Communication skills in clinical practice for undergraduates
COMMUNICATION SKILLS IN
Dr. Syahnaz Mohd Hashim
Department of Family Medicine,
Faculty of Medicine,
What is communication?
“the successful passing of a message
from one person to another”
Important principles facilitating the
Rapport between the people involved
2. The time factor, facilitated by devoting
3. The message, needs to be clear, correct,
concise, unambiguous and in the
4. The attitudes of both the communicator
and the recepient
Communication in the consultation
The doctor requires communication skills
for complete diagnosis:
If you are the patient, what will be your opinion
on this doctor?
Important positive behavior
At first contact
Address patient by his or her preferred
Make the patient feel comfortable
Be ‘unhurried’ and relaxed
Focus firmly on the patient
Use open-ended questions where
“How are you feeling today?
“Anything I could help you with?”
“Tell me more about your problem?”
an active process described by Egan..
“One does not listen with just his ears: he
listens with his eyes, mind, his heart and his
imagination. He listens to the words of
others, but he also listens to the messages
that are buried in the words. He listens to
the voice, the sounds, the gestures and to the
Listening includes four essential
2. Checking feelings
“ You seem very upset today”
“ It seems you’re having trouble coping”
Check if what was said is what you
◦ Rephrasing: “Let me say it as I understand it:
. . . .”
◦ Further Questioning: “How is that pain?”
◦ Asking for clarification: “Do you mean to
say that . . . . . “
◦ Asking for elaboration: “Can you tell me
more about it?”
Non verbal communication
IMPACT OF THE MESSAGE
Tone of voice
Body language include use of gestures, postures, position and
Barriers to effective
Authoritative attitude (usually on the side
of the medical/health professional.)
Asking only Closed questions patients
equate it to Interrogation
Closed body posture
Lack of or no eye contact
Distancing, i.e.: sitting too far apart that the
patient feels removed
Barriers to effective
Appearing too busy & too rushed
Not listening & constantly interrupting
Writing soon after opening the interview,
before listening to patient
Environmental interference, e.g. lack of
privacy, people coming in and out of room,
too hot/cold, too noisy, children interfering
“What to achieve in a 15 min
consultation” 7 Tasks of Consultation
Define the reason for patient’s
Consider other problems
Achieve a shared understanding of the
With the patient, choose an appropriate
action/management plan for each
Involve the patient in the management &
encourage patient to accept appropriate
Use time and resources appropriately
Establish and maintain a relationship
which helps achieve other tasks
Patient Centered Interviewing
Focus on eliciting symptoms and
signs of illness
Shows genuine interest in;
Their reasons for seeking help
Their perceptions of what might be
Their feeling about the problems
The impacts of this problems on their
daily lives and well-being
Advantages of patient centered
patient perspective on health including
his/ her perceive needs/ concerns/ preferences
patient to express what is most
important to him
patient to lead
patients compliance with advice and
◦ promotes patient’s health awareness
interactions itself can be
therapeutic enhanced feeling of trust and
decision making process and
disclosure of psychosocial problems are
Four Windows of Consultation
(Stott and Davis, 1979)
“The exceptional potential in each primary care
Management of Comorbidities
Prevention of Diseases /
Promotion of Health
Ending an Interview
what the patient has told you
them to check the accuracy of what
you have said
them if you have left out any
information which they feel is important
if they would like to add anything
the interview in the positive
manner and write management plan:
- when is the next follow up visit
- What is the patient suppose to do
- What will you have to do.
by thanking the patient
◦ E.g. Thank you for talking to me. Our time is
Why we need to know
“How to Break Bad News”?
part of the medical job
& useful in daily clinical work
If we do it badly, the patients or family
members may never forgive us.
If we do it well, they will never forget us.
What is bad news?
“Any news that drastically and negatively
alters the patient’s view of his or her
The 10-step Protocol
Prepare the physical set-up
Get to know the patient
Identify patient’s support systems
Find out how much the patient already knows
Find out how much the patient wants to know
Give a “Warning shot”
Share the information – Break the news gently!
Respond to patient’s feelings – Acknowledge distress
& support ventilation of feelings
Identify concerns, prioritize & answer all questions
Planning & follow-through / follow-up
1. Prepare the physical set-up
Do it in person, never over the phone!
Find a private room to ensure privacy &
Turn-off your hand phone & pager
Prevent any interruptions!
