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General Practice, Chapter 4

Chapter 4 - Communication skills


Most people have a furious itch to talk about themselves and are restrained only by the disinclination
of others to listen. Reserve is an artificial quality that is developed in most of us as a result of
innumerable rebuffs. The doctor is discreet. It is his business to listen and no details are too intimate
for his ears.
W. Somerset Maugham (1874-1965)
Summing up
Hippocrates wrote:
In the art of medicine there are three factors-the disease, the patient and the doctor ... It is not easy for
the ordinary people to understand why they are ill or why they get better or worse, but if it is explained by
someone else, it can seem quite a simple matter-if the doctor fails to mak e himself understood he may
miss the truth of the illness. 1
Francis Macnab, Doctor of Divinity and patient, wrote: 'The style of the doctor, the communication of the
doctor and the person of the doctor at the level of primary contact and primary care can be crucial in a
person's life'. 2
Much of the art of general practice lies in the ability to communicate.

Communication
Communication can be defined as 'the successful passing of a message from one person to another'.
There are five basic elements in the communication process:
the
communicator
the message
the method of communicating
the recipient
the response
Important principles facilitating the communication process are:
the rapport between the people involved
the time factor, facilitated by devoting more time
the message, which needs to be clear, correct, concise, unambiguous and in context
the attitudes of both the communicator and the recipient

Communication in the consultation


The doctor requires appropriate communication skills for complete diagnosis (physical, emotional and social)
and competent management. The majority of interaction between doctor and patient occurs in the traditional
consultation. Table 4.1 shows where the communication pattern swings between being 'patient focused' and
'doctor focused'. 3
Table 4.1 Phases of doctor-patient communication 3
Phase 1
Patient
focus

Phase 2
Doctor
focus

file:///E:/Downloads/murtagh/GP_Murtagh/html/GP-C4.htm

Phase 3
Mutual
focus

12/15/11

General Practice, Chapter 4

Introduction

Examination Management

discussion Present complaint

Investigation

Follow-

up
Other medical history

Sign-

off Family history

file:///E:/Downloads/murtagh/GP_Murtagh/html/GP-C4.htm

Social history

Important positive doctor behaviour


At first contact:
Address the patient by his or her preferred name.
Make the patient feel comfortable.
Be 'unhurried' and relaxed.
Focus firmly on the patient.
Use open-ended questions where possible.
Make appropriate reassuring gestures.
Active listening
Listening is the single most important skill. 3 Listening is an active process, described by Egan as follows:
One does not listen with just his ears: he listens with his eyes and with his sense of touch. He listens by
becoming aware of the feelings and emotions that arise within himself because of his contact with others
(that is, his own emotional resonance is another 'ear'), he listens with his 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 or encoded in all the cues that surround the words. He listens to the voice, the demeanour, the
vocabulary, and the gestures of the other. He listens to the context, verbal messages and linguistic pattern,
and the bodily movements of others. He listens to the sounds, and to the silences. 4
Listening includes four essential elements:
checking facts
checking feelings
encouragement
reflection
Listen with understanding, in a relaxed, attentive silence. Use reflective questions, such as:
'You seem very sad today.'
'You seem upset about your husband.'
'It seems you're having trouble
coping.' 'You seem to be telling me
that ...' 'Your main concern seems to
me to ...'
Attitudes
caring
empathy
respect
interest
concern
confidence
competence
responsibility
trust
sensitivity
perceptiveness
diligence
Communicating strategies

Modify
language. Avoid
jargon.
Provide clear explanations.
Give clear treatment instructions.
Evaluate the patient's
understanding. Summarise and
repeat.
Avoid uncertainty.
Avoid inappropriate reassurance.
Arrange appropriate referral (if necessary).
Ensure patient is satisfied.
Obtain informed consent.

Follow-up
Be available for phone calls.
Ensure patients obtain results of investigations ordered, including Pap smears.
Ensure any promised follow-up is carried out.
Phone the patient if you have any lingering concerns (this could be handled by the receptionist).
Arrange referral if inadequate response to treatment.
Act as an advocate if necessary, e.g. pressing for hospital admission.

