COMMUNICATION SKILLS IN
CLINICAL PRACTICE
Dr. Syahnaz Mohd Hashim
Department of Family Medicine,
Faculty of Medicine,
PPUK...
What is communication?

“the successful passing of a message
from one person to another”

2
Important principles facilitating the
communication process
Rapport between the people involved
2. The time factor, facili...
Communication in the consultation
The doctor requires communication skills
for complete diagnosis:
- Physical
- Emotional
...
If you are the patient, what will be your opinion
on this doctor?

5
Important positive behavior
At first contact
Address patient by his or her preferred
name
Make the patient feel comforta...
Open-ended questions
“How are you feeling today?
“Anything I could help you with?”
“Tell me more about your problem?”

7
Do you like the doctor? Why?

8
Doctor’s attitude
Caring
Show

empathy
Respect
Interested
Concern
Confidence
Sensitive
Competence
9
Listening
Is

an active process described by Egan..

“One does not listen with just his ears: he
listens with his eyes, m...
Listening includes four essential
elements
Checking facts
2. Checking feelings
3. Encouragement
4. Reflection
“ You seem v...
Communication Tips


Check if what was said is what you
understood
◦ Rephrasing: “Let me say it as I understand it:
. . ....
Non verbal communication
IMPACT OF THE MESSAGE
%
Words alone

7

Tone of voice

38

Non verbal
communication/Body language...
Barriers to effective
communication
◦
◦
◦
◦
◦

Authoritative attitude (usually on the side
of the medical/health professio...
Barriers to effective
communication
◦

Appearing too busy & too rushed

◦

Not listening & constantly interrupting
patient...
Using medical jargon

16
“What to achieve in a 15 min
consultation” 7 Tasks of Consultation
1.

Define the reason for patient’s
attendance

2.

Con...
4.

With the patient, choose an appropriate
action/management plan for each
problem

5.

Involve the patient in the manage...
Patient Centered Interviewing

Focus on eliciting symptoms and
signs of illness

19
What is your opinion to this doctor?

20
Shows genuine interest in;
Patients

as individuals
Their reasons for seeking help
Their perceptions of what might be
w...
Advantages of patient centered
consultation

Emphasis

patient perspective on health including
his/ her perceive needs/ c...
Other advantages
Greater

patient satisfactions

Doctor-patient

interactions itself can be
therapeutic enhanced feeling...
Four Windows of Consultation
(Stott and Davis, 1979)

“The exceptional potential in each primary care
consultation”.

A.
M...
Ending an Interview
Summarize

what the patient has told you

Ask

them to check the accuracy of what
you have said

As...
Close

the interview in the positive
manner and write management plan:
- when is the next follow up visit
- What is the p...
HOW TO BREAK BAD
NEWS?
Why we need to know
“How to Break Bad News”?
Important
Practical

part of the medical job

& useful in daily clinical wo...
What is bad news?
“Any news that drastically and negatively
alters the patient’s view of his or her
future”

29
The 10-step Protocol
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Prepare the physical set-up
Get to know the patient
Identify patient’...
1. Prepare the physical set-up
Check

your facts!
Do it in person, never over the phone!
Find a private room to ensure ...
2. Get to know the patient
Establish

rapport
Introduce self & other staff/students (if any)
Start with “normal” courte...
3. Identify patient’s support
systems
How

did he/she come?

◦ By car, by bus, taxi, friend brought him/her?
Any

one th...
Prepare setting, identify support

34
4. Find out how much the patient
already knows
•

How much do you understand about your illness? . .

. . . . . . . . . . ...
5. Find out how much the patient
wants to know
•

Would you like me to explain what is
happening?

•

Would you like me to...
6. Give a “Warning shot”
I

am afraid that the news is not very good.

“Well,

the situation does appear to be more
seri...
7. Share the information
Break the news GENTLY
Break

the news gently, but not so much that it
is not clear.

Use

simpl...
The treatment isn’t working.
The cancer has come back.
The scan shows that the cancer has spread.
The biopsy result shows ...
Patient’s reactions

40
8. Respond to patient’s feelings –
Acknowledge distress & support ventilation
of feelings
Patient says:
I

am so sorry, i...
9. Identify concerns, prioritize &
answer all questions
Patient may ask:

Am I going to die?
What happens next?
Is there a...
Never say:
“There is nothing more that we can do.”
It is not true!
Further chemotherapy probably won’t help
anymore, but t...
10. Planning & Follow through
Identify patient’s support systems.
◦ Who have you got at home?
◦ Can I phone anyone for you...
Remember..
A mentally competent and informed
patient has the right to:
•

Accept or reject any treatment offered

•

React...
How to write a referral
letter?

