1. Communication Skills
In Clinical Medicine
Prepared and presented by Marc Imhotep Cray, M.D.
Marc Imhotep Cray, M.D.

2. Communication Matters!
Communication impacts:
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Diagnosis
Adherence
Patient satisfaction
Physician satisfaction
Malpractice litigation
Marc Imhotep Cray, M.D.
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3. In Fact...
According to defense attorneys, communication
breakdown is the most important event
leading to a patient's decision to litigate.
 35% Physician communication
 35% Physician attitude
 10% Patient financial incentives
 20% Other
Physician scores on a national clinical skills examination as
predictors of complaints to medical regulatory authorities.
JAMA. 2007 Sep 5;298(9):993-1001.
Marc Imhotep Cray, M.D.
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4. Communication is Not
"Just Talking"
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Communication is the most commonly used
medical procedure
Communication skills are not innate or fixed
Communication skills can be learned and
improved
Physicians can improve health outcomes by
learning how and when to use specific
communication techniques
Richards T. Chasms in communication.
BMJ. 1990 December 22; 301(6766): 1407–1408.
PMCID: PMC1679819
Marc Imhotep Cray, M.D.
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5. Physician Tasks- The Two Fs
Biomedical Tasks
 Find it!
 Fix it!
Marc Imhotep Cray, M.D.
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6. Physician Tasks :
The Four Es
Communication Tasks
 Engage the patient!
 Empathize with the patient!
 Educate the patient!
 Enlist the patient in his/her own health care!
Poor Communication Between Doctors Costs Patients’
Lives, Apr 30, 2013
www.thedoctorschannel.com/view/poor-communicationbetween-doctor
Marc Imhotep Cray, M.D.
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7. The First E - Engagement
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Is the interview an inquiry
or an inquisition?
Who is in charge of the
inquiry process?
What does interruption say
about roles?
How many complaints are
"normal?"
Clarke AR, Goddu AP et.al. Med Care. 2013 Nov;51(11):1020-6.
Thirty years of disparities intervention research: what are we doing to close
racial and ethnic gaps in health care?
doi: 10.1097/MLR.0b013e3182a97ba3.
Marc Imhotep Cray, M.D.
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8. Agree Upon an Agenda for the Visit
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Ask - "Is there anything else you would
like to talk about?"
Ask - "Is there anything else you were
wondering about?"
Ask - "What were you hoping we'd
accomplish today?"
Marc Imhotep Cray, M.D.
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9. Pay Attention to Two "Voices"
Physicians have a "voice,"
the voice of medicine.
This voice...
 Wants to obtain a history.
 Asks close-ended questions
to get "facts"
 Constructs a differential
diagnosis.
Marc Imhotep Cray, M.D.
Patients have a voice, the
voice of experience.
This voice...
 Wants to tell the "story" of
the illness
 Is concerned with the
personal meaning of the
illness.
 Speaks in response to
openended questions
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10. Translate, Bridge, Funnel
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Translate - Converse in one "voice"
while thinking in another
Bridge - Acknowledge when topics are
being changed and give the reasons for
the changes
Funnel - Direct the flow of conversation
by asking for information about topics of
specific concern
Marc Imhotep Cray, M.D.
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11. Outcomes of Successful Engagement(1)
Develop a more accurate
diagnosis
 Obtain more information
about the illness.
 Understand the effect of
the illness upon the
patient.
Marc Imhotep Cray, M.D.
Increase the likelihood of
adherence
 Establish an improved
physician-patient
relationship.
 Discover the health
belief system of the
patient
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12. Outcomes of Successful Engagement(2)
Establish an effective relationship
 Create an opportunity for partnership.
 Demonstrate interest in the patient's
point of view
 Provide the patient with an opportunity
to tell their story
Marc Imhotep Cray, M.D.
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13. The Second E - Empathy
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Being Seen
Being Heard
Being Accepted
Flickr | caroline_1
Marc Imhotep Cray, M.D.
