Establishing Rapport


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communication skills for medical students, staff

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Establishing Rapport

  1. 1. Establishing rapport Dr / Khalid D. Al-Harby MBBS,SBFM,ABFM Family medicine trainer
  2. 2. Establishing rapport • The physician ,in order to be effective, should speak softly, be well-dressed, have quiet ways and have eyes that do not wander • Personal appearance is an important non-verbal communication DR/KHALID ALHARBY 2
  3. 3. Cont… • Lack of eye contact may be interpreted as a lack of concern • A genuine smile can be helpful in quickly establishing a friendly atmosphere and developing a warm interpersonal relationships DR/KHALID ALHARBY 3
  4. 4. Cont… • Posture:- standing erect, moving briskly with head up and stomach in is better than slouching • Listless or lethargic appearance can be interpreted as lack of concern. DR/KHALID ALHARBY 4
  5. 5. Cont… • Review the chart:- patients believe that well informed physician is truly interested in them DR/KHALID ALHARBY 5
  6. 6. Respect • Pt.must believe that the • Give +ve statements about physician values their others:- pts. do not respect comments and opinions a physician who is before trusting him or her building himself up by with information of a tearing someone else more personal nature down. • Mutual respect is • Know your feeling and important. do not act on them “ • Problems of the clenching of the physician’s side: physician’s fist is a lack of security and of self- clinical sign of the confidence. hysterical patients. DR/KHALID ALHARBY 6
  7. 7. Cont. Respect The more patients that physicians see, and the more overloaded their practices, the more likely they are to describe pt. Complaints as trivial, inappropriate, or bothersome.
  8. 8. Measures of rapport patient’s satisfaction • Most studies indicate that • Factors which interfere pt. Satisfaction depends on with the patient information, and the satisfaction :- degree to which the pt. 1. Poor communication Understands the illness 2. Perception of physician (more than doing full insensitivity examination and investigation . 3. Office foul-up e.g appointment delay, • Even pt.with chronic billing mistake, and disease has Qs to be frustration with the answered. telephone system • Increase satisfaction leads to increase compliance DR/KHALID ALHARBY 8
  9. 9. Communication and rapport • The majority of complaints against physicians are simply the results of a lack of communication between Dr. and pt. • Failure of communication can also affect the outcome of treatment, often as seriously as can an error in treatment. • Easy accessibility enhance better communication DR/KHALID ALHARBY 9
  10. 10. cont • Establishing an open • Face-to-face channel is the first element communication may be of the communication intended or unintended. process and influence all • Intended messages: that follows. Verbal and non-verbal cues (as face-to-face to transmit a message conversation in clinical (strong,unafraid, and setting). willing to face reality) • The recognition of pt’s • Unintended true thoughts and feeling message(unaware):- e.g is a central skill in tremor of the hand (in fact establishing and he is afraid) maintaining rapport DR/KHALID ALHARBY 10
  11. 11. Verbal communication • Refer to the wards 4. Reason for attendance: literally transmitted and • Oh; by the way doc. account for around 10% • Child as a ticket of the communication • Known pt (OPD) vs. only new ( as in ER where Dr • C/O,PMH,FH,DH…. talk more than the pt.) • Explore :- • The pt. cultural background and 1. Slips of the tongue educational level should 2. Major areas of omission be considered 3. Why he is telling me that • Avoid medical terminology DR/KHALID ALHARBY 11
  12. 12. Non – verbal communication • One third of the communication • It conducts the personal attitude and emotions • Elements:- 1. Paralanguage (voice effects) 2. Kinesics (body language) 3. Touch 4. Proxemics (spatial factors DR/KHALID ALHARBY 12
  13. 13. cont 5. Physical characteristics (e.g age) 6. Artifacts (clothes and accessories) 7. Environmental factors (furniture, décor,…) DR/KHALID ALHARBY 13
