The Things That Medical School Won't Teach You (11): "Communicating properly"

I'm recalling that in the course of this series, I've intimated that one of my justifications for getting into the business was my interaction with medical personnel during periods when I was sickly. Now, some of those interactions were uplifting, encouraging, even edifying; on other occasions, the interactions were simply dastardly. Medicine is indeed one of those fields where the old saying holds true: "They may forget what you said, but they will never forget how you made them feel". Every little thing you're doing, whether verbal or non-verbal, communicates something important to the patient.

My mind drifts off to the memory of "Communication 104" during Fall Semester 2002 (Messiah College). My biggest take home from that whole class was something that was taught very early on: while communicating, our responses can be broken down into 3 broad categories - Agreeing, Disagreeing, and Disconfirming. The first two are very obvious and I'm pretty sure everyone has a semblance of what they entail; whether we relate to what's being said, there is the underlying impression that we've at least recognized what the other person has put forward. Discomfirming is in a class of its own: not only are you obviously opposed to what's been put forward by your colleague, but you make it clear that you've disregarded it entirely. In other words, it is basically a "coup de grâce", a death blow.

From that little definition, let's dive into another little memory from my time at Messiah College.

I believe it was Thanksgiving 2004. My Zambian friend had been kind enough to invite a few of us from Rafiki House to go over to his host family's place for Thanksgiving Dinner. I remember it was a great meal; I especially remember developing an appreciation for pumpkin spice pie after that day (despite having disliked the taste of pumpkin up until then).

Unfortunately, the whole dinner didn't go down without incident. I remember that they had also invited over a (seemingly) 70 year old lady who had been a missionary in Sudan for a very very long time. Sometime in the middle of the dinner, she had the bright idea to chime in that she felt that the traditional systems had faded away in Africa, and thus she felt that the younger ones were lost with no one to impart the important lessons to them.

I remember being the most vocal of my friends (many of whom were predominantly African) in trying to convince this lady courteously that the picture was not that bleak. I reminded her that though traditionally my people were renowned fishermen, there is no disconnect despite the fact that we do not follow in the path of my ancestors; because between my parents, siblings and wider family, I can still get a good education on what's important in life. HOWEVER, it didn't sway her in the least, and she doubled down on her morose ideas. It's always a difficult task relating to people who are set in their ways. Here was a lady who had lived in a land steeped in civil war for decades projecting her bleak outlook on a whole continent without having ventured elsewhere within the continent. Worse still is the fact that she was old; everyone deserves a modicum of respect, especially the older generation; that being said, no one gets a blank cheque for their thoughts and tangents.

I remember casting glances at my friends during the conversation and getting two distinct vibes from them: "Richard...calm down...just let it go."

Being disconfirmed hurts no matter how old you are. It is the grand old equivalent of being patronized. It doesn't matter whether it comes from a friend, parent, sibling or colleague...it will sting deeply. Don't get me wrong: it can sometimes serve as a useful teaching tool. I am not a parent yet, but every parent definitely has a story where they've had to put a disrespectful child in their place. Those are definitely the times that children need to be humbled. There is nothing to be gained from negotiating. It is at times useful for people to be reminded who pays the bills that keep the house running, and that afford them the luxury that they experience every day. However, disconfirming should not be your primary tool of instruction. It wouldn't make a very good "coup de grâce" if you employed it willy-nilly, would it now?

Now, when I first got to Kenya after finishing med school in China, I was as "green" as they come. I hadn't really had any real employment experience, and I knew that there was probably a lot I'd have to get used to about practising medicine in a different context. It was rather convenient for me that they made me go through a 3-month pre-internship at the Kenyatta National Hospital (KNH). Surgery was my first rotation, which seemed like a great starting point because Surgery has always been my passion. The experience, on the other hand, turned out to be a mixed bag. I think that it was great to be around doctors of varying levels (Professors, Consultants, Registrars, Interns and students) as well as other cadres like nurses, nutritionists, physiotherapists, etc; however, what whittled things down a tad was the interaction with the consultants. I could understand that they were intelligent within their respective fields of specialization, but that didn't mean that they had to be so antagonistic. I especially felt sorry for the registrars; despite being my seniors, it wasn't surprising for me to encounter one of them being chewed out for no reason whatsoever by the consultants; if they were particularly unlucky, they'd be blasted in front of all the cadres of workers present during a ward round.

