Basic communication skills

Herni Suprapti

the factors that influence doctor-patient communication

some bad news

a relative has just died failed some exams

First

the setting or situation is clearly important

Second

how you feel at the time will influence what you say, and so will the attitude of the other person

The factors (patients) will influence how communicate

Personality Upbringing Social class Ethnic Cultural background

Reactions to illness include

Denial Anger Anxiety Depression

Factors influence doctor-patient communication

Patient-related factors Doctor-related factors

The interview setting

Patient-related factors

Physical symptoms Psychological factors related to illness and medical care (e.g. anxiety, depression, anger, denial) Previous experience of medical care Current experience of medical care

Doctor-related factors

Training in communication skills Self-confidence in ability to communicate Personality Physical factors (e.g. tiredeness) Psychological factors (e.g. anxiety)

The interview setting : requirements

Privacy Comfortable surroundings

An appropriate seating arrangement

Other factors that must be taken into account are :

the patients beliefs about health and illness the problem they wish to discuss their expectations of what the doctor will do (based on previous experience) how they perceive the role of the doctor

Doctor-related factors

medical student doctor easier than others to emphathise and communicate with patients other factors influence our behaviour during a consultation (Table 2.1)

medical student difficult initially when

interviewing patients who are much older than yourself sensitive issuess such as sexual behaviour are involved

have less to give particular patient

a medical student just before finals a junior doctor at the end of a long shift a GP who has already seen two-dozen patients earlier in the morning

impair communication

Tiredness Anxiety
Preoccupation with other concerns

The setting of the interview

Most consultations take place in

a hospital ward the outpatient clinic the GPs surgery

Privacy is essensial

The setting of the interview

A patient in a hospital bed

sensitive information Mrs Smith in the bed next door can hear every word through the curtains

the patient can be moved avoid interruptions Lighting Temperature

arrangement of seats

can influence how people communicate with each other and

give clues to how they perceive their own and each others roles in the encounter

outpatient clinic / GPs consulting room

chairs and desk or a table three possible ways of arranging the seating

Arrangement (a)

patient and doctor facing each other across a desk is unlikely to make the patient feel at ease or facilitate discussion the doctor may feel in control of the interview

Arrangements (b) and (c)

more informal more likely to facilitate good communication

the distance between the interviewer & the patient

Placing seats too close too far

4-9 feet distance may change during the course of the interview

in a hospital bed

standing over a patient draw up a chair so that you are on the same level as the patient

Beginning an interview

what made you feel at ease, you might have included :

a comfortable setting being greeted by name and a handshake being shown where to sit the interviewers introducing themselves and explaining the procedure an easy first question the interviewer appearing interested in your remarks

An unsatisfactory beginning is likely to lead to an unsatisfactory consultation

as the following case illustrates

How not to begin an interview

Mrs Francis, a shop assistant aged 31, attended medical outpatients at her local hospital
Here is her story :

When I went into the room which was big and bare I felt lost. I didnt know where to sit, the doctor had his head down and was writing, the nurse was on the telephone and there were some medical students talking to each other. I waited around and wanted to run out the door. After what seemed like ages the doctor told me to sit down and asked what was wrong. I didnt know his name and Im not sure that he knew mine, Id been thinking about my problems and what I wanted to tell the doctor but I forgot it all he didnt seem very interested anyway. Hope I dont have to go again.

what was wrong with the way this interview was conducted help the patient feel at ease, and begin to build up a relationship that enables them to share the story of their illness with you. Beginning the interview involves greeting the patient, introducing yourself and orientating the patient (Table 2.2).

