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Communication Skills in Medicine

Tjakra W. Manuaba Dept of General Surgery School of Medicine. University of Udayana Sanglah Academic Hospital. Bali

What is Communication
Is the act by which information is shared between humans. Such encounter might cover: Desires

Needs
Perceptions

Knowledge
Affective states

The ability to communicate well with patients to build up a trusting relationship within which curing relieving and comforting can take place, is a great challenge Why good medical communication is important? better care for our patients
Sir Charles Fletcher

RECOGNITION OF THE PROBLEMS BY HEALTH PROFESSIONALS

In recent years, some medical practitioners have warned their colleagues of the trend away from the treatment of the human being and the commitment to the patient. They recommend moving from a problem focus to a person focus. Dr. C. Everett Koop, former surgeon general, stresses that health care professionals have a spiritual heritage of cherishing life.

Gordon & Edwards 2006

RECOGNITION OF THE PROBLEMS BY HEALTH PROFESSIONALS (continued)

Dr. Koop points out, however, that We put too much emphasis on curing, especially when a disease is fatal, and not enough on caring.curing costs millions but caring comes from the heart and soul. I hope Americans never run out of it either As scientific advances have proliferated, it is widely believed that concentrating on treating the disease has come to predominate over treating the illness of the patient.

RECOGNITION OF THE PROBLEMS BY HEALTH PROFESSIONALS (continued)

It is also widely recognized that nursing has become less patient-oriented and more scientifically oriented. Nurses increasingly are more involved with the technology of care. Complex machinery and excessive paperwork... As a result they may be distracted from some of their more caring functions.

SOME RELEVANT RESEARCH FINDINGS

Some medical literature contains a large number of research studies that have evaluated physician-patient interactions and documented the undesirable results of ineffective communication in such interviews. A recent study found that in encounters lasting 20 minutes, doctors spent just a little over a minute giving information to their patients.

SOME RELEVANT RESEARCH FINDINGS (continued)

In medical school and in their internship or residency training, physicians learn to ask many questions in taking medical histories, yet the interrogative mode in a subtle way communicates, I am in charge here. Physicians who ask many questions are keeping tight control over the relationship.

No wonder so many patients complain that the doctor doesnt listen to them.

SOME RELEVANT RESEARCH FINDINGS (continued)

One way that improvement of treatment should be realized by physicians, is through increasing patient compliance or cooperation with the physicians orders. Noncompliance with prescribed medication regimens has been shown to be a significant cause of hospital admissions.

Medical Communcation
Medical communication is the usual communication encounter between doctor and the patient It can be classified according to the purpose of the interview into 4 types
History taking Consultation

Obtaining Informed Consent


Breaking bad news

DOCTORS PATIENTS RELATIONSHIP.


Not anymore paternalism Should be partnership basis. Doctor-Patient collaboration vs health problem

Equal

Medical Ethics respect the autonomy of patients Paternalism only to patients who are not able to be autonomous The only way of interfering with individual autonomy is where it prevent harm to third party or self harm

Specific Rules based on Autonomy


Tell the truth

Respect individuals privacy


Protect confidences

Ensure that consent has been obtained for medical interventions


When asked. Help others to make decisions

Components of professionalism
ALTRUISM

COMPETENCE
- CLINICAL + COMMUNICATION SKILL - ETHICOLEGAL UNDERSTANDING

HUMANISM
- RESPECT - COMPASSION - EMPATHY - HONOR - INTEGRITY

EXELLENCE

ACCOUNTABILLITY

Standard of professional conduct

Dissatisfaction with Doctor-Patient Relationships

Communication, between patients and health professionals, is seen as the core clinical procedure for diagnosing, treating, and caring for patients. Patients satisfaction is strongly influenced by the quality of the communication that occurs. Studies show that patients dissatisfaction can seriously reduce their compliance with their treatment regimen.
Gordon & Edwards

Dissatisfaction with Doctor-Patient Relationships (continued)

Dissatisfaction in communication can trigger patient doubts about the competence of their physician.
It can negatively affect how long it takes to recover. It can increase the frequency of patient malpractice sue.

The most frequent patients complaints about doctors

Doctors would not listen

Doctors would not give information


Doctors showed lack of concern & lack of respect for the patients
Lloyd and Bor, 1996.

Essentials of Patient Care

Physician

Patient

Art & Science of Medicine


Communication Medical History Physical Exam. Literature & Art in Medicine

Hagen & Pauly 2006

Communication Skills
To diagnose and treat diseases To establish/ maintain a therapeutic relationship

To offer information and educate

Communication Skills
To diagnose and treat disease and maintain a therapeutic relationship: - Data from the patient must be objective, precise, and reliable

- You must demonstrate respect, genuineness and empathy


- These skills can be learned and practice

Pathophysiology & Clinical Epidemiology

Diagnosis & Disease treatment

Objectivity

Science

Precision

Empathy

Art

Reproducibility

Therapeutic Relationship

Human behavior & Social and Cultural Context

Hagen & Pauly 2006

Communication Skills
You must demonstrate

- Respect
- Genuineness

- Empathy
These skills can be learned with practice

Respect
Remember that every patient could be you, your mom, your brother or your boy/ girlfriend
For example: How would he or she feel waiting for the doctor to come into the room?

