MEDICAL

COMMUNICATION SKILL

LECTURE
Theresia L. Toruan
Block 2, Oktober 2008

Think back for a minute on your own life

experiences
Recall from your own interaction with your
doctor or dentist
The quality of the communication that
involved

Was it clear?
Was it empathetic?
Were you left with the impression that you
were told as much as you wanted to
know?
Were you left with the impression that
your doctor was a good listener?

Our experience with health and illness

are significant to

our sense of health.

COMMUNICATION
Is an important component of patient care
Must gain an understanding of the
patients perspective on his or her illness
Carefully, not to be judgemental or
scolding,.may rapidly close down
communication

A Changing Paradigm
Communication
skills of the
physician are
critical

Paternalistic
Reductionist

Holistic and
Collaborative
Approach

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

The physician knew best

Patient accepted the recommendation
Patient without question

SHARED DECISION MAKING

(holistic and collaborative
approach)
Advising to educate his or herself
To ask question

because
PHYSICIAN-PATIENT SATISFACTION
REDUCTION IN MEDICAL RISK

Communication Age
able to communicate
information

faster
more clearly
more widely

The basis for patient-physician

alliance
Communication establishes the collaborative
nature of that alliance

shared decision-making
partnering

The benefits of 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 Statement (1999): talking

about the Essential Element of the Medical
Communication based on the task approach

Essential element of Medical

Communication
1.
2.
3.
4.
5.
6.
7.

Build a relationship
Open the discussion
Gather Information
Understand the patients perspective
Share information
Reach agreement on problems and plan
Provide closure

Essential Element of Medical Communication

(cont..)

1. Build

a Relationship
Fundamental communication task
Strong
Therapeutic
Effective relationship (idea, feelings, and
values of both)

with the patient, family

and other support system
Is an ongoing task within and across
Also relevant for work

Essential Element of Medical Communication

(cont..)

1. Build a Relationship.

(cont)

Mnemonic P E A R L S :

P..partnership, acknowledges that the physician and the patient

are in this together

E..empathy, expresses understanding to the patient

A..apology, acknowledges that the phycisian is sorry the patient

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

R..respect, acknowledges the patients suffering, difficulties, etc

L..legitimization, acknowledges that many patient are angry,

frustrated, depressed, etc

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

the patient.

Essential Element of Medical

Communication (cont)
2. Open the discussion
Physicians first greeting.
Physician show personal concern by offering
a handshake and warm smile.
Put the patient at ease in what could
otherwise to be unfamiliar, if not frightening
environment.

Essential Element of Medical

Communication (cont)
3. Gather Information

Shifting from a physician-centered to patient-centered interview

style

Physician interrupt patients an average of 18 seconds after the

patient begins to speak.

Patient rarely continued to express all their true concern once

they were interrupt

No more than 150 seconds was needed to express all their

concern at the beginning or the interview

Two words . What else?

Essential Element of Medical Communication

3. Gather Information

(cont)

Five Communication Pattern :

Narrowly biomedical
Expanded biomedical
Biopsychosocial
Psychosocial
Consumerist.

(cont

Essential Element of Medical

Communication (cont)
Five Communication Pattern

(cont)

Example :
Physician : What bring you here?
Patient
: I have headache
Physician : Where are the headache? How long do
they does? What do you do to relieve them?
This interview follows a physician centered and biomedical
model pattern.
Contrast the previous interview with the following interview.

Essential Element of Medical Communication

3. Gather Information

(cont)

(cont)

Five Communication Pattern (cont)

Example :
Physician
Patient
Physician
Patient
Physician
Patient

:
:
:
:
:
:

What brings you here today?

I have headache.
What else?
Well, I have problems on sleeping.
What else?
I am very worried about my son. He is
using drugs.

This interview follows a patient-centered and

biopsychosocial pattern

Essential Element of Medical Communication

(cont)

4. Understand the Patients Perspective

Explore contextual factors (e.g., family, culture, gender,

age, socioeconomic status, spiritually)

Explore beliefs, concern, and expectation about health and

illness

Acknowledge and respond to to the patients ideas,

feeling, and values

Essential Element of Medical Communication

5. Share Information

Use language the patient can understand

Check for understanding
Encourage questions

(cont)

Essential Element of Medical Communication

6. Reach Agreement on Problems and Plan

(cont)

Essential Element of Medical Communication

(cont)

7. Provide Closure
Ask whether the patient has other issues or
concern
Summarize and affirm agreement with the plan
of action
Discuss follow up