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14. Being Seen Techniques
N.B. See new patients with their clothes on at
the beginning of the interview
"See" the patient - acknowledge...
 Facial and bodily expressions of feelings.
 Mode of dress and physical presentation.
 Notable physical characteristics.
Eliminate physical barriers - desks, charts, etc.
Marc Imhotep Cray, M.D.
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15. Being Heard Techniques
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Use the language of the patient.
Give feedback to the patient.
Ask for feedback from the patient.
Invite the patient to tell his/her story;
welcome the story:
 Feelings
 Values
 Thoughts
Marc Imhotep Cray, M.D.
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16. But There's a Problem...
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Physicians acquire more than
13,000 new words during
their training.
They use them with patients
Adapt to the patient's "voice"
(language, beliefs, etc.).
 This requires concentration
Marc Imhotep Cray, M.D.
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17. Being Accepted Techniques
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If you must judge, judge the behavior not
the person.
Communicate your understanding of the
patient's feelings and values (do so in a
way that they can correct you).
Use appropriate self-disclosure
Marc Imhotep Cray, M.D.
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18. Steps in Communicating Empathy
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Recognize the emotional moment
Pause to question: "What's going on here?"
Name the emotion you believe is present.
Communicate your understanding of the
emotion and validate its presence
Respect the patient's efforts with the emotion
Offer support and partnership
Marc Imhotep Cray, M.D.
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19. Outcomes of Establishing an
Empathic Connection
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Reduced anxiety related to isolation or
abandonment.
Improve adherence.
Increased level of connection:
1) Increased patient satisfaction.
2) Increased physician satisfaction.
Reduced physician frustration
Marc Imhotep Cray, M.D.
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20. The Third E - Education
Assume the following
questions and answer
them as a matter of
course:
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What has happened to me?
Why has it happened to me?
What is going to happen to
me?
Can Doctors Really Educate Patients in 15 Minutes? Aug 17, 2012
http://www.thedoctorschannel.com/view/can-doctors-reallyeducate-patients-in-15-mins/
Marc Imhotep Cray, M.D.
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21. Mysteries of the Medical World
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What are you (they) doing for me (to me)?
Why are you (they) doing this rather than
that?
Will it hurt me or harm me? How much?
How long?
When and how will you know what all this
(tests, procedures, etc.) means?
Marc Imhotep Cray, M.D.
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22. Patient Survey(1)
In a telephone survey of 1000 randomly
selected adults:
 25% reported they had stopped seeing
a physician at some time because of
communication problems
 60% reported they wanted physicians to
do a better job explaining options
Patient-physician communication: why and how.
J Am Osteopath Assoc. 2005 Jan;105(1):13-8.
Marc Imhotep Cray, M.D.
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23. Patient Survey (2)
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50% said, "Ask if the patient has more
questions."
48% said, "Ensure the patient understands
what the physician has said."
47% said, "Explain what the physician is
doing."
Marc Imhotep Cray, M.D.
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24. The Fourth E - Enlistment
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The challenge is to enlist the patient as an
active decision maker and participant in
her/his health care.
Active decision making can not be assumed
Adherence can not be assumed.
Physician action influences both
participation and adherence
Marc Imhotep Cray, M.D.
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25. The Price of Failure
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Patients do not adhere to physicians'
recommendations at least 30% of the time
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Non-adherence with prophylactic
medication among asymptomatic patients
can be more than 50%
Marc Imhotep Cray, M.D.
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26. What's Going On?!?
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3 billion new prescriptions
are written in U.S. each
year
Up to 50% will never be
filled or taken
Up to 50% of those filled
will only be partially taken
Generation Rx How prescription drugs are altering American lives,
minds, and body
J Clin Invest. 2006 February 1; 116(2): 287.
doi: 10.1172/JCI27774
Americans Skimping on Medication, Sep 14, 2012
http://www.thedoctorschannel.com/view/americans-skimping-on-medication/
Marc Imhotep Cray, M.D.
