1. in
Medical Practice
drahmadtemimi@gmail.com

2. Learning objectives
 Identify communication process
 List elements of communication process
 Explain forms of communication
 Define doctor-patient communication
 Explore barriers to communication
 Describe strategies to Improve communication

3.  Communication is a mean of
connecting people.
 Good communication skills are key to
success in life, work, and
relationships.
‘Communication’ is the process of
exchanging a message from one person
to another so that the message is
completely understood by both parties.
Definition of Communication Process

4. Elements of Communication Process
Communication is a
two-way process
whereby information
(message) is enclosed
in a package
(encoded) and
imparted by a sender
to a receiver via some
medium (channel)
The receiver then
decodes the message
and gives a feedback to
the original sender,
who in turn interprets
the feedback
1 2

5. 1. Sender: the person or party who sends
the message.
2. Message: It may be an information,
ideas, or thoughts.
3. Channel: It is the means through which
the message is delivered from the
sender to the receiver.
E.g., speak face-to-face, use a
telephone, write on paper or electronic
tablet, send a fax or an email, draw a
picture, use body language.
4. Receiver: The person(s) to whom the
message is directed to.
5. Feedback: It is the receiver’s response
to the message.
– It may be verbal or non-verbal.
– It enables the sender to know whether
the receiver has understood the
message correctly or it may need to be
adjusted to be more understandable.
Elements of Communication Process
In general, there are 5 major elements in the communication process:

6. – ENCODING a message means to put the
message into some form that can be
communicated, and the receiver can
encode.
E.g., spoken or written words, symbols,
or body language.
– DECODING a message means to translate
the original message from its encoded form
into a form that the receiver understands
and make sense of the message.
– A message is only considered successfully
communicated when both the sender and the
receiver understand it in the same way.
Elements of Communication Process

7. Hello Ali.. The matter that we
agreed upon has been
postponed to another date.
Anyway, I'm ready
anytime...
OK .. Thank you
Activity: Group Discussion
Explain the communication
process in this example.

8. Forms of Communication
Verbal
Verbal
Forms of Communication
Verbal Non-Verbal
 Oral
 Written
 Body Posture
 Facial Expressions
 Eye Contact
 Gestures
 Touch
 Proximity
 Paralanguage

9. Mehrabian’s Communication Model
Mehrabian's research concluded that:
 The spoken words are less important
than other aspects of communication in
conveying or understanding people’s
messages.
 7% of face-to-face communication is
based on the literal content (spoken
words).
 38% is based on the Vocal Cues.
 55% accounts for Body Language.
55%
Body
Language
38%
Vocal
Cues
7%
Words

10. Verbal Communication
 ‘Verbal Communication’ is the process of exchanging messages
through ‘words’.
 This can be performed Orally or in Written form.
 Oral communication conveying
or receiving messages with the
use of spoken words.
 It may be achieved through
face-to-face conversations,
telephone, radio, TV, etc.
 In Written communication
the message is transmitted
in written or printed form.
 It may be achieved through
letters, notes, reports,
newspapers, emails, etc.

11. Non-Verbal Communication
“Body Language”
 It is the messages given out by body actions
and movements rather than words.
 Over 90% of the communication is
channeled through the non-verbal band.
 Personal attitudes, thoughts, feelings, and
emotions usually are communicated at the
non-verbal level.
 Non-verbal signals are under less
censorship from a conscious control than
are verbal messages, so they are likely to be
more genuine.
 Interestingly, non-verbal messages may all
work together to convey the same message.

12. Body Posture
 It refers to the position of the body and
limbs as well as muscular tone.
 For example:
– Depression: drooping head, sagging
shoulders, low muscle tone, and the
appearance of sadness or fatigue.
– Interest: leaning forward with the legs
drawn back.
– Boredom: lowered head, outstretched legs,
and a backward-leaning position.
– Avoidance: crossing arms and legs, leans
back, and may even turn the body away from
the speaker.

