Communication skills in clinical practice for undergraduates

COMMUNICATION SKILLS COMMUNICATION SKILLS IN CLINICAL PRACTICEIN CLINICAL PRACTICE

Dr. Syahnaz Mohd HashimDepartment of Family Medicine,

Faculty of Medicine,PPUKM

What is communication?What is communication?

“the successful passing of a message from one person to another”

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Important principles Important principles facilitating the facilitating the communication processcommunication process

1. Rapport between the people involved

2. The time factor, facilitated by devoting more time

3. The message, needs to be clear, correct, concise, unambiguous and in the context

4. The attitudes of both the communicator and the recepient

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Communication in the Communication in the consultationconsultationThe doctor requires

communication skills for complete diagnosis:

- Physical- Emotional- Social

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If you are the patient, what will be your If you are the patient, what will be your opinion on this doctor?opinion on this doctor?

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Important positive Important positive behaviorbehaviorAt first contactAddress patient by his or her

preferred nameMake the patient feel

comfortableBe ‘unhurried’ and relaxedFocus firmly on the patientUse open-ended questions where

possible6

Open-ended questionsOpen-ended questions

“How are you feeling today?

“Anything I could help you with?”

“Tell me more about your problem?”

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Do you like the doctor? Why?Do you like the doctor? Why?

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Doctor’s attitudeDoctor’s attitudeCaringShow empathyRespectInterestedConcernConfidenceSensitiveCompetence

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Listening Listening Is an active process described by

Egan..

“One does not listen with just his ears: he listens with his eyes, mind, his heart and his imagination. He listens to the words of others, but he also listens to the messages that are buried in the words. He listens to the voice, the sounds, the gestures and to the silence”

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Listening includes four Listening includes four essential elementsessential elements

1. Checking facts2. Checking feelings3. Encouragement4. Reflection “ You seem very upset today” “ It seems you’re having trouble

coping”

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Communication Tips Communication Tips Check if what was said is what

you understood◦ Rephrasing: “Let me say it as I

understand it: . . . .”◦ Further Questioning: “How is that

pain?” ◦ Asking for clarification: “Do you

mean to say that . . . . . “◦ Asking for elaboration: “Can you

tell me more about it?”

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Non verbal Non verbal communicationcommunication

%

Words alone 7

Tone of voice 38

Non verbal communication/Body

language

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IMPACT OF THE MESSAGE

Body language include use of gestures, postures, position and distance

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Barriers to effective Barriers to effective communication communication

◦ Authoritative attitude (usually on the side of the medical/health professional.)

◦ Asking only Closed questions patients equate it to Interrogation

◦ Closed body posture◦ Lack of or no eye contact◦ Distancing, i.e.: sitting too far

apart that the patient feels removed

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Barriers to effective Barriers to effective communication communication

◦ Appearing too busy & too rushed

◦ Not listening & constantly interrupting patient

◦ Writing soon after opening the interview, before listening to patient

◦ Environmental interference, e.g. lack of privacy, people coming in and out of room, too hot/cold, too noisy, children interfering

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Using medical jargonUsing medical jargon

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““What to achieve in a 15 What to achieve in a 15 min consultation”min consultation” 77 Tasks of Tasks of ConsultationConsultation

1. Define the reason for patient’s attendance

2. Consider other problems

3. Achieve a shared understanding of the problems

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4. With the patient, choose an appropriate action/management plan for each problem

5. Involve the patient in the management & encourage patient to accept appropriate responsibility

6. Use time and resources appropriately

7. Establish and maintain a relationship which helps achieve other tasks

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Patient Centered Patient Centered InterviewingInterviewing

Focus on eliciting symptoms and signs of illness

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What is your opinion to this doctor?What is your opinion to this doctor?

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Shows genuine interest in; Shows genuine interest in; Patients as individuals Their reasons for seeking helpTheir perceptions of what might

be wrongTheir feeling about the problemsThe impacts of this problems on

their daily lives and well-being

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Advantages of patient Advantages of patient centered consultationcentered consultation

Emphasis patient perspective on health including his/ her perceive needs/ concerns/ preferences and beliefs.