Have enough chairs & tissue (for tears)
If there are visitors, ask the patient who they
are and what relationship?
2. Get to know the patient
Introduce self & other staff/students (if any)
Start with “normal” courtesies & considerations
Does he/she have a spouse, children, work,
Open with an open question, e.g.:
◦ “How are you feeling at the moment?”
◦ “How are things today?”
◦ “Do you feel well enough to talk a bit?”
3. Identify patient’s support
did he/she come?
◦ By car, by bus, taxi, friend brought him/her?
one that came with him/her?
◦ Alone, spouse, best friend, etc.?
permission to draw “genogram”.
Not just of family ties but also draw a
genogram of “Support persons”
4. Find out how much the patient
How much do you understand about your illness? . .
. . . . . . . . . . . PAUSE . . . . . . . . . .!
What did your previous doctor tell you about your
condition? . . . PAUSE!
What have you been thinking about this
nausea/unsteadiness/breast lump . . . PAUSE!
Have you been very worried about this illness?
5. Find out how much the patient
wants to know
Would you like me to explain what is
Would you like me to tell you the full details
of the diagnosis?
Would you like to know exactly what is going
Would you prefer me to give you the outline
6. Give a “Warning shot”
am afraid that the news is not very good.
the situation does appear to be more
serious than that . . .”
saya rasa berita yang saya akan
sampaikan agak tidak begitu baik.
berat hati untuk memberi tahu
. . . . . . Silence . . . . . , Mirroring . . . . .
7. Share the information
Break the news GENTLY
the news gently, but not so much that it
is not clear.
simple language, i.e.: avoid medical jargon
◦ You have carcinoma of the mammary gland vs.
You have cancer of the breast.
◦ Cancer barah
◦ Tumor (non-malignant) ketumbuhan
The treatment isn’t working.
The cancer has come back.
The scan shows that the cancer has spread.
The biopsy result shows it is cancerous.
We were not able to resuscitate him.
Anchor the news on something firm.
for patient’s understanding frequently
and clarify information frequently
need to draw a picture for clarity
8. Respond to patient’s feelings –
Acknowledge distress & support ventilation
am so sorry, it is very hard, it is so cruel.
. . . . . . Silence . . . . ., Mirroring . . . . .
. . . . Until the patient talks again.
“Let the storm pass by”
9. Identify concerns, prioritize &
answer all questions
Patient may ask:
Am I going to die?
What happens next?
Is there any more treatment?
Who is going to look after my kids?
Answer all questions as honest & as best as you
“There is nothing more that we can do.”
It is not true!
Further chemotherapy probably won’t help
anymore, but there are lots of ways we can make
10. Planning & Follow through
Identify patient’s support systems.
◦ Who have you got at home?
◦ Can I phone anyone for you?
◦ How are you going to get home?
This is where your “Support
will help a lot.
A mentally competent and informed
patient has the right to:
Accept or reject any treatment offered
React to the news and express his own
feelings in any way he chooses.
Why do we write?
1. Part of continuing good clinical care
(i.e. good quality referral letters)
2. Interphase between healthcare
professionals in primary and
secondary / tertiary care
3. Flexible means of info transfer
between healthcare professionals
What should be heading?
HANDWRITING! / typed
biodata (NRIC/Hospital R/N)
letter was written
whom the letter is written
What should be the content?
problem as a title before the
Brief & relevant history, including current
Past medical history
Any treatment tried to date & outcomes,
current drug treatment
investigations to date (with a copy of
State what was told to the patient in
cases of a potentially serious diagnosis
Reason for the referral second opinion
exclusion of a serious diagnosis
polite & grammatically correct.
copy is kept in the medical
Example of Referral letter
To: Bandar Tasek Selatan
Kindly see the above named who has
uncontrolled hypertension. Seen here
at A&E BP 180/100. ECG : Normal
Kindly do the needful.
To: Medical Officer-in –charge, Pusat
Perubatan Primer UKM, BTS
Kindly see the above named a 59 yr old /C/ Female
who has background history of uncontrolled
hypertension X 6 years-on PRN GP follow-up. She
does not know her antihypertensive medications &
compliance is poor. Seen here at A&E BP
180/100. Pulse rate: 66 bpm. ECG :
Kindly do the needful. (Kindly see her for regular
monitoring of her hypertension.) TQ.
Dr XOX (Official