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27. American Prescription Drug Use
“The average number of prescriptions drugs per person,
annually, in 1993 was seven
The average number of prescriptions drugs per person,
annually, in 2000 was eleven
The average number of prescriptions drugs per person,
annually, in 2004 was twelve”
Generation Rx How prescription drugs are
altering American lives, minds, and body
J Clin Invest. 2006 February 1; 116(2): 287.
Marc Imhotep Cray, M.D.
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28. The Poor Adherence Myth
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Myth - "Poor adherence can be attributed to
patient characteristics."
In fact, no consistent relationship has been shown
between adherence and...
Age
Gender
Social economic status
Marital status
Personality traits (introverted, gregarious, etc.)
Marc Imhotep Cray, M.D.
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29. Factors Affecting Adherence
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The objective severity of the disease does
not affect adherence;
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what the physician believes has limited impact
The subjective perception of the
seriousness of the disorder does affect
adherence;
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what the patient believes is critical
Marc Imhotep Cray, M.D.
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30. What Does Affect Adherence?
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The patient's perception of the seriousness
of the disease
The patient's perception of the efficacy of
the treatment
The duration of the treatment and the illness
The complexity of the regimen
The relationship with the physician
Marc Imhotep Cray, M.D.
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31. Enlistment Techniques
To improve adherence physicians must:
 Demonstrate compassion
 Communicate:
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Personal concern for the patient.
Personal interest in the patient's future wellbeing
Activate patient motivation
Share responsibility with the patient
Marc Imhotep Cray, M.D.
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32. Assume a Self Diagnosis
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The patient has an internal belief system
which explains to the patient what is
happening with his or her health
This includes
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cause of a health problem,
meaning (consequences and symbolism) of
the problem, and
how the problem might be resolved
Marc Imhotep Cray, M.D.
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33. To Improve Adherence, the
Physician Must Be Willing to...
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Discover the patient's beliefs:
“cause, meaning and cure”
Discuss the patient's beliefs
Marc Imhotep Cray, M.D.
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34. Enlistment Technique
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Ask - "This is what I think is
going on.
(State your explanation.)
How does my explanation fit
with what you have been
considering?"
Walker J, Leveille SG et.al.
Inviting patients to read their doctors' notes: patients and
doctors look ahead: patient and physician surveys.
Ann Intern Med. 2011 Dec 20;155(12):811-9.
Marc Imhotep Cray, M.D.
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35. Outcomes of Enlistment
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Increased likelihood of adherence.
Empowerment of the patient: motivation.
Greater range of choices for physician
and patient.
Partnership between physician and
patient.
Increased patient and physician
satisfaction
Marc Imhotep Cray, M.D.
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36. There is a Need to EndHow to Disengage
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Summarize diagnosis, treatment,
and prognosis
Review next steps:
Future visits, phone calls, etc.
Tests, referrals, etc.
Say good-bye, express hope
Marc Imhotep Cray, M.D.
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37. Selected References
PubMed
A communication skills course for preclinical students: evaluation of general practice based
teaching using group methods.
Kendrick T, Freeling P. Med Educ. 1993 May;27(3):211-7.
http://www.ncbi.nlm.nih.gov/pubmed/8336570
Effects of communication skills training on students' diagnostic efficiency.
Evans BJ, Stanley RO, Mestrovic R, Rose L. Med Educ. 1991 Nov;25(6):517-26.
http://www.ncbi.nlm.nih.gov/pubmed/1758333
Teaching communication skills: a skills-based approach. Wagner PJ, Lentz L, Heslop SD.Acad
Med. 2002 Nov;77(11):1164.
http://www.ncbi.nlm.nih.gov/pubmed/12431944
Simpson M, Buckman R, Stewart M, Maguire P, Lipkin M, Novack D, Till J. Doctor-patient
communication: the Toronto consensus statement.
BMJ. 1991 Nov 30;303(6814):1385–1387.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1671610/
Kerr DN. Teaching communication skills in postgraduate medical education.
J R Soc Med. 1986 Oct;79(10):575–580.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1290495/
Marc Imhotep Cray, M.D.
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38. THE END,
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