I remember experiencing something similar during my internship. It was particularly surprising when I would encounter it from the medical officers who oversaw us as interns. It's easier for me to sympathize with consultants who've been far removed from the experiences of their underlings for such a long time; but I could not understand how a medical officer - who was probably just an intern a few months prior - could be so quick to dish out the type of demeaning treatment that they had previously suffered to a whole new generation of interns. It bugged me to my core that someone would choose to incorporate such poor teaching methods, but then "that's the breaks".

I'm not trying to say that ALL Kenyan doctors are deficient in the communication department, but a lot of the ones I've encountered sadly fall into that bracket. I have encountered very many great teachers in this field, but the bad ones leave a particularly bad aftertaste. This is very different from what I'd experienced in China where we were free to mingle with all levels of doctors from Professors down to our own colleagues. Not knowing medical facts was not seen as a time to disgrace a student in front of his peers, but rather as a teachable moment in which to impart knowledge to the student. Sometimes, as an added bonus, the professor might provide you with the "cheats" that make him remember specific pertinent facts in a few seconds. Compassion goes much further in teaching than browbeating someone to a pulp. By the time I'd finished my KNH pre-internship, I felt pretty sure that I was not going to be pursuing post-graduate studies within Kenya. After slogging through a tumultous internship, it is now my conviction! I mean, an internship may seem long and tedious, but they can only stretch one year so long...and eventually it ends. I cannot fathom what 3 - 5 years of a registrar postgraduate experience must feel like given the same circumstances, but it is definitely something I would not look forward to.

Like I've already mentioned earlier, all these forms of communication are important in conveying ideas and truths. In light of how I've focused so negatively on disconfirming, you might think that I am totally against it...and that would be totally far from the truth. I remember at one point having to disconfirm a vast swathe of the members of my class at medical school. And that memory goes a little like this:

A surgeon had walked into our class to teach us about "The Liver". I couldn't tell you how much of the class was acting up, however, they were creating such a sizeable ruckus such that it was impossible to ignore them. It really was an untenable situation because the surgeon was having a hard time teaching, and the students who were actually trying to listen we're having the hardest of times hearing what was being taught.

My mind flashed back to the previous weekend. I had attended an international surgical conference at a symposium hall within the Medical Healthcare Centre at the First Affiliated Hospital (of Wenzhou Medical University) in the city. I remember 2 highlights from that experience - watching a livestreamed session of bariatric surgery which was taking place within one of the First Affiliated Hospital theaters; the second was a lecture on Selective decongestive devascularization shunt of gastrosplenic region (SDDS-GSR ), which is an adjunct measure to relieving liver and spleen issues arising from chronic liver disease. You could tell that people's minds were blown by this novel approach and people were eager for highly decorated Prof. Qiyu Zhang to explain it in detail.

A few days later, standing in front of my class and attempting to deliver a lecture to a bunch of unruly international students is none other than Prof. Qiyu Zhang. I was livid! A few days earlier, medical professionals from a host of countries had patiently waited to listen to this man, but today so-called doctors-in-training couldn't even bother to give him the time of day.

I walked up to the front of the classroom and pleaded with Prof. Zhang for a chance to talk to my colleagues. Taking the mic from his hands, I proceeded to lay into them for all the embarrassment that they had caused us. I contrasted their behaviour with that of the specialist audience a few days prior, and reminded them that within their respective countries they would never tolerate such belligerence from their juniors; the message was clear - sit down, keep quiet and act right!

I am glad to say that the class quieted down, and we had a problem-free lecture (at least for that day!).

I feel sad that my school really didn't bother relaying information about certain things to the international students...things that were very obvious to the Chinese students. I for one think that it would have been important for us to have known that Prof. Zhang was formerly THE PRESIDENT of the First Affiliated Hospital. Years earlier, this man had joined me at my table as I ate a meal alone in the hospital cafeteria, and I never found out that he had been a pillar of the hospital until much later!

If I had been in his position, and I was in a vengeful mood, I would have made things seriously difficult for the international students in my year. Only one year later we were slated to get placements for internships within the Wenzhou Medical University's affiliated hospitals, and he had the power to make that very difficult for us. Just have to thank God that he let things slide.

I know I focus on the medical aspect of things a lot, but the message here serves everyone: it is important to invest yourself in learning to communicate properly. Since medicine is such a hallowed profession, people usually make excuses for specialists who are poor teachers because of their clinical acumen. (they do that for pretty much any specialist in any field). You shouldn't make the same mistake. Acknowledge that people are differently gifted and aid them in their pursuit of personal betterment. Use all tools available at your disposal (including disconfirming), but reach out for compassion faster than anything else. The world will thank you for it.

God Bless