11.Communication 07

MEDICAL MEDICAL COMMUNICATION SKILLCOMMUNICATION SKILL

LECTURELECTURETheresia L. ToruanTheresia L. Toruan

Think back for a minute on your own Think back for a minute on your own life experienceslife experiences

Recall from your own interaction with Recall from your own interaction with your doctor or dentistyour doctor or dentist

The quality of the communication The quality of the communication that involvedthat involved

Was it clear?Was it clear? Was it sympathetic?Was it sympathetic? Were you left with the impression Were you left with the impression

that you were told as much as you that you were told as much as you wanted to know?wanted to know?

Were you left with the impression Were you left with the impression that your doctor was a good listener?that your doctor was a good listener?

COMMUNICATIONCOMMUNICATION

Is an important component of patient Is an important component of patient carecare

Must gain an understanding of the Must gain an understanding of the patient’s perspective on his or her patient’s perspective on his or her illnessillness

Carefully, not to be judgemental or Carefully, not to be judgemental or scolding,….may rapidly close down scolding,….may rapidly close down communicationcommunication

A Changing ParadigmA Changing Paradigm

PaternalistPaternalisticic

ReductioniReductionistst

Holistic and Holistic and Collaborative Collaborative

ApproachApproach

Communication skills of the physician are critical

Paternalistic approachPaternalistic approach

To deciding what should be done for a To deciding what should be done for a patient:patient:

The physician knew bestThe physician knew best Patient accepted the Patient accepted the

recommendationrecommendation Patient without questionPatient without question

SHARED DECISION MAKINGSHARED DECISION MAKING(holistic and collaborative (holistic and collaborative

approach)approach)

Advising to educate his or herselfAdvising to educate his or herself To ask questionTo ask question

PHYSICIAN-PATIENT SATISFACTIONPHYSICIAN-PATIENT SATISFACTION

REDUCTION IN MEDICAL RISKREDUCTION IN MEDICAL RISK

““Communication Age”Communication Age”

able to communicate able to communicate information …information …

– fasterfaster– more clearlymore clearly– more widelymore widely

The basis for patient-physician The basis for patient-physician alliancealliance

Communication establishes the Communication establishes the collaborative nature of that alliancecollaborative nature of that alliance

– shared decision-making shared decision-making – partneringpartnering

Medical communication….. own life experience!Medical communication….. own life experience!

Clear?Clear? Sympathetic?Sympathetic? Left in the impression not told as much as wanted to Left in the impression not told as much as wanted to

know?know? Left with the impression the doctor was a good Left with the impression the doctor was a good

listener?listener?

Our experience with health and illness are significant Our experience with health and illness are significant to to

our sense of health.our sense of health.

The benefits of good The benefits of good communication:communication:

Good communication:Good communication:

• • builds trust between patient and doctor;• may help the patient disclose information;• enhances patient satisfaction;• involves the patient more fully in health

decision making;• helps the patient make better health

decisions;• leads to more realistic patient expectations;• produces more effective practice; and• reduces the risk of errors and mishaps.

Toronto Consensus Statement (1980): talking

about the importance of Medical communication Skill

and

Kalamazoo Consensus Treatment (1999):

talking about the Essential Element of the Medical

Communication based on the task approach

Essential element of Medical Essential element of Medical CommunicationCommunication

1.1. Build a relationshipBuild a relationship2.2. Open the discussionOpen the discussion3.3. Gather InformationGather Information4.4. Understand the patient’s Understand the patient’s

perspectiveperspective5.5. Share informationShare information6.6. Reach agreement on problems and Reach agreement on problems and

planplan7.7. Provide closureProvide closure

Essential Element of Medical Communication Essential Element of Medical Communication (cont..)(cont..)

1. Build a Relationship1. Build a Relationship Fundamental communication taskFundamental communication task StrongStrong TherapeuticTherapeutic Effective relationship Effective relationship (idea, feelings, (idea, feelings,

and values of both)and values of both)

Also relevant for work Also relevant for work with the patient, with the patient, family and other support system family and other support system

Is an ongoing taskIs an ongoing task withinwithin and and acrossacross

Essential Element of Medical Essential Element of Medical Communication… Communication… (cont..)(cont..)

Mnemonic P E A R L S :Mnemonic P E A R L S : P..P..partnership, acknowledges that the physician and the partnership, acknowledges that the physician and the

patient are in this togetherpatient are in this together E..E..empathy, expresses understanding to the patientempathy, expresses understanding to the patient A..A..apology, acknowledges that the phycisian is sorry the apology, acknowledges that the phycisian is sorry the

patient had to wait, that a laboratory test had to be patient had to wait, that a laboratory test had to be repeated, etcrepeated, etc

R..R..respect, acknowledges the patient’s suffering, difficulties, respect, acknowledges the patient’s suffering, difficulties, etc etc

L..L..legitimization, acknowledges that many patient are legitimization, acknowledges that many patient are angry, frustrated, depressed, etcangry, frustrated, depressed, etc

S..S..support, acknowledges that the physician will not support, acknowledges that the physician will not abandon the patient.abandon the patient.

