2 Basic Comm

8/12/2019 2 Basic Comm

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Basic communication skills

Herni Suprapti


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the facto rs that inf luence

doctor-patient commun icat ion


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some bad news

a relat ive has jus t d ied fai led some exams


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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


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The factors (patients) will influence

how communicate

Personality

Upbringing

Social class

Ethnic

Cultural background


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Reactions to illness include

Denial

Anger

Anxiety

Depression


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Factors influence doctor-patient

communication

Patient-related factors

Doctor-related factors

The interview setting


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Patient-related factors

Physical symptoms

Psychological factors related to illnessand medical care (e.g. anxiety,

depression, anger, denial)

Previous experience of medical care

Current experience of medical care


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Training in communication skills

Self-confidence in ability tocommunicate

Personality

Physical factors (e.g. tiredeness) Psychological factors (e.g. anxiety)


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The interview setting :

requirements

Privacy

Comfortable surroundings

An appropriate seating arrangement


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medical student

doctor

easier than others to emphathise andcommunicate with patients

other factors influence our behaviour

during a consultation (Table 2.1)


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impair communication

Tiredness

Anxiety

Preoccupation with other concerns


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The setting of the interview

Most consultations take place in

a hospital ward

the outpatient clinic the GPs surgery

Privacy is essensial


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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


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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

t ti t li i / GP


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outpatient clinic / GPs

consulting room

chairs and desk or a table

three possible ways of arranging the

seating


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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


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Arrangements (b) and (c)

more informal

more likely to facilitate good

communication

th di t b t th


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the distance between the

interviewer & the patient

Placing seats

too close

too far

4-9 feet

distance may change during the courseof the interview


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in a hospital bed

standing over a patient

draw up a chair so that you are on the

same levelas the patient


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Beginning an interview

h t d f l t


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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


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An unsatisfactorybeginningis likely to

lead to an unsatisfactoryconsultation

as the following case illustrates


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How no t to beg in an interv iew

Mrs Francis, a shop assistant aged 31,

attended medical outpatients at her

local hospital

Here is her story :


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When I went into the room which was big andbare I felt lost. I didnt know where to sit, the

doctor had his head down and was wri t ing, thenu rse was on the telephone and there were some

medical students talk ing to each other. I waited

around and w anted to run out the doo r. After

what seemed l ike ages the doc tor told me to si t

down and asked what was wrong. I didnt knowhis name and Im not sure that he knew mine, Idbeen think ing about my problems and what I

wanted to tel l the doc tor bu t I forg ot i t al lhedidnt seem very interested anyway. Hope I donthave to go again.


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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 theirillness with you.

Beginning the interview involves greeting

the patient, introducing yourself andorientating the patient (Table 2.2).

Guidelines for conducting an


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Guidelines for conducting an

interview

Beginning the interview

The main part of the interview

Ending the interview


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Beginning the interview

Greet the patient by name (Good morningMr 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 presentproblem)

Say how much time is available Explain the need to take notes and ask if this

is acceptable


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Maintain a positive atmosphere, warm manner, goodeye contact

Use open questions at the beginning

Listen carefully

Be alert and responsive to verbal and non-verbalcues

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


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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


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Questioning

Listening

Facilitating

are three of the key skills that enable us tocommunicate effectively with others


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medical students & doctors often


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medical students & doctors often

:

ask too many questions and do notallowthe patient to tell their story intheir own words

ask questions that are too long, toocomplicated and confusing

ask questions in such a way that theymay bias the answers given

ignore questions that patients may ask


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So it must be concluded that asking

questions is a valuable skill that needs

to be learnt


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Open and closed questions


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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?


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closed questions

Asking spesific (i.e. closed) questions

gives the patient little choice in the way

they answer and ussually elicits a yesor a no

Have you been feeling unwell today?


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Case example 2.2

A patients response to open and

closed quest ions


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Dr Yates I see from your notes that you h ave had som e chest pain. Do

you st i l l have the pain ? Mr Clark

No, not now

Dr Yates Was i t tight or d ul l ?

Mr Clark It seemed a very dul l pain

Dr Yates Did i t go dow n your arm ?

Mr Clark No, I dont think so

Dr Yates Did i t get worse wh en you exerc ise ? Mr Clark

No, it didnt


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Mr Clark is seen by Dr Vale :

Dr Vale I understand that yo u have had pain. Would y ou please tel l

me more about i t ?

Mr Clark Well, i t was in m y chest and it came on when I was s it t ing at

my desk. It was a funny d ul l pain that stayed in the midd le ofmy chest. Ive had it a few times recently, always when Imat work

Dr Vale Can you te l l me what br ings i t on ?

Mr Clark Well, I was thinking about that. Ive been very busy at work

recent ly, and it seems to happen when I feel worr ied aboutsometh ing


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the advantagesof using open

questions and

the disadvantagesof closed

questions


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Dr Vale obtained considerably more

informationby using open questions

than Dr Yates, who used closed

questions

open style question is preferable


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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 closedquestions are asked.

open questions : some


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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


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closed style of questioning :

the information obtained is restricted tothe questions asked

the interview is controlled by the

interviewer who decides the content ofthe questions

the interviewer has little opportunity toexpress their concern and feelings.This may make them feel frustated

C


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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

P bi i


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Probing questions

help a patient to think more clearly

about an answer they have given

Probing questions may be used


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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 ?