Guidelines for conducting an interview

Beginning the interview The main part of the interview

Ending the interview

Beginning the interview

Greet the patient by name (Good morning Mr Ricardson) and shake hands Ask the patient to sit down Introduce yourself (I am Judy William, as a medical student) Explain the purpose of the interview (I would like to find out about your present problem) Say how much time is available Explain the need to take notes and ask if this is acceptable

The main part of the interview

Maintain a positive atmosphere, warm manner, good eye contact Use open questions at the beginning Listen carefully Be alert and responsive to verbal and non-verbal cues Facilitate the patient both verbally (Tell me more) and non-verbally (using posture and head nods) Use specific (closed) questions when appropriate Clarify what the patient has told you Encourage the patient to be relevant

Ending the interview

Summarise what the patient has told you and ask if your summary is accurate Ask if they would like to add anything Thank the patient

The main part of the interview

Questioning Listening Facilitating

are three of the key skills that enable us to communicate effectively with others

Asking questions

the purposes of interviewing a patient is to obtain information about the condition for which they are seeking help
The information must be accurate, complete and as relevant as possible

medical students & doctors often :

ask too many questions and do not allow the patient to tell their story in their own words ask questions that are too long, too complicated and confusing ask questions in such a way that they may bias the answers given ignore questions that patients may ask

So it must be concluded that asking questions is a valuable skill that needs to be learnt

Open and closed questions

Open questions

obtain a great deal of information and also allows the patient to tell their own story sould be used as much as possible, particularly at the start of the interview e.g. would you please tell me how you have been feeling in the past few days?

closed questions

Asking spesific (i.e. closed) questions gives the patient little choice in the way they answer and ussually elicits a yes or a no Have you been feeling unwell today?

Case example 2.2

A patients response to open and closed questions

Mr Clark is an accountant aged 47 years.

He comes to the accident and emergency department following an attack of the chest pain. He is seen first by Dr Yated :

Dr Yates

I see from your notes that you have had some chest pain. Do you still have the pain ? No, not now Was it tight or dull ? It seemed a very dull pain

Mr Clark

Dr Yates

Mr Clark

Dr Yates

Did it go down your arm ?

No, I dont think so Did it get worse when you exercise ? No, it didnt

Mr Clark

Dr Yates

Mr Clark

Mr Clark is seen by Dr Vale :

Dr Vale

I understand that you have had pain. Would you please tell me more about it ?
Well, it was in my chest and it came on when I was sitting at my desk. It was a funny dull pain that stayed in the middle of my chest. Ive had it a few times recently, always when Im at work Can you tell me what brings it on ? Well, I was thinking about that. Ive been very busy at work recently, and it seems to happen when I feel worried about something

Mr Clark

Dr Vale

Mr Clark

the advantages of using open questions and the disadvantages of closed questions

Dr Vale obtained considerably more information by using open questions than Dr Yates, who used closed questions

open style question is preferable because :

more relevant information can be obtained in a given time the patient feels more involved in the interview the patient can express all the concern and anxieties about their problems; these may be missed if closed questions are asked.

open questions : some disadvantages

the interview may take longer and be more difficult to control some of the information may not be relevant recording answers may be more difficult

closed style of questioning :

the information obtained is restricted to the questions asked the interview is controlled by the interviewer who decides the content of the questions the interviewer has little opportunity to express their concern and feelings. This may make them feel frustated

Closed question

obtain specific information that the patient has not given when the patient is shy or withdrawn when it is necessary to obtain a limited amount of factual information in a limited period of time

painful arm after a fall

Probing questions

help a patient to think more clearly about an answer they have given

Probing questions may be used to :

Clarify : What do you mean by that ? Justify : What makes you think that ? Check accuracy : You definitely took three tablets a day ?

Questions to be avoided

Complex questions Leading questions

The questions should be
easily understood asked in such a way that does not influence the patients response

Complex questions

confuse both the patient and the interviewer Ex : Did your vomiting start yesterday or today and have you had diarrhoea? only one part of the question would be answered

Leading questions

the person responding to give the answer that the interviewer expects or wants

3types of leading question

Conversational :

to open or stimulate conversation e.g. Arent we having awful weather this year?.
influence the patient to agree with the interviewers viewpoint and should not be used e.g. You dont sleep well do you?.

Simple :

Subtle :

to influence the repondent should be avoided

the wording of a question can influence the answer

a study of the frequency of headaches in a group of individuals

Do you get headaches frequently and, if so, how often?

the average response was 2.2 headaches per week.

Do you get headaches occasionally and, if so, how often?

the average reponse was 0.7 headache per week.

