Consultation Skills

Dr Sarah Street

Why is it important? Are there problems in communication

between doctors and patients? Can clinical communication skills be learnt

and do they make a difference? How to learn – skills based approach Consultation models

Consultation Skills – Why Bother?

Doctor-patient communication is central to clinical practice◦Doctors perform about 200 000 consultations

in a professional lifetime

Communication is a core skill

One of the four essential components of clinical competence:◦knowledge base◦communication skills◦physical examination◦problem solving ability

Why is it important?

Communication is not just ‘being nice’ but produces a more effective consultation for both patients and doctors

Effective communication significantly improves:◦ accuracy, efficiency and supportiveness◦ health outcomes for patients◦ satisfaction for both patient and doctor◦ the therapeutic relationship

How we communicate is just as important as what we say◦ communication bridges the gap between

evidence-based medicine and working with individual patients

Why is it important?

45% of patient complaints and 45% of pt concerns not elicited

Most patients want their doctors to provide more information than they do

Doctors overestimate the time they devote to explanation and planning by up to 90%

There are significant problems with patient’s recall and understanding of the information doctors impart

On average 50% of medication prescribed is not taken or taken incorrectly

Problems in communication is the critical factor in >80% of complaints

Are there problems in communication between doctors and patients?

The longer the doctor waits before interrupting at the start, the more likely they are to discover the full spread of issues the patient wants to discus and the less likely it will be that new complaints arise at the end of the consultation

Discovering and acknowledging patients expectations improves patient satisfaction

Does better communication make a difference?

Discovering patient’s expectations leads to greater patient adherence to plans made whether or not those expectations are met by the doctor

Patient satisfaction is directly related to the amount of information that patients perceive they have been given by their doctors

Content skills – what healthcare professionals communicate

Process skills – how they do it Perceptual skills – what they are thinking

and feeling

Types of Communication Skills

An awareness of the structure prevents the consultation from wandering aimlessly and important points from being missed.

Essential when it all goes wrong! Models of the consultation

◦ Disease – Illness Model◦ The Calgary-Cambridge Guide

Consultation Models

PATIENT PRESENTS PROBLEMGathering information

Parallel search of two frameworks

Illness Framework Patients agenda Ideas Concerns Expectations Feelings, Thoughts, Effects Understanding the patients unique experience of illness

Disease framework Doctors agenda Symptoms Signs Investigations Underlying pathology Differential diagnosis

DISEASE ILLNESS MODEL

Integration Explanation and planning in terms the patient can understand and accept

ProvidingStructure

Physical examination

Explanation and planning

Gathering information

Building the relationship

Closing the session

Initiating the session• preparation• establishing initial rapport• identifying the reason(s) for the consultation

exploration of the patient’s problems to discover the biomedical the patient’s

perspective perspective background information - context

providing the correct amount and type ofinformation

aiding accurate recall and understanding achieving a shared understanding:

incorporating the patient’s illness framework planning: shared decision making

• Appropriate point of closure• Forward planning

The Calgary-Cambridge Guide – Expanded Framework

J Silverman et al. Skills for communicating with patients. 2005

An example of the interrelationship between content and processGathering information

Process skills for exploration of the patient’s problemspatient’s narrative

question style: open to closed coneattentive listening

facilitative responsepicking up cues

clarificationtime-framing

internal summaryappropriate use of language

additional skills for understanding patient’s perspective

Content to be discoveredthe biomedical perspective (disease) the patient’s perspective (illness)

sequence of events ideas and beliefssymptom analysis concerns

relevant systems review expectations effects on life feelings

background information (context)past medical history

drug and allergy historyfamily history

personal and social historyreview of systems

Initiating the Consultation Gathering Information Building the Relationship Providing Structure Explanation and Planning

◦ Giving Information◦ Shared Decision Making

Closing the Session

Micro-Skills

Establishing a supportive environment Developing an awareness of the patient’s

emotional state Identifying as far as possible all the

problems or issues that the patient has come to discuss

Establishing an agreed agenda or plan for the consultation

Enabling the patient to become part of a collaborative process

Initiating The Consultation  Objectives

Preparation◦ Put aside last task, attends to self comfort◦ Focus attention and prepares for this consultation

Establishing initial rapport◦ Greeting, introduction, patient’s physical comfort,

demonstrate interest and respect Identifying the reasons for the patient’s attendance

◦ Opening question◦ Active listening without interruption◦ Screening – check and confirm list of problems or issues◦ Agenda setting

Initiating The Consultation  Skills

Reduces uncertainty for patient and doctor May allow for more efficient and effective

use of time Gives more chance for the patient to raise

other concerns and identify the most important concern they wish to explore on this occasion

Encourages negotiation and mutual partnership

Agenda Setting

Listen to the first problem and allow some of the story to come out

Summarise the problems and check you have understood and heard them correctly

Acknowledge the problems; show concern verbally and non-verbally

Ask for any other problems Prioritise the problems – negotiate which

one(s) you will explore on this occasion

Agenda Setting - Strategies

Useful phrases that people have used?

Agenda Setting

‘What’s the first thing you’d like to discuss….?’

