Magic of communication

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug’- Modern Hippocratic Oath (1964, Dr Louise Lasagna)

I am sure you must have heard your patient say, “Doctor, I feel better just by meeting you.” Do you remember feeling the same for your doctor, when you fell sick and ‘knew’ that seeing your favourite family doctor would make you feel better instantly? I remember!

Why do you think patients pass such statements? They have not started your treatment yet, but they claim that they will be better nonetheless. That is because they see that you care. You communicate skilfully, that you are there for them through your words and gestures. You empathise. And herein lies the power of empathetic communication.

Communication: Understanding the four styles

Communication forms the basis of a doctor’s practice. It’s not just about prescribing medicines. Because if medicines were the only answer to our patients’ problems, only a pharmacist would suffice. And communication is not a gift that all of us may have. I had to work hard to learn it too.

And here is what I learnt: that there are four different styles of communication*:

1. Apathy

2. Antipathy

3. Sympathy

4. Empathy

As dermatologists, we all change our styles of communication a day-to-day basis, rather than on a patient-to-patient basis.

Here is how: You may show apathy if you were seeing the 10th case of eczema in your practice. Apathy is a generalised disinterest and can present as a lack of emotional expression. In this context, it is not a total absence of emotions, but it is the lack of expressing them. Since eczema is easily spotted, and you as a dermatologist do not need an entire detailed history to treat the condition, you may be in a hurry to start writing the prescription as soon as you see the skin lesion (unfortunately that is what I did on most occasions when I worked as an SR in a busy municipal hospital with an OPD of 400). But remember this universal truth: As much as you are an expert in skin diseases and their treatments, the patient is an expert in their disease. They may be your 10th case of eczema, but you are the first dermatologist they are visiting. They are not seeking only your medical help, but they want to understand why this happened and more importantly, they want you to listen to their story of how it started.

I remember showing antipathy in a patient with psoriasis back when I had no information on the topic Iam penning down. The patient was a 48-year-old male and had consulted a lot of dermatologists before he had come to seek my advice. From the word go, he seemed aloof and arrogant, almost as if he were doing a favour to me by coming to see me. “I do not believe in dermatologists anymore, but since you were recommended by a friend, I have come to see you,” is what I remember him saying. As a young dermatologist who has just started her clinical practice, such a statement can be quite jarring. My experience of emodermatology alluded me at the time and so I entered amode of antipathy and communicated with the patient in a complete state of aversion and dislike. Antipathy means showing a total lack of emotion, unlike apathy where there is a lack of expression of emotion. In a very robotic voice, I stated the facts of the condition called psoriasis, enumerated the options for treatment, and let him select from the potpourri of treatments that I had listed. As expected, the patient chose one option, took my prescription, and never returned. In hindsight, as I recall this experience, empathy was what I needed to apply. Some may say, I could have been more sympathetic in my style. But that would not have worked either. Because although we as ahuman race are experts in sympathising, it does not worry effectively as empathy does.

What is the difference between sympathy and empathy is the question that arises. Sympathy is the sharing of the emotion that the person (patient) is feeling. Empathy is when you understand the person’s emotions but do not necessarily share them. Sympathy may arise from a position of superiority where you feel better off for not being in the person’s situation. It comprises a feeling of pity for that person. How many times do we feel relieved when we see a person with extensive psoriasis or vitiligo and think, “Thankfully, I don’t have this.” Since Iam being completely honest here, I accept that once upon a time I had these thoughts when I was studying dermatology as a resident.

Empathy, however, arises from a place of equality and not superiority. It is more practical. It is putting yourself in the shoe of the patient and trying to understand the feelings that he/she/they are experiencing. Not getting overwhelmed by them.

Components of empathetic communication

I remember, in the early years of practice, I used to come home emotionally drained from my work, desperately needing my one hour of me-time. And I am sure that most of you will echo these thoughts at some point or the other. Because sharing a distressing negative emotion of sadness, grief, despair and hopelessness with all your patients is tiring. Feeling them is even more tiring. And feeling them over and over again is a completely different ball game altogether. So empathetic communication is what we need to learn.

