Communication skills brief summary
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The document emphasizes the importance of effective communication skills in medicine, detailing how they enhance patient care, satisfaction, and outcomes. It outlines common deficiencies in traditional medical interviews and advocates for a patient-centered approach that values the patient's perspective and promotes empathy. The content also highlights necessary interpersonal skills and strategies for improving communication between doctors and patients.
Communication skills brief summary
- 1. Communication Skills What You Must Know? Prof. Shad Salim Akhtar MBBS, MD, MRCP(UK), FRCP(Edin), FACP(USA) FASCO (USA) Member AUICC Fellows Overseas Advisor Royal College of Physicians UK Consultant Medical Oncologist Hakim Sanaullah Sp. Hospital & Cancer Centre
- 2. Williams Novak etc Why Should We learn Communication skills? “….the heavy science requirements of medicine leave many physicians without an education in humanities,” CMAJ 2004;
- 4. Specific tasks and observable behaviour which include: • Interviewing • Medical history taking • Explaining a diagnosis & prognosis • Therapeutic instruction • Information for informed consent – Diagnostic or therapeutic procedure • Counselling for motivation – Participation in therapy or symptom relief Duffy FD et al: Acad Med 2004;79:495-507
- 5. • More than just good manners or being a good guy • Improves patient care • Improves disease outcome •It enables us to become good doctors Effective Communication Skills Advantages
- 6. Advantages of Good Communication • Sine qua non for productive relationship • Helping pts make informed decisions – Clinical competence • Physicians benefits – Increased satisfaction – Decreased risk of burn out – Lesser risk of litigation – Greater pt adherence to guidelines • Better outcome Schapira L: Semin Oncol 2005; 32:139
- 7. Why Do People Come To Us? • Acute medical condition • Chronic medical condition • Advice – Maintaining good health • Nutrition • Exercise • Disease prevention – End of life care • Social issues – Disability benefits – Financial assistance – Leave & return to work etc..even manzium yaer advice
- 8. Types of communication • With the patient • About the patient • About medicine and science Kalet A et al:Acad Med 2004;79:511-520
- 9. Parties to a medical interview Doctor Patient 3rd person
- 10. Doctors Agenda in a Consultation • Description of symptoms • Physical signs • Differential diagnosis • Investigations • Management • Prescribing and driven by the fact
- 11. Role of history-Don’t forget 80% of diagnostic information comes from medical history aloneHampton JR et al: BMJ 1975; 31:486-9
- 13. A traditional medical interview • Introduction of the patient • Chief complaint • History of present illness • Past medical history • Family history • Personal & social history • Drug and allergy history • Functional enquiry/system review
- 15. Do we have data that there are problems in this kind of patient doctor
- 16. Traditional Interview Major Deficiencies Maguire P et al: BMJ 2002; 325:697-700 Diagnosi s • Information is not sought regarding –Patient’s perception of the problem –Impact on physical and social aspects
- 17. Traditional Interview Major Deficiencies • Failure to elicit a belief may cause patient to withhold important information • Approximately 50% of patient’s complaints and concerns are not elicited Maguire P et al: BMJ 2002; 325:697-700
- 18. Traditional Interview Major Deficiencies • Planned management is discussed in an inflexible manner • Little attention is paid to pts comprehension Maguire P et al: BMJ 2002; 325:697-700
- 19. Lack of patient compliance Poor patient satisfaction Maguire P et al: BMJ 2002; 325:697-700 Traditional Interview Major Deficiencies
- 20. During her role in Wit Actor Megan Cole, recognised gaps in the patient-doctor communication. She now regularly visits University of Texas Medical Centre as a faculty member to teach her course, “The Craft of Empathy”CMAJ 2004; 170:1779
- 21. Reasons For Deficiency • Fear of increasing pt distress • Fear of taking more time • Threatening doctors own emotional survival Maguire P et al: BMJ 2002; 325:697-700
- 22. Reasons For Deficiency • Deficient curriculum –Undergraduate –Postgraduate • Reluctance to depart from a strictly medical model • Lack of confidence in handling stressful situations Maguire P et al: BMJ 2002; 325:697-700
- 23. How Do We Respond To Deficiencies • Offering advice and reassurance even before the main problems have been identified • Explaining away distress as normal • Attending to physical aspects only • Switching the topic • “Jollying the patient along” Maguire P et al: BMJ 2002; 325:697-700
