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Basic communication skills

Herni Suprapti
the factors that influence

doctor-patient communication
some bad news

a relative has just died


failed some exams
First
the setting or situation is clearly
important

Second
how you feel at the time will
influence what you say, and so
will the attitude of the other
person
The factors (patients) will
influence how communicate

Personality
Upbringing

Social class

Ethnic

Cultural background
Reactions to illness
include
Denial
Anger

Anxiety

Depression
Factors influence doctor-
patient communication

Patient-related factors

Doctor-related factors

The interview setting


Patient-related factors

Physical symptoms
Psychological factors related to
illness and medical care (e.g.
anxiety, depression, anger, denial)
Previous experience of medical care
Current experience of medical care
Doctor-related factors

Training in communication skills


Self-confidence in ability to
communicate
Personality
Physical factors (e.g. tiredeness)
Psychological factors (e.g.
anxiety)
The interview setting :
requirements

Privacy

Comfortable surroundings

An appropriate seating
arrangement
Other factors that must be
taken into account are :
the patients beliefs about
health and illness
the problem they wish to discuss
their expectations of what the
doctor will do (based on previous
experience)
how they perceive the role of the
doctor
Doctor-related factors
medical student
doctor
easier than others to emphathise
and communicate with patients
other factors influence our
behaviour during a consultation
(Table 2.1)
medical student

difficult initially when


interviewing patients who are
much older than yourself
sensitive issuess such as sexual
behaviour are involved
have less to give particular
patient

a medical student just before


finals
a junior doctor at the end of a
long shift
a GP who has already seen two-
dozen patients earlier in the
morning
impair communication

Tiredness

Anxiety

Preoccupation with other


concerns
The setting of the
interview
Most consultations take place in
a hospital ward
the outpatient clinic
the GPs surgery

Privacy is essensial
The setting of the
interview
A patient in a hospital bed
sensitive information
Mrs Smith in the bed next door can
hear every word through the curtains

the patient can be moved


avoid interruptions
Lighting
Temperature
arrangement of seats

can influence how people


communicate with each other
and

give clues to how they perceive


their own and each others roles
in the encounter
outpatient clinic / GPs
consulting room
chairs and desk or a table

three possible ways of arranging


the seating
Arrangement (a)

patient and doctor facing each


other across a desk
is unlikely to make the patient
feel at ease or facilitate
discussion
the doctor may feel in control of
the interview
Arrangements (b) and (c)

more informal

more likely to facilitate good


communication
the distance between the
interviewer & the patient
Placing seats
too close
too far

4-9 feet

distance may change during the


course of the interview
in a hospital bed

standing over a patient

draw up a chair so that you are


on the same level as the patient
Beginning an interview
what made you feel at
ease, you might have
included :
a comfortable setting
being greeted by name and a handshake
being shown where to sit
the interviewers introducing themselves
and explaining the procedure
an easy first question
the interviewer appearing interested in
your remarks
An unsatisfactory beginning is
likely to lead to an
unsatisfactory consultation

as the following case illustrates


How not to begin an
interview
Mrs Francis, a shop assistant
aged 31, attended medical
outpatients at her local hospital

Here is her story :


When I went into the room which was big
and bare I felt lost. I didnt know where to
sit, the doctor had his head down and was
writing, the nurse was on the telephone
and there were some medical students
talking to each other. I waited around and
wanted to run out the door. After what
seemed like ages the doctor told me to sit
down and asked what was wrong. I didnt
know his name and Im not sure that he
knew mine, Id been thinking about my
problems and what I wanted to tell the
doctor but I forgot it all he didnt seem
very interested anyway. Hope I dont have
to go again.
what was wrong with the way this
interview was conducted

help the patient feel at ease, and


begin to build up a relationship that
enables them to share the story of
their illness with you.

Beginning the interview involves


greeting the patient, introducing
yourself and orientating the patient
(Table 2.2).
Guidelines for
conducting an interview
Beginning the interview

The main part of the interview

Ending the interview


Beginning the interview
Greet the patient by name (Good
morning Mr Ricardson) and shake
hands
Ask the patient to sit down
Introduce yourself (I am Judy William,
as a medical student)
Explain the purpose of the interview (I
would like to find out about your
present problem)
Say how much time is available
Explain the need to take notes and ask
if this is acceptable
The main part of the
interview
Maintain a positive atmosphere, warm manner,
good eye contact
Use open questions at the beginning
Listen carefully
Be alert and responsive to verbal and non-
verbal cues
Facilitate the patient both verbally (Tell me
more) and non-verbally (using posture and
head nods)
Use specific (closed) questions when
appropriate
Clarify what the patient has told you
Encourage the patient to be relevant
Ending the interview

