Publication Module On Health Communication

Communication Skills in
Medicine
Prepared & published by BCPS and DGHS

With WHO support
Under WHO BAN HRH
June 2008
ISBN- 984-300-002199-0
Foreword
I would like to express my great appreciation that “Module on Communication Skills in
Medicine” is going to be published. The ability to communicate with patient and their
family members is by far the most precious skill that a doctor should learn.
Nearly all the problems of present day medicine including dissatisfaction of patients and
their family members result from poor communication. Overall improvement in the
Communication Skill will bring the confidence of patient population on doctor and is
expected that number of patients seeking treatment abroad will be reduced.
This module was reviewed by the top level scientific committee and provides a frame work
informations and suggestions about different types of communication skills in a coordinated
manner.
Communication skills are learnt and developed by “doing” rather than “reading a book”.
However, the path will be easier if a guide is provided. I sincerely hope that this module
will bring about the positive impact among doctors in the field of Communication Skill.
I would like to acknowledge WHO Bangladesh support for improving the quality of health
resources for health education and performance, which includes supporting publishing this
module and its use in organizing future training.
Professor Md. Abul Faiz

Director-General of Health Services
Ministry of Health & Family Welfare
Government of the People’s Republic
of Bangladesh
i
Preface
The module on “Communication Skills in Medicine” is indeed a well-prepared document

that highlights various aspects of communication between doctors and patients and can
serve to be a model in the teaching of communication skills to our young doctors’
community.
The Module on “Communication Skills in Medicine” is the research products of the author
carried out with the assistance from the BCPS under HNPSP of the Ministry of Health and
Family Welfare, Govt. of the People’s Republic of Bangladesh. It is a matter of great
satisfaction that research carried out such is posing to be an important teaching tool.
It is recommended that this printed module will help in teaching of trainee doctors of
different specialities. This type of teaching and learning module is going to be published
first time in our country and shall be of significant value as a teaching material in general in
the country and abroad.
Finally, I would like to express my sincere thanks to the contributors and to WHO
Bangladesh for the continuous support of BCPS activities, including supporting the
publication of this module.
Professor T.I.M. Abdullah-Al-Faruq

Honorary Secretary
Bangladesh College of Physicians and Surgeons (BCPS)
ii
Teaching and Learning Communication Skills in Medicine
List of contributors
Core Faculty
1. Professor Md. Abul Faiz
Introduction to basic communication
2. Professor A K M Rafique Uddin
The medical history and
Giving information
3. Professor M Abul Kashem Khandaker
Counseling for seeking permission to do procedures
4. Professor F M Siddiqui
Challenging consultations: special problems in doctor-patient
communication
5. Professor M Rajibul Alam
Breaking bad news
Communication with patient’s family
6. Professor Md. Ridwanur Rahman
Taking sexual history, conducting examination of such a patient and
counseling related to HIV
How to take informed consent
List of other contributors:

1. Dr. Md. Shafiqul Bari
2. Dr. Rubina Yasmin
3. Dr. S M Arif
4. Dr. Habib Ahmed
5. Dr. Ariful Basher
6. Dr. Md. Belalul Islam
iii
Teaching and Learning Communication Skills in Medicine
Contents
Titile Page No
Foreweord i
Preface ii
List of contributors iii
Module- 1: Introduction to basic communication skills 1-11
Module- 2: (a) The medical history and (b) Giving information 12-18
Module- 3: Breaking bad news 19-24
Module- 4: Taking sexual history, conducting examination of such

a patient and counseling related to HIV 25-31
Module- 5: Communication with patient’s family 32-36
Module- 6: How to take informed consent 37-42
Module- 7: Challenging consultations: special problems in

doctor-patient communication 43-48
Module- 8: Counseling for seeking permission to do procedures 49-54

Introduction and overview of the course
Background:
Communication skill needs to be taught and learned. Teaching and learning communication
is a learnable and teachable skill. ‘Experience alone can be a poor teacher in communication
skills’. Observation of ‘bedside manner’ is an inefficient way of teaching communication
skills. Successful educational interventions require multi-pronged strategies including
building up knowledge, demonstration, feedback, reflection, and self-assessment, repeated
practice in safe and simulated environment.
Specific teaching and learning methods are required in communication skill training.
The prize on offer from communication skill training is improved clinical performance.
Objectives of the Module:

General objective:
1. To see the efficacy of prepared teaching -learning module on communication skills
in Medical science.
Specific objectives:
1. To develop a module on communication skills
2. To provide teaching on communication skills based on developed module
3. To develop instruments for assessment of communication skills
4. To test the competency of communication skills based on developed instruments for
assessment.
Focus of the Module:
Content skills- what the healthcare professionals communicate
Process skills- how they do it
Perceptual skills – what they are thinking and feeling
Marrying contents and process
Essential Components of Communication:
a) Listen to patients, ask for and respect their views about their health, and respond to
their concerns and preferences
b) Share with patients, in a way they can understand, the information they want or need
to know about their condition, its likely progression, and the treatment options
available to them, including associated risks and uncertainties
c) Respond to patients’ questions and keep them informed
d) Make sure that patients are informed about how information is shared within teams
and among those who will be providing their care.
1
kills.
Module – 1
(a) The medical history and (b) Giving
Introduction to basic communication skills
information
Breaking bad news
Taking sexual history, conducting

examination of such a patient, and
Communication with patient’s family

/party).
How to take informed consent?
Challenging consultations: special

problems in doctor-patient
communication
Counseling for seeking permission to

do procedures
Introduction to basic communication kills

2
Learning objectives of the module:
• Be aware of the concept of communication skill in medicine
• An overview of an overall curriculum of doctor-patient communication skills- what
to teach and learn
Learning Objectives after completion of this module, trainees will be able to
1. Interpret basic knowledge of communication skill in relation to medical science
a) List Basic Methods of communication
b) Describe components of good communication
c) Describe Importance of good communication with medical profession
d) List factors related to doctor-patient communication
e) List and categorize different aspects of communication in medical profession
considering different specialties
2. Understand steps of interview process
a) List steps of an interview
b) Comprehend process of communication (structure of a consultation )
c) Take an interview successfully
Lesson Plan
Pre-
Trainers
Objectives Requisite Methods Trainees Activity Assessment
activity
knowledge
1.a & b General Brainstorming Ask Q’s & Respond & Informal
Categorize comprehend
knowledge
1 c&d General Presentation Lecture with Ask Q;s & Informal
OHP comprehend
knowledge
/Multimedia
1e Perceived Brainstorming Ask Q’s & Comprehend & MCQ
knowledge give cues categorize
2. a Perceived Presentation Lecture with Ask Q;s & Informal
knowledge OHP comprehend
/Multimedia
2.b Perceived Presentation Lecture with Ask Q;s & Informal
knowledge OHP comprehend
/Multimedia
2c Role Play Arrange role Observe and Checklist
play comprehend

3
Overview of the module:
Initiating the session
Building the relationship

Gathering information
Providing structure
Physical examination
Explanation and planning
Closing the session
4
Initiating the session
• Preparation
• Establishing initial rapport
Providing
Building the
structure Gathering information relationship
• Make • Exploration of the patient's problems to discover the: • Using
appropriate
organization biomedical perspective patient's perspective non-verbal
overt background information - context behaviour
•Attending • Involving the
to now Physical examination patient
Explanation and planning
• Providing the correct type and amount of information

• Aiding accurate recall and understanding
• Achieving a shared understanding: incorporating the
patient's illness framework
• • Planning: shared decision making
Closing the session

• Ensuring appropriate point of closure
• Forward planning
5
Calgary-Cambridge Guides Communication Process Skills
• Initiating the session

- Establishing initial rapport
• Identifying the reason(s) for the consultation
• Gathering information
- Exploration of patient’s problems
• Additional skills for understanding the patient perspective
• Providing structure to the consultation
- Making organization overt
- Attending to flow
• Building relationship
- Using appropriate non-verbal behavior
- Developing rapport
- Involving the patient
• Explanation and planning
- Providing the correct amount and type of information
- Aiding accurate recall and understanding
- Achieving a shared understanding: incorporating the patient’s perspective
- Planning: shared decision making
• Closing the session
- Forward planning
- Ensuring appropriate point of closure
• Options in explanation and planning (includes content and process skills)
- If discussing opinion and significance of problem
- If negotiating mutual plan of action
- If discussion investigations and procedures

6
Skills for Building the Relationship (To be considered in this section)
Using appropriate non-verbal communication

• Demonstrates appropriate non-verbal behaviour:
– Eye contact, facial expression
– Posture, position, movement
– Vocal cues e.g. Rate, volume, intonation
• Use of notes: if reads, writes notes or uses computer, does so in a manner that does
not interfere with dialogue or rapport
• Picks up patient's non-verbal cues (body language, speech, facial expression);
checks them out and acknowledges them as appropriate
What do we mean by Non-verbal Communication