- 24. Two Experts In a Medical Interview • The Doctor – History – Disease – Investigations – Diagnosis – Treatment – Side effects – Prognosis • The Patient –His/her body –Beliefs –Wishes –Hope –Worldview Persuad R: BMJ 2003; 326:1337Schapira L: Semin Oncol 2005;
- 25. Medical consultation- Patient’s agenda-vs--Doctor’s agenda • Effects of symptoms on life • Feelings and worries • Ideas and concerns • Uncertainty about tests • Understanding illness • Side effects of treatment • Description of symptoms • Physical signs • Differential diagnosis • Investigations routine and specific • Management • Prescribing
- 27. Medical Interview Should be Patient Centred • Recognize and value patient’s perspective of the illness • Understand the illness experience, not just the disease • Seek a partnership approach in management decisions
- 28. Cochrane review • 15 randomized trials of patient centered interview • Evidence supported patient centered model • Positive impact on pt satisfaction (NS) Lewin SA etal: The Cochrane Library Issue 1, Update Software; 2003 Bradely CP : ACP J Club 2002; 137:34
- 29. Communication with the patient- Applications type • New pt • Established pt • Family • Telephone • Medical interpreter • Email & What’s app Kalet A et al:Acad Med 2004;79:511-520
- 30. Communication with the patient Applications-situation-content areas • Advance directive • Breaking bad news • Informed consent • Limitation of treatment • Organ and tissue donation • Abusive relationship • Substance abuse • Others Kalet A et al:Acad Med 2004;79:511-520
- 31. Important Constituents of a Medical Interview • Build a patient doctor relationship • Open the discussion • Gather information • Understand patient’s perspective • Share information • Reach agreement • Provide closure Kalamazoo Consensus Statement: Acad Med 2001;76:390-3
- 32. What skills do you need? •Interpersonal skills •Communication skills Duffy DF et al: Acad Med 2004; 79:495-507
- 33. How Can We Develop These Skills “LEARN”
- 34. Interpersonal skills • Respect & treat the patient like you wish to be treated • Pay attention to the patient • Personal presence in the moment • Mindful of the importance of relationship The Kalamazoo II Report Acad Med 2004;79:495-507
- 35. • Caring intent not only to relieve suffering but be curious and interested in pts ideas, values and concerns • Flexibility and ability to monitor relationship in real time and adjust interpersonal skills The Kalamazoo II Report Acad Med 2004;79:495-507 Interpersonal skills
- 36. Interpersonal skills • Relational and process oriented • Focus on the effect of communication on other person • “HUMANISTIC QUALITIES” • Qualities of a good MUSLIM The Kalamazoo II Report Acad Med 2004;79:495-507
- 38. Communication Skills • Verbal – Language what we say ( words used, structure of speech) – Intonation how we say (pitch, stressed syllables) • Non verbal – Behavioural what we do (body posture, eye contact, facial expressions, gestures) – Other cues how we do it (timing, hesitation, non speech noises hum, um, uh-ah, laughter etc)
- 39. • Develop and maintain relationship (Empathic) • Identify the problem (Exploratory) • Education and counselling (Explanatory) Medical interview what should it accomplish? Kalet A et al:Acad Med 2004;79:511-520
- 41. Doctor patient encounter Begin Open Patient education Negotiate and agree on a plan Communicate during the physical examination or procedure Elicit & understand patients perspective Gather information End interview Close Use relationship building skills Manage flow
- 42. Begin • Review details – Set goals for interview • Assess and prepare physical environment – Optimize comfort and privacy – Minimize interruptions and distractions • Assess your personal issues, values, biases and assumptions • Taking notes Kalet A et al: Acad Med 2004;
- 43. Provide r agenda Patient’ s agenda Strike a Transition Non directive dimension Directive dimension Teutsch C: Med Clin N Am 2003; 87:1115
- 44. Open the Discussion • Greet & welcome the patient & family member • Introduce yourself • Role explanation orient patient to flow of visit • Detect and minimize barriers to communication • Language and vocabulary calibration to patient’s • Ensure, accommodate patient’s comfort & privacy • Indicate time available and other constrains
- 45. Open the discussion • Invite patient to tell his story • Allow the pt to complete the opening statement • Follow patients leads • Elicit full set of concerns • Establish & maintain personal connection • Establish agenda for interview Kalamazoo Consensus Statement: Acad Med 2001;76:390-3
- 46. Gather information • Start with open ended non focussed questions • Invite patient to tell chronological story • Allow patient to talk without interrupting • Actively listen • Encourage completion of the details of all complaints • Invite more
