MEDICAL COMMUNICATION SKILLLECTURETheresia L. Toruan

Think back for a minute on your own life experiencesRecall from your own interaction with your doctor or dentistThe quality of the communication that involved

Was it clear?Was it sympathetic?Were you left with the impression that you were told as much as you wanted to know?Were you left with the impression that your doctor was a good listener?

COMMUNICATIONIs an important component of patient careMust gain an understanding of the patients perspective on his or her illnessCarefully, not to be judgemental or scolding,.may rapidly close down communication

A Changing ParadigmPaternalisticReductionistHolistic and Collaborative ApproachCommunication skills of the physician are critical

Paternalistic approach

To deciding what should be done for a patient:

The physician knew bestPatient accepted the recommendationPatient without question

SHARED DECISION MAKING(holistic and collaborative approach)Advising to educate his or herselfTo ask question

PHYSICIAN-PATIENT SATISFACTION REDUCTION IN MEDICAL RISK

Communication Ageable to communicate information

fastermore clearlymore widely

The basis for patient-physician allianceCommunication establishes the collaborative nature of that alliance

shared decision-making partnering

Medical communication.. own life experience!

Clear?Sympathetic?Left in the impression not told as much as wanted to know?Left with the impression the doctor was a good listener?

Our experience with health and illness are significant to our sense of health.

The benefits of good communication:Good communication:

builds trust between patient and doctor; may help the patient disclose information; enhances patient satisfaction; involves the patient more fully in health decision making; helps the patient make better health decisions; leads to more realistic patient expectations; produces more effective practice; and reduces the risk of errors and mishaps.

Toronto Consensus Statement (1980): talking about the importance of Medical communication Skill

and

Kalamazoo Consensus Treatment (1999): talking about the Essential Element of the Medical Communication based on the task approach

Essential element of Medical Communication

Build a relationshipOpen the discussionGather InformationUnderstand the patients perspectiveShare informationReach agreement on problems and planProvide closure

Essential Element of Medical Communication (cont..)1. Build a RelationshipFundamental communication taskStrongTherapeuticEffective relationship (idea, feelings, and values of both)Also relevant for work with the patient, family and other support system Is an ongoing task within and across

Essential Element of Medical Communication (cont..)Mnemonic P E A R L S :P..partnership, acknowledges that the physician and the patient are in this togetherE..empathy, expresses understanding to the patientA..apology, acknowledges that the phycisian is sorry the patient had to wait, that a laboratory test had to be repeated, etcR..respect, acknowledges the patients suffering, difficulties, etc L..legitimization, acknowledges that many patient are angry, frustrated, depressed, etcS..support, acknowledges that the physician will not abandon the patient.1. Build a Relationship. (cont)

Essential Element of Medical Communication (cont)2. Open the discussionPhysicians first greeting.Physician show personal concern by offering a handshake and warm smile.Put the patient at ease in what could otherwise to be unfamiliar, if not frightening environment.

3. Gather InformationShifting from a physician-centered to patient-centered interview style Physician interrupt patients an average of 18 seconds after the patient begins to speak.Patient rarely continued to express all their true concern once they were interruptNo more than 150 seconds was needed to express all their concern at the beginning or the interviewTwo words . What else?Essential Element of Medical Communication (cont)

Five Communication Pattern :Narrowly biomedicalExpanded biomedicalBiopsychosocialPsychosocialConsumerist. Essential Element of Medical Communication (cont)3. Gather Information (cont)

Five Communication Pattern (cont)Example :Physician: What bring you here?Patient: I have headachePhysician: Where are the headache? How long do they does? What do you do to relieve them?This interview follows a physician centered and biomedical model pattern. Contrast the previous interview with the following interview.Essential Element of Medical Communication (cont)3. Gather Information (cont)

Five Communication Pattern (cont)

Example :Physician: What brings you here today?Patient: I have headache.Physician: What else?Patient: Well, I have problems on sleeping.Physician: What else?Patient: I am very worried about my son. He is using drugs.

This interview follows a patient-centered and biopsychosocial pattern Essential Element of Medical Communication (cont)3. Gather Information (cont)

4. Understand the Patients Perspective Explore contextual factors (e.g., family, culture, gender, age, socioeconomic status, spiritually)Explore beliefs, concern, and expectation about health and illnessAcknowledge and respond to to the patients ideas, feeling, and valuesEssential Element of Medical Communication (cont)

5. Share InformationUse language the patient can understandCheck for understandingEncourage questionsEssential Element of Medical Communication (cont)

6. Reach Agreement on Problems and PlanEssential Element of Medical Communication (cont)

7. Provide Closure Ask whether the patient has other issues or concernSummarize and affirm agreement with the plan of actionDiscuss follow upEssential Element of Medical Communication (cont)