  14. 14. Paralanguage • Rather than concentrating on what the pt. is saying but on how he is saying it • Velocity, tone, volume, sighs, grunts, pauses, and inflections • Sarcasm is a common example of a contradiction between vocal and verbal messages. DR/KHALID ALHARBY 14
  15. 15. Touch • Should be appropriate and • The limp or “wet dishrag” socially acceptable handshake indicates lack • Touching can an effective of interest or insincerity, method for especially if it is rapidly communicating or withdrawn compassion and can break • A moist palm is a sign of down some of the nervousness or defensive barriers to apprehension communication. • The “half way there” • It can be done by fingers – only handshake handshaking or indicate reluctance or application of the Lt.hand indecision. to the upper or lower arm • Pt. DR/KHALID ALHARBY Often feel better after 15 a
  16. 16. cont routine physical examination. • The magic of touch can be good medicine, especially when combined with concern, support, and reassurance. • Infants deprived of touch and stroking suffer mental and physical deterioration (adults also require stroking to maintain a healthy emotional state) DR/KHALID ALHARBY 16
  17. 17. Kinesics • The study of non-verbal • If they are different: non- gestures, or body verbal message message is movements, and their more accurate than verbal meaning as a form message communication • Positive verbal • Body language alone does communication as “you not reveal the entire are looking better today” behavioral image any when accompanied by –ve more than does verbal non-verbal cues will be language alone (they are interpreted by the pt. As meaningful only when insincere. considered in the context • Premature reassurance of a person’s total may be interpreted as DR/KHALID ALHARBY 17 behavioral pattern rejection
  18. 18. Cont… Reassurance should be:- genuine,realistic, and given only after a thorough evaluation of the problem. The physician will see the fear and uncertainty in the pt’s face only if he or she is looking at the pt. Rather than the medical record. DR/KHALID ALHARBY 18
  19. 19. Body position • Tense persons sets erect with a fairly rigid posture. • Moderately relaxed lean forward 20 degrees& side lean 10 • Higher pt. Satisfaction is ass. with physician’s forward body lean, rotation of the torso toward the pt., relaxation of the chin in his hands, and gaze directly at the pt. • Pt. DR/KHALID ALHARBY Feel more comfort and 19
  20. 20. Mirroring • When good rapport exists between two persons, each will mirror the other’s movements. • If the physician notices sudden disruption of mirroring activity by the patient, more attention should be focused on the comment that led to the change of position * DR/KHALID ALHARBY 20
  21. 21. Head position • Head is held forward in anger, backward in defiance, anxiety, or fear, and downward in sadness, shame, or guilt. • Tilting the head to one side indicates interest, and attention. • The physician should sit forward in the chair with an interested, attentive facial expression and the head slightly tilted.* DR/KHALID ALHARBY 21
  22. 22. Face • The facial expression of emotions, when undisguised, is independent of culture and is identical throughout the world. (especially the eyebrows, eyes, and the forehead)** DR/KHALID ALHARBY 22
  23. 23. Micro-expressions • Most facial expressions last more than one second, but micro-expressions last only one fifth of a second (the time to blink the eye) • Easily missed if the physician is not carefully observing pt. • It occurs when the pt. Begins to show a true facial expression, senses this and immediately neutralizes or masks the DR/KHALID ALHARBY 23 expression
  24. 24. Eyes • The principle organ of • They constrict if expression. unpleasant • When anonymity is • Dilated pupil indicate desired, only the eyes interest and vice versa need to be covered. • The best method for • Eyebrows have 40 conveying sincerity is different positions of frequent eye contact expression and eyelids 23 • A listener who doesn’t • Even the lower eyelids maintain eye contact, but alone can convey continue to look down, or considerable information* away from the speaker • Pupils dilate when seeing may be shy, depressed, or rejecting (speaker or his 24 something pleasant DR/KHALID ALHARBY