1. Build a Relationship…. 1. Build a Relationship…. (cont…)(cont…)

Essential Element of Medical Essential Element of Medical Communication… Communication… (cont…)(cont…)

2. Open the discussion2. Open the discussion Physician’s first greeting.Physician’s first greeting. Physician show personal concern by Physician show personal concern by

offering a handshake and warm smile.offering a handshake and warm smile. Put the patient at ease in what could Put the patient at ease in what could

otherwise to be unfamiliar, if not otherwise to be unfamiliar, if not frightening environment. frightening environment.

3. Gather Information3. Gather Information Shifting from a Shifting from a physician-centered physician-centered to to patient-centered patient-centered

interview style interview style Physician interrupt patients an average of 18 seconds Physician interrupt patients an average of 18 seconds

after the patient begins to speak.after the patient begins to speak. Patient rarely continued to express all their true concern Patient rarely continued to express all their true concern

once they were interruptonce they were interrupt No more than 150 seconds was needed to express all No more than 150 seconds was needed to express all

their concern at the beginning or the interviewtheir concern at the beginning or the interview

Two words ……. Two words ……. What else?What else?

Essential Element of Medical Communication… Essential Element of Medical Communication… (cont…)(cont…)

Five Communication Pattern :Five Communication Pattern : Narrowly biomedicalNarrowly biomedical Expanded biomedicalExpanded biomedical BiopsychosocialBiopsychosocial PsychosocialPsychosocial Consumerist. Consumerist.


3. Gather Information… 3. Gather Information… (cont…)(cont…)

Five Communication Pattern…Five Communication Pattern… (cont…)(cont…)

Example :Example : PhysicianPhysician : What bring you here?: What bring you here? PatientPatient : I have headache: I have headache PhysicianPhysician : Where are the headache? How long do : Where are the headache? How long do

they does? What do you do to relieve they does? What do you do to relieve them?them?

This interview follows This interview follows a physician centered and a physician centered and biomedical model pattern. biomedical model pattern.

Contrast the previous interview with the following Contrast the previous interview with the following interview.interview.



Five Communication Pattern…Five Communication Pattern… (cont…) (cont…)

Example :Example :PhysicianPhysician : What brings you here today?: What brings you here today?PatientPatient : I have headache.: I have headache.PhysicianPhysician : : What else?What else?PatientPatient : Well, I have problems on sleeping.: Well, I have problems on sleeping.PhysicianPhysician : : What else?What else?PatientPatient : I am very worried about my son. He is : I am very worried about my son. He is

using drugs. using drugs.

This interview follows This interview follows a patient-centered and a patient-centered and biobiopsychosocialpsychosocial pattern pattern



4. Understand the Patient’s Perspective4. Understand the Patient’s Perspective Explore contextual factors (e.g., family, culture, Explore contextual factors (e.g., family, culture,

gender, age, socioeconomic status, spiritually)gender, age, socioeconomic status, spiritually)

Explore beliefs, concern, and expectation about Explore beliefs, concern, and expectation about

health and illnesshealth and illness

Acknowledge and respond to to the patient’s ideas, Acknowledge and respond to to the patient’s ideas,

feeling, and valuesfeeling, and values


5. Share Information5. Share Information Use language the patient can understandUse language the patient can understand Check for understandingCheck for understanding Encourage questionsEncourage questions


6. Reach Agreement on Problems and Plan6. Reach Agreement on Problems and Plan


7. Provide Closure 7. Provide Closure Ask whether the patient has other issues Ask whether the patient has other issues

or concernor concern

Summarize and affirm agreement with the Summarize and affirm agreement with the

plan of actionplan of action

Discuss follow upDiscuss follow up


Special Medical Special Medical CommunicationCommunication

End-of-life communicationEnd-of-life communication Bad NewsBad News Old PatientOld Patient Family caregiversFamily caregivers

End-of-life communicationEnd-of-life communication

Reflection:Reflection:

““And I came to understand that this was And I came to understand that this was medicine, and this was so much greater than medicine, and this was so much greater than my naÏve ideas of complete cures and my naÏve ideas of complete cures and miraculous recoveries, which are too few and miraculous recoveries, which are too few and far between; that the true practice of far between; that the true practice of medicine is not the miraculous cure of a medicine is not the miraculous cure of a disease but the total care of a person.”disease but the total care of a person.”

