MEDICAL COMMUNICATION SKILL

LECTURE
Theresia L. Toruan

Think back for a minute on your own life experiences Recall from your own interaction with your doctor or dentist The 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?

COMMUNICATION
Is an important component of patient care Must gain an understanding of the patients perspective on his or her illness Carefully, not to be judgemental or scolding,.may rapidly close down communication

A Changing Paradigm
Paternalistic
Reductionist

Communication skills of the physician are critical

Holistic and Collaborative Approach

Paternalistic approach
To deciding what should be done for a patient:

The physician knew best Patient accepted the recommendation Patient without question

SHARED DECISION MAKING (holistic and collaborative approach)

Advising to educate his or herself To ask question

PHYSICIAN-PATIENT SATISFACTION REDUCTION IN MEDICAL RISK

Communication Age
able to communicate information

faster more clearly more widely

The basis for patient-physician alliance

Communication 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

1. 2. 3. 4. 5. 6. 7.

Build a relationship Open the discussion Gather Information Understand the patients perspective Share information Reach agreement on problems and plan Provide closure

Essential Element of Medical Communication 1. Build

(cont..)

a Relationship Fundamental communication task Strong Therapeutic Effective relationship (idea, feelings, and
values of both)

with the patient, family and other support system Is an ongoing task within and across
Also relevant for work

Essential Element of Medical Communication 1. Build a Relationship. (cont)

Mnemonic P E A R L S :

(cont..)

P..partnership, acknowledges that the physician and the patient are in this together
E..empathy, expresses understanding to the patient A..apology, acknowledges that the phycisian is sorry the patient had to wait, that a laboratory test had to be repeated, etc R..respect, acknowledges the patients suffering, difficulties, etc L..legitimization, acknowledges that many patient are angry, frustrated, depressed, etc

S..support, acknowledges that the physician will not abandon the patient.

Essential Element of Medical Communication

(cont)

2. Open the discussion Physicians 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.

Essential Element of Medical Communication

(cont)

3. Gather Information

Shifting 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 interrupt
No more than 150 seconds was needed to express all their concern at the beginning or the interview Two words . What else?

Essential Element of Medical Communication

3. Gather Information
(cont)

(cont)

Five Communication Pattern : Narrowly biomedical Expanded biomedical Biopsychosocial Psychosocial Consumerist.

Essential Element of Medical Communication

3. Gather Information
(cont) (cont)

(cont)

Five Communication Pattern

Example : Physician : What bring you here? Patient : I have headache Physician : 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

3. Gather Information
(cont)

(cont)

Five Communication Pattern (cont)

Example : Physician Patient Physician Patient Physician Patient : : : : : : What brings you here today? I have headache. What else? Well, I have problems on sleeping. What else? 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)

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 illness Acknowledge and respond to to the patients ideas, feeling, and values

Essential Element of Medical Communication

(cont)

5. Share Information

Use language the patient can understand Check for understanding Encourage questions

Essential Element of Medical Communication

(cont)

6. Reach Agreement on Problems and Plan

Essential Element of Medical Communication

(cont)

7. Provide Closure
Ask whether the patient has other issues or
concern Summarize and affirm agreement with the plan of action Discuss follow up

Special Medical Communication

End-of-life communication Bad News Old Patient Family caregivers

Special Medical Communication

(continue)

End-of-life communication

Reflection: 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

(cont)

Bad News

Mnemonic S P I K E S protocol for breaking bad news. S..etting and listening skills P..erception by patient of condition and seriousness I..nvitation from patient to give information K..nowledge - giving medical facts E..xplore emotions and empathize as patient responds S..trategy and Summary

Special Medical Communication

(cont)

Old Patient

Working Memory Capacity Diminish Hearing and Vision lost Reflective listening Create Hope

Special Medical Communication (cont)

Family Caregivers
Understand that illnes and disability are a family affair. Let the patient know

Be sensitive about place talking to caregivers about difficulty subjects. Not appropriate in waiting room and corridors.

EMPHATY
Of all the element involved in effective communication: the most powerful 1880, psychologist Theodore Lipps: einfuhlung (in-feeling)

emotional appreciation of anothers feeling

To describe:
Being a psychiatric or mental health expert emphatetic communication

is not necessary for using

The 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 ourselves By being a participant-observer, we came to understand how the other person feels EMPHATY versus SYMPHATY?

Empathy

Key skill used to built doctor patient-relationship

Empathic 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 experience Balance curiosity to leading to a deeper understanding of another human being The capacity to understand another person experience from within that person s frame of reference The ability to put oneself in anothers shoes

Empathy

(cont)

Begins to look something like:

Touch the patient on the arm

Look them in the eye

If 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 charade

Effectively teaching useful approaches to physicianpatient relationship

Empathy
Deepened understanding of Empathy

(continue)

For one year now, I have been trying to come to terms with the notion of sacred, esteemed, professional doctorpatient 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 nonverbal 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 position L leaning slightly forward with Eeye contact in a R relaxed posture

Collaboration in Health Care

Involves coordination of individual actions in

Cooperating in planning Working together Sharing 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 Collaboration
Nurse Practitioner-Physician Collaboration Social Worker-Physician Collaboration Pharmacist-Physician Collaboration Physician-Physician Collaboration

The Impact of Poor Communication

Poor 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 Obstacles
The 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 obstacles
The 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