Communication Skills Medical Communication Skills: Communication as a very basic sign of human existence is not only crucial between physician and patient in establishing a trustful therapeutic relationship, but also between students, doctors and other members of the medical and paramedical team. Communication skills (CS) are a central issue in training and assessing future doctor and not mastering these skills may lead to a number of negative consequences. The most common thing that a physician does in his/her career is to communicate with patients, this is the method that physicians obtain information (history), educate patients about their illness and obtain informed consent regarding the various therapeutic options.

A healthy doctor-patient relationship is the foundation of humanistic care, defined as viewing patients as autonomous, unique, and irreplaceable persons, who should be treated with empathy and warmth, and should share in decisions with health care providers in a reciprocal and egalitarian relationship.

The disease-centred approach, the traditional clinical method, in general use since the early 1900's in most medical schools, focuses on the patient’s chief complaint. The method then proceeds with the history of present illness, past medical history, social history, family history, review of systems or functional inquiry, physical examination, differential diagnosis, plan of evaluation and management. In this method, there is little teaching on how to actually conduct a medical interview; instead while physicians are taught how to make written and oral presentation of their findings in clinical encounters. Many physicians are criticized for being uncaring because they fail to compensate for problems with this traditional clinical method.

A new transformed clinical method, with the patient at the centre, was introduced in 1986 by a family physician, Dr. Ian Mc Whinney, called the patient-centred interviews, the physician seeks the patient’s point of view and encourages him or her to speak openly and ask questions. The patient-centred clinical method results in increased patient and doctor satisfaction. With modifications, it is also effective in emergency and specialist consultation settings.

Definition of terms: Communication: "Communication is the process by which information and feelings are shared by people through an exchange of verbal and non-verbal messages". In the context of medical education, its primary function is to establish understanding between patient and doctor. In an atmosphere of effective communication, patients improve faster, cope better with post-operative pain, require less psychotropic drugs, and experience numerous other health benefits.

Communication skills: "Communication skills is the proficiency in the interchange of information". The idea that doctors automatically learn communication through experience or that doctors are inherently either good or bad communicators is being largely abandoned. It is now widely believed that such skills can be taught to both students and doctors by a variety of professionals including doctors and specialists in CS as an important part of undergraduate as well as postgraduate and continuing medical education.

The Importance & Benefits of Effective Communication Skills in Medical Practice: 1. Effective communication is an integral part of diagnosis. 2. Effective communication enhances patient compliance to treatment plan. 3. Effective communication contributes to patient satisfaction. 4. Effective communication contributes to physician’s satisfaction, clinical competence and self assurance. 5. Effective communication may contribute to cost and resource effectiveness. 6. Effective communication contributes to a better health outcomes. 7. Effective communication skills training can give rise to institutional gains. 8. Effective communication contributes to the decrease of medical malpractice claims.

The deficiencies in medical communication( the current global medical problem) : The Core Committee of IIME grouped the 'essentials' under following seven, broad educational outcome-competence domains: I- Professional Values, Attitudes, Behavior and Ethics. II- Scientific Foundation of Medicine. III- Communication skills. VI- Clinical Skills. V- Population Health and Health Systems. VI- Management of Information. VII- Critical Thinking and Research.

The reasons for deficiencies in communication: I - Personal barriers (blocking behaviors in communication) for both doctors and patients: A. Personal barriers for doctors: -A lack of skill and understanding - for example the failure to understand the importance of using clear and simple language, giving structured explanations and listening to patients' views and encouraging two-way communication; -Undervaluing the importance of communicating - for example not appreciating the importance of keeping patients adequately informed; -Negative attitudes by doctors towards communication and giving it a low priority due to their concern primarily to treat illness rather than focus on patients' other needs which may be psychological or related to social wellbeing; -A lack of inclination to communicate with patients. This can be due to a lack of time, uncomfortable topics, lack of confidence and concerns relating to confidentiality; -Human failings, such as tiredness and stress; -Inconsistency in providing information. One of the biggest complaints from patients is of being given conflicting information by different healthcare providers; -Language incompetence. Doctors are required to be competent in the language that by which communicate with patients.

B. Personal barriers for patients: -Belief that nothing can be done; -Reluctance to burden the doctor; -Desire not to seem pathetic or ungrateful; -Concern that it is not legitimate to mention them; -Doctors' blocking behaviors; -Worry that their fears of what is wrong with them will be confirmed. II - Organizational barriers: Organizational barriers are usually outside a doctor's direct control and they include: -Having a lack of time; -Pressure of work; -Being subjected to interruptions; -Absence or insufficient CST curriculum.