Encourages patient to express what is most important to him

Allows patient to lead

Greater patients compliance with advice and treatments◦ promotes patient’s health awareness

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Other advantagesOther advantagesGreater patient satisfactions

Doctor-patient interactions itself can be therapeutic enhanced feeling of trust and understanding

Clinical decision making process and disclosure of psychosocial problems are facilitated

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Four Windows of Four Windows of ConsultationConsultation(Stott and Davis, 1979)(Stott and Davis, 1979)“The exceptional potential in each primary care “The exceptional potential in each primary care consultation”.consultation”.

A. Management of Acute problems

B. Modification of

Behaviour

C. Management of Co-

morbidities

D. Prevention of Diseases / Promotion of Health

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Ending an InterviewEnding an InterviewSummarize 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 which they feel is important

Enquire if they would like to add anything

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Close the interview in the positive manner and write management plan:

- when is the next follow up visit- What is the patient suppose to do- What will you have to do.

End by thanking the patient◦E.g. Thank you for talking to me. Our

time is now up.

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HOW TO BREAK BAD NEWS?

Why we need to know Why we need to know “How to Break Bad News”?“How to Break Bad News”?

Important part of the medical job

Practical & useful in daily clinical work

Remember…If we do it badly, the patients or family

members may never forgive us.

If we do it well, they will never forget us.

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What is bad news?What is bad news?

“Any news that drastically and negatively alters the patient’s

view of his or her future”

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The 10-step ProtocolThe 10-step Protocol

1. Prepare the physical set-up

2. Get to know the patient

3. Identify patient’s support systems

4. Find out how much the patient already knows

5. Find out how much the patient wants to know

6. Give a “Warning shot”

7. Share the information – Break the news gently!

8. Respond to patient’s feelings – Acknowledge distress & support ventilation of feelings

9. Identify concerns, prioritize & answer all questions

10. Planning & follow-through / follow-up 30

1. Prepare the physical 1. Prepare the physical set-upset-upCheck your facts!Do it in person, never over the phone!Find a private room to ensure privacy

& confidentialityTurn-off your hand phone & pagerPrevent any interruptions!Have enough chairs & tissue (for

tears)If there are visitors, ask the patient

who they are and what relationship?

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2. Get to know the 2. Get to know the patientpatientEstablish rapportIntroduce self & other staff/students (if

any)Start with “normal” courtesies &

considerations (drink, washroom)Does he/she have a spouse, children,

work, etc.?Open with an open question, e.g.:

◦“How are you feeling at the moment?”◦“How are things today?”◦“Do you feel well enough to talk a bit?”

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3. Identify patient’s support 3. Identify patient’s support systemssystemsHow did he/she come?

◦By car, by bus, taxi, friend brought him/her?

Any one that came with him/her?◦Alone, spouse, best friend, etc.?

Ask permission to draw “genogram”. Not just of family ties but also draw a genogram of “Support persons”

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Prepare setting, identify supportPrepare setting, identify support

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4. Find out how much the 4. Find out how much the patient patient already knowsalready knows• How much do you understand about your

illness? . . . . . . . . . . . . . PAUSE . . . . . . . . . .!

• What did your previous doctor tell you about your condition? . . . PAUSE!

• What have you been thinking about this nausea/unsteadiness/breast lump . . . PAUSE!

• Have you been very worried about this illness?

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5. Find out how much the 5. Find out how much the patient patient wants to knowwants to know• Would you like me to explain

what is happening?

• Would you like me to tell you the full details of the diagnosis?

• Would you like to know exactly what is going on, OR

• Would you prefer me to give you the outline only?

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6. Give a “Warning shot”6. Give a “Warning shot”I am afraid that the news is not very

good.

“Well, the situation does appear to be more serious than that . . .”