Special Medical Communication

End-of-life communication
Bad News
Old Patient
Family caregivers

Special Medical Communication

(continue)

End-of-life communication

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

Special Medical Communication

(cont)

Bad News

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

S..etting and listening skills

P..erception by patient of condition and seriousness

I..nvitation from patient to give information

K..nowledge - giving medical facts

E..xplore emotions and empathize as patient

responds

S..trategy and Summary

Special Medical Communication

(cont)

Old Patient

Working Memory Capacity Diminish

Hearing and Vision lost
Reflective listening
Create Hope

Special Medical Communication (cont)

Family Caregivers
Understand that illnes and disability are a
family affair. Let the patient know

Be sensitive about place talking to caregivers

about difficulty subjects. Not appropriate in
waiting room and corridors.

EMPHATY
Of all the element involved in effective
communication: the most powerful
1880, psychologist Theodore Lipps: einfuhlung
(in-feeling)

emotional appreciation of
anothers feeling
To describe:

Being a psychiatric or mental health expert

emphatetic communication

is not necessary for using

The only requirement is an awareness of opportunities for emphaty as

they arise during the interview with the patient

Active Listening

The most important skill of medical communication

to learn.
Involves two way tramsmission of verbal and nonverbal behaviour between doctor and patient.
The aim is to encourage the patient to continue their
opening statement as far as possible without
interruption.
Closely linked to the doctors capacity to recognize
emotional factors contributing to illness and distress.

Active Listening

(cont)

Mnemonic S O L E R , positive non-verbals that can

be used to indicatephysician are listening supportively.
Ssitting square on to the patient with an
Oopen position
L leaning slightly forward with
Eeye contact in a
R relaxed posture

Collaboration in Health Care

Involves coordination of individual actions in

Cooperating in planning
Working together
Sharing of goal, planning, problem solving, decision
making and responsibility

Can happened between two people who

represent the same or different disciplines.

Collaboration in Health Care

Nurse-Physician Collaboration

Nurse Practitioner-Physician Collaboration

Social Worker-Physician Collaboration

Pharmacist-Physician Collaboration

Physician-Physician Collaboration

(cont)

The Impact of Poor Communication

Poor communication:

decreases confidence and trust in medical care;

deters the patient from revealing important information;
causes significant patient distress;
leads to the patient not seeking further care;
leads to misunderstandings;
leads to the misinterpretation of medical advice;
underlies most patient complaints; and
predicts negligence claims.

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

patient.

Doctor-related Obstacles
The doctor may be:
inadequately trained in communication skills;
lacking in sensitivity or empathy;
unwilling to recognise patient autonomy;
unaware of problems arising from differences in
language and culture;
affected by time pressures; or distracted by external
or personal factors.

Patient-related obstacles
The patient may be:

affected by the condition, illness or medication;

anxious, embarrassed or in denial about the medical condition;
inexperienced in identifying and describing symptoms;
intimidated by health care settings;
overawed by the doctors perceived status;
disadvantaged by differences in language and culture;
confused by the use of medical jargon;
reluctant to ask questions; or
concerned about time pressures.

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

COMMUNICATION

Its a series of learned skill

Experience is a poor teacher: it needs

observation plus well intentioned,
constructive, detailed and
descriptive feedback plus rehearsel
to effect change

What is patient centered?

J. Bensing
Doctor vs. patient centered
control

Disease vs. patient centered

content

Conceptualize two independent axes

which patients will vary on how they
want their care to be given
Pt. Ed. and Counseling, 39 (2000) 17-25

What is patient centered?

R Smith
Contrasts with doctor-centered and seeks
an integration of both into the interview
allows the patient to lead and direct
the conversation to important personal
data, usually the personal context of
symptoms and disease.

What is patient centered?

Stewart et al
Six components
Exploring both the disease and illness
experience
Understanding the whole person
Finding common ground
Incorporating prevention and health
promotion
Enhancing the doctor-patient relationship
Being realistic

But that takes too long

A Real-time Patient Centered Visit
Agenda Setting

History and Exam

PC
Patient Centered
Minutes

----

Assessment / Plan

PC

PC

PC
Doctor
Work

Doctor Centered
3

--------------------

Charting

6 -------------------

-----------------

12 -----------------

15

Understanding the Whole Person

Disease vs Illness

Disease-oriented vs.
Illness-oriented
Which would you prefer?

A physician is
not only a scientist or a good technician. He
must be more than that-he must have
good human qualities. He has to have a
personal understanding and sympathy for
the suffering of human beings.
Albert Einstein