COMMUNICATION SKILLS IN MEDICINE

ABDELAZIZ ELAMIN, MD, PhD, FRCPCH

Professor of Child HealthSultan Qaboos University

Muscat, Oman

Communication

Is the act by which information is Is the act by which information is shared between humans. Such shared between humans. Such encounters may cover: encounters may cover:

Desires Desires

Needs Needs Perceptions Perceptions Knowledge Knowledge Affective Affective states.states.

Communication/2Communication is the process by which we relate and interact with other people.

It is a mutual process between 2 sides (Dialogue) not a one sided monologue.

It includes listening & understanding with passion & respect as well as expressing views & ideas and passing information to others in a clear manner.

Communication/3Communication/3

Communication is natural process Communication is natural process which may be intentional or which may be intentional or unintentional. unintentional.

It may involve conventional or non-It may involve conventional or non-conventional signals.conventional signals.

It may take linguistic or non-It may take linguistic or non-linguistic forms.linguistic forms.

It may occur through spoken or It may occur through spoken or other modes.other modes.

COMMUNICATION THEORY

Communication is a learned skill or a series of learned skills which is based on 3 pillars: Accuracy Efficiency Supportiveness all combine to contribute to

effectiveness of communication

COMMUNICATION THEORY/2Experience is a poor teacher: it needs observation with well intentioned, constructive, detailed and descriptive feedback plus rehearsal to effect change.

Communication is an art and like other arts it is a learned skill, which is influenced by presence of special gift or talent in some persons.

Communication: Types

VerbalNon verbal Body language Tone of voice written

Communication: Why?

Communication is essential for all aspects of life.

Effective communication is the basis of mutual understanding & trust.

Poor communication causes a lot of misunderstanding & hinders & hinders work & productivity.work & productivity.

Communication & Communication & MedicineMedicine

Historically the emphasis was on the biomedical model in medical training which places more value on technical proficiency than on communication skills.

Recently learning communication skills & evidence based practice become the corner stones of modern medicine.

Do doctors need communication?

Doctors need to learn essentials of good communication more than other professionals because patients are humans with sensitive needs.

Doctors can not practice medicine without effective communication skills.

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

Communication Training why?

to acquire knowledge of the basic features of verbal and non-verbal communication.to learn how to take a medical history from patients & relatives. to know about illness behavior, physician and patient roles, and relevant cultural beliefs.to learn how to draw up a plan for an interview, open and close interviews, explain the purpose and summary.

Communication Training why?/2

to know how to communicate with patients who have a learning disability.

to gain further experience of doctor-patient communication with different types of patient (e.g. male, female, different social and ethnic groups, school age children & elderly people).

to learn the basic principles of clinical problem solving.

Communication: With whom?

Patients & care-giversNurses & auxiliary staffColleaguesAdministratorsEvidence in courtReporting research findingsTalking to the mediaPublic & legislature

Communication: How?

The medical interview is the usual communication encounter between the doctor and the patient.It can be classified according to the purpose of the interview into 4 types: History taking Breaking bad news Consultations Obtaining informed consent

Effective communication

Ensures good working relationship

Increases patients satisfaction

Increases patients understanding of illness & management

Improves patients compliance with treatment

Principles of effective communication

Ensures an interaction rather than a direct transmission process (telling someone what to do or only listening is not enough). Reduces uncertainty.Demonstrates dynamism (i.e. enthusiasm and involvement as well as flexibility in relating to different individuals and contexts).

Principles of effective communication

Requires planning and thinking in terms of outcomes.Follows the helical model ( i.e. what I say influences what you say in a spiral fashion and coming back around the spiral of communication at a little different level each time is essential)..

Shows empathy & learn how to Shows empathy & learn how to handle emotional outbreaks.handle emotional outbreaks.

COMMUNICATE AS A TEAM

patientpatient familyfamily physicianphysician other health other health

care providerscare providers

psychologistpsychologist nursenurse social workesocial workerr dieticiandietician

Communication with peers

Mutual trust & respect

Exchange information

Ask your seniors

Do your share of work

Communicate with patients in peers

Seminar & workshops help in good communication

Doctors’ Mission

Doctors’ primary goals are:

To treat and cure where possibleTo bring relief in suffering.To help the patient cope with

illness, disability and death.

Doctor-Patient Relationship

•The doctor-patient relationship is built on: HonestyConfidentialityTrust

Communication & Medical care

Good communication should be Good communication should be established on admission between clients, established on admission between clients, family and the treating multidisciplinary family and the treating multidisciplinary team.team.

Client & family are encouraged to Client & family are encouraged to participate and verbalize in the ward participate and verbalize in the ward round discussion about:round discussion about: Offered medical care & treatment Offered medical care & treatment Rehabilitation Rehabilitation Follow- up/re-admission plansFollow- up/re-admission plans Doubts & worries.Doubts & worries.

Communication & Medical care

Proper information to clients and family Proper information to clients and family regarding services available and how they can regarding services available and how they can utilize them. utilize them.

Information should be made available on:Information should be made available on: Health Education/ Counseling & Psychiatry. Health Education/ Counseling & Psychiatry. Endocrine, Metabolic, Neurology & Endocrine, Metabolic, Neurology &

nephrology.nephrology. Cardiology, Respiratory, GIT & hematology.Cardiology, Respiratory, GIT & hematology. Nutrition, Immunization & ambulatory care.Nutrition, Immunization & ambulatory care. Infections & infection control.Infections & infection control. Clinical pharmacy & therapeutics.Clinical pharmacy & therapeutics. Hygiene and Safety.Hygiene and Safety.