Q ti t b id d


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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

C l ti


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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


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3t f l di ti


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3types of leading question

Conversat ional: 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?.

Subt le: to influence the repondent

should be avoided

the wording of a question can


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the wording of a question can

influence the answer

a study of the frequency of headaches

in a group of individuals


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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.

Li t i


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Listening

patients appreciate and respons positively

is one of the most obvious components ofthe communication process

active or effective listening is one of themost difficult skills to acquire

The first step is receiving the message from

the other person.

li t i


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listening

Listening involves

receiving information

being in tune with the speaker

responding appropriately

This is active or effective listening


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Pi ki


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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.

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verbal cues

Dr Stone Hello Mrs Fine, com e and sit down . How can I help today?

Mrs Fine I thought Id come to see you, doctor, about my headaches

Dr Stone Perhaps yo u co uld tel l 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 feeldizzy. Im really worried about them

Dr Stone Could you tel l me why y ou are worr ied about them ?


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Dr Stone has picked up one of theverbal cues.

The other cue is that Mrs Fine relatesthe symptoms to her mothers death,

and Dr Stone should go on to explore

her reaction, e.g. Could you tell memore about how you felt after your

mothers death?

Non verbal cues


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Non-verbal cues

a lot of information about ourselves and ourfeelings in our body languagethe 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 duringthe interview.

non verbal cues :


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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 :


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non-verbal cues :

Gestures: the angry patient with clenched fists or the

anxious patient who wrings their hands or taps

their feet continously.

Facialexpressions:

sadness, anger & happiness

The way the voice is used:

tone, timing, emphasis on certain words andvocalisation other than with words.

(Paralinguistics.)

Demonstrating active


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g

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


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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.


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give the patient time to respond afteryou have spoken.

Non-verbal : adopting an appropriate

posture

lean slightly forward towards the patient

maintain eye contact

nod your head at appropriate times

Clarification


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ask the patient to clarify somethingthey have said.

This can be done in several ways :

Please tell me exactly when your

abdominal pain started.

Can you describe the pain in moredetail?

What do you mean by dizziness?

Reflection


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Reflection

what they have just said may help themto 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


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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


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relevant

For example :

What youve just told me about your job

is interesting, but Id like to hear moreabout the headaches youve been having.

It would help me to know more about the

c i rcumstances that br ing on your chest

pain.

Silence


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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 onthe interview so far and to plan the next stage

Summarising


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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 :


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Summarising serves several important functions :

check the accuracy of the patients story : opportunity tocorrect any misunderstandings

review the patients story and deduce what else needs tobe explored, and it allows you to buy time if you getstuck and cant think of what to ask next.

help the patient to carry on discussing their problemsitis 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


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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 thatthey 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


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Empathy

means putting yourself in other persons

place

The doctor can demonstrate


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empathy by :

looking at the patient and adopting an

appropriate posture

indicating that you understand what is

happening to them, e.g.:


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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


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communication

the doctor has taken the dominant role in a consultation

with a patient

paying little attention to the patients concernsand understanding of their illness

not involving the patient in decisions about

their treatment

Patient-centred consultations


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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


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interviewing styles

Mrs Fraser works as a clerk in an office. She hasbeen referred to her local hospital by her GPbecause she has had a persistent cough andwheeze for the past 6 months. She has tried to

stop smoking but is finding this difficult. Hercough is worse when she is at work and she isworried that it is brought on by the airconditioning in the office. She is afraid that she

may have to leave her job, which she dependson to support herself and her three children.

Doctor-centred style


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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 theevening

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 othertests and Ill see you in 1 months time

Patient-centred style


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Patient centred style

Dr Eliot Your doctor says that you have a cough. Please could you tell me more about it and aboutany 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 airconditioning

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 Ican 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 losemy job and get behind with the mortgage.

The features of a patient-centred


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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

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communication :

Helping the patient to feel at ease andadopting an empathic approach

Using open questions

Picking up and responding to verbal cuesby listening actively to what the patient is

saying

Picking up and responding to non-verbalcues


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Touch


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Touch

is a powerful means of communication that weuse to express a whole range of emotionstenderness, love, anger, etc.

touch can convey concern and empathy, and itcan have a therapeutic effect in itself

touch must be used appropriately and with dueregard to the sensitivities of the patient and toprofessional codes of conduct.

When should touch be used in the

d t ti t t ?


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doctor-patient encounter ?

Shaking a patients hand on meeting at the startof an interview is socially appropriate

Putting your arm around a distressed person tocomfort them

placing your hand on the arm of a patient who is

having difficulty expressing their thoughts and

emotions conveys empathy, and this often helpsthe person to continue

two general guidelines when

t hi ti t


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touching patients :

Try to assess the patients likely response tobeing 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 thepatient.

Communication during the physical

i ti


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examination

touching during a physical examination

Remember that the patient is likely to be very

conscious of their vulnerability and the power ofthe 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 :


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guidelines :

respect the patients sensitivity and modesty a blanket

Explain what you are going to do. Do they haveany concerns about this ?

Be careful not to instil anxiety at this stage byyour facial expressions, or by spending a longtime on one part of the examination withoutexplanation

Avoid causing discomfort if possible by watchingthe patients expressions or by saying, Pleasetell me if I hurt you.


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