20 HOW TO TREAT: COMMUNICATING WITH PATIENTS
20 HOW TO TREAT: COMMUNICATING WITH PATIENTS
13 FEBRUARY 2026 ausdoc. com. au from their earlier life experiences. A London paediatrician, Dr Simon Yudkin, highlighted this point in his paper entitled,‘ Six children with coughs. The second diagnosis’( see later). 5 Recognising and addressing the second diagnosis and / or the non-presenting symptom may, at times, be more important in achieving a better outcome than dealing only with the presenting symptoms.
POOR COMMUNICATION
Impact on patients
WHAT are the pitfalls of poor communication? Is the clinician aware it is occurring? Studies have highlighted the impact of poor communication( see box 1).
Impact on clinicians
How does a patient encounter affect the clinician, especially if the consultation is emotionally charged? The impact varies with each individual. Some clinicians start speaking faster, or maybe slower. Some may raise their voice or speak more softly, the patient / parent struggling to hear what is being said. To ease tension, the doctor may giggle or even crack a joke. Some practitioners may become irritated or angry( see figure 1), particularly if their recommendations seem to be ignored, rejected or questioned by the patient. Alternatively, the clinician may just withdraw and cease their efforts to help.
Introducing technical terms or jargon that further isolates the clinician from the patient may provide temporary respite from the tension that has developed during the consultation. In the process, the clinician may fail to recognise that their message may not be getting across to the patient.
Monash Health in Melbourne has provided guidelines regarding how to improve communication and convey empathy towards patients( see box 2).
IMPACT OF EMOTIONALLY CHARGED INTERVIEWS
HOW should one deal with emotionally charged interviews such as breaking bad news? 9 For example, as a paediatrician,“ Your infant has a serious heart abnormality” or“ Your child has a malignancy” or“ When you were angry and you smacked your
10, 11 son, he bled into his eyes”.
The doctor’ s affect when communicating bad news is at times more effective than words in getting their concerns across to the patient and / or parent—“ Doctor, you look worried”. 12
Impact on the patient / parent and clinician
Breaking bad news is always stressful for all concerned, especially if the diagnosis is unexpected and serious. 9-12 In contrast, patients presenting with a particular symptom that results in a diagnosis, even if serious, may at times feel relieved in that their concerns have been vindicated. Selfblame and resultant guilt may occur if the symptom was ignored, made light of or denied, especially if the delay in the diagnosis led to a poorer outcome. That realisation becomes particularly painful for the patient and / or parent if they had inadvertently contributed to the delay.
Grief reaction
Any diagnosis, especially if serious,
Figure 1. Some practitioners may become irritated or angry, particularly if their recommendations seem to be ignored, rejected or questioned by the patient.
Box 1. The impact of poor communication
• In Korsch et al, a paediatrician working in an emergency department commented:“ If the doctor failed repeatedly to heed her( mother), she may cease to try … [ and become ] completely mute … Things said and done by the doctor after that critical point may not be perceived by the mother.” Pay“ attention to the patient’ s own ideas about the illness and [ provide ] relief of feeling of self-blame”.“ Longer sessions were consumed largely by failures of communication.” 6
• In Raimbault et al, a paediatric endocrinologist observed how“ the doctors interrupt or did not listen to what the patient’ s concerns were”. 7
• A medical student commented after seeing a child and his parents in an ambulatory paediatric setting:“ I was trying to make a diagnosis but not concentrating on the whole problem before me. This uncovered a few other difficulties( that I have not been aware of before)— for example, not really listening, asking or trying to ask the correct questions— but not listening to the answers, not concentrating on the significance thereof … and sometimes just not listening at all!” 8
leads to the onset of a grief reaction of varying intensity, where resolution may take months, extend to years or remain unresolved. 12, 13 The reaction depends to some extent on the seriousness of the problem at hand, and is further influenced by the life experiences of the patient / parent. The grief reaction has multiple components that may occur serially one after the other, before gradual resolution and reconstitution, only to revert
13, 14 to an earlier response at any time.
The grief reaction usually starts with shock, where the details of the consultation are often not heard or absorbed(“ Doctor, you never mentioned that before”).
12, 13
This may be followed by denial(“ It can’ t be”), or disbelief(“ I don’ t believe you”).
Anger may be expressed overtly or in other formats, not uncommonly directed towards the person breaking the bad news, usually the caring clinician trying to help the patient( see figure 3). This may lead to questioning the competence of the doctor:
•“ Have you seen this before?”
•“ How often?”
•“ Do you need to do more tests?”
14, 15
•“ Should I see someone else?” Anger may be followed by a feeling of guilt, and at times shame, for possibly contributing or even causing the problem that is now under examination. Subsequently, there may be attempts to bargain for a reprieve through wishful thinking, such as quietly carrying out a good deed or seeking help through prayer. This is in the hope that the problem may improve or disappear. For example, the author recalls the mother of an infant who had Fallot’ s tetralogy and was listed for surgery opted to travel to a shrine to pray that her daughter’ s problem would miraculously disappear.
Finally, there is a gradual resolution and reconstitution with a slow return to a feeling of normality and wellbeing, if at all possible. Time is of the essence to allow for recovery, remembering that each of the above profound distressing reactions may recur in no set order.
Box 2. Tips for communicating and conveying empathy
• Sitting next to and facing the patient( see figure 2).
• Attuning to patients and their family members, and attempting to interpret facial expressions, gestures and other non-verbal behaviours, and the meaning behind their words.
• Listening to patients and / or their family members without interrupting or judging.
• Providing opportunity for them to tell their story.
• Showing interest through verbal behaviours( eg,“ Please go on”) and non-verbal behaviours( eg, nodding, maintaining eye contact, slightly leaning forward).
• Repeating or paraphrasing statements as a way of verifying understanding(“ I’ m hearing you say that”,” Let me see if I’ ve got this right”,” So you think / feel that”).
• Validating the patient’ s or family member’ s feelings( eg,“ You have every right to be angry”).
• Repeatedly asking patients about their fears and concerns and offering reassurance.
Source: Circulated to clinical staff by Monash Health
Impact on the doctor
Clinicians themselves may also feel the pain of reaching a serious diagnosis, especially those caring individuals who know their patients well
10, 11
( see figure 4):
•“ Could I have reached a diagnosis earlier?”
•“ Why did I ignore this?”
•“ Why did I fail to carry out a particular test”
•“ Why did I not seek advice earlier?” However, despite the clinician
Breaking bad news is always stressful for all concerned, especially if the diagnosis is unexpected and serious.
going through their own attenuated grief reaction, they still need to maintain their professional role to ensure that appropriate management is undertaken. In addition, it is important for the patients to maintain their ego strengths( resilience), particularly if they have to contribute to any decision-making if provided with more than one option. 12
HOSTILE PATIENT
HOW do clinicians cope with the hostile / angry patients who turn against them, despite the clinician’ s concern for the welfare of the patient? Any anger felt by the clinician and / or patient needs be contained to maintain ongoing contact with the patient / family to allow for optimal care. This is especially important for children, as they are only able to attend if brought by a parent. It is so easy, for example, for clinicians to collude with parents, thereby deflecting the anger and making it easier for themselves, rather than challenging the parents if they do not accept what is in the best interests of the child. This further emphasises the need to acquire skills to help deal with the non-compliant parent / patient. 16
DEPENDENT PATIENT
IN contrast, the dependent / depressed patient may see the clinician as all-knowing and omnipotent— able to accomplish wonders. In such situations, it is easy to foster dependency that may lead to a sense of helplessness, which is not infrequently shown by such patients. Nothing seems to help, leading to frustration on the