Maaf, saya rasa berita yang saya akan sampaikan agak tidak begitu baik.

Saya berat hati untuk memberi tahu

. . . . . . Silence . . . . . , Mirroring . . . . .37

7. Share the information7. Share the informationBreak the news GENTLYBreak the news GENTLYBreak the news gently, but not so much

that it is not clear.Use simple language, i.e.: avoid

medical jargon

◦You have carcinoma of the mammary gland vs. You have cancer of the breast.

◦Cancer barah

◦Tumor (non-malignant) ketumbuhan

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The treatment isn’t working.

The cancer has come back.

The scan shows that the cancer has spread.

The biopsy result shows it is cancerous.

We were not able to resuscitate him.

Anchor the news on something firm.Check for patient’s understanding

frequentlyReinforce and clarify information

frequentlyMay need to draw a picture for clarity

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Patient’s reactionsPatient’s reactions

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8. Respond to patient’s feelings – 8. Respond to patient’s feelings – Acknowledge distress & support Acknowledge distress & support ventilation of feelingsventilation of feelingsPatient says:

I am so sorry, it is very hard, it is so cruel.

. . . . . . Silence . . . . ., Mirroring . . . . .WAIT . . . . Until the patient talks

again.

“Let the storm pass by”

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9. Identify concerns, 9. Identify concerns, prioritize & answer all prioritize & answer all questionsquestionsPatient may ask:

Am I going to die?What happens next?Is there any more treatment?Who is going to look after my kids?

Answer all questions as honest & as best as you can.

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Never say: “There is nothing more that we can do.”

It is not true!

Further chemotherapy probably won’t help anymore, but there are lots of ways we can make you comfortable.

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10. Planning & Follow 10. Planning & Follow throughthroughIdentify patient’s support systems.

◦Who have you got at home?◦Can I phone anyone for you?◦How are you going to get home?

This is where your “Support Genogram”

will help a lot.

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Remember..Remember..

A mentally competent and informed patient has the right to:

• Accept or reject any treatment offered

• React to the news and express his own feelings in any way he chooses.

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How to write a referral letter?

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Why do we write?Why do we write?

1. Part of continuing good clinical care (i.e. good quality referral letters)

2. Interphase between healthcare professionals in primary and secondary / tertiary care

3. Flexible means of info transfer between healthcare professionals

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What should be heading?What should be heading?Official clinic/hospital letterhead

LEGIBLE HANDWRITING! / typed

Patient’s biodata (NRIC/Hospital R/N)

Date/time letter was written

To whom the letter is written48

What should be the What should be the content?content?Patient’s problem as a title before

the main textBrief & relevant history, including

current medicationPast medical historyAllergiesSocial circumstances±Any treatment tried to date &

outcomes, current drug treatment49

What else?What else?Any investigations to date (with a

copy of the results)State what was told to the

patient in cases of a potentially serious diagnosis

Reason for the referral- second opinion exclusion of a serious diagnosis treatment failure

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Very importantly…Very importantly…

Be polite & grammatically correct.

Ensure copy is kept in the medical records

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Example of Referral letterExample of Referral letter

To: Bandar Tasek Selatan

Kindly see the above named who has uncontrolled hypertension. Seen here at A&E BP 180/100. ECG : Normal

Asymptomatic. Kindly do the needful.

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To: To: Medical Officer-in –charge, Medical Officer-in –charge, Pusat Perubatan Primer UKM, Pusat Perubatan Primer UKM, BTSBTSDear Colleague,

Kindly see the above named a 59 yr old /C/ Female who has background history of uncontrolled hypertension X 6 years-on PRN GP follow-up. She does not know her antihypertensive medications & compliance is poor. Seen here at A&E BP 180/100. Pulse rate: 66 bpm. ECG : Normal.Asymptomatic.

Kindly do the needful. (Kindly see her for regular monitoring of her hypertension.) TQ.

Dr XOX (Official Stamp)

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THANK YOU FOR YOUR ATTENTION

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