‘What’s the one most troubling you….?’ ‘Which one shall we tackle/focus on first/” ‘Which one is the most important to you?’ ‘Let’s start going through them and see

where we get to…” ‘We’ll try to deal with as many problems as

possible….depending on time/how we get on…’

Agenda Setting – Useful Phrases

Exploration of problems◦ Patient’s narrative◦ Question style◦ Listening◦ Facilitative response◦ Clarification◦ Internal summary◦ Language

Understanding the patient’s perspective◦ Ideas and concerns◦ Effects◦ Expectations◦ Feelings and thoughts◦ Cues

Gathering Information

Discuss with your neighbour and feed back to the group.

Useful Phrases to elicit ideas and concerns?

Summarise the problem back to the patient first, then ask:

 “What was in your mind......?”  “What were you concerned/worried  about...?”

(remember that using the word concern helps patient to disclose their worries; most think that their doctor thinks they may be neurotic if they answer to the word worry)

 “Was there a particular concern......?”  “Tell me what you think the problem is.................have

you any clues or theories.....?”  “Have you any ideas about................”  “Tell me what you think is the cause............”  “Do you have any specific worries about..........”  “Tell me what was concerning you.......... is it cancer?”  

(go for it)  “Is there anybody else you know who has had this

problem?” 

Useful Phrases To Elicit Ideas And Concerns:

“Do you think it might be something serious............?”  .......... something in particular.....?”

 “It’s obviously concerning you........is there any particular reason why?”

 “What in your worst moments did you think it was?”          “While you have been waiting to see me ..................... 

what have been your thoughts?”  “During those hours when you have been lying awake at

night........what have your thoughts been  about the problem?” 

“Some people with the same sort of symptoms that you have think that they have something serious like cancer.......is that what you have been thinking?” 

“I’m interested in your ideas about.........I’d like to hear about them because I think they will help us both to understand the problem better.....”

“What were your feelings about this?”  “I’m sorry to press you, but what was really on your

mind....?”

What has worked well for you?

Useful phrases to elicit expectations?

“What did you think we might ............  “What were you hoping that we might be able to do for

this.........  “I’m interested in your thoughts about what might be

helpful before I make any suggestions........  “Were you hoping that I might do something in

particular............  “You’ve obviously given this some thought,.......tell me

what you were expecting.....  A good strategy is to give a range of options and then ask

what the patient was expecting from the consultation; “we could try something to help you with the pain; you

might like to see a physiotherapist…..what were you hoping I might do….?”

Useful Phrases To Elicit Patients’ Expectations

If appropriate, pick up a cue: “you said that your knee was giving you a

lot of trouble, I was wondering how that was affecting you……”

“I know that you spend a lot of time working for the WRVS/looking after you disabled husband…..tell me how you are coping……”

To Ask About How A Problem Affects A Person’s Life

Developing rapport to enable the patient to feel understood, valued and supported

Reducing potential conflict between doctor and patient Encouraging an environment that maximises accurate and

efficient initiation, information gathering and explanation and planning

Enabling supportive counselling as an end in itself Developing and maintaining a continuing relationship over

time Involving the patient so they understand and is

comfortable with the process of the consultation Increasing both the doctor’s and the patient’s satisfaction

with the consultation

Building the RelationshipObjectives

Non-verbal communication◦ Demonstrate appropriate non-verbal behaviour◦ Use of computer◦ Picks up patient’s non-verbal cues

Developing rapport◦ Acceptance◦ Empathy and support◦ Sensitivity

Involving the patient◦ Sharing of thoughts◦ Provide rational◦ Examination

Building the RelationshipSkills

Can you think of any ways this has worked well for you?

Any useful tips – please share with the group.

Responding to Cues

‘You appear to be in a lot of pain …’ ‘It sounds like a difficult situation.’ ‘That must be really hard for you.’ ‘Is it something that you want to discuss

with me?’ ‘You seem very …

upset/frustrated/angry/annoyed/ambivalent/negative/elated.’

‘You mentioned about ….’

Responding to Cues; Acknowledging Emotions

Summarise – end of specific line of enquiry/section of the consultation to verify own interpretation of what patient has said, to ensure no important information omitted

Signposting – progress from one section to another using transitional statements; including rational for next section

Sequencing – structure consultation in a logical sequence

Timing – attend to time and keep consultation on task

Providing Structure

Gauging the correct amount and type of information to give to each individual patient

Providing explanations that the patient can remember and understand

Providing explanations that relate to the patient’s illness framework

Using an interactive approach to ensure a shared understanding of the problem with the patient

Involving the patient and planning collaboratively to increase the patient’s commitment and adherence to plans made

Continuing to build a relationship and provide a supportive environment

Information Giving, Explanation And Planning - Objectives

Giving information – checking (Man with Two Brains)

http://www.youtube.com/watch?gl=US&v=3r4rS0yzQ1M

Chunk and check Assess patient’s starting point; prior

knowledge; extent of wish for information Ask what other information would be helpful Give explanation at appropriate times –

avoid giving premature information, advice or reassurance

Providing the correct amount and type of information

Organise explanation – divide into sections, logical sequence

Explicit categorization or signposting Repetition and summarizing Language Visual aids Check understanding