There are three different components of empathetic communication:*

1. Active listening

2. Unconditional acceptance

3. Non-judgemental attitude

Active listening: This is a skill in itself. We think we listen, but when we listen to answer or offer solutions, it defies the concept of active listening. Listening consists of focusing on:

• Verbal- non-verbal clues or observation (patient fidgeting with fingers, sweating in an air-conditioned room, restless in their seat)

• Actively reacting or mirroring the person’s gestures (sitting facing the patient)

• Giving feedback on what you are listening to (as in head nods or even a ‘yes I understand’)

Unconditional acceptance: This includes removing or keeping aside all the prejudices or biases you may have regarding the topic discussed or the person discussing it. Agood example would be when you are consulting a case of venereal disease.

Non-judgemental attitude: Here, it is not labelling the person as good or bad. Nice or rude. Some judgemental statements that we could avoid would be: “He is a trouble maker” or “She is not going to listen . . .” or “All these people from this clan are like that only . . .”

We all have defied the rules of empathetic communication at some point in our journey as a dermatologist. But when we start actively becoming aware of thoughts and training our minds, is when we see how this magic of empathy and emodermatology works in all patients when we apply it.

Having said this, knowing when not to use empathy is also important. As much as we want to be kind and considerate dermatologists, we also need to coach our patients into healing, not just guide them. Different patients will have different personalities; some may be submissive, while others may be narcissistic. Understanding that not all will respond to the same approach is crucial. You may need to employ apathy, antipathy, or even sympathy as strategies in your day-to-day practice. Empathy can serve as your default communication style, but, as in any battle, merely following a pattern may render it ineffective. Strategising becomes essential.

A journey from empathy to healing

Acouple of years ago, I dealt with an arrogant man who had reached his point of frustration regarding his psoriasis (my tryst with distressed psoriasis patients continues). He had tried all forms of treatment, allopathy and otherwise, and had finally come to me saying, “You are the last dermatologist Iam seeing…”. Now with the experience of emodermatology that teaches the power of empathetic communication, I handled it thus:

1. I followed the rules of empathy during the first visit. I actively listened to his entire story, mirrored his gestures, and maintained a non-prejudiced and unbiased tone, despite his unpleasant demeanour. After he finished speaking, I summarised his journey to ensure he knew I was fully engaged. Then, I explained the entire basis of the NICE (neuro-cutaneous-immuno-endocrine) system and how his irrational thoughts (A’s) affected his psoriasis. I taught him the ABC formula (REBT -Rational Emotive Behaviour Therapy) and provided a detailed prescription before sending him off.

2. The follow-up after 15 days remained unpleasant for me. Despite having established a sense of trust with him, he remained uncertain about whether the medicines or the ABC formula were effective. He expected miraculous results and a complete reduction of the lesions, which is rarely achievable within such a short timeframe. At this point, I strategised and implemented apathy.

3. Lo and behold, it worked, and I shifted back to empathy during his third visit. Witnessing the fading of the psoriasis lesions, he entered my clinic with confidence, assured of his path to healing.

I cannot help but quote Nelson Mandela’s words here: “If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart.”

Emodermatology and communication is a skill that needs to be learned today. With so many avenues of misinformation that are available to our patients, it is getting harder and harder not only to make them stick to treatments but also to give them sustainable results.

Remember the iconic phrase “All is well” echoing throughout the movie “Munna Bhai MBBS” (bless Vidhu Vinod Chopra for this film). It forms the foundation of a patient’s mindset when they encounter their healing doctor – that eventually, everything will be well – and “pyaar ki jhappi” becomes your language to comfort them. It serves as a metaphor that your words of kindness hold significance, and the way you convey that kindness through empathetic communication matters even more. Often, it heals better than medicines.

When you think about it, it is all about empathy. It always has been.

*excerpts from the online emodermatology batch of 2024 conducted by Psychiatrist Dr Anand Nadkarni and Dr Pradnya Manwatkar

About the author: Dr Pradnya Manwatkar, MBBS, DDVL, is a distinguished Consultant Dermatologist at Skin Matra Clinic in Mahim West, Mumbai. Renowned for her expertise, she has authored two insightful books, “How To Tell Your Skin To Heal Itself” and “From Skin Breakouts to Skin Breakthroughs”, offering valuable insights into skincare.