Summarise what the patient has


told you and ask if your summary
is accurate
Ask if they would like to add
anything
Thank the patient
The main part of the
interview
Questioning
Listening
Facilitating

are three of the key skills that


enable us to communicate
effectively with others
Asking questions

the purposes of interviewing a


patient is to obtain information
about the condition for which
they are seeking help

The information must be


accurate, complete and as
relevant as possible
medical students & doctors
often :
ask too many questions and do
not allow the patient to tell their
story in their own words
ask questions that are too long,
too complicated and confusing
ask questions in such a way that
they may bias the answers given
ignore questions that patients
may ask
So it must be concluded that
asking questions is a valuable
skill that needs to be learnt
Open and closed questions
Open questions

obtain a great deal of information and


also allows the patient to tell their own
story

sould be used as much as possible,


particularly at the start of the interview

e.g. would you please tell me how you


have been feeling in the past few days?
closed questions

Asking spesific (i.e. closed)


questions gives the patient little
choice in the way they answer and
ussually elicits a yes or a no

Have you been feeling unwell


today?
Case example 2.2

A patients response to open and


closed questions
Mr Clark is an accountant aged
47 years.

He comes to the accident and


emergency department following
an attack of the chest pain.

He is seen first by Dr Yated :


Dr Yates
I see from your notes that you have had some chest
pain. Do you still have the pain ?
Mr Clark
No, not now
Dr Yates
Was it tight or dull ?
Mr Clark
It seemed a very dull pain
Dr Yates
Did it go down your arm ?
Mr Clark
No, I dont think so
Dr Yates
Did it get worse when you exercise ?
Mr Clark
No, it didnt
Mr Clark is seen by Dr
Vale :
Dr Vale
I understand that you have had pain. Would you
please tell me more about it ?
Mr Clark
Well, it was in my chest and it came on when I was
sitting at my desk. It was a funny dull pain that
stayed in the middle of my chest. Ive had it a few
times recently, always when Im at work
Dr Vale
Can you tell me what brings it on ?
Mr Clark
Well, I was thinking about that. Ive been very
busy at work recently, and it seems to happen
when I feel worried about something
the advantages of using open
questions and

the disadvantages of closed


questions
Dr Vale obtained considerably
more information by using open
questions than Dr Yates, who
used closed questions
open style question is
preferable because :
more relevant information can be
obtained in a given time
the patient feels more involved in
the interview
the patient can express all the
concern and anxieties about their
problems; these may be missed if
closed questions are asked.
open questions : some
disadvantages
the interview may take longer
and be more difficult to control
some of the information may not
be relevant
recording answers may be more
difficult
closed style of questioning :

the information obtained is


restricted to the questions asked
the interview is controlled by the
interviewer who decides the
content of the questions
the interviewer has little
opportunity to express their
concern and feelings. This may
make them feel frustated
Closed question

obtain specific information that the


patient has not given
when the patient is shy or withdrawn
when it is necessary to obtain a
limited amount of factual
information in a limited period of
time
painful arm after a fall
Probing questions

help a patient to think more


clearly about an answer they
have given
Probing questions may be
used to :
Clarify : What do you mean by
that ?
Justify : What makes you think
that ?
Check accuracy : You definitely
took three tablets a day ?
Questions to be avoided

Complex questions
Leading questions

The questions should be


easily understood
asked in such a way that does not
influence the patients response
Complex questions

confuse both the patient and the


interviewer
Ex : Did your vomiting start
yesterday or today and have you
had diarrhoea?
only one part of the question
would be answered
Leading questions

the person responding to give


the answer that the interviewer
expects or wants
3types of leading
question
Conversational :
to open or stimulate conversation
e.g. Arent we having awful weather this
year?.
Simple :
influence the patient to agree with the
interviewers viewpoint and should not be
used
e.g. You dont sleep well do you?.
Subtle :
to influence the repondent
should be avoided
the wording of a question can
influence the answer

a study of the frequency of


headaches in a group of
individuals
Do you get headaches
frequently and, if so, how often?
the average response was 2.2
headaches per week.