  25. 25. Eyes cont • Prolonged eye contact or • The frequency of eye staring can be offensive. contact also can provide • The acceptability of eye clues to whether pt. Is contact varies significantly anxious or depressed among different cultures • Anxious pts: their eyes • Patients are most blink frequently or darted comfortable when the back and forth, they can’t physician looks at them maintain eye contact, approximately 50% of the stroke them selves more time and are (hand on hand, hand on uncomfortable when eye face), smile less, have contact is avoided rigid torsos, afraid to move, and have rapid R.R. DR/KHALID ALHARBY 25
  26. 26. Eyes cont. • Depressed pts: • In case of abdominal 1. Maintain eye contact pain : pt. with organic only 1/4th as normal disease keep more eye 2. Have downward contact during contraction of the abdominal mouth and a examination than downward angling of those with non- the head specific pain DR/KHALID ALHARBY 26
  27. 27. Hands • Sadness: flaccid, and the index finger, pulling droopy hands. at the ear lobe, or raising • Anxiety: fidgety or to the lips ( NB/ it may grasping hands, shake also indicate hidden when holding a pen information : attempt to • Anger: clenched hands suppress a comment) • Confidence & assurance The “THINKING position” : in the comments being 1. Index finger across the made(steepling)* lips • Palms outward: a warm & 2. Index finger extended friendly greeting along the cheek • Urge to interrupt : slight raising of the hands orDR/KHALID ALHARBY 27
  28. 28. Cont. 3. One sitting with elbows on the table and hands clenched in front of the mouth. DR/KHALID ALHARBY 28
  29. 29. Arms • Crossed arms : 1. Defensive posture, or disagreement * 2. sign of insecurity 3. Position of comfort • The resistant position (in anger): Clenched fists held tightly against the body in a holding-back manner (preventing them from hitting) * DR/KHALID ALHARBY 29
  30. 30. Legs • Crossed legs : 1. Common position of comfort 2. Protection (shutting out) against the outside world (will not give diagnostic information, will not follow instructions)* • Anxious or scared person : 1. Sit forward in the chair 2. Feet in the ready-to-run position DR/KHALID ALHARBY 30
  31. 31. Cont • Angry person: place the feet widely apart in a position of instability Sad person : Move in a slow circular pattern DR/KHALID ALHARBY 31
  32. 32. Preening gesture • Be carefull of the seductive patients (more than expected of peering gestures) DR/KHALID ALHARBY 32
  33. 33. Respiratory avoidance response • Frequent clearing of the describes a split between throat when no phlegm or inner thoughts and mucous is present.(it can outward action be a non-verbal indication Associated with : of disgust or rejection) 1. Lying • NOSE-RUB: * 2. The struggle to appear (not vigorous & repeated as calm while suppressing that used normally to anger or discomfort relieve itch) Soft, one or two tight strokes DR/KHALID ALHARBY 33
  34. 34. Verbal – non verbal mismatch • Clues that pt. Is not telling the truth:- 1. “how is the relation between you and your wife?” “fine” while looking sad and avoiding eye contact 2. Asymmetrical facial expression 3. Prolonged smile 4. Expression of a amazement DR/KHALID ALHARBY 34
  35. 35. Proxemics “(spatial factors)” • The study of how people distance for most people unconsciously structure • The space can be divided the space around them. into: • It varies with culture: 1. Intimate space :range 1. In north American (body from close physical bubble or distance contact to 18 inches gaze)* 2. Personal space :18 in to 2. In middle east (no body 4 feet bubbles (proper to 3. Social space : 4F – 12F invade this area) 4. Public space : >12F • The arm’s length is a • Placing a desk between 2 good measure of persons shifts personal to appropriate personalDR/KHALID ALHARBY social space 35
  36. 36. Hidden or masked communication(concern) • The average person • If the physician deals only has a symptom about with the symptom (e.g headache), the real every 6 days, he visits concern (e.g. meningitis) a physician only once / may go undetected, and 4months the result will be a • Those who visit more dissatisfied & a non- frequently tends to compliant patient have a higher level of • Investigate the pt’s current life stresses when visits anxiety, fear, grief, or are made if there is no frustrations change in clinical status DR/KHALID ALHARBY 36