13. Facial Expressions
 The human face provides a rich source of
information regarding emotions.
 It is difficult to control facial expressions.
 The eyes may reflect feelings of joy and
happiness or sorrow and grief.
 A smile conveys a positive attitude. False
smiles do not involve the cheeks or the eyes.
 Movements of the cheeks, mouth, nose, and
brow may express happiness, interest, surprise,
fear, anger, disgust, or sadness.
 Facial expressions can provide the speaker with
feedback (e.g., the listener is interested,
surprised, or disgusted).
 A smile serves as a reinforcer and encourages
the speaker to continue.

14. Eye Contact
 The eye contact illustrates interest in giving and
receiving messages.
 Staring may be interpreted as an invasion of
privacy, discourteous, and even hostile.
 In normal conversation, direct eye contact
occurs for about 50% of the time.
 For speakers, the average length of gaze is
usually less than 3 seconds.
 In listeners, gaze lasts longer (about 8 seconds)
because of their function as a social reinforcer
and a way to indicate attention.
 Strive to establish an amount of eye contact
where both you and the listener are comfortable.

15. Gestures
 Gestures are movements of part of the body,
especially hand and head, to express an idea
or meaning.
 It may be used when speech is ineffective
(e.g., a language barrier).
 E.g., a hand extended outward may signify
“stop” or “wait” and a finger across the lips
may signify “quiet”.
 Gestures may be used to relieve stress (e.g.,
running one’s hand through his hair).
 It also used to regulate the flow of
conversation. (e.g., a head nod may signify
“continue”).

16. Touch
 Caring for patients often involves
some form of touch.
 It serves as a critical tool for
examining, diagnosing, and treating.
 Touch is important in establishing
rapport between the doctor and the
patient.
 Touch decreases patient anxiety and
demonstrate caring, empathy, and
sincerity.
 However, it may evoke negative
reactions in some people.

17. Proximity
 There are four generally accepted distance
zones to be considered when interacting with
others.
 Personal space provides an individual with a
sense of identity, security, and control.
 People often feel threatened or
uncomfortable when their space has been
invaded.
 However, establishing close interpersonal
space can be perceived as supportive.
 Patients are often required to give up their
personal space so that they may be properly
examined and treated.
 Doctors are legitimate and necessary to enter
the patient’s space to manage them.
(up to 45 cm)
(45 cm to 1.2 m)
(1.2 m to 3.6 m)
(3.6 m to 4.5 m)

18. Paralanguage “Vocal Cues”
 ‘Paralanguage’ is the voice effect that
accompanies or modifies talking.
 It refers to how something is said rather than
focusing on what is said.
 It includes the velocity of speech, tone and
volume of voice.
 It also include adjustments such as pauses,
and inflections or non-words, such as "huh" or
"hmm".
 Urgency, sincerity, confidence, hesitation,
sadness, fear and apprehension all are
conveyed by vocal cues.
 Studies have shown that when the vocal and
verbal messages transmit contradictory
information, the vocal is more accurate.

19.  Communication is a core clinical skill for all health
care providers.
 It is the most commonly used medical procedure.
 Despite advances in medical technology, effective
communication remains the physician’s most
powerful diagnostic tool.
 The key to improving outcomes of care is the ability
to communicate effectively and empathetically with
patients.
 Communication is important not only to doctor-
patient interaction but also within the health care
team.
Communication in Medical Practice

20. Doctor-patient Communication
It is the verbal and non-verbal processes through which a doctor obtains and shares
information with a patient to produce a change in both parties in view of their knowledge,
attitude, or behavior.
 The effective doctor-patient communication is
characterized by trust, support, clarity, and
empathy.
 The main areas of doctor-patient communication:
– Consultation process.
– Health education and counseling process.
– Problem-solving and decision-making.
– Breaking bad news.
– Dealing with difficult patients or relatives.
– Disclosing medical errors.
– Patients referral.