Do you get headaches


occasionally and, if so, how
often?
the average reponse was 0.7
headache per week.
Listening

patients appreciate and respons


positively
is one of the most obvious
components of the communication
process
active or effective listening is one of
the most difficult skills to acquire
The first step is receiving the
message from the other person.
listening
Listening involves
receiving information
being in tune with the speaker

responding appropriately

This is active or effective


listening
The key features of active
listening are :
gathering & retaining the
information accurately
understanding the implications for
the patient of what is being said
responding to verbal and non-
verbal signals or cues
demonstrating that you are paying
attention and trying to understand
Picking up cues

A patient may be unable or


unwilling to articulate their real
concern and feelings.

it is important that their verbal


and non-verbal cues are picked
up.
verbal cues
Dr Stone
Hello Mrs Fine, come and sit down. How can I help
today?
Mrs Fine
I thought Id come to see you, doctor, about my
headaches
Dr Stone
Perhaps you could tell me more about these
headaches
Mrs Fine
Well, theyre really bad, and getting worse. They
started soon after my mother died and now theyre
making me feel dizzy. Im really worried about them
Dr Stone
Could you tell me why you are worried about them ?
Dr Stone has picked up one of the
verbal cues.

The other cue is that Mrs Fine


relates the symptoms to her
mothers death, and Dr Stone
should go on to explore her
reaction, e.g. Could you tell me
more about how you felt after your
mothers death?
Non-verbal cues
a lot of information about ourselves
and our feelings in our body language
the way we dress, our posture,
gestures and facial expressions
When you interview a patient, you
can learn a good deal by watching
them enter the room (their
appearance, posture, gait, etc).
be sensitive to their body language
during the interview.
non-verbal cues :
Eye contact :
difficulty in maintaining eye contact
feels depressed
embarrassed about what they are saying
uninterested in the conversation
excessive eye contact : anger & aggression
Posture :
the confident person : sit upright
the patient depressed : sit slouched with
head bent forward.
non-verbal cues :
Gestures :
the angry patient with clenched fists or
the anxious patient who wrings their
hands or taps their feet continously.
Facial expressions :
sadness, anger & happiness
The way the voice is used :
tone, timing, emphasis on certain words
and vocalisation other than with words.
(Paralinguistics.)
Demonstrating active
listening
show the patient that you are listening carefully.

use of
eye contact
posture (e.g. sitting slightly forward facing the patient)
nodding your head
saying hmm go on

active listening :
asking questions directly related to
following on from the patients last statement.
Facilitation
essential part of effective listening
the aim : to help the patient to talk
as fully as possible about problems

Ex : verbal facilitation :
Please go on and tell me more about
your pain.
Yes, I understand please continue.
give the patient time to respond
after you have spoken.

Non-verbal : adopting an
appropriate posture
lean slightly forward towards the
patient
maintain eye contact

nod your head at appropriate times


Clarification
ask the patient to clarify
something they have said.

This can be done in several ways :


Please tell me exactly when your
abdominal pain started.
Can you describe the pain in more
detail?
What do you mean by dizziness?
Reflection
what they have just said may
help them to proceed with their
story

particularly when they may be


finding it difficult to go on
because of their feelings
Helping the patient to be
relevant

your time as efficiently as


possible.
helping the patient not to stray
from the main point of the
interview.
interrupt at an appropriate point
and try to redirect the interview.
Helping the patient to be
relevant
For example :
What youve just told me about
your job is interesting, but Id like
to hear more about the headaches
youve been having.
It would help me to know more
about the circumstances that bring
on your chest pain.
Silence
make us feel uncomfortable
can be a temptation to rush in with
another question

Silences are valuable


giving the patient time to reflect on what has
been said
use them yourself to observe the patient, to
reflect on the interview so far and to plan the
next stage
Summarising

summarise what the patient has told


you
e.g. Id like to make sure that Ive
understood you correctly. You told me
that .
Summarising serves several important
functions :

check the accuracy of the patients story :


opportunity to correct any misunderstandings
review the patients story and deduce what else
needs to be explored, and it allows you to buy
time if you get stuck and cant think of what to
ask next.
help the patient to carry on discussing their
problems it is one method of facilitation.
help you to keep the patient on track.
let the patient know that you have been listening
carefully and are interested
It is an appropriate way to close an interview
Ending an interview
Summarise 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 that they feel is important
Enquire if they would like to add anything
End by thanking the patient, e.g. Thank
you for talking to me; our time is now up.
Empathy

means putting yourself in other


persons place
The doctor can
demonstrate empathy by :

looking at the patient and adopting


an appropriate posture

indicating that you understand what


is happening to them, e.g.:
Patient
My father died from a heart attack
seven years ago whilst I was on holiday
in France