Aiding accurate recall and understanding

Relate explanation to patient’s illness framework: to previously elicited ideas, concerns and expectations

Provide opportunities and encourage patient to contribute

Pick up and respond to verbal and non-verbal cues

Elicit patient’s beliefs, reactions and feelings re information given, terms used; acknowledge and respond

Achieving a shared understanding: incorporating the patient’s perspective

Share own thoughts: ideas, thought processes and dilemmas as appropriate

Involve patient by making suggestions rather than directives

Encourage patient to contribute their thoughts: ideas, suggestions, preferences

Negotiate a mutually acceptable plan Offer choices Check with patient: if plans accepted;

concerns addressed

Planning: Shared Decision Making

End summary Contacting – next steps for patient and

doctor Safety netting Final checking

Closing the Consultation

It is equally important to consider both the medical and patient perspectives of the patient’s problem It is important to gather all relevant information and share an understanding of the issues before moving on to discuss management options A Shared Understanding means that:

◦The Doctor understands the patient’s ideas and views

◦The Patient understands the medical aspects and effects of treatment options

In Summary

Improved clinical communication skills leads to more effective consultations and improved outcomes for both patients and doctors

The prize on offer

I hear and I forgetI see and I rememberI do and I understand

Old Chinese proverb

Discovering the reasons for the patient’s attendance 54% of patients’ complaints and 45% of their concerns are

not elicited (Stewart et al. 1979) In 50% of visits, patient and doctor do not agree on the

nature of the main presenting problem (Starfield et al. 1981)

Gathering information Both a ‘high control style’ and premature focus on medical

problems can lead to an overnarrow approach to hypothesis generation and inaccurate consultations (Platt & McMath 1979)

Doctors rarely ask their patients to volunteer their ideas and often evade their patients’ ideas and inhibit their expression. Discordance between doctors’ and patients’ ideas and beliefs about the illness is likely to result in poor understanding, adherence, satisfaction and outcome (Tuckett et al. 1985)

Are there problems in communication between doctors and patients?

Explanation and planning◦ Doctors generally give sparse information to

their patients, with most patients wanting more (Waitzkin 1984;Beisecker & beisecker 1990; Pinder 1990)

◦ Doctors overestimate the time they devote to explanation and planning by up to 90% (Waitzkin 1984; Makoul et al. 1995)

◦ Patients and doctors disagree over the relative importance of imparting different types of medical information: patients place the highest value on information about prognosis, diagnosis and causation while doctors overestimate their patients’ desire for information concerning treatment and drug therapy (Kindelan & Kent 1987)

Problems in communication between doctors and patients

Patient adherence◦ On average 50% of patients do not take their

medication at all or take it incorrectly (Meichenbaum & Turk 1987; Butler et al. 1996)

◦ Massively expensive

Medio-legal issues◦ Breakdown in communication between patients and

doctors is a critical factor leading to malpractice litigation (Levinson 1994)

◦ Lawyers identified doctors’ communication and attitudes as the prime reason for patients pursuing a malpractice suit in 70% of cases (Avery 1986)

◦ Four communication problems present in >70% of malpractice claims: deserting the patient, devaluing the patient’s view, delivering information poorly and failing to understand patients’ perspective (Beckman et al. 1994)

Problems in communication between doctors and patients

Process of the interview◦ The longer the doctors waits before

interrupting at the beginning of the consultation, the more likely they are to discover the full spread of issues that the patient wants to discuss and the less likely will it be that a new complaint arises at the end of the interview (Beckman & Frankel 1984; Joos et al. 1996)

◦ The use of open rather than closed questions and the use of attentive listening leads to greater disclosure of patients’ significant concerns (Cox 1989; Wissow et al. 1994; Maguire et al. 1996)

◦ The more questions patients are allowed to ask of the doctor, the more information they obtain (Tuckett et al. 1985)

Evidence that communication skills make a difference

Patient satisfaction◦ Greater ‘patient centredness’ in the

consultation leads to greater patient satisfaction (Stewart 1984; Arborelius & Bremberg 1992)

◦ Discovering and acknowledging patients’ expectations improves patient satisfaction (Korsch et al. 1968; Eisenthal & Lazare 1976; Eisenthal et al. 1990)

◦ Patient satisfaction is directly related to the amount of information that patients perceive they have been given by their doctors (Hall et al. 1990)

Evidence that communication skills make a difference

Adherence◦ Doctors can increase adherence to treatment

regimens by explicitly asking patients about knowledge, beliefs, concerns and attitudes to their own illness (Inui et al. 1976; Maimen et al. 1988)

◦ Discovering patients’ expectations leads to greater patient adherence to plans made whether or not those expectations are met by the doctor (Eisenthal & Lazare 1976: Eisenthal et al. 1990)

Outcome◦ Patients who are coached in asking questions

of, and negotiating with, their doctor not only obtained more information but actually achieved better blood pressure control in hypertension and improved blood sugar control in diabetes (Kaplan et al. 1989; Rost et al. 1991)

Evidence that communication skills make a difference