Consultant in Family Medicine COMMUNICATION SKILLS DR. Yousif Elgizoli Consultant in Family Medicine MRCGP (UK), JMHPE-MAASRTICHT

What is Communication?

Communication has been derived from the Latin word "communis", meaning to share. Two-way process of reaching mutual understanding, in which participants not only exchange (encode-decode) information but also create and share meaning. "sending, giving, or exchanging information and ideas.

Communication requires a sender, a message, and an intended recipient. (cont) Communication requires a sender, a message, and an intended recipient.

Most common ways to communicate Visual Images Speaking Writing Body Language

Purposes of Communication

To solve problems Reassurance To form and maintain relationship alleviate distress COMMUNICATION convey feelings give information make decisions persuade

Benefits identify patients' problems more accurately: Improve Pts understanding & Information retention Increase adherence to treatment Patients adjust better psychologically Pts more satisfied with their care

Benefits Doctors with good communication skills have greater job satisfaction and less work stress, Delivery of high-quality health care. (Roter 1987, Betakis 1991, Stewart 1995)

Communication skills - why bother? Why learn communication skills? Can you learn communication skills? What is there to learn? How is it taught? Where next?

Why learn communication skills? l reasons for the patient's attendance l gathering information l explanation and planning l adherence to plans l medico-legal Enables us to become better doctors clinically Improves patient care and disease outcomes

Can communication skills be taught? communication is a clinical skill it is a series of learnt skills experience is a poor teacher there is conclusive evidence that communication skills can be taught and that communication skills teaching is retained

How to teach communication skills? Observation Video or audio playback Well-intentioned feedback Rehearsal Active small group or 1:1 learning

Effective communication is essential to the practice of high quality medicine

Effect on Health Outcomes The reduction of anxiety. The reduction of psychological distress. Pain relief. Symptom resolution. Mood improvement. Reduction of high blood pressure. (Stewart 1995).

“physicians were not listening enough to their complaints.” “The main remarks made by patients in the PHC centers in Riyadh was that: “physicians were not listening enough to their complaints.” ( Saeed 2001)

Setting:- Privacy, Avoid interruptions, Comfortable lighting & temperature, Arrangement of seats, Distance, Level.

Co-operation Confrontation. Conversation Co-operation Confrontation Conversation Seating arrangements of doctor and patient

ACTIVE LISTENING…(cntd…) Use Non-verbal Communication: Smile, Gestures, Eye contact, Your posture.

Techniques to improve listening skills SUMMARIZE Pull together the main points of a speaker PARAPHRASE Restate what was said in your own words QUESTION Challenge speaker to think further, clarifying both your and their understanding

Non-Verbal Communication 55% Face and body: non-verbal communication or face and body language. 38% voice dynamics: tone + inflection + volume + accent + non-word sounds; and...

RECOGNIZING NON VERBAL COMMUNICATION FACIAL EXPRESSION GESTURES & POSTURES VOCAL CHARACTRISTICS

RECOGNIZING NON VERBAL COMMUNICATION PERSONAL APPREARENCE TOUCH TIME & SPACE

Example of body language Folded arms and leg crossed away from you: Rejection Tapping fingers: Impatience Avoiding eye contact: Untrustworthy

Example of body language Sitting with legs crossed, foot kicking slightly: Boredom Biting nails: Anxiety Shoulder hunched, hands in pockets Depression/Dejection

Effective Communication Skills (Models)

Effective Communication Skills Greet the person by their names. Make eye contact ,introduce yourself warmly Smile (ease the tension on either side) Shake hands. Ask the person to sit down by indicating a chair. establish a rapport by asking a simple open- ended question , explain that you may need to take notes,

Effective Communication Skills Aim to encourage emotional expression as this will often prove to be the most therapeutic aspect of the interaction. If you think you are not getting through to the other person, resist the temptation to raise your voice. Being positive

Effective Communication Skills At the end: Summarize Give a chance to ask Agree a time for a follow-up. Thank and escort him to the door

in Communication with Pts PITFALLS in Communication with Pts

Blocking behavior Interrupting; Offering advice and reassurance before the main problems have been identified; Lack of concern; Attending to physical aspects only; Switching the topic.

LEARNING Communication SKILLS Practice Rehersal Recording Refelection Feedback

To Be a Good Doctor/Teacher we Have to Be a Take Home Message To Be a Good Doctor/Teacher we Have to Be a GOOD COMUNICATOR

The consultation

DEFINITION

Definition The occasion when, a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trust. (Wright & Macadam)

CONSULTATION IN HOSPITAL CONSULTATION IN PHC Vs. CONSULTATION IN HOSPITAL

Sara is 38 years old lady, complaining of 2 weeks history of headache. How are you going to conduct this consultation?