Doctor
That must have been a distressing time
for you
doctor-centred style of
communication
the doctor
has taken the dominant role in a
consultation with a patient
paying little attention to the patients
concerns and understanding of their
illness
not involving the patient in decisions
about their treatment
Patient-centred consultations

many patients want to know more


about their illness and be involved in
treatment decisions

leads to greater satisfaction and


compliance with treatment
Doctor & patient-centred
interviewing styles
Mrs Fraser works as a clerk in an office. She
has been referred to her local hospital by
her GP because she has had a persistent
cough and wheeze for the past 6 months.
She has tried to stop smoking but is finding
this difficult. Her cough is worse when she is
at work and she is worried that it is brought
on by the air conditioning in the office. She
is afraid that she may have to leave her job,
which she depends on to support herself
and her three children.
Doctor-centred style
Dr Eliot
Your doctor says that you have a cough, how long have you
had it for and is there anything else wrong ?
Mrs Fraser
Ive had it for 6 months and sometimes I wheeze
Dr Eliot
Do you smoke ?
Mrs Fraser
Well Ive been trying to stop and now I only smoke two
cigarettes in the evening
Dr Eliot
Your symptoms are probably due to your smoking. I strongly
advise you to stop smoking. Ill arrange for you to have a chest
X-ray and other tests and Ill see you in 1 months time
Patient-centred style
Dr Eliot
Your doctor says that you have a cough. Please could you tell me more about it
and about any other symptoms you may have ?
Mrs Fraser
Well Ive had this cough for about 2 months now and sometimes I feel short of
breath, particularly in the morning
Dr Eliot
Could you tell me if you bring up any sputum when you cough ?
Mrs Fraser
Yes, sometimes I do in the morning but I think thats because I smoke, although I
am trying to cut down. Also, I wheeze particularly when Im at work and I think
thats due to the air conditioning
Dr Eliot
You seem to have two concerns. First, you want to stop smoking and I am sure
that is important for your health. Second, you are worried about your work. How
do you think that I can help ?
Mrs Fraser
Well I would like some help to smoking and I wonder if you could write a letter to
the doctor at work because Ive had quite a lot of time off work recently. Im
really scared that I will lose my job and get behind with the mortgage.
The features of a patient-
centred consultation are :
Exploring the patients experience of illness
Allowing the patient to express their beliefs
about their illness, e.g. what caused it.
Allowing the patient to express their concerns
about the impact of their illness on their life
Treating the patient as a partner when
discussing treatment
practising the principles of
good communication :
Helping the patient to feel at ease
and adopting an empathic approach
Using open questions
Picking up and responding to verbal
cues by listening actively to what the
patient is saying
Picking up and responding to non-
verbal cues
Is patient-centred interviewing always
appropriate ?
is appropriate in the majority of
consultations and leads to better
outcomes for the patient and doctor.

some patients prefer doctor-centred


consultations, i.e. they want the
doctor to take a more paternalistic
approach and to take charge of the
consultation and their treatment.
Touch

is a powerful means of communication that


we use to express a whole range of
emotions tenderness, love, anger, etc.

touch can convey concern and empathy,


and it can have a therapeutic effect in itself

touch must be used appropriately and with


due regard to the sensitivities of the patient
and to professional codes of conduct.
When should touch be used in the
doctor-patient encounter ?
Shaking a patients hand on meeting at the
start of an interview is socially appropriate

Putting your arm around a distressed


person to comfort them
placing your hand on the arm of a patient
who is having difficulty expressing their
thoughts and emotions conveys empathy,
and this often helps the person to continue
two general guidelines
when touching patients :
Try to assess the patients likely response
to being touched; you can pick up clues
from the way in which they relate their
story, their posture and other aspects of
body language.

If you feel uncomfortable about touching


patients, it is probably advisable not to do
it you might communicate your anviety
to the patient.
Communication during the
physical examination
touching during a physical examination

Remember that the patient is likely to be


very conscious of their vulnerability and
the power of the doctor as they lie on the
couch waiting to be examined. They may
also feel embarrased and anxious about
what may be found. Try to put them at
ease.
guidelines :
respect the patients sensitivity and
modesty
a blanket
Explain what you are going to do. Do they
have any concerns about this ?
Be careful not to instil anxiety at this stage
by your facial expressions, or by spending a
long time on one part of the examination
without explanation
Avoid causing discomfort if possible by
watching the patients expressions or by
saying, Please tell me if I hurt you.

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