosed cerebral metastasis of lung carcinoma.

Being alone at home probably she frustrated and in anxiety as well, therefore give her mental support and also, can make sure that she is getting it repeatedly. For that if necessary, involve a counsellor to counsel her as per her needs.

She is a retired lady and she may have financial problem also. Therefore, doctor should try to explore that if she needs particularly financial support etc. doctor can try to organize a social grant for her from the state and also, doctor can involve social welfare officer as a multidisciplinary team to support her.

There will barrier from doctor side, doctor needs to consult or involve multidisciplinary team (as palliative care team) and sometimes it will not be possible because of the availability of human resource.

Her daughter is in overseas and she has a little bay to look after. So, there is no love one around her at this stage. Also being alone the patient is missing her daughter and the grand child at this moment. She needs both mental and physical support at this stage. However, it is our duty as a doctor to satisfy her at this stage of her life and to make sure that she is comfortable or happy with the approach of palliative care etc to her.

To disclose her recent condition that the cancer has already metastasis to the bone. It is really very difficult and a barrier for breaking another bad news to the patient as a doctor, because she is already under stress about the death of her husband and who had almost similar kind of illness. To overcome from this particular situation, it is good to follow the steps to break bad news.


# Pain assessment in general as a palliative care physician: Definition of pain:

Pain is an unpleasant and emotional experience associated with actual or potential tissue damage or describes in terms of such damage.


# The perception of pain modulated by the followings:

Patient's MOOD. Patient's MORALE. MEANING of pain by the patients.

Depression, anxiety, fear and low morale can all lead to an increase severity of the perceived pain. The meaning of the pain can also influence perceived severity of pain e.g. the headache due to brain metastasis signifies a threat to the patient's way of life, unlike an everyday headache.

Total pain has few components:
? Physical. ? Mental. ? Inter-personal. ? Spiritual. ? Financial.

# Assessment of pain in this particular patient:

In figure it is shown that the patient has pain at her back, and which is every possibility due to the metastasis from the breast cancer of her.

There are very much need to assess psychological factors for the pain such as follows:
? Anxiety. ? Anger. ? Fear. ? Depression. ? Boredom.
? Insomnia and tiredness.

? Social isolation.

To check the severity and the total component of pain I follow the mnemonic tools that are PQRSST.

? What are the precipitating or exacerbating factors of pain which patient noticed most of the time in her daily life? ? What is factors patient noticed to get relief from the pain? ? What is the quality of pain? E.g. the pain is sharp or dull in nature etc. ? Does the radiate any other parts of the body? ? To make sure that any other associated symptoms or signs rather than nausea and vomiting.

? Time and the course of pain.

After assessing the patient thoroughly, I quote the severity of the pain numerically from 0 to 10.


# Examination:

We need to do both physical and systemic examination to find out the source, nature, severity of pain in her case.

? By due proper examination I will find out that the pain is due compression on the nerves at thoracic or lumber plexuses. ? Need to look for the most localise tenderness as well if there is any. ? Need to look for is the patients is jaundice, anaemic, dehydrated or oedematous etc? ? Need to look for any other abdominal mass or oranomegaly during my systemic examination. ? Are there any signs or symptoms of renal involvement? ? Are there any signs and symptoms of metabolic impairment such as hypercalcaemia due to severe bone involvement? ? By doing full neurological examination, I will try to explore is there any nerve compression etc?

Investigations:

? Full blood count.

? Blood urea and electrolytes.

? Blood for tumour marker.

? Serum calcium.

? Liver function test.

? X ray of whole spine.

? If necessary, CT or MRI scan.


# Differential diagnosis:

Her pain areas which are all spotted at the back due to the metastasis form the primary cancer and which could be related with the cord compression as well.

Keywords:

? Communication.

? Skills.

? Patient's interest.

? Pain.

? Relationship.


# II.


# Conclusion

Improving communication skills for a health care professional especially doctors and nurses is not an 'option, but it is necessary'. Learning communication skills in times of change and uncertainty depends on an emotional openness to self and others.

To develop effective interventions to promote better communication, it is useful to explore specific communication patterns within the border context of the type decision making process within which communication is embedded.

Teaching communication should be included at all level of the medical education and even importantly, should be a mandatory element of the medical school curriculum and programme continuing medical education. This can be achieved by the support from the specialist physician policy maker in medical faculty at different university level Proper pain assessment is very important in patient with suffering from any cancer. To know how to assess the pain properly we need the palliative care skills. It is also important to control pain, because our one of major goal in palliative care medicine.

A holistic approach of pain control is essential, rather only attending to the physical aspect of the pain.
		
		
			

				


* 
	
		Topics in Palliative care -PAIN -written by Dr. Ian Black
				
			1997
		
	




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		Management of dying patient -Ilora G Finlay
		
			UK
		
		
			University of Wales
		
	




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		4. How to improve communication between doctors and patients
	
	
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		Cathy Charles, Amiram Gafni, and Tim Whelan
		
			11
			1
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* 
	
		Improving doctor-patient communication
	
	
		Editorials
		Siegfried Meryn
		
			316
			27
			June 1998
		
	
	BMJ




* 
	
		Breaking bad news and the challenge of communication
	
	
		European Journal of palliative care
		
			4
			2
			1997
		
	
	by Allison Franks