Characteristics of Hospital Model It is doctor centred and disease oriented. A diagnosis must be arrived at "objectively" before treatment. It takes long time No consideration of the psychosocial dimensions explanation, health education, health promotion and treatment by reassurance

PHC Model of Consultation (Bio-psychological Model)

Characteristics of PHC Consultation Model Patient – centred Holistic approach (Bio-psycho – social) Prevention & Health education Treatment by reassurance Appropriate use of time & resources

Models of consultation

Stott and Davis (1979)

Roger Neighbor

NEIGHBOUR’S 5 CHECKPOINTS (Roger Neighbour “The Inner Consultation”) 1. CONNECTING. 2. SUMMARISING. 3. HANDING OVER. 4. SAFETY NETTING. 5. HOUSEKEEPING.

NEIGHBOUR’S 5 CHECKPOINTS 1. CONNECTING. Achieving rapport & empathy. 2. SUMMARISING. Demonstrate to patient you understand why he’s come, hopes, feeling, concerns & expectations. 3. HANDING OVER. Has the patient accepted the management plan we have agreed? Negotiating, influencing & gift-wrapping.

“The Inner Consultation” (Continued) 4. SAFETY NETTING. Predicting what could happen – what if? Or have I anticipated all likely outcomes? 5. HOUSEKEEPING. Clearance of any emotional responses to patients we have seen or to those we are about to see. Am I in good condition for the next patient.

Schofield, Tate and Havelock (1984) PENDLETON’S MODEL Schofield, Tate and Havelock (1984)

Seven Tasks: 1. To define the reasons for the Patient’s attendance, including: (i) The nature and history of the problems; (ii) Their aetiology; (iii) The Patient’s ideas, concerns & expectations; (iv) The effects of the problems. 2. To consider other problems: (I) Continuing problems; (ii) At risk factors.

3. To choose with the Patient. An appropriate. action for each problem 3. To choose with the Patient. An appropriate action for each problem. 4. To achieve a shared understanding of the problems with the patient. 5. To involve the Patient in the management and encourage him to accept appropriate responsibility. 6. To use time and resources appropriately. 7. To establish or maintain a relationship with the Patient which helps to achieve the other tasks.

Doctor-centred / Patient-centred Doctor is the expert and the Pt. just to cooperate. Focus only on the physical aspects Tightly controlled the interview Qs. are mainly of ‘closed’ type Biomedical disease framework  Lack for patients to express their ICE. Much less controlling style Encourage and facilitate pt. participation Fostering a relationship of ‘mutuality’. Greater use of ‘open’ questions more time to active listening Responding to Pt. cues Considered Pt. ICE

Performance Criteria?

  Your name is Ahmad a 35-Ys- old, working as a bus driver in near school, 3 days ago after you hold a heavy tire, you felt a LBP  The pain is down the back and not goes down, it is stabbing in nature, aggravated by leaning forward and stiff in the morning, it is ease by lying in a bed   Your concern today is that, it could be a disc prolapse because you have an elder brother who had a prolapse last Year, your expectation is that your doctor to ask for MRI to be reassured, give you a potent pain killer (injection) and also to offer you a sick leave.

A- DISCOVER THE REASONS FOR THE PATIENT'S ATTENDANCE 1- Encourage 2-Respond to signals (Cues) 3-Psych-social 4- ICE

B- DEFINE THE CLINICAL PROBLEM(S) 5- Red Flags 6- Examination 7- Working Diagnosis

C- EXPLAIN THE PROBLEM(S) TO THE PATIENT 9- Explanation incorporate Pt.’ ICE 10- Confirm Pt.’ understanding

D- ADDRESS THE PATIENT’S PROBLEM(S) 11- Management Plan 12- INVOLVE Pt. in management plan

E- MAKE EFFECTIVE USE OF THE CONSULTATION 13- Enhance Concordance 14- Follow-Up

IMPROVING CONSULTATION SKILLS

IMPROVING CONSULTATION SKILLS * Constant Learning and Practice * Feed-Back: - Self monitoring/Peer review - Audio-visual technique - Role play

Dysfunctional consultation

Signs of Dysfunctional consultation Poor reputation among patients Upset patients or doctors Increasing complaints Increasing critical events Reduced job satisfaction

Hearing or linguistic difficulties Upset patients Psychiatric illness Patient factors Hearing or linguistic difficulties Upset patients Psychiatric illness Loss of faith in the doctor (poor reputation, adverse incident etc) Patients that ‘violate’ the doctors values e.g. drug misusers or alcoholics Problem Patients

Doctor factors: Attitudes – a doctor centred consulter, burnt out depersonalisation, angry, defensive, ‘over caring’- always wanting to be liked or hard-line doctors. Poor emotional housekeeping. Skills – poor consultation or clinical skills resulting in an inappropriate management plan. Knowledge – lack of knowledge leading to an inappropriate or suboptimal management plan. Bored –lack of personal or professional development

Patient–doctor factors Cultural issues Failure to identify hidden agendas. Failure to identify the patients fears, beliefs or expectations. Failure to generate a management plan appropriate to the patient’s circumstances.

Practice factors: Pressure of time – running late. Poor systems (e.g. telephone access, appointments, admin). Poor staffing, inappropriate skill mix etc which unnecessarily increase workload. Unnecessary interruptions – telephone, staff, patients. Physical factors - lay out of the room, lighting, extraneous noise.

Doctor should be able to * Cure some time. * Relieve often. * Prevent hopefully. * Comfort always.

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