21. Benefits of Effective
Doctor-patient Communication
 Establishing an ongoing relationship between
the doctor and the patient.
 Enabling the doctor to identify his patient’s
needs, perceptions, and expectations more
accurately.
 Reinforcing the patient’s self-confidence,
motivation, and positive view of his health
status, which may influence his health
outcomes.
 Making the patient more satisfied with his care.
 It helps to equip patients with the facts, ideas,
and attitudes they need to make informed
decisions about their health.
 Encouraging the patient to share
pertinent information for accurate
diagnosis of his problem(s), follow
advice, and adhere to the prescribed
treatment.
 Improving doctor’s job satisfaction, and
reducing work-related stress and
burnout.
 Making the health system more efficient
and cost-effective and reducing the
utilization of health services.
 Reducing the risk of medical
malpractice.

22. SENDER RECEIVER
MESSAGE
FEEDBACK
CHANNEL
Activity:
Group
Discussion
Activity:
Group
Discussion Discuss the common barriers
to communication.

23. Barriers to Doctor-patient Communication
 Physiological Barriers: e.g., a deaf, mute, or a blind
Patient.
 Psychological Barriers: e.g., emotional
disturbances, depression, neurosis, etc.
 Environmental Barriers: e.g., excessive noise,
difficulties in vision, congested areas and
crowding.
 Time Barriers: time is one of the greatest
challenges for a busy doctor.
 Language Barriers: e.g., medical jargon and
abbreviations.
 Cultural Barriers: communication with people of
different cultures is especially challenging.

24. Active Listening
Emphasis on Body
Language
Using of Clear Speech
Using of Silence
Confrontation
Questioning
Empowering the
Patient
Eliciting Patient’s
Perspective
Providing Empathy
Entering Patient’s
Frame of Reference
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3
4
5
6
7
8
9
10
Strategies to Improve
Doctor-Patient Communication

25. Active Listening
 ‘Active Listening’ is a dynamic process that
includes both hearing what is being said as
well as processing and interpreting the
words that are spoken (and/or unspoken)
to understand the complete message that
is being delivered.
 Active listening is the first communication
skill which has to be mastered by the doctor.
 It helps establish rapport, trust, and bridges
differences between doctor and his patients.
 The doctor needs to listen carefully to the
patient’s verbal and non-verbal cues.
1

26. Active Listening
To listen effectively, you should:
– Pay attention, make eye contact with the
speaker, not to be distracted.
– Minimize distractions (e.g., answering
telephone or writing down notes extensively).
– Try to put yourself in the other’s place to
enable better understanding.
– Take notes if the information is complex or
exact details are required.
– Be patient and avoid interruption.
– Be aware of non-verbal cues.
– Use facilitation.
– When speaker has finished, provide feedback
to verify understanding.
– Use a warm tone of voice.
Facilitation:
 It shows that the doctor is interested and
encourages the patient keep speaking.
 This done by using manner, gesture, or words.
 For example:
– nods of the head
– postural shifts towards the patient
– encouraging words like “I’m listening”,
“Yes, I see”, “Go on” or ‘Mmm’ sounds
 These are called facilitators or encouragers.

27. Active Listening
 After the greeting, it takes the physician, on
average, about 18 seconds to interrupt the
patient.
 Without interruption, patients spontaneously
complete their stories in under 2.5 minutes.
 The doctor should allocate the first few minutes
of the interview to the patient, and concentrate on
listening and facilitating rather than questioning.
Attentive listening serves a number of
purposes in medical interaction:
 Allowing hearing the patient’s story.
 Demonstrating interest in, and respect for,
the patient.
 Preventing making premature
hypotheses.
 Reducing late-arising complaints.
 Providing reassurance and reducing
anxiety.
 Helping to appreciate the patient’s
perspective “Agenda”.