• Posture: sitting, standing, erect, relaxed
• Proximity: use of space, physical distance between and positioning of
communicators
• Touch: handshake, pat, physical contact during physical examination
• Body movements: hand and arm gestures, fidgeting, nodding, foot and leg
movements
• Facial expression: raised eyebrows, frown, smile, crying
• Eye behavior: eye contact, gaze, staring
• Vocal cues: pitch, rate, volume, rhythm, silence, pause, intonation, speech errors
• Use of time: early, late, on time, over time, rushed, slow to respond
• Physical presence: race, gender, body shape, clothing, grooming
• Environmental cues: location, furniture placement, lighting, temperature, colour.
Developing rapport:
• Acceptance: accepts legitimacy of patient's views and feelings; is not judgmental
• Empathy: uses empathy to communicate understanding and appreciation of the
patient's feelings or predicament; overtly acknowledges patient's views and feelings
• Support: expresses concern, understanding, willingness to help; acknowledges
coping efforts and appropriate self-care; offers partnership
• Sensitivity: deals sensitively with embarrassing and disturbing topics and physical
pain, including when associated with physical examination

7
Involving the patient:
• Sharing of thoughts: shares thinking with patient to encourage patient's
involvement (e.g. 'What I'm thinking now is . . .')
• Provides rationale: explains rationale for questions or parts of physical examination
that could appear to be non sequiturs
• Examination: during physical examination, explains process, asks permission

8
Summary:
• The ability to communicate effectively and sensitively is central to all medical

activities and to those working in all specialties. There is evidence that good
communication leads to:
- Accurate history-taking and diagnosis
- Patients' compliance with their treatment plan
- Patients' satisfaction with the care they receive.
• Communication skills can and should be taught:

- There is evidence that good communication skills can be learnt and that the
skills are retained.
• Communicating effectively with patients involves the core skills of questioning,
active listening and facilitating.
• These skills can be learned and need to be practised.
• Asking questions
- Use open questions as often as possible, particularly at the beginning of an
interview.
- Obtain specific information using focused and closed questions.
- Use probing questions to clarify, check accuracy and to help the patient expand
on what they have said.
- Avoid using leading questions.
- Avoid asking several questions at once: this is confusing.
- Allow the patient time to answer your question.
- Rephrase a question using simpler language if they do not understand or if their
answer is unclear.
• Listening
- Listening is one of the core skills of good communication.
- Allow patients to talk without interruption.
- Effective listening means concentrating on what the patient says and trying to
understand their feelings as they speak.
- Be alert to verbal and non-verbal cues.
- To demonstrate your attention, use appropriate body language and facilitate
comments.
- Allow pauses or silences.
9
• Leave time at the end of the interview to summarize what the patient has said and
ask if they have anything to add.
• Some common pitfalls to be avoided are:
- Asking too many questions
- Not allowing the patient to tell their story in their own words
- Unnecessary interruptions
- Failing to pick up important verbal and non-verbal cues.
10
Module – 2 : (a) The medical history and (b) Giving information
Learning Objectives of the Module
Focus of the Module

To apply knowledge of structure and process of interview into a practical clinical situation
Introduction
11
skills.
Module – 2
(a) The medical history and (b) Giving (a) The medical history and (b) Giving
information information
Breaking bad news

Communication with patients’ family

(party).

communication

do procedures
(a) The medical history and (b) Giving information
12
Gathering information- The trainees will be able to
1. a) Explore the patient’s problems to discover the biomedical perspective and the
background information
1. b) Ensure that information gathered is accurate, complete and mutually understood
1. c) Develop a Continuing supportive environment and collaborative relationship
Giving information-
2. a) Assess the correct amount and type of information to give to any individual patient.
2. b) Provide explanations that the patient can remember and understand
2. c) Provide explanations that relates to the patient’s perspective
Lesson Plan
Pre-
Trainers Trainees
Objectives Requisite Methods Assessment
activity Activity
knowledge
1.a) Previous Re call Ask Q’s & Respond & Informal
Components of knowledge categorize comprehend
a medical Presentation lecture with
history OHP /
(What) Multimedia
Structure and Role play Arrange Participates Observation
process in an role play & practice with a
interview checklist
(How) Practice Feedback Clarify
1b
Summarizing
Signposting
sequencing
1c Perceived Brainstorming Ask Q’s & Comprehend MCQ
Developing knowledge give cues & categorize
rapport
involving
patient
2. a Perceived Presentation Lecture Ask Q;s & Informal
i) Contents knowledge with OHP comprehend
ii) Process /Multimedia
2.b Explaining Perceived Presentation Lecture Ask Q;s & Checklist
knowledge role play with OHP observe and
/Multimedia comprehend
2c Planning