Special Medical Communication… Special Medical Communication… (continue)(continue)

Bad NewsBad News

Mnemonic Mnemonic S P I K E S S P I K E S protocol for breaking bad protocol for breaking bad news. news.

SS....etting and listening skillsetting and listening skills P..P..erception by patient of condition and erception by patient of condition and

seriousnessseriousness I..I..nvitation from patient to give informationnvitation from patient to give information K..K..nowledge - giving medical factsnowledge - giving medical facts E..E..xplore emotions and empathize as patient xplore emotions and empathize as patient

respondsresponds S..S..trategy and Summarytrategy and Summary

Special Medical Communication… Special Medical Communication… (cont…)(cont…)

Old PatientOld Patient

Working Memory Capacity DiminishWorking Memory Capacity Diminish Hearing and Vision lostHearing and Vision lost Reflective listeningReflective listening Create HopeCreate Hope

Special Medical Communication… Special Medical Communication… (cont…)(cont…)

Family CaregiversFamily Caregivers

Understand that illnes and disability are Understand that illnes and disability are a family affair…. Let the patient knowa family affair…. Let the patient know

Be sensitive about place talking to Be sensitive about place talking to caregivers about difficulty subjects. caregivers about difficulty subjects. Not appropriate in waiting room and Not appropriate in waiting room and corridors.corridors.

Special Medical Communication…Special Medical Communication… (cont…)(cont…)

EMPHATYEMPHATY

Of all the element involved in effective Of all the element involved in effective communication: the most powerfulcommunication: the most powerful

1880, psychologist Theodore Lipps: 1880, psychologist Theodore Lipps: einfuhlung einfuhlung (in-feeling)(in-feeling)

To describe: To describe: emotional appreciation of emotional appreciation of another’s feelinganother’s feeling

Being a psychiatric or mental health expert Being a psychiatric or mental health expert is not necessaryis not necessary for using emphatetic communicationfor using emphatetic communication

The only requirement is The only requirement is an awarenessan awareness of opportunities for of opportunities for emphaty as they arise during the interview with the patientemphaty as they arise during the interview with the patient

In emphaty, we “borrow” another’s In emphaty, we “borrow” another’s feelings to observe, feel, and feelings to observe, feel, and understand them - - but to take them understand them - - but to take them onto ourselvesonto ourselves

By being a participant-observer, we By being a participant-observer, we came to understand how the other came to understand how the other person feelsperson feels

EMPHATY versus SYMPHATY? EMPHATY versus SYMPHATY?

EmpathyEmpathy

Key skill used to built doctor patient-relationshipKey skill used to built doctor patient-relationship

Empathic processes affect how the physician (observer) Empathic processes affect how the physician (observer)

thinks, feels (intrapersonal outcomes), and behaves thinks, feels (intrapersonal outcomes), and behaves

(interpersonal outcomes) with the patient (target) (interpersonal outcomes) with the patient (target)

The process of understanding a person’s subjective The process of understanding a person’s subjective

experienceexperience

Balance curiosity to leading to a deeper understanding Balance curiosity to leading to a deeper understanding

of another human beingof another human being

The capacity to understand another person experience The capacity to understand another person experience

from within that person ‘s frame of referencefrom within that person ‘s frame of reference

The ability to “The ability to “put oneself in another’s shoes”put oneself in another’s shoes”

Empathy… Empathy… (cont…)(cont…)

Begins to look something like:Begins to look something like:

– Touch the patient on the armTouch the patient on the arm

– Look them in the eyeLook them in the eye

If the patient stop talking, repeat the last word that If the patient stop talking, repeat the last word that

they said to show you are listening and interested.they said to show you are listening and interested.

Doing so without also developing a Doing so without also developing a genuine interestgenuine interest

in the resulting connection can lead to an in the resulting connection can lead to an empty empty

charadecharade

Effectively teaching useful approaches to Effectively teaching useful approaches to

physician-patient relationshipphysician-patient relationship

Empathy… Empathy… (continue)(continue)

Deepened understanding of EmpathyDeepened understanding of Empathy

“ “ For one year now, I have been trying to come to For one year now, I have been trying to come to

terms with the notion of sacred, esteemed, terms with the notion of sacred, esteemed,

professional ‘doctor-patient relationship’. Somehow, professional ‘doctor-patient relationship’. Somehow,

I had gotten the idea in my head that this relationship I had gotten the idea in my head that this relationship

should be somehow devoid of emotions. It took a should be somehow devoid of emotions. It took a

women like nurse Cindo and a patient like Mr. Lanang women like nurse Cindo and a patient like Mr. Lanang

to help me to realize that it might actually be okay, to help me to realize that it might actually be okay,

normal, and human to cry and to express emotions normal, and human to cry and to express emotions

about a wonderful dying patient” about a wonderful dying patient”

Active Listening

The most important skill of medical The most important skill of medical communication to learn.communication to learn.

