lecture notes

1. COMMUNICATION SKILLS IN
CLINICAL PRACTICE
Dr. Syahnaz Mohd Hashim
Department of Family Medicine,
Faculty of Medicine,
PPUKM

2. What is communication?
“the successful passing of a message
from one person to another”
2

3. Important principles facilitating the
communication process
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
1.
3

4. Communication in the consultation
The doctor requires communication skills
for complete diagnosis:
- Physical
- Emotional
- Social
4

5. If you are the patient, what will be your opinion
on this doctor?
5

6. Important positive behavior
At first contact
Address 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
6

7. Open-ended questions
“How are you feeling today?
“Anything I could help you with?”
“Tell me more about your problem?”
7

8. Do you like the doctor? Why?
8

9. Doctor’s attitude
Caring
Show
empathy
Respect
Interested
Concern
Confidence
Sensitive
Competence
9

10. 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”
10

11. Listening includes four essential
elements
Checking facts
2. Checking feelings
3. Encouragement
4. Reflection
“ You seem very upset today”
“ It seems you’re having trouble coping”
1.
11

12. 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?”
12

13. Non verbal communication
IMPACT OF THE MESSAGE
%
Words alone
7
Tone of voice
38
Non verbal
communication/Body language
55
Body language include use of gestures, postures, position and
distance
13

14. Barriers to effective
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
14

15. Barriers to effective
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
15

16. Using medical jargon
16

17. “What to achieve in a 15 min
consultation” 7 Tasks of Consultation
1.
Define the reason for patient’s
attendance
2.
Consider other problems
3.
Achieve a shared understanding of the
problems
17

18. 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
18

19. Patient Centered Interviewing
Focus on eliciting symptoms and
signs of illness
19

20. What is your opinion to this doctor?
20

21. Shows genuine interest in;
Patients
as individuals
Their reasons for seeking help
Their perceptions of what might be
wrong
Their feeling about the problems
The impacts of this problems on their
daily lives and well-being
21

22. Advantages of patient centered
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
22

23. Other advantages
Greater
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
23

24. Four Windows of Consultation
(Stott and Davis, 1979)
“The exceptional potential in each primary care
consultation”.
A.
Management of
Acute problems
B.
Modification of
Behaviour
C.
Management of Comorbidities
D.
Prevention of Diseases /
Promotion of Health
24

25. Ending an Interview
Summarize
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
25

26. 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.
26

27. HOW TO BREAK BAD
NEWS?

28. Why we need to know
“How to Break Bad News”?
Important
Practical
part of the medical job
& 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.
28

29. What is bad news?
“Any news that drastically and negatively
alters the patient’s view of his or her
future”
29

30. The 10-step Protocol
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Prepare the physical set-up
Get to know the patient
Identify patient’s support systems
Find out how much the patient already knows
Find out how much the patient wants to know
Give a “Warning shot”
Share the information – Break the news gently!
Respond to patient’s feelings – Acknowledge distress
& support ventilation of feelings
Identify concerns, prioritize & answer all questions
Planning & follow-through / follow-up
30

31. 1. Prepare the physical set-up
Check
your facts!
Do it in person, never over the phone!
Find a private room to ensure privacy &
confidentiality
Turn-off your hand phone & pager
Prevent any interruptions!
Have enough chairs & tissue (for tears)
If there are visitors, ask the patient who they
are and what relationship?
31

32. 2. Get to know the patient
Establish
rapport
Introduce 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?”
32

33. 3. Identify patient’s support
systems
How
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”
33

34. Prepare setting, identify support
34

35. 4. Find out how much the patient
already 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?
35

36. 5. Find out how much the patient
wants 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?
36

37. 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

38. 7. Share the information
Break the news GENTLY
Break
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
38

39. 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 frequently
Reinforce
May
and clarify information frequently
need to draw a picture for clarity
39

40. Patient’s reactions
40

41. 8. Respond to patient’s feelings –
Acknowledge distress & support ventilation
of feelings
Patient 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”
41

42. 9. Identify concerns, prioritize &
answer all questions
Patient 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.
42

43. 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.
43

44. 10. Planning & Follow through
Identify 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.
44

45. 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.
45

46. How to write a referral
letter?
46

47. 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
47

48. What should be heading?
Official
clinic/hospital letterhead
LEGIBLE
HANDWRITING! / typed
Patient’s
biodata (NRIC/Hospital R/N)
Date/time
To
letter was written
whom the letter is written
48

49. What should be the content?
Patient’s
problem as a title before the
main text
Brief & relevant history, including current
medication
Past medical history
Allergies
Social circumstances±
Any treatment tried to date & outcomes,
current drug treatment
49

50. 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
50

51. Very importantly…
Be
polite & grammatically correct.
Ensure
copy is kept in the medical
records
51

52. Example 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.
52

53. To: Medical Officer-in –charge, Pusat
Perubatan Primer UKM, BTS
Dear
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)
53

54. THANK YOU FOR YOUR
ATTENTION
54