Communication is the cornerstone of patient care. Patients trust healthcare workers with whom they connect. In the current era of COVID-19, connecting with patients and their families is both critical and yet more difficult than ever before. We draw from our experiences as internal medicine residents to outline the current landscape and provide tips on how to communicate more clearly.

COVID-19 brings unique challenges to the art of communication, such as serious illness conversations. We have found that effective communication is significantly hindered by the presence of personal protective equipment (PPE). This is exacerbated by heightened levels of healthcare worker anxiety, patient characteristics such as hearing loss, and situational factors like ambient noise.

PPE, including masks and face shields, hide our facial expressions, a tool for displaying empathy. Smiling, one of the easiest and most instinctual ways to connect with another person, is no longer an option. N95 respirators muffle our voices, making it difficult for even those with intact hearing to catch every word. This challenge is intensified for elderly patients or those with hearing loss, particularly if they do not have hearing aids in place. The scarcity of PPE and lengthy protocol of donning and doffing limits the number of times healthcare workers may enter the room. Finally, healthcare workers grapple with anxieties related to our proximity to COVID-positive patients. Whether unconscious or not, these fears may stifle our ability to be present.

Based on experiences providing care during this pandemic, we suggest the following approaches:

Use technology to your advantage. Before you even meet your patient, take advantage of their cellphone/bed phone/iPad to ally with them. Make “small talk” before “big talk.” Ask patients about their lives before they were hospitalized and who they are. In the right setting, it can be sustaining and powerful to ask, “What are you looking forward to once you get home?” Tell them a little about yourself. These approaches can break down communication barriers. When you enter the room, you will already have a foundation upon which to build.

Have sensitive conversations in person. You can do a lot with technology, but nothing can replace human presence for difficult conversations. Consider naming an emotion that you might hear in a patient’s voice. For example: “You must be scared right now. I know I would be.”

Make good eye contact. Remember, your face sits behind both a mask and a face shield. When we wear this much protective equipment, we rely on our eyes alone. When you are with patients, ensure that you are sitting at eye level—do not stand over them. Make good, gentle eye contact. You may want to practice “softening your gaze” by raising your eyebrows and tilting your head slightly.

Speak loudly, but gently. N95s and PAPRs muffle your voice, and many elderly folks have baseline hearing loss. It’s helpful to speak in a somewhat louder voice, but do not yell; try to remove the harsh tones despite the higher volume.

Consider physical contact. Imagine how terrifying it is to have a room full of people who only come into your room wearing hazmat suits. The internalized stigma felt by patients can be profound. “Am I dirty?” they might think. Consider holding your patient’s hand and coming in close to their body. If you feel comfortable, showing them that you are not afraid of them or their bodies can be powerful. Stigma and social contagion are a part of every pandemic; making contact can be a personal and political gesture of solidarity.

Improve the message. Consider placing a nametag and photograph of yourself onto your gown so that patients can associate a face to your PPE-clad person.  Encourage your team to print face sheets clearly showing the names and images of all the healthcare workers to provide to patients. If feasible, encourage family members to send in photos of patients and their loved ones to decorate the room, allowing patients to recall life outside the hospital and allowing providers to see patients as people.

Practice. It may sound contrived, but once you have a sense of what you might say to a patient, it is worth practicing wearing PPE and having a conversation with one of your colleagues. Ask them for feedback: “Can you hear me clearly? Am I too harsh? Am I conveying compassion with my eyes?”

The strategies above reflect a few that have worked in our experience. Ultimately, this is an era when communication is extremely challenging: We have to find ways to meet our patients where they are, through heightened attention to our behavior and comportment. A little extra effort goes a long way in bringing humanity to our care at a time when it is needed most.

Kham Kidia and Amrapali Maitra are internal medicine residents.

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