Respect
Introduce yourself to the patient/ family
Explain who you are and your role Shake hands, but dont force physical contact if patient is uncomfortable Call the adult patient MrMrsMs (do not use first name)

Respect
Maintain privacy
Keep doors and curtain closed Acknowledge and greet others in the room Maintain a professional appearance clean, neat, conservative, white coat, name tag (professional authority)

Respect
Make sure the patient is comfortable
Sit at the patient level Be aware of the patients personal space (can vary among cultures) Continue to consider the patient comfort during history taking and physical examination

Respect
Appear interested and ready to listen

Use your posture to do this


- S -- Sit square to the patient

- O -- Open to the patient


- L -- Lean toward the patient - E -- Eye contact with the patient - R -- Relax

Genuineness
The ability to be yourself in relationship despite your professional role

Genuineness
It is OK to laugh at patients jokes
If patients spouse has died you might say: I am sorry to hear that. How are you doing?

Show your true interest in the patient

Empathy
Is the ability to understand the patients experiences and feeling accurately as well as to demonstrate that understanding to the patient Is an active process
Is more than sympathy, or feeling sorry for someone

Empathy
If you are empathetic you will maximize your ability to gather accurate and objective data about patients thoughts and feelings

Empathy
Observe the patient Pay attention to the patients nonverbal communication Is the patient looking away, fidgeting or leaning away from you while he or she talks?

Empathy
Dont interrupt In one study 69% physician interrupted patients within 18 seconds 77% of patients didnt get to fully explain their problem

Empathy
Enhance empathy by the way you respond to what the patient says
Show the patient you have been listening to the content of their problem Show the patient you understand their perspective on the problem

Empathy
Do not ignore what the patient says Avoid minimizing his or her symptoms Instead, reflect back to the patient

Reassurance

To solve problem

To form & maintain relationship

Communication
To alleviate distress To give information To make Decision Communication Purposes (Lloyd & Bor, 1996) To Convey Feelings

To persuade

Factors Influence Doctors Patients Communication

Patient Related Factors


- Physical

Symptoms

- Psychological Factors anxiety, depression, anger, denial - Previous Experience of medical care

- Current experience medical care


- PTSD

Doctors Related factors


- Training

in communication skills

- Self Confidence in ability to communicate


- Personality

- Physical factors (tiredness)


- Psychological (anxiety, PTSD)

The Interview Setting: Requirements


- Privacy
- Comfortable surrounding - An appropriate seating arrangement

Beginning an Interview?

Patients Expression ease the interview

A comfortable setting

Being greeted by name & handshake


Being shown where to sit

The interviewer introducing her/himself & explaining the procedure


An easy first question

The Interviewer appearing interesting in your remarks

Guidelines For Conducting an Interview


Beginning The Interview - Greet the patient (by names) & shake hands - Ask patient to sit down - Introduce yourself as the doctor

- Explain the purpose of the interview


- Say how much time available - Explain the need to take notes and ask if this is acceptable

The Main Part of The Interview


- Maintain positive atmosphere, warm manner, good eye contact - Listen carefully - Be alert to verbal and non-verbal cues

- Facilitate patients verbally and non verbally


- Use specific questions when appropriate - Clarify what patient has told you - Encourage patient to be relevant

Guidelines For Conducting an Interview

Ending The Interview - Summarize what patient has told you and ask if your summary is accurate

- Ask if they would like to add anything


- Thank the patient

By Understanding The Whole Process in Medical Communication

BETTER COMMUNICATION

-Clearer -More effective & efficient communication -Honesty & openness. -Trust -Mutual respect -Politeness -Adherence -Collaboration. -More accurate information -Prevention of violent situation -Informed consent -Legal aspects

BREAKING BAD NEWS.


CONDITIONING PLANNING EXPLANATION

Bad News
Inevitable part of medical practice
Not widely taught in medical schools Studies how patients/ families cope with bad news not the process of breaking bad news Bad news is a relative concept & should depend on patients interpretation of information & their reaction to it where patients feel the news will adversely affect their future

Why is it difficult to break bad News


The messenger may feel responsible and fears being blamed Not knowing how best to do it Possible inhibition because of personal experience of loss Reluctance to change the existing doctor-patient relationship Fear of upsetting the patients existing family roles/ structure Not knowing the patient, their resources & limitation

Fear of the implications for the patient (disfigurement, pain, social and financial losses)
Fear of the patients emotional reaction Uncertainty as to what may happen next and not having answers to some questions Lack of clarity about ones own role as a health care provider

Lloyd and Bor, 1996

Managing difficult situation in breaking bad news

To whom should bad news be given


Who should give bad news When should bad news be given

How much bad news should be given


Should you give hope and reassurance along with bad news

How to give bad news

Personal preparation
The Physical Setting Talking to patient and responding to concerns

Arranging for follow-up or referral


Feed and handover to colleagues

KEY CORE SKILL FOR BREAKING BAD NEWS EXPLANATION & PLANNING.

Preparation

Summarizing
Negotiating the Agenda Listening Picking up Cues The use of Silence Discovering the patients concern and ideas Encouraging the expression of feeling Picking up the non verbal cues

Conclusions
Do doctors need communication?

Doctors need to learn essentials of good communication more than under professionals because patients are human with sensitive needs.
Doctors can not practice medicine without effective communication skills

Poor communication causes a lot of medico-legal and ethical problems

Thank you