Home 
Contact 
Profile 
Videos 
Presented at the 10th Annual Surgical Research and Residents Day at the Department of Surgery King Faisal Specialist Hospital on 28th October 2010 by Prof Omar Hasan Kasule Sr MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Department of Bioethics King Fahad Medical City Riyadh omarkasule@yahoo.com
SUMMARY
The presentation is divided into 2 parts: aspects of successful communication and ethico-legal issues in staff to staff communication of confidential information. A medical practitioner must communicate successfully with colleagues to ensure successful professional interaction in the healthcare team as it carries out its teaching and care delivery functions. Communication is not about speaking; it is a wider concept involving personal interaction, behaviors and attitudes, and the etiquette of being with others in a group. Practitioners must be proficient in face to face and written communication with one another to ensure accurate transfer of medical information while observing ethico-legal requirements. Practitioners must be aware that communication of confidential medical information to other colleagues has ethico-legal constraints; only those directly involved in care have the right to know. Disclosure to other colleagues for education, research, and audit purposes will require patient consent. There are many ethico-legal challenges in the disclosure of personal health status to other colleagues or disclosing medically useful information when not part of the therapeutic team..
31.0 ETIQUETTE OF PROFESSIONAL INTERACTION
1.1 Composition of the health care team:
The health care team in a teaching hospital is very complex, multi-disciplinary and its members play complementary and inter-dependent roles. It consists of both academic and hospital personnel all engaged in the care of patients. The academic personnel are the medical faculty as well as the students (under-graduate and post-graduate). The hospital staff is the consultants, nurses, nursing aides, auxiliary medical personnel.
1.2 Dual functions of teaching and delivering care
All members of the team have the dual function of both teaching and delivering health care. The teaching process is complex. There is programmed and structured teaching. However most of the teaching is passive; there is a lot of learning of attitudes, skills, and facts by being present and watching what is being done to the patient. There is also continuous learning from one another. Students learn from consultants but consultants may also get new insights from students.
1.3 The teacher's etiquette:
Teachers should have the humility to know that their knowledge is limited and that they can always learn more. They should make the atmosphere and circumstances of learning easy for the students. Teachers must be careful in their actions, attitudes, and words at all times because being models and leaders they are seen and are emulated. They must be aware that sometimes they can teach using body language without saying anything.
1.4 The student's etiquette:
The student should respect the teacher. This is respect for knowledge and not the individual. Students should be quiet and respectfully listen to the teacher all the time. Students should cooperage such that one who attends a teaching session will inform the others of what was learned. Students should ask questions to clarify points that they did not understand or which seem to contradict previous knowledge and experience.
1.5 Etiquette of inter-personal interaction:
Greeting is necessary whenever members meet again even after a short separation. A small group will initiate greeting the larger group. The walking person initiates greeting the one sitting down. Everybody must be greeted whether known or not known. Those in an assembly must make room for any new comer. Two individuals should not engage in secret conversation in the presence of others because that may create an impression of backbiting and suspicion. Standing up when a person enters is a sign of respect. You should not force a sitting person from his seat. When a person goes away for a temporary period, he has the right to reclaim his seat.
1.6 Positive behaviors and attitudes
The following positive behaviors and attributes should be encouraged in the team: mutual love, tawadud, and empathetic caring for one another, rahmat & hilm; leniency, rifq, in everything; co-operation and mutual support, ta'awun; generosity, karam; truthfulness, sidq; patience, sabr; modesty, haya; cheerful disposition, imbisaat; calling people by their favorite names, ahabb al asma; recognising the rights and the position of those older than you, irfan haqq al kabir; and self control in anger, malk al nafs inda al ghadhab.
1.9 Negative behaviors and attitudes
The following negative attributes should be avoided: harshness in speech, rumor mongering, namiimat, excessive praise of others in their presence, al ghulw fi al thana, mutual jealousy and turning away from other, tahasud & taba'ud, & tadabur, avoiding interaction with a colleague, hijrat, for more than 3 days following a misunderstanding; anger, ghadhab; spying on the privacy of others, tatabu'u awrat al nas. You should avoid repeating the same mistake twice. It is required not to volunteer information about your personal weaknesses, al satr ala al nafs, unless it involves correcting a mistake related to the general medical work
2.0 ETIQUETTE OF THE MAJLIS
2.1 On the first meeting: The first impressions that people get about you on first meeting are lasting. Make sure you project a positive but true image of yourself. Take care of your physical appearance. Your hair must be combed well, the nails clipped, your clothes and face clean and appropriate. Your greetings must exude warmth and confidence. Eye contact with those of the same gender enhances communication. Before starting communication in small groups you can do some things that facilitate the process: Greetings, shaking hands, standing up as a sign of respect, kissing, and embracing. Take the initiative to greet or shake hands first. Be personal and informal; the personal touch has a lasting impact. Meet others with a cheerful countenance and maintain it throughout the communication process. Express emotions and love for your partners.