The rationale for investment in communication skills training: 1 The rationale for investment in communication skills training: 1. Communication skills training is a small investment with great potential gain: As already discussed, CST is a relatively small investment in time and resources in comparison with the considerable potential benefits for patients, medical schools, and health care system. 2. The feasibility of CST has been widely demonstrated: There are examples of CS being taught in this way in medical schools in Britain, Ireland, USA, Canada, and in Australia. Other courses have been developed to respond to the more specific needs of interns and of students during clinical training. In such courses, CS are taught in the context of specific aspects of doctor-patient interaction. 3. Communication skills training has been shown to improve doctor’s CS: A review of communication skills training (CST) for medical students and general practitioners found many reports of success of CST worldwide and even that a brief small group interviewing course can effect a positive change in student’s CS. 4. CST found to be overwhelming support for doctors to be provided with greater support to develop the kind of CS that are required to help create a truly patient-centered health service. Good communication is good for patients, good for doctors and good for the health service. The better doctors can be supported, the better prepared they will be to respond to the challenges before them.

Teaching communication skills: “The question is no longer whether to teach and assess CS and attitudes, but rather how to do so most efficiently and effectively because effective communication is one of the most important clinical skills a physician can have to improve health care delivery today”. This statement was said by Dr. Toni Laidlaw, Director of CS Program at Dalhousie University (Kurtz et al.,1999).

The most useful varieties of learning methods in CS: 1 The most useful varieties of learning methods in CS: 1. Interactive lectures: Short lectures on relevant theories and research, followed by questions and discussion. 2. Written materials: Reading Texts, Journal Reporting, evidence-base subjects related, researches on the subject of concern. 3. Videotapes: regarding CS. 4. Experiential learning (practical) :Which includes: - Modeling: such as -Tutor models: tutors can demonstrate CS in classroom with real patients, simulated patients, or student simulated patients. -Clinician models: Clinicians in medical settings usually serve as role models for medical students; it is thus highly desirable that clinician’s own CS reflect those which students are being taught. -Video film models: Professionally produced videotape films can be shown to students to demonstrate appropriate CS. - Role play: Student role plays with other student are very effective and a relatively inexpensive method of providing opportunities for practice and feedback about skills, students can work in threes (as a doctor, as a patient and as an observer). - Simulated patients: Rehearsal of ways of communicating by observing role-plays with simulated patients.

5. Feedback: is crucial in any CS training and evaluation 5. Feedback: is crucial in any CS training and evaluation. A very powerful form of feedback is by videotaping the task that student did, and appropriate feedback technique are crucial for effective learning under the following guidelines: A. Should be given as early as possible after learner’s contribution. B. The learner should be first in giving feedback on his performance. C. Successful aspects of the learner should be mentioned first. D. Less successful aspects of the learner should not be referred to in critical terms, but as “things which might be worth doing differently”. E. Feedback should be as specific and concrete as possible. Sources of feedback can include: patients/simulated patients, clinicians, tutors, other staff, other student, and even by self assessment. Discussion of feedback of the videotaped interviews and role play will incorporate the principles of ALOBA (Agenda-Led Outcome-based Analysis).

Curriculum Content (Teaching strategies): The communication curriculum includes the following key components: 1. Core communication (medical interviewing) skills: The Comprehensive Clinical Method (CCM) which is used at Dalhousie University is defined as the explicit integration of traditional clinical method with effective CS. CCM is derived from the influential CS model of the interview, the Calgary-Cambridge Observation Guide (CCOG). It has been specifically redrawn both to incorporate the structural elements of the traditional clinical method and also to more explicitly demonstrate the links with the fundamentally important disease-illness model of patient-centered medicine. The following outlines and domains construct the main important points in the core CS:

(1) Doctor-Patient Interpersonal skills: which include; A (1) Doctor-Patient Interpersonal skills: which include; A. Initiating the Session; B. Building the Relationship; C. Providing the structure to the consultation; D. Closing the Session. (2) Information Gathering Skills: which include; A. Initial Exploration of Patient’s Problems (disease & illness). B. Further Exploration of the Disease Framework (doctor perspective). C. Further Exploration of the Illness framework (patient perspective). D. Essential Background Information. (3) Information Giving Skills: which include; A. Providing the correct amount and type of information. B. Planning shared decision making. These upper tasks, physicians routinely attempt to accomplish in everyday clinical practice. The tasks provide a logical organizational schema for both doctor-patient interactions and CS teaching and learning.

2. Advanced (specific) communication skills: Although these specific issues may call for special adaptations and even additional skills, the skills of the CCM Guide remain the primary resource used for effective management of all these communication issues and challenges. The skills delineated in the guide are the core CS required in all these circumstances, providing a secure platform on which specific communication issues and challenges can be super-imposed. The following outlines and domains construct the main important points in the advanced CS:

2. Advanced Communication Skills: (1) Skills for Motivating Patient Adherence to Treatment Plans. (2)Protocol for Breaking Bad News. (3) Dealing with Angry Patient. (4) The Very Short Contact. (5) Special Groups: as A. Special groups of population ( e.g. Families and couples). B. Special Groups of disorders (e.g. Mentally retarded). C. Special personality problems (e.g. Non-cooperative and hostile patients). D. Special clinical situations (e.g. Preparation for operation).

You have to tell this patient in front of you that he must go tomorrow morning at 9 AM to the central lab. Beside Al-Zahrawi teaching hospital to do CBP because of his pale appearance and to return the result to you here. (the time allowed for this station is only 5 minutes)