Communication Barriers among Physicians in Care at the End of Life: Experience from a Postgraduate Residency Training in Java, Indonesia

Introduction

One of the major issues in medicine is the interaction and communication among health professionals in a medical team. In medical education, in particular for postgraduate residency training, communication among physicians in a teaching hospital with its complex training hierarchy has become a critical concern.

"Hierarchy" refers to a group of individuals ranked to authority, capacity, or position; while "medical hierarchy" describes the power relationship between a superior and a subordinate in medical training, often involving increasing power with each rank subject to the next higher level authority.¹ This describes the interaction among medical students (co-assistants), residents, and consultants (teaching staff) in a teaching hospital, which conveys perceptions of seniority and "powerful others". Medical students and residents are low in the medical hierarchy and are dependent upon their supervisors (seniors) for learning and instructions. However, hierarchy and differences in power and authority appear to lead to hesitancy to communicate openly among team members, and therefore communicating and discussing problems in patient care in such a system is often complicated and difficult.^{1, 2}

This article addresses issues of communication in patient care at the end of life among Indonesian academic physicians, including residents and consultants. It is part of the larger study of how Indonesian and American physicians respond emotionally to their patients' deaths.^{3, 4} In this study, we analyse the qualitative narrative data which emerged when we asked physicians to describe the end-of-life care and deaths of their patients. In particular, we examine how physicians speak about hierarchy in the training system and the ways hierarchy influences communication among medical team members and across medical specialties. This article on Indonesian physicians' discussions about barriers in communication is part of an effort to understand and improve Indonesian medical education and clinical training system. In cross-cultural comparisons of Indonesian and American physicians, we find similar issues and concerns arise when physicians speak about barriers in communication among clinicians that lead to less than optimal end-of-life care.^{2, 4-6}

Methods

The study methodology utilises qualitative measures. Physician participants were selected through chart reviews of patient deaths from the internal medicine and paediatric units in a teaching hospital between 1 January and 30 April 2004. One to two patient cases per week were randomly selected for a total of 38 patient cases. For this study, we only included residents and consultants. Residents are medical students in postgraduate training for specialisation, ranked from first-year residents (R1), second-year (R2), third-year (R3), to fourth-year residents (R4). Consultants are attending physician specialised or sub-specialised in each department, categorised into junior consultants (specialist or subspecialist) and senior consultants (subspecialist and head of department or sub-department). Residents and consultants caring for the patient cases were identified and invited to participate in the study. A total of 57 physicians (43 residents and 14 consultants) participated in the interviews, as shown in Tables 1 and 2.

For the purpose of this study, we focus on the narratives physicians told about the deaths of patients in their care and on their discussions of the training hierarchy. All the physicians' narratives, discussing both the most recent and most emotionally powerful deaths, were transcribed and read by the

Table 1.

Physicians by department and sex

Table 2.

Physicians by rank

research team members in order to identify a range of thematic content. Types of narratives about characteristics of patient deaths and about physicians' work in caring for patients at the end of life were categorised by the collaborating research team members. All interviews were then coded utilising an OpenCode (Version 2.1, June 2001) computer programme, allowing for identification of quotations and segments of interviews relevant to particular topics. Themes related to communication and the training hierarchy emerged directly from the narratives; categories were "emic" — in other words, they emerged directly from...