Listening

patients appreciate and respons positively is one of the most obvious components of the communication process active or effective listening is one of the most difficult skills to acquire The first step is receiving the message from the other person.

listening

Listening involves
receiving information being in tune with the speaker responding appropriately

This is active or effective listening

The key features of active listening are :

gathering & retaining the information accurately understanding the implications for the patient of what is being said responding to verbal and non-verbal signals or cues demonstrating that you are paying attention and trying to understand

Picking up cues

A patient may be unable or unwilling to articulate their real concern and feelings.
it is important that their verbal and nonverbal cues are picked up.

verbal cues

Dr Stone

Hello Mrs Fine, come and sit down. How can I help today? I thought Id come to see you, doctor, about my headaches Perhaps you could tell me more about these headaches Well, theyre really bad, and getting worse. They started soon after my mother died and now theyre making me feel dizzy. Im really worried about them Could you tell me why you are worried about them ?

Mrs Fine

Dr Stone

Mrs Fine

Dr Stone

Dr Stone has picked up one of the verbal cues.

The other cue is that Mrs Fine relates the symptoms to her mothers death, and Dr Stone should go on to explore her reaction, e.g. Could you tell me more about how you felt after your mothers death?

Non-verbal cues

a lot of information about ourselves and our feelings in our body language the way we dress, our posture, gestures and facial expressions When you interview a patient, you can learn a good deal by watching them enter the room (their appearance, posture, gait, etc). be sensitive to their body language during the interview.

non-verbal cues :

Eye contact :

difficulty in maintaining eye contact

feels depressed embarrassed about what they are saying uninterested in the conversation

excessive eye contact : anger & aggression the confident person : sit upright the patient depressed : sit slouched with head bent forward.

Posture :

non-verbal cues :

Gestures :

the angry patient with clenched fists or the anxious patient who wrings their hands or taps their feet continously.
sadness, anger & happiness tone, timing, emphasis on certain words and vocalisation other than with words. (Paralinguistics.)

Facial expressions :

The way the voice is used :

Demonstrating active listening

show the patient that you are listening carefully.

use of

eye contact posture (e.g. sitting slightly forward facing the patient) nodding your head saying hmm go on

active listening :

asking questions directly related to following on from the patients last statement.

Facilitation

essential part of effective listening the aim : to help the patient to talk as fully as possible about problems Ex : verbal facilitation :
Please go on and tell me more about your pain. Yes, I understand please continue.

give the patient time to respond after you have spoken. Non-verbal : adopting an appropriate posture
lean slightly forward towards the patient maintain eye contact nod your head at appropriate times

Clarification

ask the patient to clarify something they have said. This can be done in several ways :
Please tell me exactly when your abdominal pain started. Can you describe the pain in more detail? What do you mean by dizziness?

Reflection

what they have just said may help them to proceed with their story particularly when they may be finding it difficult to go on because of their feelings

Helping the patient to be relevant

your time as efficiently as possible. helping the patient not to stray from the main point of the interview. interrupt at an appropriate point and try to redirect the interview.

Helping the patient to be relevant

For example :
What youve just told me about your job is interesting, but Id like to hear more about the headaches youve been having. It would help me to know more about the circumstances that bring on your chest pain.

Silence

make us feel uncomfortable can be a temptation to rush in with another question

Silences are valuable

giving the patient time to reflect on what has been said use them yourself to observe the patient, to reflect on the interview so far and to plan the next stage

Summarising

summarise what the patient has told you e.g. Id like to make sure that Ive understood you correctly. You told me that .

Summarising serves several important functions :

check the accuracy of the patients story : opportunity to correct any misunderstandings review the patients story and deduce what else needs to be explored, and it allows you to buy time if you get stuck and cant think of what to ask next. help the patient to carry on discussing their problems it is one method of facilitation. help you to keep the patient on track. let the patient know that you have been listening carefully and are interested It is an appropriate way to close an interview

Ending an interview

Summarise what the patient has told you Ask them to check the accuracy of what you have said Ask them if you have left out any information that they feel is important Enquire if they would like to add anything End by thanking the patient, e.g. Thank you for talking to me; our time is now up.