46
Why do we write?
1. Part of continuing good clinical care
(i.e. good quality referral letters)
2. Interphase between healt...
What should be heading?
Official

clinic/hospital letterhead

LEGIBLE

HANDWRITING! / typed

Patient’s

biodata (NRIC/H...
What should be the content?
Patient’s

problem as a title before the
main text
Brief & relevant history, including curre...
What else?
Any

investigations to date (with a copy of
the results)
State what was told to the patient in
cases of a pot...
Very importantly…
Be

polite & grammatically correct.

Ensure

copy is kept in the medical
records

51
Example of Referral letter
To: Bandar Tasek Selatan
Kindly see the above named who has
uncontrolled hypertension. Seen her...
To: Medical Officer-in –charge, Pusat
Perubatan Primer UKM, BTS
Dear

Colleague,

Kindly see the above named a 59 yr old ...
THANK YOU FOR YOUR
ATTENTION

54
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  • Recognizing non verbal
  • Communication skills in clinical practice for undergraduates

    1. 1. COMMUNICATION SKILLS IN CLINICAL PRACTICE Dr. Syahnaz Mohd Hashim Department of Family Medicine, Faculty of Medicine, PPUKM
    2. 2. What is communication? “the successful passing of a message from one person to another” 2
    3. 3. Important principles facilitating the communication process Rapport between the people involved 2. The time factor, facilitated by devoting more time 3. The message, needs to be clear, correct, concise, unambiguous and in the context 4. The attitudes of both the communicator and the recepient 1. 3
    4. 4. Communication in the consultation The doctor requires communication skills for complete diagnosis: - Physical - Emotional - Social 4
    5. 5. If you are the patient, what will be your opinion on this doctor? 5
    6. 6. Important positive behavior At first contact Address patient by his or her preferred name Make the patient feel comfortable Be ‘unhurried’ and relaxed Focus firmly on the patient Use open-ended questions where possible 6
    7. 7. Open-ended questions “How are you feeling today? “Anything I could help you with?” “Tell me more about your problem?” 7
    8. 8. Do you like the doctor? Why? 8
    9. 9. Doctor’s attitude Caring Show empathy Respect Interested Concern Confidence Sensitive Competence 9
    10. 10. Listening Is 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 silence” 10
    11. 11. Listening includes four essential elements Checking facts 2. Checking feelings 3. Encouragement 4. Reflection “ You seem very upset today” “ It seems you’re having trouble coping” 1. 11
    12. 12. Communication Tips  Check if what was said is what you understood ◦ 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?” 12
    13. 13. Non verbal communication IMPACT OF THE MESSAGE % Words alone 7 Tone of voice 38 Non verbal communication/Body language 55 Body language include use of gestures, postures, position and distance 13
    14. 14. Barriers to effective communication ◦ ◦ ◦ ◦ ◦ 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 14
    15. 15. Barriers to effective communication ◦ Appearing too busy & too rushed ◦ Not listening & constantly interrupting patient ◦ 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 15
    16. 16. Using medical jargon 16
    17. 17. “What to achieve in a 15 min consultation” 7 Tasks of Consultation 1. Define the reason for patient’s attendance 2. Consider other problems 3. Achieve a shared understanding of the problems 17
    18. 18. 4. With the patient, choose an appropriate action/management plan for each problem 5. Involve the patient in the management & encourage patient to accept appropriate responsibility 6. Use time and resources appropriately 7. Establish and maintain a relationship which helps achieve other tasks 18
    19. 19. Patient Centered Interviewing Focus on eliciting symptoms and signs of illness 19
    20. 20. What is your opinion to this doctor? 20
    21. 21. Shows genuine interest in; Patients as individuals Their reasons for seeking help Their perceptions of what might be wrong Their feeling about the problems The impacts of this problems on their daily lives and well-being 21
    22. 22. Advantages of patient centered consultation Emphasis patient perspective on health including his/ her perceive needs/ concerns/ preferences and beliefs. Encourages patient to express what is most important to him Allows patient to lead Greater patients compliance with advice and treatments ◦ promotes patient’s health awareness 22
    23. 23. Other advantages Greater patient satisfactions Doctor-patient interactions itself can be therapeutic enhanced feeling of trust and understanding Clinical decision making process and disclosure of psychosocial problems are facilitated 23
    24. 24. Four Windows of Consultation (Stott and Davis, 1979) “The exceptional potential in each primary care consultation”. A. Management of Acute problems B. Modification of Behaviour C. Management of Comorbidities D. Prevention of Diseases / Promotion of Health 24