  37. 37. Patient expectations • Rapport and satisfaction will be enhanced if the physician identifies and satisfies the patient’s expectations for the visit DR/KHALID ALHARBY 37
  38. 38. Hand –on- the –doorknob syndrome • The patient’s parting Mentioning the real reason phrase is sometimes a clue for the visit to the primary reason for • Ask your pt. Routinely at the visit the end of a visit “is there • With the hand on the door, any thing we have not escape is readily covered or any thing else accessible if the you would like to ask me” physician’s reaction is • Apprehension regarding unfavorable cancer is widespread, and • Because of the fear of often the only cure for this rejection or humiliation, fear is a therapeutic the pt. May test the conversation with the physician with minor physician DR/KHALID ALHARBY 38 complaints before
  39. 39. cont • “Oh, by the way doctor” is a variation of the hand – on – doorknob syndrome • About 20% of the patients raise their new problems at the end of the visit DR/KHALID ALHARBY 39
  40. 40. Listening well • A good family physician must be a good listener • It is the most important communication skill essential to rapport • The physician, to be a good listener should bend forward, maintain eye contact, appear relaxed yet attentive, and be non- judgmental • The less physician will say DR/KHALID ALHARBY more the pt. Will say 40 the
  41. 41. Silence • Silence can be as effective mean of eliciting information as direct questions • It should be used only when the physician is relatively certain that there is more information to follow the last statement • A shift of position, or a nod and a smile, properly timed and coupled with silence, can be more DR/KHALID ALHARBY 41 effective than a comment
  42. 42. Interruption • Physicians usually use closed- ended questions to interrupt the pt. and thereby inappropriately control the interview • This prematurely terminates opportunities for pts. to present their primary concern • Male physicians tend to interrupt more often than female physicians DR/KHALID ALHARBY 42
  43. 43. Interviewing effectively • The skilled family that we have not physician can spend 10 discussed? minute with a pt. & the pt. • Rather than assuming that Feels it was 20 minutes the pt. Have understood • Even the busiest physician the instructions, ask them can accomplish wonders to repeat as they in a few minutes by understood indicating that their full • use the pt’s name or ask attention is on the patient him what he prefer to be • Please conclude every called as interview with the • Use “how can I help you? statement “ is their any Rather than “what brings thing else bothering you DR/KHALID ALHARBY here today?” you 43
  44. 44. Cont • Facilitating techniques communicating very well. - and then? Can you tell me what is - Repeating a portion of the wrong? statement just made. • Summarizing • Humor (paraphrasing) two-edged sward - brief restatement of what the patient has said can Can be used to break the ice give both the interviewer and to show “We are and the pt. a chance to together” correct errors or • Confrontation misunderstanding. -you look unhappy - A summary gives the pt. -We do not seem to be DR/KHALID ALHARBYopportunity to add an 44
  45. 45. cont more details but also let if the physician “at the him know that you are same time” : listening 1. Put away the pen and - “let me see if I have pad understood you correctly” 2. Closes the chart - It can be used to change 3. Start edging toward the the subject by the door physician • Open ended question • Concluding a history -the single most valuable -to avoid leaving gaps in H/O rapport-promoting “is there any thing else you element of the verbal would like to mention ?” communication DR/KHALID ALHARBY - It can be of little value To be effective, physician 45
  46. 46. cont should appear relaxed and • Signals that discourage ready to listen regardless communication: of the amount of pressure -people can turn off the from waiting patients speaker if they frequently comment “yes” in a -once it becomes apparent manner that conveys that more time is necessary disinterest or impatience than is available, a new • Confidentiality: appointment should be -is a cardinal principle of made so that adequate time professionalism is assured -pt. Should feel secure that their information is kept secret (esp.adolescents) 46 DR/KHALID ALHARBY