2.2 Being in a group: When sitting in a group, do not ignore anyone. People hate being ignored. Try to involve everybody in the conversation. You can not engage in secret talks in the presence of others. You should also not use a language unknown by some of the people in the group. Be kind and generous to the young and respectful to the elderly. Never embarrass anyone in a gathering. Always pray for those who say or do something good. When sitting in a gathering, give place to the newcomers and let them feel welcome. The newcomer should also avoid displacing anyone. It is better he sits even at the end.
3.0 FACE TO FACE COMMUNICATION
3.1 Advantages of face to face communication
Face-to-face communication is usually the best form of communication because of immediate feedback. Writing never conveys fully what is conveyed by direct face-face interaction.
3.2 Language use: For successful communication speak clearly, be specific and concise, objective, repeat to ensure understanding, and ask for feedback. Focus on the topic of discussion. Do not say too much and thus create an information overload. Use simple but precise language. Repeat to ensure understanding. Base your communication on objective facts.
3.3 Feedback is necessary to ensure that your message is going through. Watch for, ask for, and welcome feed-back. Take the initiative to ask questions to make sure you are understood. Listen more than you talk. Do not talk continuously. Pause for questions and comments. Stop talking so that moments of silence may make the message sink
3.4 Voice and speed: Your pitch, voice inflections, volume, and speed must be appropriate for the listener, the type of message, and the circumstances. The speed of conversation is important. Too rapid is difficult to follow. Too slow is boring and causes the listener's mind to wander off.
3.5 Body language: Learn to use body language to enhance your verbal communication and make sure that the verbal and non-verbal communication cues are coordinated and are not contradictory. The message conveyed by body language may support or contradict that conveyed verbally. The body language message is more believable.
4.0 ARGUING YOUR CASE:
4.1 Logic: When arguing your case, start by establishing some common ground on which to build. Use only logical reasoning and avoid being emotional. If you have strong arguments be careful not to prove anyone a fool. That is the quickest way to lose an argument. Do not be defensive. Try to show advantages for others in agreeing with you.
4.2 Plan: why? what? who to argue with? how? Choose the time carefully.
4.3 Aim at reaching agreement: Discuss with the aim of reaching agreement. Define area of disagreement. Watch for feedback. Do not talk about subjects you do not know. Concentrate, listen well, give undivided attention, paraphrase what others say to show you respect them, and be polite. Be calm, sympathetic, kind, and lower your voice. Avoid words that hurt. Do not be diverted to branches. Do not prejudge or judge hastily. Do not stereotype. Be brief and concise
5.0 USING THE TELEPHONE:
5.1 Start: When using the telephone, start with a pleasant but short greeting. Establish rapport immediately. Project a positive and credible image at the beginning; this will facilitate further conversation. Speak with a powerful and confident voice. Sound interested and motivated. Be brief and get to the point immediately. Pause and allow for responses.
5.2 Choice of words: There are words and expressions used in face-to-face communication that will lead to misunderstandings in a telephone conversation because there is no supporting body language.
5.3 Ending: Train yourself to signal that you want to end the conversation without offending your listener. You must learn techniques appropriate to your culture of cutting off a rambling caller tactfully.
5.4 Difficult communication: When an angry, aggressive, and obnoxious person calls you, be careful not to get emotional. Listen him out and ask clarifying questions to understand his motives then act appropriately. It is always better to end such a talk quickly and plan a follow-up at a later time when the caller may be in a better emotional situation.
7.0 THE ART OF LISTENING
7.1 Listening: Listening activity involves comprehension and 3 transactional processes (direct feed-back, indirect feed-back, and delayed feed-back). In active listening the listener shows obvious interest and asks questions. He or she asks questions to understand. The questions should seek clarifications or additional information.
7.2 Improving listening: As a listener you can improve your listening in various ways. Talk less and listen more. Clear your mind of other matters before start of the conversation and give undivided attention to the speaker. Let the speaker know you are listening. Write notes. Ask open-ended questions for clarification and also for encouragement of the speaker. Give feed-back. Summarize or paraphrase some of what the speaker says. Separate content from feelings and deal with each accordingly knowing that each is important. Do not be too argumentative even if you do not agree with the speaker. Listen, then think, then respond, and then comprehend.
9.0 CONFIDENTIALITY OF MEDICAL INFORMATION
9.1 Rights of privacy
Privacy and confidentiality are two different concepts that are sometimes confused with one another. An individual has a right to privacy that implies the right to make decisions about personal or private matters and blocking access to private information. The physician can enter into this privacy only if there is an autonomous decision of informed consent. Any information obtained in the process is confidential and cannot normally be disclosed to third parties.
