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Clinical Clinical CommunicationCommunication

Professor Craig JacksonProf. Occupational Health Psychology

Head of Psychology BCU

Clinical Communications OutlineClinical Communications Outline

Benefits for clientsBenefits for clients

Benefits for cliniciansBenefits for clinicians

DemeritsDemerits

SkillsSkills

Shut up and listenShut up and listen

Clinical Communications OutlineClinical Communications Outline

““The good clinician treats the The good clinician treats the disease, but the great clinician disease, but the great clinician treats the patient”treats the patient”

William Osler William Osler

Relatively new areaRelatively new area

Communication was a “wet skill”Communication was a “wet skill”

Now part of curriculumNow part of curriculum

Seen as important ( not more important than clinical skill) . . .Seen as important ( not more important than clinical skill) . . .

. . . Clinical skills viewed as worthless without communication. . . Clinical skills viewed as worthless without communication

Communication skills not universalCommunication skills not universal

Different types of communication Different types of communication

Depends on therapists’ Depends on therapists’ TrainingTrainingPhilosophyPhilosophyinclinationinclinationTheoretical positionTheoretical position

PsychodramaPsychodrama

Holotropic breathworkHolotropic breathwork

CBTCBT

RETRET

““Hello Chris”Hello Chris”

Covert naturalistic experimentCovert naturalistic experiment

8 sessions with psychotherapist8 sessions with psychotherapist

Was NOT psychotherapyWas NOT psychotherapy

Pseudo hypnotherapyPseudo hypnotherapy

DistractionsDistractions

. . . . . iPad. . . . . iPad

Not the “breathy voice” againNot the “breathy voice” again

Sounds too “American”Sounds too “American”

. . . Too controlled. . . Too controlled

. . . Too therapeutic. . . Too therapeutic

. . . Too effortful. . . Too effortful

. . . Not naturalistic. . . Not naturalistic

Benefits for Clinicians & ClientsBenefits for Clinicians & Clients

Time savingTime saving

Effective & efficientEffective & efficient

Reduces Stress & BurnoutReduces Stress & Burnout

Reduces litigationReduces litigation

Clients more satisfiedClients more satisfied

Best predictor of resolutionBest predictor of resolution(e.g. Chronic headache; Headache study group Ontario (1986)(e.g. Chronic headache; Headache study group Ontario (1986)

Shorter care neededShorter care needed(coronary care patients with emotional support - 2 days less bed time)(coronary care patients with emotional support - 2 days less bed time)Mumford et al 1982Mumford et al 1982

Benefits for ClientsBenefits for Clients

Positive evaluationsPositive evaluations

Both Clinician and Client agree on reason for consultationBoth Clinician and Client agree on reason for consultation

Clinician asks client about ideas, concerns or health beliefsClinician asks client about ideas, concerns or health beliefs

Clinician takes time to achieve a shared understanding with clientClinician takes time to achieve a shared understanding with client

Positive consultations take no longer than negative onesPositive consultations take no longer than negative ones(Arborelius & Bremberg 1992)(Arborelius & Bremberg 1992)

Improved outcomesImproved outcomes

A Meeting of ExpertsA Meeting of Experts

Any clinical consultation is a meeting of two expertsAny clinical consultation is a meeting of two experts

ClinicianClinician - Skills & Knowledge- Skills & Knowledge

ClientClient - Their body & Experience- Their body & Experience

But sometimes, people just want to be told what to do . . . But sometimes, people just want to be told what to do . . .