Special Medical CommunicationEnd-of-life communicationBad NewsOld PatientFamily caregivers

End-of-life communicationReflection:And I came to understand that this was medicine, and this was so much greater than my nave ideas of complete cures and miraculous recoveries, which are too few and far between; that the true practice of medicine is not the miraculous cure of a disease but the total care of a person.Special Medical Communication (continue)

Bad NewsMnemonic S P I K E S protocol for breaking bad news. S..etting and listening skillsP..erception by patient of condition and seriousnessI..nvitation from patient to give informationK..nowledge - giving medical factsE..xplore emotions and empathize as patient respondsS..trategy and SummarySpecial Medical Communication (cont)

Old PatientWorking Memory Capacity DiminishHearing and Vision lostReflective listeningCreate HopeSpecial Medical Communication (cont)

Family CaregiversUnderstand that illnes and disability are a family affair. Let the patient knowBe sensitive about place talking to caregivers about difficulty subjects. Not appropriate in waiting room and corridors.Special Medical Communication (cont)

EMPHATYOf all the element involved in effective communication: the most powerful1880, psychologist Theodore Lipps: einfuhlung (in-feeling)To describe: emotional appreciation of anothers feelingBeing a psychiatric or mental health expert is not necessary for using emphatetic communicationThe only requirement is an awareness of opportunities for emphaty as they arise during the interview with the patient

In emphaty, we borrow anothers feelings to observe, feel, and understand them - - but to take them onto ourselvesBy being a participant-observer, we came to understand how the other person feelsEMPHATY versus SYMPHATY?

EmpathyKey skill used to built doctor patient-relationshipEmpathic processes affect how the physician (observer) thinks, feels (intrapersonal outcomes), and behaves (interpersonal outcomes) with the patient (target) The process of understanding a persons subjective experienceBalance curiosity to leading to a deeper understanding of another human beingThe capacity to understand another person experience from within that person s frame of referenceThe ability to put oneself in anothers shoes

Empathy (cont)Begins to look something like:Touch the patient on the armLook them in the eyeIf the patient stop talking, repeat the last word that they said to show you are listening and interested.Doing so without also developing a genuine interest in the resulting connection can lead to an empty charadeEffectively teaching useful approaches to physician-patient relationship

Empathy (continue)Deepened understanding of Empathy For one year now, I have been trying to come to terms with the notion of sacred, esteemed, professional doctor-patient relationship. Somehow, I had gotten the idea in my head that this relationship should be somehow devoid of emotions. It took a women like nurse Cindo and a patient like Mr. Lanang to help me to realize that it might actually be okay, normal, and human to cry and to express emotions about a wonderful dying patient

Active Listening

The most important skill of medical communication to learn.Involves two way tramsmission of verbal and non-verbal behaviour between doctor and patient.The aim is to encourage the patient to continue their opening statement as far as possible without interruption.Closely linked to the doctors capacity to recognize emotional factors contributing to illness and distress.

Active Listening (cont)Mnemonic S O L E R , positive non-verbals that can be used to indicatephysician are listening supportively.Ssitting square on to the patient with an Oopen positionL leaning slightly forward withEeye contact in aR relaxed posture

Collaboration in Health CareInvolves coordination of individual actions inCooperating in planningWorking togetherSharing of goal, planning, problem solving, decision making and responsibility

Can happened between two people who represent the same or different disciplines.

Collaboration in Health Care (cont)Nurse-Physician CollaborationNurse Practitioner-Physician CollaborationSocial Worker-Physician CollaborationPharmacist-Physician CollaborationPhysician-Physician Collaboration

The Impact of Poor CommunicationPoor communication: decreases confidence and trust in medical care; deters the patient from revealing important information; causes significant patient distress; leads to the patient not seeking further care; leads to misunderstandings; leads to the misinterpretation of medical advice; underlies most patient complaints; and predicts negligence claims.

These difficulties may lead to poor or sub-optimal outcomes for the patient.

Doctor-related ObstaclesThe doctor may be: inadequately trained in communication skills; lacking in sensitivity or empathy; unwilling to recognise patient autonomy; unaware of problems arising from differences in language and culture; affected by time pressures; or distracted by external or personal factors.

Patient-related obstaclesThe patient may be: affected by the condition, illness or medication; anxious, embarrassed or in denial about the medical condition; inexperienced in identifying and describing symptoms; intimidated by health care settings; overawed by the doctors perceived status; disadvantaged by differences in language and culture; confused by the use of medical jargon; reluctant to ask questions; or concerned about time pressures.

All of these factors may impede the patients capacity to provide, take in and retain information.

COMMUNICATION Its a series of learned skill

Experience is a poor teacher: it needs observation plus well intentioned, constructive, detailed and descriptive feedback plus rehearsel to effect change