    25. 25. Ending an Interview Summarize what the patient has told you Ask them to check the accuracy of what you have said Ask them if you have left out any information which they feel is important Enquire if they would like to add anything 25
    26. 26. Close 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. End by thanking the patient ◦ E.g. Thank you for talking to me. Our time is now up. 26
    27. 27. HOW TO BREAK BAD NEWS?
    28. 28. Why we need to know “How to Break Bad News”? Important Practical part of the medical job & useful in daily clinical work Remember… If we do it badly, the patients or family members may never forgive us. If we do it well, they will never forget us. 28
    29. 29. What is bad news? “Any news that drastically and negatively alters the patient’s view of his or her future” 29
    30. 30. The 10-step Protocol 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 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 30
    31. 31. 1. Prepare the physical set-up Check your facts! Do it in person, never over the phone! Find a private room to ensure privacy & confidentiality 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? 31
    32. 32. 2. Get to know the patient Establish rapport Introduce self & other staff/students (if any) Start with “normal” courtesies & considerations (drink, washroom) Does he/she have a spouse, children, work, etc.? 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?” 32
    33. 33. 3. Identify patient’s support systems How did he/she come? ◦ By car, by bus, taxi, friend brought him/her? Any one that came with him/her? ◦ Alone, spouse, best friend, etc.? Ask permission to draw “genogram”. Not just of family ties but also draw a genogram of “Support persons” 33
    34. 34. Prepare setting, identify support 34
    35. 35. 4. Find out how much the patient already knows • 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? 35
    36. 36. 5. Find out how much the patient wants to know • Would you like me to explain what is happening? • Would you like me to tell you the full details of the diagnosis? • Would you like to know exactly what is going on, OR • Would you prefer me to give you the outline only? 36
    37. 37. 6. Give a “Warning shot” I am afraid that the news is not very good. “Well, the situation does appear to be more serious than that . . .” Maaf, saya rasa berita yang saya akan sampaikan agak tidak begitu baik. Saya berat hati untuk memberi tahu . . . . . . Silence . . . . . , Mirroring . . . . . 37
    38. 38. 7. Share the information Break the news GENTLY Break the news gently, but not so much that it is not clear. Use 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 38
    39. 39. 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. Check for patient’s understanding frequently Reinforce May and clarify information frequently need to draw a picture for clarity 39
    40. 40. Patient’s reactions 40
    41. 41. 8. Respond to patient’s feelings – Acknowledge distress & support ventilation of feelings Patient says: I am so sorry, it is very hard, it is so cruel. . . . . . . Silence . . . . ., Mirroring . . . . . WAIT . . . . Until the patient talks again. “Let the storm pass by” 41
    42. 42. 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 can. 42
    43. 43. Never say: “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 you comfortable. 43
    44. 44. 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 Genogram” will help a lot. 44
    45. 45. Remember.. 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. 45
    46. 46. How to write a referral letter? 46
    47. 47. 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 47
    48. 48. What should be heading? Official clinic/hospital letterhead LEGIBLE HANDWRITING! / typed Patient’s biodata (NRIC/Hospital R/N) Date/time To letter was written whom the letter is written 48
    49. 49. What should be the content? Patient’s problem as a title before the main text Brief & relevant history, including current medication Past medical history Allergies Social circumstances± Any treatment tried to date & outcomes, current drug treatment 49
    50. 50. What else? Any investigations to date (with a copy of the results) 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  treatment failure 50
    51. 51. Very importantly… Be polite & grammatically correct. Ensure copy is kept in the medical records 51
    52. 52. 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 Asymptomatic. Kindly do the needful. 52
    53. 53. To: Medical Officer-in –charge, Pusat Perubatan Primer UKM, BTS Dear Colleague, 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 : Normal.Asymptomatic. Kindly do the needful. (Kindly see her for regular monitoring of her hypertension.) TQ. Dr XOX (Official Stamp) 53
    54. 54. THANK YOU FOR YOUR ATTENTION 54

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