It’s all subjective of courseIt’s all subjective of course

Clients rating their cliniciansClients rating their clinicians

Not knowledge basedNot knowledge based

Not skills basedNot skills based

Based on communication and subtle cuesBased on communication and subtle cues

They might be wrong . . . but their perception is everythingThey might be wrong . . . but their perception is everything

MedspeakMedspeak

JargonJargon

Sets boundaries - reminds of power relationshipsSets boundaries - reminds of power relationships

Lay personLay person ClinicianClinician

““Sick”Sick” IllnessIllness Vomit Vomit ““Nerves”Nerves” AnxietyAnxiety NeurologyNeurology““Chronic”Chronic” SevereSevere Long durationLong duration““Acute”Acute” SevereSevere Sudden onsetSudden onset““Diet”Diet” Calorie restrictionCalorie restriction IntakeIntake““Drugs”Drugs” NarcoticsNarcotics MedicationMedication““Stomach”Stomach” AbdomenAbdomen OrganOrgan““HistoryHistory““ The pastThe past Previous diseasePrevious disease

Interruptions & Redirections Interruptions & Redirections

Consultations start with clientConsultations start with client

Appearing rushedAppearing rushed

Checking watchChecking watch

FidgetingFidgeting

Monitoring emailMonitoring email

28% of clinicians interrupt client in first opening28% of clinicians interrupt client in first openingMean of 23 seconds (Mean of 23 seconds (Marvel et al 1999Marvel et al 1999) )

Average of 2 interruptions per consultationAverage of 2 interruptions per consultationMean of 12 seconds in home consultations (Mean of 12 seconds in home consultations (Rhoades et al 2001Rhoades et al 2001))

Valerie: HIV patient in 1985Valerie: HIV patient in 1985

Useful sourcesUseful sources

90% of info comes from taking a history90% of info comes from taking a history

10% (or less) from case files and records10% (or less) from case files and records

Visual metaphor Visual metaphor

Might come in bits and piecesMight come in bits and pieces

Communication Skills: General MannerCommunication Skills: General Manner

1.1.Responds to cuesResponds to cues

2.2.Active ListeningActive Listening

3.3.Use EmpathyUse Empathy

4.4.Offer SupportOffer Support

5.5.Non-judgementalNon-judgemental

6.6.Avoid personal beliefsAvoid personal beliefs

7.7.Simple languageSimple language

8.8.Use appropriate body languageUse appropriate body language

9.9.Questioning styleQuestioning style

10.10.Information givingInformation giving

11.11.Information gatheringInformation gathering

Information GatheringInformation Gathering

Appropriate languageAppropriate language

Ordered and MethodologicalOrdered and Methodological

Comprehensive / SuccinctComprehensive / Succinct

CoaxingCoaxing

Use triangulation . . . “So you said that . . . Therefore . . .”Use triangulation . . . “So you said that . . . Therefore . . .”

Offer partners or collaborators to inputOffer partners or collaborators to input

Props e.g. clipboard, notes, questionnaireProps e.g. clipboard, notes, questionnaire

Information Gathering . . . Don’t rely on symptomsInformation Gathering . . . Don’t rely on symptoms

““Doorknob concerns”Doorknob concerns”

““By the Way” syndrome (By the Way” syndrome (Robinson 2001Robinson 2001))

Clients often reveal real reason only when comfyClients often reveal real reason only when comfy

Real reason is not the first reason hey giveReal reason is not the first reason hey give

Psychosocial issuesPsychosocial issues

Worries about futureWorries about future

Their own ideasTheir own ideas

Social context of their problemSocial context of their problem

Barry et al 2000Barry et al 2000

Information GivingInformation Giving

Convey info Convey info

Check understandingCheck understanding

Control of consultation (allows it to vary)Control of consultation (allows it to vary)

Signpost change of directionSignpost change of direction

Summarises / indicates next stepsSummarises / indicates next steps

Recognise and respond to client’s concerns and anxietiesRecognise and respond to client’s concerns and anxieties

Consultation General SkillsConsultation General Skills

1.Gives name and explains role; checks patient’s name 2.Gives greeting appropriate to culture (handshake not always needed)3.Non-verbal behaviour appropriate to culture (eyes not always needed)4.Establishes purpose of interview 5.Clarifies why interview is taking place:

