AIIMS teaches its doctors what to ask a patient. It must also teach them how

This year’s Mera Aspataal or “My Hospital” survey, deployed by the Ministry of Health and Family Welfare to accumulate data about patients’ experiences of government hospitals, finds that the satisfaction of patients at the All India Institute of Medical Sciences has improved since last year. The most widely-cited finding in news reports about the survey was that among the 22% of patients who claimed dissatisfaction, the prominent reason was staff behaviour.

The insight such surveys offer is limited given their inability to probe more deeply the reasons for patients’ responses. Nevertheless, the AIIMS administration responded to the report by saying that it intends to pay more attention to inculcating communication and “soft skills” in its doctors.

Communication skills are not currently part of the compulsory MBBS curriculum at AIIMS. Communication is predominantly learned through observation. Some faculty members make an effort to teach appropriate methods of communication and the department of psychiatry runs occasional workshops at which attendance is voluntary, but there is no coherent institutional approach to communication skills as part of a young doctor’s training.

Why does this matter? Because even as treatment becomes ever more technologised, communication remains at the heart of the medical encounter. We all know from our experience as patients that how a doctor behaves towards us – whether we feel truly listened to, or whether we are made to feel like a nuisance and dismissed without being heard – has a direct impact on how we evaluate the care we have received. More than simply the presence or absence of courtesy, such reflections suggest how communication as a conduit of social relations influences medical practice.

Why patients prefer AIIMS

Patients who frequent corporate, or “five star”, hospitals might respond to a dissatisfying encounter by changing their doctor. The majority of patients at government hospitals – like those who queue up outside the AIIMS gates at 3 am – do not have that option. For many of them, a rushed consultation with an irritated doctor is an inevitable component of an already stressful and confusing hospital experience.

The majority of the patients I spoke with described the behaviour of AIIMS doctors as superior to that of their colleagues in other government hospitals. They had sympathy for the pressures doctors work under in an institution that sees an average of 8,000 outpatients a day. They perceived a clear difference between acts of fleeting impatience and a tangible lack of respect, however.

“Too many patients come here,” said Sunita who was recently waiting in the main outpatient department for her sister who had been admitted with a deteriorating kidney condition. Sunita felt that overall AIIMS treatment of patients, even given the large numbers, was fine. But her assessment of the hospital’s communication was complex.

“The doctors are compassionate, their behaviour is good, and they are thorough,” she said. “But they get irritated if you talk too much, if you ask too many questions. They say they don’t have time to answer useless questions, they say that the treatment is underway, so it’s all fine. It’s also probably our fault that we ask too much, to clear things up or to ask their opinions. But sometimes we need to.”

Time pressures

Students at AIIMS are also concerned that communication methods are not part of the curriculum. Rahul, who is in his fourth year and asked that his real name not be used, said before his internship, “History-taking is taught, like what you need to ask to a patient, but how you are going to ask the patient, that’s the thing.”

Following his internship experience, Rahul said that he had a better understanding of how difficult it is to fully engage with patients under severe time pressure, but that he still tried to give time to those who seemed particularly distressed.

We should not assume that doctors in corporate hospitals are necessarily more sensitive communicators than their public sector colleagues. After all, many of them will have been trained in the same medical colleges without instruction in communication methods. They are, however, differentiated by two main factors: they have more time, and broadly speaking they occupy the same socioeconomic position as their patients. Both of these factors facilitate, but do not guarantee, effective communication.

This is where the deeper role of communication becomes apparent. Medical professionals must be able to talk to patients in such a way as to address the power differential between doctors and patients. This power differential is reflected in social determinants such as class, caste and gender, which are partly responsible for driving patients to AIIMS in the first place.

At present, students have little opportunity to discuss and learn from the ways in which social structures affect patients’ experiences of receiving, and doctors’ experiences of providing, medical care. When observing faculty is the only manner in which students learn about communication in the clinic, they received mixed messages about what it means to be a proficient doctor and a “good patient”.

During an outpatient department session one afternoon, a doctor repeatedly asked an elderly man to explain his complaint in his own words. “Aapko kya takleef hai?” He asked. What’s the problem?

When the patient proffered a sheet of test results, the doctor shook his head.

“Nahin – kya hai takleef?” he asked again. No - what is the problem?

The doctor persisted until everyone in the room, the patient included, was smiling. There was a palpable ripple of achievement when the patient mumbled a few words about his stomach. The doctor nodded in satisfaction and patted the man’s shoulder.

On another occasion, however, during an outpatient session in a different department, a middle-aged woman accompanied by her husband and son expressed concern about a tremor in her hands. The doctor directed her students to involve the patient’s attendants in a conversation if it might be helpful for the diagnosis. Accordingly, she asked the men to describe what they had observed in the patient and they both responded with “kamzori” – weakness. The doctor shook her head and pronounced that this was a subjective feeling, not an objective judgement. Cowed, the family sat in silence.

AIIMS was established with a mandate to create innovation in medical education that could be replicated around the country. A syllabus that incorporates an introduction to the social sciences, extending beyond communication as etiquette, would signal a determination to produce self-aware doctors better equipped to communicate effectively. Attention to these dimensions of medicine is long overdue – a challenge that awaits the institute’s new director.

The writer recently completed her PhD in anthropology at King’s College London, for which she produced an ethnographic study of medical education at AIIMS.