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‘Health professionals need medical communication training’ 

08 Feb 2021

Practically oriented training sessions on medical communication, specifically on risk-related assessment, communication, and management during outbreaks of epidemics and pandemics, should be conducted for healthcare professionals, a concept note recommended last year.  Furthermore, medical ethics, the ethics of social media use, information gathering, and fact-checking should be included in continuous professional development programmes for all categories of healthcare professionals, and be included in their basic, post-basic, and postgraduate training programmes.  These recommendations were made in an opinion piece cum concept note (written on 17 May 2020) titled the “Ground Realities of Covid-19 in Sri Lanka: A Public Health Experience on Fear, Stigma, and the Importance of Improving Professional Skills Among Health Care Professionals” authored by G.L.W.M. Bandara, I.N. Thotawaththa, and A.W.I.P. Ranasinghe (all three attached to the Office of the Regional Director of Health Services, Matale) and published recently in the Sri Lanka Journal of Medicine. Among the many obstacles encountered by healthcare professionals in dealing with Covid-19, the stigma attached to the Covid-19 disease and gaps in professional skills related to risk assessment for Covid-19 were high on the list. The stigma attached to Covid-19 resulted in an unacceptable level of fear among the general public as well as healthcare professionals. This associated stigma has led to healthcare professionals not trusting patient histories.  The unethical use of the media was one of the main reasons for the stigma associated with Covid-19, as a large proportion of the general public did not receive enough scientific information about the disease and its preventive measures through the media and were instead overloaded with emotionally provocative information. Many media reports were delivered in a judgemental manner, and frequently the fault was attributed to individuals who got the disease. Also, some patients were labelled as to having hidden pertinent facts or lied about their members being taken to quarantine centres. This may in turn have led some patients to hide their histories. This reluctance to disclose details led some healthcare professionals to have a similar perception about patients. It was not uncommon to observe that healthcare professionals assumed that patients would deliberately hide symptoms, their contact history, or other relevant information. Elsewhere, public health staff were encouraged, for the purpose of history taking, to use some techniques frequently used in counselling. Sometimes, talking to neighbours gave more clues to the patient having symptoms. Hiding symptoms was mainly due to the fear of being blamed for deliberately transmitting the infection to others or the fear of their loved ones being taken to quarantine centres. It was also observed that some suspected Covid-19 patients could not provide adequate information during history taking and that this situation was misinterpreted as to be the deliberate withholding of information, whereas the exact reason was the language barrier which was not perceived by the healthcare professionals. A skilled professional approach to history taking puts patients at ease. It was found that after spending a few extra minutes to make patients and contacts comfortable and also reassuring them that the healthcare professionals were there to help, they tended to divulge their histories in full.  Fear and stigma interfere with health-seeking behaviour and this in turn leads to patients not seeking treatment or hiding their details. The portrayal on television of patients infected with Covid-19 as criminals has resulted in major damage to both public health control measures and hospital procedures, the authors noted.  Enhancing the professional skills of healthcare professionals and training them to spend time in taking histories is essential to ensure that all information required to implement control measures are obtained from patients, the researchers added, noting further in this regard that healthcare professionals need to re-train especially in communication skills such as respecting others, building rapport, empathy, active listening, and accepting what patients/clients say until the facts are verified.  Taking histories in the field to assess the risk of Covid-19 should be done by trained healthcare professionals, and all relevant field health staff such as Medical Officers of Health (MOHs), Public Health Nursing Sisters (PHNSs), PHN Officers (PHNOs), Public Health Inspectors (PHIs), and Public Health Midwives (PHMs) should be trained in this regard, the authors emphasised.  Public health staff who are healthcare professionals should not, the authors pointed out, divulge any personal information to the media.  The presence of the media during contact tracing, specimen collection, and quarantine procedures in the community, should be, according to the researchers, actively discouraged, while taking photographs without consent and exhibiting these on social media also is to be discouraged.  Continuous efforts to train healthcare professionals on the professional handling of information and communication with people, with hands-on training at the community level are useful to prevent stigma, they noted.  Ensuring patient confidentiality is mandatory when history taking is done by any healthcare professional and when liaising with other stakeholders such as the Police, regional administrators, and the military. Public health teams should therefore assess any risk exposure in detail and be confident about the data gathered, prior to communicating with the other authorities involved, the authors explained.  Another aspect is that assessing the risk of getting Covid-19 in people who present with respiratory symptoms, pregnant women, and the contacts of confirmed Covid-19 confirmed patients, requires an updated, broad understanding of the interim guidelines and case definitions and this becomes a challenge in a scenario where case definitions and guidelines are updated in quick succession. Therefore, healthcare professionals had to learn ways to gather and disseminate knowledge on the frequently updated guidelines.  The epidemiology (frequency and distribution of cases) of Covid-19 is very dynamic and therefore, healthcare professionals are expected to be very up to date about the disease situation and their locality, and aware of the evidence-based preparedness and response practices in institutional and community settings. However, the authors elaborated that the Sri Lankan health system lacks a proper process to update healthcare professionals during such dynamic situations. The updating of healthcare professionals at the provincial, district, and divisional levels, they noted, were mostly dependent on a few self-motivated professionals rather than through a process.  Moreover, a lack of understanding about the disease dynamics and guidelines led to panic among healthcare professionals, which in turn hindered proper risk assessment and risk communication, resulting in unnecessary testing, the irrational use of personal protective equipment (PPE), unnecessary travel restrictions in the form of local lockdowns, and problems related to the handling of dead bodies.  On another related note, the researchers said that Sri Lanka does not have a mandatory continuous professional development requirement for any healthcare professional category, adding that the pandemic illustrated the need for such a programme for all categories of healthcare professionals. The panic created during the initial period meant that other categories also had to be retrained on how to adjust their work during the pandemic, without contributing to further panic while adequate precautions were being taken. Furthermore, they pointed out the need to conduct awareness programmes for many stakeholders including the Police, district officers, educational officers, complementary and traditional medical practitioners, and owners of funeral parlours.  The use of non-scientific methods on disease prevention such as the use of disinfectant chambers, direct spraying on humans, and spraying on roads and open public places were not, the authors noted, advised as per the technical guidelines of the World Health Organisation (WHO). However, these practices rapidly gained ground in local communities, as they created an atmosphere of perceived protection which has in turn led to undue pressure on public health staff because local politicians and some government officials have demanded the same practice which has been frequently shown by the media. The amount of chemicals wasted and subsequently added to the environment as a result of such practises may contribute to environmental health problems, they further explained. Also, as there were no guidelines available during the initial few weeks of the pandemic, it was a difficult task to resist such requests, coming from various stakeholders, from healthcare workers themselves to politicians.  Another new challenge for public health officers, the study noted, was to acquire the skill of specimen collection from quarantine centres and the community. Further, collecting a large number of samples from different places in the community and from quarantine centres, while ensuring that the quality of samples was not compromised, and PPE use was minimised, was a challenge with the in-house preparation of triple packs for sample transportation, to the donning and doffing of PPE in the community. It was also noted by the authors that awareness among healthcare professionals about the disease was mostly dependent on the information gleaned through social media and television news rather than through scientific communications. This, they noted, was a challenge, as myth busting required additional effort in a backdrop in which knowledge on the evidence hierarchy and its applicability for scientific decision-making was lacking. Therefore, they concluded that reorienting the health system to prepare and practice evidence-based epidemiological interventions in any outbreak situation is a timely and national need.

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