28. Active Listening
 Part of the ‘art of listening’ is making sure that the speaker knows his story is being listened to.
 This achieved by repeating back to the speaker parts of his story.
 Repeating can be accomplished through a combination of 4 communication techniques:
Echoing: It is repeating the last few words of
patient’s sentences when he pauses.
– Echoing shows that the doctor is listening and
understanding the patient.
– It enables the patient to hear what he has just
said.
– This technique should be used in moderation.
Reflection: These are statements that reflect
back not only what is being said, but also what
feelings and emotions the patient is experiencing
when sharing their story with you.
– Reflections use similar but different words so
that the patient knows that the doctor has
understood what he meant.
Paraphrasing: It is repeating back your
understanding of the most important details of
what the patient has just said, using your own
words.
– A paraphrase reflects the essence of what has
been said.
– Paraphrases can be just a few words or one or
two brief sentences.
Summarizing: It is the rephrasing of a series of
statements that have occurred through a
conversation.
– It helps to verify information and display that the
doctor is actively listening.
– It also provide the patient with the opportunity to
revise any misunderstandings.

29. SOLER method for Active Listening
 SOLER method is a non-verbal
techniques described by Gerard Egan as
a tool enabling doctors listening actively
to their clients.
 SOLER stands for:
–Sit squarely in relation to the patient.
–Open posture.
–Lean forward towards the patient.
–Eye contact.
–Relaxed posture.

30. Emphasis on Body Language
– The doctor needs to pay close attention to
the patient’s non-verbal cues.
– He should be aware that non-verbal
language is culturally bound.
– Matching doctor’s position to the patient’s
can signify increased rapport.
– The doctor can also mirror the patient’s
paralanguage, or qualities of speech.
– When a doctor moves closer or makes a
physical contact, like placing his hand on the
patient’s arm, can convey empathy or
support which enables the patient to gain
control of difficult feelings.
2

31. Using of Clear Speech
& Appropriate Language
– Speaking clearly is essential,
particularly with a patient who may
have difficulties when receiving or
giving messages.
– A doctor’s choice of words, as well as
the way he speaks, influences the
effectiveness of his communication.
– He has to use a language adjusted to
suit the patient’s language, culture,
level of maturity and education.
– The doctor needs to use simple words
and avoid medical terminology.
3

32. Using of Silence
4
– Silence can be of real importance to the
communication and therapeutic relationship.
– Doctors need silence to give themselves time to
collect their thoughts, and to be able to stay fully
with the material that is going on, the same is true
for the patient.
– The doctor can use silence as a natural end on
particular area, and to move onto something
different.
– There is one time when it is mandatory for a doctor
to use silence; this is when the patient has stopped
speaking from being overwhelmed with emotion.
– Silence in communication is not about just being
physically present yet quiet, psychological contact
must remain in place too.

33. Helpful Silence
– In general, long silence is likely to be uncomfortable
and embarrassing rather than helpful.
– A doctor can use non-verbal cues to gauge each
patient independently to determine the appropriate
length of time to be silent and when to break the
silence.
– Determining the appropriate length of silence to use
is definitely an art.
– In general, the silence should be long enough to
provide the patient a chance to gather his thoughts
but not so long as to make the patient feel
uncomfortable.
– However, silence may also indicate that the patient
has not understood the doctor’s question. Non-verbal
cues will help the doctor determines the difference.

34. Benefits of Silence
– It encourages the patient to explore themselves.
– It allows the patient to speak about their issues without
interruption.
– It enables the patient to collect his own thoughts,
remember events, assess values and reflect on feelings.
– It gives a space in which feelings can be nurtured and
allowed to develop.
– It enables the patient to elicit a response from the doctor,
such as satisfying a need for approval or advice.
– It gives the patient autonomy within the session, so that
they set the pace for the interaction.
– It gives the patient time to make connections–to find the
words, images or feelings they are looking for (e.g., find
the words to describe a symptom).