Difficulties in communication
The Victorian Medical Board lists poor communication as the most important factor causing complaints from
patients and relatives against doctors. 5
Effective communication depends on four interrelated factors concerning the message-the doctor (the
sender), the patient (the recipient), the message itself and the environment in which the message is sent
(Fig. 4.1). 6

Fig. 4.1 The four k ey factors affecting communication

Environment
The physical environment is important (Table 4.2). The appearance, size and layout of consulting rooms,
waiting rooms and patients' rooms will affect communication, sometimes adversely, especially if privacy is
threatened by, say, leaving the consulting room door open. The doctor can create an obstacle simply by a
physical 'barrier', for example a large desk distancing the doctor from the patient (Figure 4.2).

Fig. 4.2 The physical barrier

The hospital environment will encourage the 'sick' role and generally is not conducive to good communication
because of a low level of privacy.
A busy practice affected by time constraints on doctor or patient will influence communications seriously. A
doctor in Wales has a notice in his waiting room: 'If the doctor is a long time with a patient don't get mad: it
might be you'.
Table 4.2 Summary of environmental factors that can adversely influence communication

Waiting room

Poor physical layout


Length of waiting time

Time pressure

'Traffic' level
? busy
? noisy
? sense of urgency

Physical factors Desk-barriers


Layout inappropriate
Poor record system
Substandard examination couch
Privacy

Dressing/undressing
Sound
Interruptions-phone

The message
The nature and content of the message may be uncomfortable for the doctor or the patient or both (Table
4.3). This applies to emotionally charged, complex or subtle content such as sexual problems, malignant
disease, drug abuse, bereavement, malingering and psychiatric disorders.
Table 4.3 Negative communication related to the message

Language difficulties
Complex problems
Emotional problems
Uncertainty and
doubt Examples:
sexuality, such as incest, STDs
malignancy
multiple complaints: 'the shopping list'
infertility
unwanted pregnancy
abortion

The patient may find the message difficult to comprehend because of inappropriate delivery or explanation
by the doctor. Failure to use good follow-up strategies, including appointment times and appropriate patient
education material, will aggravate communication breakdown. Language difficulties can distort the message
and generate frustration in both parties. Good interpreters often help.
The doctor may also fail to appreciate that certain symptoms such as chronic pain or the presence of a
lump mean 'cancer' to the patient. Failure to reassure the patient (where appropriate) distracts the patient.

Doctor-patient interaction

There are several general characteristics that affect communication between doctor and patient. These
include:

poor past relationships and experiences leading to unresolved interpersonal conflict, e.g. an incorrect
diagnosis or poor treatment outcome and indifferent compliance in following treatment or paying
accounts
personal differences, openly expressed, which may create subtle barriers, including differences in
age, sex, religion, culture, social status and doctor/patient roles (occasionally influenced by political
factors)
the communication skills of doctor and patient, both as the sender and receiver of messages
the personal honesty and integrity of both parties in dealing with difficult messages
psychosocial problems that will establish barriers, e.g. psychiatric illness or speech
impediments familiarity between patient and doctor, e.g. friends or relatives

The doctor
Although we believe that most doctors satisfactorily meet professional standards, there are times when the
communication factor is adversely affected by inbuilt negative forces, including chronic tiredness, stress,
domestic problems and poor health (Table 4.4).
Table 4.4 The doctor's personal factors that influence communication

Age

Elderly, young

Sex

Opposite

Senses

Deafness, speech

idiosyncrasy Handicap
Competence

Health
understanding
Professional training
Social awareness
Empathy

Attitudes

Bias-patient attending other doctors or alternative

practitioners Communication style differences Religion, sexual practices


Social class
Ethnic group
Political
group Dress
Eccentricities
Familiarity

Furthermore, there are many strategies, roles, 'games' or 'hobby-horses' that some of us appear to rely on,
especially when confronted with difficult or threatening circumstances, such as the management of the
terminally ill.
Dare we recognise in ourselves some of the following unkind caricatures of doctors, i.e. personality types
who may generate unfavourable communication? 7 8
Dr Al Oof (Fig. 4.3). The prima donna doctor (not necessarily a surgeon); aloof; omnipotent; dark suit
with matching Mercedes; club tie or bow-tie; feared by medical students; partial to Scotch; pronounces
certain cures; powerfully dispels doubts; no faith in the healing process before surgery but unshakeable
faith after surgery; unavailable in the patient's decline.

Fig. 4.3 Dr Al Oof


Dr N. Zyme (Fig. 4.4). The scientific doctor; machine-like; cool; assured; obsessive; drives an Italian car;
orders a new test and drug at every visit; conversant with the cellular biochemistry of the disease process
but ignorant of its host.