Involves two way tramsmission of verbal and non-Involves two way tramsmission of verbal and non-verbal behaviour between doctor and patient.verbal behaviour between doctor and patient.

The aim is to encourage the patient to continue The aim is to encourage the patient to continue their opening statement as far as possible without their opening statement as far as possible without interruption.interruption.

Closely linked to the doctor’s capacity to Closely linked to the doctor’s capacity to recognize emotional factors contributing to illness recognize emotional factors contributing to illness and distress.and distress.

Active Listening…Active Listening… (cont…)(cont…)

Mnemonic Mnemonic S O L E RS O L E R , positive non-verbals that , positive non-verbals that can be used to indicatephysician are listening can be used to indicatephysician are listening supportively.supportively.

• S…sS…sitting square on to the patient with itting square on to the patient with an an

• O…O…open positionopen position• LL… leaning slightly forward with… leaning slightly forward with• EE…eye contact in a…eye contact in a• RR… relaxed posture… relaxed posture

Collaboration in Health CareCollaboration in Health Care

Involves coordination of individual actions Involves coordination of individual actions inin– Cooperating in planningCooperating in planning– Working togetherWorking together– Sharing of goal, planning, problem solving, Sharing of goal, planning, problem solving,

decision making and responsibilitydecision making and responsibility

Can happened between two people who Can happened between two people who represent the same or different represent the same or different disciplinesdisciplines..

Collaboration in Health Care…Collaboration in Health Care… (cont…)(cont…)

Nurse-Physician CollaborationNurse-Physician Collaboration

Nurse Practitioner-Physician Nurse Practitioner-Physician

CollaborationCollaboration

Social Worker-Physician CollaborationSocial Worker-Physician Collaboration

Pharmacist-Physician CollaborationPharmacist-Physician Collaboration

Physician-Physician CollaborationPhysician-Physician Collaboration

The Impact of Poor The Impact of Poor CommunicationCommunication

Poor communication:Poor communication:• • decreases confidence and trust in medical care;decreases confidence and trust in medical care;

• • deters the patient from revealing important information;deters the patient from revealing important information;

• • causes significant patient distress;causes significant patient distress;

• • leads to the patient not seeking further care;leads to the patient not seeking further care;

• • leads to misunderstandings;leads to misunderstandings;

• • leads to the misinterpretation of medical advice;leads to the misinterpretation of medical advice;

• • underlies most patient complaints; andunderlies most patient complaints; and

• • predicts negligence claims.predicts negligence claims.

These difficulties may lead to poor or sub-optimal outcomes for These difficulties may lead to poor or sub-optimal outcomes for the patient.the patient.

Doctor-related ObstaclesDoctor-related Obstacles

The doctor may be:The doctor may be:

• • inadequately trained in communication skills;inadequately trained in communication skills;

• • lacking in sensitivity or empathy; lacking in sensitivity or empathy;

• • unwilling to recognise patient autonomy;unwilling to recognise patient autonomy;

• • unaware of problems arising from differences unaware of problems arising from differences in language and culture;in language and culture;

• • affected by time pressures; or distracted by affected by time pressures; or distracted by external or personal factors.external or personal factors.

Patient-related obstaclesPatient-related obstacles

The patient may be:The patient may be:• • affected by the condition, illness or medication;affected by the condition, illness or medication;• • anxious, embarrassed or in denial about the medical anxious, embarrassed or in denial about the medical condition;condition;• • inexperienced in identifying and describing symptoms;inexperienced in identifying and describing symptoms;• • intimidated by health care settings;intimidated by health care settings;• • overawed by the doctor’s perceived status;overawed by the doctor’s perceived status;• • disadvantaged by differences in language and culture;disadvantaged by differences in language and culture;• • confused by the use of medical jargon;confused by the use of medical jargon;• • reluctant to ask questions; orreluctant to ask questions; or• • concerned about time pressures.concerned about time pressures.

All of these factors may impede the patient’s capacity to All of these factors may impede the patient’s capacity to provide, take in and retain information.provide, take in and retain information.

COMMUNICATION COMMUNICATION

It’s a series of learned skillIt’s a series of learned skill

Experience is a poor teacherExperience is a poor teacher: it : it needs needs observationobservation plus plus well well intentionedintentioned, , constructive, constructive, detaileddetailed and and descriptive descriptive feedbackfeedback plus plus rehearselrehearsel to effect to effect changechange

11.Communication 07

Documents

realistic patient expectations

benefits of good communication

good listener

sense of health

health decision making

collaborative nature

collaborative approachadvising

better health decisions