Talking to your patient’s family and friends

Professor Bill Noble, executive medical director at Marie Curie, discusses the difficulties doctors face when dealing with a patient’s family and friends. 

Doctors’ communication skills have come a long way. In my first clinical teaching session at medical school, the professor warned us: ‘When you talk to patients and they tell you what is wrong with them, sometimes they start crying. It’s best just to ignore it; I generally do and they generally stop.’

That was 1975 and it’s different now. Communication skills training features in the medical course and exams. The GMC mandates it. Young GPs are soaked in communication skills training and even surgeons are tested to see if they can speak effectively to patients in their college exams. All medical professionals prove their communication competence in annual appraisals, but there is a problem.

Talking about end of life care: communication from Media Trust on Vimeo

Remembering the family

All this effort is directed at the interactions between doctors and patients. The most important people in the lives of those patients, the people that love them most, the ones that care for them and will grieve when they are dead, get an entirely different deal from our profession. In my experience, almost everyone in the field fails to teach students or professionals how to talk to families, relatives, friends or carers.

In my experience, almost everyone in the field fails to teach students or professionals how to talk to families, relatives, friends or carers.

This matters because talking to families is different from talking to patients. The principles are different, as well as the skills and the quality of the relationships. Family therapy, a branch of psychotherapy influenced by systems theory and practised mostly in child psychiatry, is a discipline that has worked it out and established a clinical method that can be taught.

Dealing with family dynamics

Families are different from individuals; they have qualities that are not the same as the individual’s. They are not just a small crowd; their relationships give the family group a structure. They can be close or distant, role sharing or dividing, open or closed. Their stories give them shared assumptions, beliefs, myths and scripts that they turn to when things get difficult.

Talking to families is different from talking to patients. The principles are different, as well as the skills and the quality of the relationships.

To get a message over to a family group, a doctor will need to be more assertive than they are when talking to an individual. Listening is more difficult and includes paying attention to what’s not being said when the family convenes. They have a tendency to contrary responses, sometimes doing the opposite to your advice. They can be excluding, intimidating, or they can draw you in. We know this stuff from our own family and social lives, so why do we leave it at home when working in clinic?

Perhaps the most valuable spin-off from learning the basics of systemic thinking is the insight you gain into the individual. Concepts such as resonance or transference are applied to the phenomena that arise out of family narratives and relationships that build our personality and influence our behaviour. This was the basis of the insights that Michael and Enid Balint gave to GPs struggling to treat patients within six-minute consultations in the 1970s.

Listening is more difficult and includes paying attention to what’s not being said when the family convenes.

I wonder why we are so reluctant to engage with the families. It can be scary. I remember, one night, driving up to the house of a patient I knew to be terminally ill. Lights were on in every window and I could see that there were people in every room. Big families are scarier than small ones and more complicated. They have relationships and stories that never exist in a single version.

Overcoming the challenges

Dealing with families can be intellectually difficult as well as emotionally demanding. However, most families can be helped if you pay them attention.

We do need to check that patients are happy to share information with the family or friends. There are circumstances that mean that communication can’t be open, but in my experience these are relatively rare, for instance, when there is a family conflict, an issue of safeguarding, or specific instructions on the part of a patient that they never wish to hear information about their condition.

There is no such thing as not communicating, so it would be better if we were trained to communicate well with everyone around our patients.

There was a brief attempt to embed the principles of family therapy in palliative care in the late 1980s. The leading institution then is still training professionals now, and nearly everyone who passes through the portals of the Tavistock carries these ideas for the rest of their careers. Experiential learning is definitely the best way to pick it up.

There is no such thing as not communicating, so it would be better if we were trained to communicate well with everyone around our patients.

Headshot of Professor Bill NobleProfessor Bill Noble is the executive medical director at Marie Curie, and is the charity’s lead on medical matters, clinical governance, palliative care research and service design. He is Honorary Professor of Community Palliative Care at Sheffield Hallam University.

 

 

Related posts

GP Dr Catherine Millington Sanders shares her experiences and top tips on having difficult conversations

Dr Kirsty Boyd, a consultant in palliative medicine, talks about her experiences of speaking with patients and families about future care planning

Alan Richardson blogs about the invaluable support he received from doctors while caring for his mother when she was diagnosed with dementia

2 responses to “Talking to your patient’s family and friends

  1. Pingback: Round up: user feedback and talking to your patient’s family and friends – Good doctors·

  2. I agree with Professor Noble that good communication skills are essential when dealing with terminally ill patients and their carers. Empathy and compassion are important in addressing emotional and psychological needs but there is a reluctance among doctors to address spiritual needs which are equally important.

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