Fig. 4.4 Dr N. Zyme


Dr G. Rumble. The gruff doctor; grunts in mono-syllables; brilliant but appears tough and unapproachable;
actually quite shy, soft and kind behind the facade; drives a Ford.
Dr No Komento (Fig. 4.5). The secretive doctor; strong and silent, or is he weak and silent, threatened? In
another world! Drives a BMW; a computer buff.

Fig. 4.5 Dr No Komento


Dr I. Knowall (Fig. 4.6). Glib; assured; garrulous; drives latest red sports car; drapes stethoscope around
neck; accepts invitations to lecture on all subjects; rarely available on the phone; keeps patients waiting for
hours.

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General Practice, Chapter 4

Fig. 4.6 Dr I. Knowall


Dr S. Winger. Modern, swinging and trendy; superficial; on first name terms with patients; drives beaten-up
Renault held together by political stickers; works only 35 hours a week; cavalier; undiplomatically blunt.
Dr X. Cytabull. Fanatic; madly enthusiastic about rarities; overreacts to physical abnormalities; compulsive
writer to medical editors; refers patients ad nauseam; drives yellow Porsche.
Dr Genghis M. Pyre. Longs for a mega-practice, assistants (not partners) and a pathology service; addicted
to conferences and cocktail parties; also yearns for a Daimler, a halo and New Year's honours.
Dr Buzz Bee. Ever busy; flits from one consulting room to another; frequent phone user during consultation;
creates a sense of urgency everywhere; charming to patients but intimidates them; overservices; holds pilot's
licence; drives Landcruiser when licence not suspended.
Dr Go Along Cassidy. Feels comfortable when he is giving patients what they ask for; has a 'conveyor
belt' type practice; rarely leaves his chair and doesn't examine his patients; drives a Colt.
Dr I. Kling. Protective and possessive; hangs on to patients; refers only under pressure; overconfident;
likes to be liked; indifferent medical record system; compulsive drug prescriber; still drives 1969 Volvo.
Dr Nat Ure. Strong on 'alternatives'; pleasant chap; keen on Blackmore's publications and remedies; health
shop (run by spouse) next door for fibre, sprouts and vitamin pills; attracts an attractive clientele; mutters
audibly while writing the rare script; into massage, yoga and transcendental meditation; wears a knitted tie;
rides a bicycle.
Dr Fi Mayle. The invisible doctor; juggles patients, children and the PC with one hand while cooking dinner
with the other; earns less, pays more; shuns cocktail parties in preference to continuing medical education
(CME) meetings with child care; prefers to be really achieving something through her division rather than
waiting for the power boys to do it for her; finds continuing care and collegiate relationships difficult; drives
whatever will take her reliably from A to B many times a day. 9 (reprinted with permission)
Dr Amy Preschool. Ever late to start surgery; smartly dressed in three-year-old fashions (bought before the
baby was born) bearing tell-tale infant food stains; babysitting problems; caring of mums and kids; constant
attender of paediatric continuing education programs to find the cause of her child's continual diarrhoea;
drives a late model Japanese-built station-wagon with a recommended car seat in the back. 10
Dr Family Practice. The conservative doctor; married to a university sweetheart; practising from home for
many years with her husband; prescribes mist magnesium trisilicate for peptic ulceration, Relaxa-Tabs for
panic states and the 'Red tonic' for depression; children grown up and at university; both left at home with
the ageing parents, two dogs and two cars; she drives the Austin A30. 10
Dr Susie Nirvana. Pap smear queen; always working, never in the same place twice; takes her entourage of
similar searching patients with her. Drives someone else's car. 10
Dr Magoo. Always in court; popular with solicitors; never examines patients; great conversationalist; rarely
looks; misses obvious signs; can't afford a car.
Dr Ann Osmia. Socialite doctor with 'special' clientele; senseless to sensory signs such as abnormal
smells, sights and sounds; has difficulty with diagnosing alcohol abuse, gastrointestinal disorders and
diabetes; harbours secret bad experiences with neurology tutor; drives a Saab cabriolet with matching
poodle.