9.2 The concept of kitman al sirr
Keeping secrets should be the default position, revelation is the exception. However in the behavior of most humans revelation is the normal default and secrecy the exception. The Prophet taught us to rely on keeping secrets in managing our affairs, al I'itimad ala al kitman fi qadhai al hajat
9.3 The culture of keeping secrets: Keeping a secret therefore requires effort and discipline. Keeping a secret is a sign of good Islamic character; you need not tell all you know. Information should be kept secret even if there is no foreseeable harm in its revelation. The Prophetic teaching is to listen more and speak less. The injunction about keeping secrets involves even probing to look for information not related to the present care because this will constitute spying, tajassus, that was prohibited by Law. It is forbidden to try digging into the privacy of another person, la yattabi’u ‘awrat akhiihi.
9.4 Anonymous information
There is an almost unanimous agreement that anonymous information that cannot be used to identify an individual can be releases without patient consent. This position is very true and understandable in societies that have a high level of individualism. Muslim societies where the communal interest is generally above individual interest, more care has to be taken about anonymous information if it can reflect community disease experience in a negative way.
10.0 RELEASE OF THE INFORMATION TO OTHER HEALTH WORKERS
10.1 Speaking little and for a reason:
The caregiver should cultivate the Islamic habit of speaking and only when there is necessity. Speaking too often and to anybody may unconsciously lead to divulging confidential information.
10.2 Disclosure to the healthcare team:
Customarily information can be disclosed to other members of the healthcare team on a need to know basis. This disclosure is allowed under the fiqh principle of dharurat. As in all cases of necessity, only what is necessary should be disclosed, al dharurat tuqaddar bi qadriha. Disclosure to healthcare workers who are not in the treatment team is generally frowned upon.
10.3 Disclosure for research purposes
Disclosure of information to other healthcare workers for research purposes is allowed only with patient consent to participate in the research in general and specifically to have his/her information disclosed.
10.4 Disclosure for education purposes:
Disclosure of information to other healthcare workers in the course of education and training does not in my opinion constitute a situation of dharurat that can override the patient's autonomous right to privacy.
10.5 Disclosure for audit purposes
Disclosure of information to other health professionals involved in audit or quality control activities is not a situation of dharurat that requires breaching confidentiality. It can only be done if the patient consents or of the information is anonymous.
10.6 Divided or conflicting loyalties
Some physicians find themselves in a situation of conflict and divided loyalty. Military physicians may also have to report medical information to medical colleagues at higher military rank when they feel that the disclosure will hurt the patient and is not part of the therapeutic process. In most cases the autonomous right of the patient to privacy overrides other considerations.
11.0 CASE STUDIES FOR DISCUSSION:
1. Is a midwife obliged to disclose his/her infection status to colleagues?
A midwife who had contracted HIV due to transfusion hid her status for 5 years. She was very meticulous during deliveries observing all precautions and during that time no patient was reported to have been infected. After a family quarrel her husband revealed her status to the newspaper. The editor failed to interview her before publication of the report. The midwife refused a request by the head of obstetrics to have an HIV test. The hospital suspended her and charged her for criminal negligence in the high court.
2. Is a surgeon obliged to disclose his/her neurological disability to colleagues?
A cardiothoracic surgeon was involved in a road traffic accident with injuries to the head. During convalescence he experienced mild convulsions on two occasions and a result secretly prescribed anti-convulsants for himself. He occasionally experiences momentary absences in lengthy surgeries. His condition has never affected his work over the past 5 years.
3. Reporting suspected contagious disease in a colleague to other colleagues?
A specialist surgeon in a depressed state since the death of his wife several years ago. He is noticed by colleagues to have needle marks on his arms. He recently developed several skin lesions that experienced infectious disease specialists suspect to be due to HIV infection. None of them has the courage to confront him or talk about him to someone else.
4. How can a doctor communicate to a colleague with unethical behavior?
A 60-year old surgeon was known by everybody in the hospital to cause pain while examining patients without prior explanation and consent. He used to make lewd jokes about female patients. He discussed diagnoses with his friends at the café and details of many patients were known in the community. A junior doctor who complained to the hospital director was told to keep quiet. Nobody else dared to complain about him because of his seniority.
5. Communicating confidential information to a spouse who is also a doctor
An infectious disease specialist treating a woman who was HIV+ve but who refused to inform her husband, became desperate and told her gynecologist who happened to be his wife working at the same hospital.
6. Stopping a colleague from asking irrelevant questions
A family physician called an orthopedic surgeon to consult on a suspected fracture in a 70-year old man who had fallen from a hospital bed where he was being treated for complications arising from diabetes. When the consultant started asking questions about sex life and taking alcohol, the family physician shouted at him to stop.
7. Non-medical secrets that can help reach a diagnosis
A doctor in the cafeteria is discussing a case with colleagues without mentioning the name. He has difficulty making a diagnosis and is seeking help. A junior doctor who knew the patient in another hospital and has details about his personal life that can help clinch the diagnosis keeps quiet.