35. Confrontation
– In this technique, the doctor describes to the
patient something striking about his verbal
or non-verbal behavior.
– E.g., “You look sad”, “You seem frightened”,
“You sound angry”, “You’re trembling”, or “I
notice that you have been rubbing the back
of your neck”.
– It is appropriate to confront a patient when
his voice, posture, facial expression, or
bodily movements betray emotions.
– Confrontation reflects a sympathetic interest
in the patient.
5

36. Questioning
 Questions during a communication
with a patient can help to:
– elicit information from a patient.
– clarify ambiguous information.
– aid in a patient’s journey of self-
exploration.
 You have to be knowledgeable about
the different types of questioning
techniques.
 Remember, be aware and cautious of
over-questioning.
6

37. Types of Questioning Techniques
Open-ended Questions
 These questions encourage a patient to speak
in more depth about something.
 They are ‘open’ because they invite a person
to open up and to further discuss issues of
concern.
 Asking one open question often leads to
asking another.
 Open-ended questions generally start with the
following: How? What? Why? Where? When?
Which? Who?
 The best two examples of open questions are:
– “How can I help you?”
– “What brings you here today?”
Closed-ended Questions
– These questions prompt a short and
focused answer, or a one-word answer
frequently just a “yes” or “no”.
– These are helpful in filling in gaps in
what a patient says, or in keeping track
of a patient’s information for medical
record purposes.
– An efficient doctor will understand when
it is appropriate to use open-ended and
closed-ended questions.

38. Types of Questioning Techniques
Probing Questions
 These questions can help a patient to
think more clearly about an answer he
has 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?”
Leading Questions
– A leading question can give the patient a
clue about how to respond.
– This can be done through the words that
are used in the question or by the tone of
voice.
– E.g., The pain is severe, isn’t it?
– Leading questions should be avoided as
they may introduce an agenda outside of
the client's frame of reference.

39. Tips to enhance
questioning technique
1. Questioning should proceed from
open-ended to focused questions.
2. If necessary, ask questions that
require a graded response rather than
a single answer.
3. Be sure to ask one question at a time.
4. Sometimes, offer multiple choices for
answers.

40. Empowering the Patient
 The patient has many reasons to feel
vulnerable.
 He may be in pain, worried about a
symptom or unfamiliar with the health
care system.
 Therefore, the patient must be
empowered to take responsibility for
his own health and health care.
 The patient must also feel confident in
his ability to follow through on the
doctor’s advice.
How a doctor shares power with his
patient:
– Elicit the patient’s perspective.
– Express interest in the patient, not just
the problem.
– Explore the patient’s emotional content.
– Share information with the patient.
– Make clinical reasoning transparent to
the patient.
– Reveal the limits of own knowledge.
7

41. Understanding the
Patient’s Perspective
 Concepts of ‘health and illness’ have a
strong individual component and rely
on a patient’s own perspective and
frame of reference.
 To the consultation, the patient brings
ideas, concerns, and expectations (ICE
triad) related to his health problem.
 Embedded in the ICE triad are the
patient’s feelings and the effects of the
problem on his life.
 These areas are often grouped together
and called the “Patent’s Agenda”.
8

42. The Patient’s Agenda
1. Ideas: What a patient thinks and feels about his
health problem, its causes, its effects, and its
management.
– What do you think is causing your health
problem?
1. Concerns: The worries and fears about the
problem, its implications, and its effects on the
patient’s personal, family, and occupational life.
– What are you worried that it might be?
1. Expectations: These are the information, the
involvement, and the care that a patient expects,
hopes, or wishes for.
– What are you hoping we might be able to do
for this?
Generally, there are 3 issues in patient’s mind, which
are the real reasons to see a doctor (the ICE triad):

43. Providing Empathy
 Empathy is the ability to see the world
through another person’s eyes and
perceive his emotions.
 It means that the doctor understands
how the patient feels and understands
problems from a patient’s perspective.
 The patient will always tell the doctor
how he is feeling, even when he is
trying not to. Either through verbal or
non-verbal means.
 Thus, the doctor must be an effective
listener and observer.
9

44. Providing Empathy
Empathy is sometimes confused with
Sympathy, but there are important
differences between these two concepts.
Sympathy is to feel sorry for that other
person but do not feel the same
emotions or are not in the same
situation.
Showing Empathy for a patient can
build rapport, whereas showing
sympathy can show the distance
between the doctor and the patient, and
even cause negative feelings on the
patient’s part toward the doctor.
Empathy has many positive effects:
 It helps the patient comes to trust
the doctor as someone who cares
about his welfare.
 It helps the patient understands his
own feelings more clearly.
 It facilitates the patient’s own
problem-solving ability.
Being in the client's frame of
reference is an important
component of empathy which
is a requirement in a
therapeutic relationship.