- 47. Don not forget patient’s perspective • Thoughts about the nature and cause of problem • Feelings, fears about the problem • Expectations of the clinician & health care • Effect of the problem on his life • Prior similar personal or family experience • Therapeutic responses he has already tried
- 48. Needed skills to Gather information • Eye contact – Establish at the beginning and maintain • Encourage pt to be exact about the sequence of happenings • Events of key importance-secure dates for those • Effects on social, emotional, psychological aspects of pt and family
- 49. X Needed skills to Gather information • Active listening & respond to cues • Adaptive questioning • Avoid interrupting before completion of story • Abridge the acquired information –Summarize and show the pt you are caring –Let them correct any mistakes Maguire P et al: BMJ 2002; 325:697-700
- 50. Adaptive questioning • Directed questioning – From general to specific – Should not be leading • Questioning to elicit a graded response • Asking a series of questions one at a time • Offering multiple choices for answers • Clarifying what the patient means Bickley SL et al: Bate’s Guide to Physical Exam 2003; LWW p31
- 51. SOURCES your key for gathering information • Simple questions • Open questions • Unbiased questions • Responsive questions • Clarification • Encouragement • Summarizing
- 52. Understand pts perspective & explore • Contextual factors –Gender/age –Race –Family –Socioeconomic status • Beliefs and concerns • Acknowledge and respond to pts ideas, feelings and values Kalamazoo Consensus Statement: Acad Med 2001;76:390-3
- 53. During the whole interview • Relationship building skills –Allow patient to express self –Be attentive –Communicate; non judgmental, respectful and supportive –Detect emotion, feeling –Empathy non verbal –Frequent PEARLS statements
- 54. PEARLS • Partnership • Empathy • Apology • Respect • Legitimization • Support • Do not redirect the talk, respond to emotion Kalet A et al: Macy Initiative of Health Comm Acad Med 2004; 79:511
- 55. Skills Needed for Providing information • Ask Tell Ask approach • Use language patient can understand • Prioritize the needs of the pt • Itemize the information – Tackle the most important one first – Confirm comprehension – Confirm need for further support/information • Use visual aids
- 56. Skills needed for Treatment options • Inform the pt of different options available • Involve the patient in the decision making –Up to the extent of pts desire • Identify pts perspective before suggesting life style change
- 57. How Much Information To Give • European American Cultural Model – Respect for individual autonomy – Give choice to the patient – Patient is regarded • Rational • Self assertive – Information • A valuable asset Kagawa-Singer M et al: Acad Med 2003;78:577
- 58. How Much Information To Give • Complete disclosure –Patients feel • Grateful • Satisfied • Eases tension about matters of terminal care • Limited approach • No consensus
- 59. How Much Information To Give • Primary or Adjuvant therapy – Consider the perception of • Risks • Benefits
- 60. • Palliative – Disclosure of prognosis • Cure not possible • Short survival (accurate estimates of life expectancy cannot be given) • Many oncologists give an optimistic prognosis – Formulation of goals • Personal • Therapeutic How Much Information To Give
- 62. Breaking the Bad News PSPIKES • Preparation • Setup • Perception • Invitation • Knowledge • Empathize • Summarize and strategize • No single model works • Stay with the patient literally and emotionally Himelstein BP et al: J Clin Oncol 2003; 21:41
- 63. Agree on a plan • Encourage pt to participate in the decision making process • Limit the involvement to the extent of pts desire • Survey problems and delineate options • Elicit patients understanding, concerns, preferences • Arrive at mutually acceptable solution • Check ability and willingness to follow the plan • Identify and enlist resources and support Kalamazoo Consensus Statement: Acad Med 2001;76:390-3
- 64. Provide closure Kalamazoo Consensus Statement: Acad Med 2001;76:390-3 • Signal closure • Ask if there are other issues and concerns to discuss • Summarize and affirm agreement with the plan • Discuss follow up and the next visit • Plan for unexpected outcome
- 65. Thank patient with an appropriate parting statement
- 66. Effective communication skills- are there advantages? • Accurate identification of problems • Better patient satisfaction • Improved patient compliance • Less patient distress and anxiety • Improved doctors’ well being Maguire P et al: BMJ 1986;292:1573-8 Silverman J et al: Skills for communicating .. 1998 Roter DL et al: Arch Intern Med 1995; 155:1877-84 Parle M et al: Psychol Med 1996; 26:735-44 Ramirez AJ et al: Lancet 1995; 16:724-8
- 67. Common Errors •Lack of empathy •Interrupting the patient Fogarty LA et al:J Clin Oncol 1999; 17:371 Roter DL et al: JAMA 2002; 288:756