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General Practice, Chapter 4

Dr Otto Sclerosis. The clinic's unpopular doctor; doesn't listen; doesn't hear; preoccupied; has gambling and
drinking problem; drives Range Rover when driver's licence not suspended.
These caricatures mirror something of ourselves, so that, it is to be hoped, we can understand our own
attitudes and behaviour. The stereotypes portrayed may well adversely affect our relationship with our
patients and colleagues.

The patient
Do we recognise, with significant emotion, these patients in our practice?
'Smith speaking-I insist on speaking to you directly and not to the "iron curtain" out front.'
'Doctor, I've lost my script again-be a good fellow and ...'
'Those pills you prescribed yesterday are doing nothing for me.'
'Doctor, you're the only one who can help me.'
Yes, doctors are human and can harbour hostility towards the difficult patient, including the demanding
patient, the seductive patient, the 'compo' patient, the difficult 'ethnic' patient, the hypochondriac, the bad
debtor or the manipulative patient.
Some patients appear to have the irrepressible ability to create conflict, so often heralded by an
upset receptionist, thus setting the scene for a potentially difficult consultation (Table 4.5).
Table 4.5 Patient characteristics that can influence communication

Age

Adolescent, elderly

Sex

Opposite

Senses

Deaf, blind, speech impairment

Handicapped

Speech disorders, visual impairment

Illness

Acutely ill/injured

Psychological
Attitudes

Anxiety/depression
Dementia
Fears and phobias, e.g. AIDS
Health understanding
Hysteria
Hypochondriasis
Personality disorders
Sensitive issues, e.g. sexuality, bereavement, malignancy
Social
Social class
Ethnic group
Education
Dress
Political group
Familarity

Aggressive, hostile
Demanding
Aggrieved, e.g. fees, mistakes
Perception of doctor's authority

However, doctors have a professional responsibility to transcend interpersonal conflict and facilitate
productive communication by establishing a caring and responsible relationship even with 'difficult' patients.
Not surprisingly, such patients can also be found to be warm and pleasantly human beneath their 'shoulderchip' facade and so be helped immeasurably by an empathetic doctor.
It is important to bear in mind that medical communication often occurs in an emotional
environment, because 'disease' has important emotional connotations for patients and their
relatives and friends. Inappropriate communication and management can generate hostility.
The doctor-become-patient in the hands of his colleagues learns fast, but possibly too late. Illness plus
defective communication can bring confusion, anxiety and pain; suspicion and confinement add new
dimensions to suffering.
Sooner or later we come to see ourselves as persons, both as doctor and as patient ('wearing his
moccasins'). The patient in us longs for the ideal doctor who is truly professional with sound knowledge
and sane judgment, who is available, unhurried, caring and responsible.

Non-verbal communication
Non-verbal communication or body language is a most important feature of the communication process.
Birdwhistle 11 has shown that more human communication takes place by the use of gestures, postures,
position and distances (non-verbal communication or body language) than by any other method. Albert
Mehrabian showed that non-verbal cues comprise the majority of the impact of any communicated message
(Table 4.6). 12
Table 4.6 Impact of the message

%
Words alone

Tone of voice

38

Non-verbal communication 55

Recognition of non-verbal cues in our communication is important especially in a doctor-patient


relationship. The ability to recognise non-verbal cues improves communication, rapport and understanding
of the patient's fears and concerns. Recognising body language can allow doctors to modify their
behaviour, thus promoting optimum communication. 13

Interpreting body language 11 13


The interpretation of body language, which differs between cultures, is a special study in its own right but
there are certain cues and gestures that can be readily interpreted. Examples illustrated include the
depressed patient (Fig. 4.7), barrier-type signals often used as a defensive mechanism to provide comfort
or indicate a negative attitude (Figs 4.8 a,b,c ) and a readiness gesture indicating a desire to terminate the
communication (Fig. 4.9).

Fig. 4.7 Posture of a depressed person-head down, slumped, inanimate; position of desk and
people correct

Fig. 4.8 Body language-barrier signals: (a) arms folded; (b) legs crossed; (c) 'ank le lock ' pose

Fig. 4.9 Body language-'readiness to go' gestures


Having noted the non-verbal communication the doctor must then deal with it. This may require
confrontation, that is, diplomatically bringing these cues to the patient's attention and exploring the
associated feeling further.
It is not difficult to appreciate the importance of body language in the doctor-patient relationship. A hunch
or gut feeling can be better understood, reinforced or corrected by skilled observation and interpretation of
body language. A doctor can recognise a patient's non-verbal cues and explore the issues raised. By
improving one's skills, and modifying one's behaviour (and consulting room configuration) the doctor can
encourage communication and a better understanding of the patient.
The skill to interpret non-verbal cues can be achieved by conscious observation of people's interaction,
including our own. A technique suggested by Pease 11 is to watch television without sound for 15
minutes each day and check your interpretation each five minutes. By the end of three weeks, he
suggests, you will have become a more skilled body language observer.