- from client’s perspective - from clinician’s perspective

6.Checks that patient is happy to proceed 7.Establishes desired outcome of interview 8.Establishes baseline knowledge/understanding 9.Uses open questions 10.Listens 11.Confirms what s/he has learned 12.Signals move to information-giving at end

Some natural cynicism from medical circlesSome natural cynicism from medical circles

Date Symptoms Referral Investigation Outcome

1980 (18)1980 (18) Abdominal painAbdominal pain GP --> surgical OPGP --> surgical OP AppendictomyAppendictomy NormalNormal

1983 (21)1983 (21) PregnancyPregnancy GP --> obs and gynae GP --> obs and gynae Termination Termination(boyfriend in prison)(boyfriend in prison) OPOP

1985-71985-7 Bloating, abdominal Bloating, abdominal GP --> Gastro andGP --> Gastro and All tests normalAll tests normal IBS diagnosisIBS diagnosis(23-25)(23-25) blackouts (divorce)blackouts (divorce) neurology OPneurology OP unexplained syncopeunexplained syncope

1989 (27)1989 (27) Pelvic painPelvic pain GP --> obs and gynaeGP --> obs and gynae SterilisedSterilised Pain persists for 2 yearsPain persists for 2 years(wants sterilisation)(wants sterilisation) OPOP

1991 (29)1991 (29) FatigueFatigue GP --> infectiousGP --> infectious Nothing abnormalNothing abnormal Diagnosis of ME by patientDiagnosis of ME by patientdiseases unitdiseases unit and self help groupand self help group

1993 (31)1993 (31) Aching musclesAching muscles GP --> rheumatologyGP --> rheumatology Mild cervical Mild cervical Pain clinic - TryptizolPain clinic - Tryptizolclinicclinic spondylosisspondylosis

1995 (34)1995 (34) Chest pain, breathlessChest pain, breathless A&E --> chest clinicA&E --> chest clinic Nothing abnormalNothing abnormal Refer to psychiatric servicesRefer to psychiatric services(child truanting)(child truanting) poss hyperventilationposs hyperventilation

Case Summary of a counselling clientCase Summary of a counselling client

SummarySummary

Clinicians expected to be good communicatorsClinicians expected to be good communicators

Clinical skill does not make up for communication lackingClinical skill does not make up for communication lacking

Communication does not replace clinical skillsCommunication does not replace clinical skills

Getting it right worthwhileGetting it right worthwhile

Rewards Rewards

Getting it right takes time and experienceGetting it right takes time and experience

Clinical supervision essentialClinical supervision essential

Case reviews essentialCase reviews essential

Communication without KnowledgeCommunication without Knowledge

Communication without KnowledgeCommunication without Knowledge

Some ReferencesSome References

Makoul, G. (2001). Essential elements of communication in medical encounters: Makoul, G. (2001). Essential elements of communication in medical encounters: the Kalamazoo consensus statement. the Kalamazoo consensus statement. Academic Medicine, Academic Medicine, 76(4)76(4): 390-393.: 390-393.

RSM forum on Communication in Healthcare (2004). Core curriculum for RSM forum on Communication in Healthcare (2004). Core curriculum for communication skills in medical schools. In E. McDonald (ed). communication skills in medical schools. In E. McDonald (ed). Difficult Difficult Conversations in Medicine.Conversations in Medicine. Oxford: Oxford University Press. pp 209-211. Oxford: Oxford University Press. pp 209-211.

Simpson, M et al. (1991). Doctor-patient communication: the Toronto consensus Simpson, M et al. (1991). Doctor-patient communication: the Toronto consensus statement. statement. British Medical Journal. British Medical Journal. 303(6814): 303(6814): 1385-1387.1385-1387.

Von Fragstein, M. et al. (2008) UK consensus statement on the content of Von Fragstein, M. et al. (2008) UK consensus statement on the content of communication curricula in undergraduate medicine education. communication curricula in undergraduate medicine education. Medical EducationMedical Education 42(11): 42(11): 1100-1107.1100-1107.