Barriers to effective communication

Personal attitudes

Language

Time management

Working environment

Ignorance

Human failings (tiredness, stress)

Inconsistency in providing information

Lack of communication: why?

Clinicians focus often on relieving patients' bodily pain, less often on their emotional distress, seldom on their suffering.Some of them view suffering as beyond their professional responsibilities.If clinicians feel unable to, or simply do not want to, address the powerful issue of patient suffering, it is appropriate to refer the patient to another professional on the healthcare team who is more comfortable in this arena.

The Art of ConsultationGauging the correct amount and type of information to give to each individual patient.Providing explanations that the patient can remember and understand & which relate to the patient’s illness framework.Using an interactive approach to ensure a shared understanding of the problem with the patient.Involving the patient and collaborative planning increase the patient’s commitment and adherence to plans made.Continuing to build a relationship and provide a supportive attitude.

Initiating the ConsultationEstablishing a supportive environment.Developing an awareness of the patient’s emotional state.Identifying as far as possible all the problems or issues that the patient has come to discuss.Establishing an agreed agenda or plan for the consultation.Enabling the patient to become part of a collaborative process.

Closing the interviewConfirming the established plan of care.Clarifying next steps for both doctor and patient.Establishing contingency plans.Maximizing patient adherence and health outcomes.Making efficient use of time in the consultation.Continuing to allow the patient to feel part of a collaborative process and to build the doctor-patient relationship for the future.

Questions to ask yourself after each consultationWas I curious? Do I know significantly more about this person as a human being than before they came through the door?Did I listen? Did I make an acceptable working diagnosis?Did I explore their beliefs?

Questions to ask yourself after each consultation/2

Did I use their beliefs when I started explaining? Did I share options for investigations or treatment?Did I share in decision-making? Did I make some attempt to see that my patient understood?Did I develop the relationship?   

Doctors-Patients Relationship

Developing rapport to enable the patient to feel understood, valued and supported.

Encouraging an environment that maximizes accurate and efficient information gathering, planning & and explanation.

Enabling supportive counseling as an end in itself.

Doctors-Patients Relationship/2

Involving the patient so that he/she understands and is comfortable with the process of the consultation.

Increasing both the physician’s and the patients’ satisfaction with the consultation.

Developing and maintaining a continuing relationship of trust & respect over time.

Dealing with emotional Dealing with emotional PatientsPatients

Set an example: don’t ask patients to calm down, model calmness. Get patients’ attention: lower your voice, move so they must turn in your direction.encourage them to sit down but let them control their emotions at their pace.Listen not just to the patients needs, but also for underlying issues/concerns and unexpressed expectations.

Dealing with emotional Dealing with emotional Patients/2Patients/2

The use of “uh- huh” and “um” has been shown to help patients settle down on their own. Feels like a lot of time, but really isn’t.Avoid arguments, use disarming statements.Consider rolling with the resistance and agreeing with the patient if possible. Take a step back from the demand and ask probing questions to find underlying concerns. This may change a rant into a conversation.

Dealing with emotional Dealing with emotional Patients/3Patients/3

Don’t assume things, ask to find out Don’t get emotionally involved, keep

your professional attitude. Don’t give false reassuring comments. Say no in a tactful manner to the

patient’s unrealistic wishes & demands.

Breaking Bad News

clinicians are responsible for delivering bad news, this skill is rarely taught in medical schools, clinicians are generally poor at itbreaking bad news is one of a physician’s most difficult duties.

medical education typically offers little formal preparation for this task.

THE PAST AND THE THE PAST AND THE PRESENTPRESENT

Hippocrates advised concealing most Hippocrates advised concealing most things from the patientthings from the patient..

OOlder physicians, who trained duringlder physicians, who trained duringthe 1950s and 60s, were taughtthe 1950s and 60s, were taught to to "protect" patients from disheartening "protect" patients from disheartening newsnews..

IIn the past decades traditional n the past decades traditional models of patient care have given models of patient care have given wayway to an emphasis on patient to an emphasis on patient autonomyautonomy..

BREAKING BAD NEWS/2

MMany health care professionals tendany health care professionals tend

to define 'bad news' as worst case to define 'bad news' as worst case

scenarios (eg. telling a patient they scenarios (eg. telling a patient they

have cancer or that their loved one have cancer or that their loved one

has died)has died), B, But a knee cartilage ut a knee cartilage

problem requiring rest for a problem requiring rest for a

waitress may mean no paywaitress may mean no pay

BREAKING BAD NEWS/3

any news that drastically and any news that drastically and

negatively alters the patientnegatively alters the patient’s’s view of view of

his or her futurhis or her future.e.

it results in a cognitive, behavioral, it results in a cognitive, behavioral,

or emotional deficit in the personor emotional deficit in the person..

receiving the news that persists for receiving the news that persists for

some time after the news is receivedsome time after the news is received..

Message to take homeCommunication between the Communication between the client, family and heath team play client, family and heath team play a vital role in the compliance to a vital role in the compliance to outpatient clinic visits and in-outpatient clinic visits and in-patient care programs.patient care programs.Good communication is essential Good communication is essential for proper doctor-patient for proper doctor-patient relationship and help avoids relationship and help avoids problems of misunderstanding.problems of misunderstanding.Effective communication is the Effective communication is the key to success in professional key to success in professional career.career.