45. Empathetic Process
Empathy is a two-way transaction – that is, it’s not
enough for us to be understanding their true feelings; the
client must also perceive that they have been understood,
then the empathy circle is complete. The Two-Stage are:
 First, clarifying and gaining both a clear
understanding and appreciation of another person’s
situation or feelings.
 Second, communicating that understanding back to
the patient in a visible and supportive way.
– Many doctors go halfway; they may acknowledge
and be sensitive to a patient’s situation, but they
often do not visibly show it.
– The real key to empathy is the overt demonstration
and expression of sensitivity to the patient in a way
that the patient perceives the doctor’s support.

46. Verbal & Non-Verbal Empathy
 Verbal skills allow the doctor to demonstrate
empathy through supportive comments.
 Verbal empathy can name and appreciate
the patient’s effect or predicament.
– “I can see that your husband’s memory
loss has been very difficult for you to
cope with”.
– “I can appreciate how difficult it is for
you to talk about losing your baby”.
– “I can sense how angry you have been
feeling about your illness”.
 Statements reflecting empathy are highly
effective because they tell the patient that
the doctor has heard him completely.
 Empathy may also be Non-Verbal (e.g.,
facial expression, eye contact, proximity,
touch, the tone of voice, or silence).
 Empathic non-verbal communication can
say more than a thousand words.
 For example, when a doctor offers a
tissue to a crying patient or gently
placing his hand on a patient’s arm to
show understanding.
 Using a non-verbal behavior can clearly
signal to the patient that the doctor is
sensitive to his predicament.

47. Frame of Reference
 Frame of Reference is a complex set of beliefs,
attitudes, ideas, values, preferences, and
expectations that provide us with an overall
perceptual, conceptual, affective, and action set,
which is used to define self, people, and the
world.
 It is point of view or perspective that act as
filters that drive our perceptions of reality of the
world and affect our ability to make decisions,
act, and react in a wide array of situations and
circumstances.
 Each of us has a unique and personal frame of
reference; a window through which we view and
interact with the world and surroundings. So it is
not true to assume that other people look at the
world just as we do.
10

48. Entering Patient’s
Frame of Reference
 Our frame of reference begins to develop
from birth. It is created by culture, education,
upbringing, personality, experiences, the
media, and much more, and continues to
evolve throughout our lives.
 Frames influence how we observe, perceive,
and respond to a situation and filter the
messages others send us.
 In order to communicate effectively, it is
important to understand the other's
perception of reality.
 Not taking into account the other’s frame of
reference sufficiently may make it more
difficult to understand their wants and needs.

49. Ways to increase
Frame of Reference
A limited frame of reference is a barrier to
effective communication. It is important to
increase one’s frame of reference and see
things from multiple viewpoints:
 Recognize that each person has a
unique frame of reference.
 Always listen attentively to others.
 Put yourself in someone else’s place.
 Understand that nobody knows
everything.
 Do not assume anything you do not
understand.

50.  Communication is the act of exchanging information
between people and a means of connecting people.
 Good communication skills are key to success in
life, work, and relationships.
 Effective communication is the physician’s most
powerful tool to improving outcomes of patient’s
care.
 Effective communication is essential to establish a
good doctor-patient relationship.
 Doctors and patients face a number of different
barriers to communicating effectively with each
other.
 There are several techniques that can help
physicians to overcome barriers and communicate
effectively with their patients.
Take-home Message