Rapport-building techniques
A person can develop rapport with another by mimicking their body language, speech, posture, pace and
other characteristics. This method is a type of neuro-linguistic programming based on the work of Bandler
and Grinder. 14 Such techniques can be used to help the doctor communicate better with the patient and
also to improve a patient's attitude by changing the patient's body language position. It will be difficult for the
patient
to maintain a negative attitude if the body language position is not congruent. 13

Mirroring
Mirroring is a useful technique whereby the limb positions and body angles of the person you are talking
to can be copied. A mirror image is formed of their position so that when they look at you they see
themselves as in a mirror. It is not necessary to copy uncomfortable gestures or unusual limb positions
such as hands behind the head. A partial mirror is often sufficient.

Pacing
People exhibit a certain rhythm or pace that can be revealed through their breathing, talking, and
movements of the head, hands or feet. If you can copy the pace of another person, it will establish a sense
of oneness or rapport with them. Once this pace is established you can change their pace by changing
yours. This is called leading.

Vocal copying
Vocal copying is a rapid and effective way to develop rapport with people. It involves copying intonation,
pitch, volume, pace, rhythm, breathing and length of the sentence before pausing.

Engaging in these strategies will bring you into such close rapport that you can intuitively pick up all kinds
of things about people that were not obvious beforehand. It may also have the unfortunate effect of making
you feel that you are 'drowning' in their problems. If you feel overwhelmed, then break the rapport and

diplomatically go into a leading phase. 15

Practice tips
A fundamental prerequisite for effective communication is listening; this includes not only hearing the
words but also understanding their meaning in addition to being sensitive to the feelings accompanying
the words. 16
Undertake the strategies of paraphrasing and summarising during the consultation to emphasise
that listening is occurring and to provide a basis for defining the problems.
Associated with listening is the observation of the non-verbal language, which may in many
instances be the most significant part of the communication process.
Good communication between doctors and patients decreases the chance of dissatisfaction
with professional services, even with failed therapy, and the likelihood of litigation.

References
1. Elliott-Binns E. Medicine: The forgotten art. Tunbridge Wells, Kent: Pitman Books, 1978, 35.
2. Macnab F. Changing levels of susceptibility in sickness and in health. Aust Fam Physician,
1986; 15:1370.
3. Mansfield F. Basic communicating skills. Aust Fam Physician, 1987; 16:216-222.
4. Kidd M, Rose A. An introduction to consulting sk ills. Community Medicine Student Handbook.
Melbourne: Monash University, 1991, 15.
5. Medical Board of Victoria. Third Annual Report, 1982/3. Melbourne: FD Atkinson, Government
Printers, 1983, 12.
6. Carson N, Findlay D. Communication sk ills. Student Handbook. Melbourne: Monash
University, Department of Community Medicine, 1986, 31.
7. Elliott CE. 'How am I doing?' Med J Aust, 1979; 2:644-645.
8. Murtagh JE, Elliott CE. Barriers to communication. Aust Fam Physician, 1987; 16:223-226.
9. Ivory K. The invisible doctor. Medical Observer, 12 April 1996, 19.
10. Saltman D. Rectifying a sexual bias (Letter to the editor). Aus Fam Physician, 1987; 16:545.
11.Pease A. Body language. London: Camel Publishing, 1985, 1-63.
12.Mehrabian A. Silent messages. Belmont, Calif: Wadsworth, 1971.
13.Findlay D. Body language. Aust Fam Physician, 1987; 16:229.
14. Bandler R, Grinder J. Re-framing: Neuro-linguistic programming and the transformation of meaning.
Moab, Utah: Real People Press, 1982, 1-203.
15.Oldham J. Neuro-linguistic programming. Aust Fam Physician, 1987; 16:237-240.
16. Lloyd M, Bor R. Communication sk ills for medicine. London: Churchill Livingstone, 1996, 17-25.