Empathy

means putting yourself in other persons place

The doctor can demonstrate empathy by :

looking at the patient and adopting an appropriate posture

indicating that you understand what is happening to them, e.g.:

Patient

My father died from a heart attack seven years ago whilst I was on holiday in France

Doctor

That must have been a distressing time for you

doctor-centred style of communication

the doctor
has taken the dominant role in a consultation with a patient paying little attention to the patients concerns and understanding of their illness not involving the patient in decisions about their treatment

Patient-centred consultations

many patients want to know more about their illness and be involved in treatment decisions
leads to greater satisfaction and compliance with treatment

Doctor & patient-centred interviewing styles

Mrs Fraser works as a clerk in an office. She has been referred to her local hospital by her GP because she has had a persistent cough and wheeze for the past 6 months. She has tried to stop smoking but is finding this difficult. Her cough is worse when she is at work and she is worried that it is brought on by the air conditioning in the office. She is afraid that she may have to leave her job, which she depends on to support herself and her three children.

Doctor-centred style

Dr Eliot

Your doctor says that you have a cough, how long have you had it for and is there anything else wrong ? Ive had it for 6 months and sometimes I wheeze Do you smoke ? Well Ive been trying to stop and now I only smoke two cigarettes in the evening Your symptoms are probably due to your smoking. I strongly advise you to stop smoking. Ill arrange for you to have a chest X-ray and other tests and Ill see you in 1 months time

Mrs Fraser

Dr Eliot

Mrs Fraser

Dr Eliot

Patient-centred style

Dr Eliot

Your doctor says that you have a cough. Please could you tell me more about it and about any other symptoms you may have ? Well Ive had this cough for about 2 months now and sometimes I feel short of breath, particularly in the morning Could you tell me if you bring up any sputum when you cough ?

Mrs Fraser

Dr Eliot

Mrs Fraser

Yes, sometimes I do in the morning but I think thats because I smoke, although I am trying to cut down. Also, I wheeze particularly when Im at work and I think thats due to the air conditioning
You seem to have two concerns. First, you want to stop smoking and I am sure that is important for your health. Second, you are worried about your work. How do you think that I can help ? Well I would like some help to smoking and I wonder if you could write a letter to the doctor at work because Ive had quite a lot of time off work recently. Im really scared that I will lose my job and get behind with the mortgage.

Dr Eliot

Mrs Fraser

The features of a patient-centred consultation are :

Exploring the patients experience of illness Allowing the patient to express their beliefs about their illness, e.g. what caused it. Allowing the patient to express their concerns about the impact of their illness on their life Treating the patient as a partner when discussing treatment

practising the principles of good communication :

Helping the patient to feel at ease and adopting an empathic approach Using open questions Picking up and responding to verbal cues by listening actively to what the patient is saying Picking up and responding to non-verbal cues

Is patient-centred interviewing always appropriate ?

is appropriate in the majority of consultations and leads to better outcomes for the patient and doctor.

some patients prefer doctor-centred consultations, i.e. they want the doctor to take a more paternalistic approach and to take charge of the consultation and their treatment.

Touch

is a powerful means of communication that we use to express a whole range of emotions tenderness, love, anger, etc. touch can convey concern and empathy, and it can have a therapeutic effect in itself
touch must be used appropriately and with due regard to the sensitivities of the patient and to professional codes of conduct.

When should touch be used in the doctor-patient encounter ?

Shaking a patients hand on meeting at the start of an interview is socially appropriate Putting your arm around a distressed person to comfort them placing your hand on the arm of a patient who is having difficulty expressing their thoughts and emotions conveys empathy, and this often helps the person to continue

two general guidelines when touching patients :

Try to assess the patients likely response to being touched; you can pick up clues from the way in which they relate their story, their posture and other aspects of body language. If you feel uncomfortable about touching patients, it is probably advisable not to do it you might communicate your anviety to the patient.

Communication during the physical examination

touching during a physical examination Remember that the patient is likely to be very conscious of their vulnerability and the power of the doctor as they lie on the couch waiting to be examined. They may also feel embarrased and anxious about what may be found. Try to put them at ease.

guidelines :

respect the patients sensitivity and modesty

a blanket

Explain what you are going to do. Do they have any concerns about this ? Be careful not to instil anxiety at this stage by your facial expressions, or by spending a long time on one part of the examination without explanation Avoid causing discomfort if possible by watching the patients expressions or by saying, Please tell me if I hurt you.