13
Overview of the module :
Developing a management plan for a patient
Establish a relationship with Gather information

a patient • History
• Physical
examination
• Investigations
Make a diagnosis if possible
Explain and discuss this with Formulate a management plan

the patient
15
Key Points to Take the Medical History
Detailed history taking is important as for majority of cases diagnosis is made from history
alone.
Structure of medical history:
• Basic information about the patient
• Description of presenting problem
• History of presenting problem
• Review of body systems
• Past medical history
• Family history
• Social history
Modifications of history taking sequences are necessary in following situations:

• Patients with compound fracture in Accident and emergency department
• Patients with acute chest pain in Coronary care unit
• Management of critically ill patients
Some special practical hints for taking a history:

• Take every opportunity you are given interview patients
• Be prepare to spend time with patients
• Use every skill to obtain a good history
• If taking notes are essential, explain with the patient for its reason
• Establish intermittent eye contact during taking notes, DON’T give the impression
that your notes are more important than what the patient is saying
Giving Information;
Importance of giving information
1) Patients level of anxiety and stress will be decrease
2) The outcome of procedure will be better who are fully informed before the procedure
e.g. operation.
3) Patients satisfaction about their care will be higher if there fully inform
4) Patients compliance with treatment will be better

16
Guidelines for giving information to a patient:
¾ Describe what information you plan to give
Results of the physical examination
Results of test
Diagnosis (or provisional diagnosis)
Cause of the problems
Necessary further investigations
Treatment planned
Prognosis
¾ Summarize your understanding of patients problem
¾ Find out their understanding of the condition
¾ Outline the structure of the rest of the interview and discuss about
Diagnosis
Further investigation
Treatment
¾ Use appropriate language
¾ If relevant, use drawing to supplement the information
¾ Give the most important piece of information first
¾ Explore the patients view on information given
¾ Negotiate management
¾ Check the patients understanding of what has been said
17
Summary:
• It is important to obtain a complete and accurate history: for the majority of patients,
a diagnosis can be made on the history alone.
• Develop and practice a systematic approach to taking a history:
- Introduction and explanation of task
- Personal details
- Presenting problem(s)
- History of presenting problem(s)
- Review of body systems
- Past medical history
- Family history
- Social history
- Summarize and conclude interview.
• Good communication skills are essential. Use open questions, listen carefully, and
pick up and respond to verbal and non-verbal cues.
• The way in which information is given influences patients' satisfaction and
compliance with treatment
• Before giving information, find out what the patient knows about their problem and
its possible treatment and take this into account when giving them information.
• Outline the stages of giving the information (diagnosis, treatment, etc.).
• When giving information:
- Give the most important information first
- Use short words and short sentences
- Avoid medical jargon
- Avoid vagueness — give specific information.
• When deciding on a treatment plan with a patient:
- Identify and acknowledge their beliefs and worries about their problem and its
management
- Find out their treatment preference
- Negotiate a treatment plan.
• At the end of the interview, ask the patient to summarize what has been agreed.

18
Module – 3: Breaking bad news

Focus of the Module
Introduction
19
Module – 3 skills.
Breaking bad news

information
Breaking bad news


(party).

communication

do procedures
Learning objectives of the module –
What bad news consists of
Addresses why it is often difficult to break bad news
Describe an approach to give bad news in different settings

At the end of this module the participants will be able to
1. Write examples of Bad News
2. Anticipate problems (difficulties) of giving a bad news
3. Describe the steps of giving bad news
4. Give bad news to appropriate person in a suitable situation
Lesson Plan
Pre-
Trainers Trainees
activity Activity
knowledge
1 General Brainstorming Ask Q’s & Respond & Informal
categorize comprehend
knowledge
2 Personal Brainstorming Lecture with Ask Q’s & Informal
experience & presentation OHP comprehend
/Multimedia
3 Nil Small group Arrange group Participate & MCQ
discussion work & comprehend
4a Steps of Role play Arrange Ask Q’s & Informal
breaking role play & Comprehend
bad news give feedback
4b Practice Practice with Observation Practice Checklist
peer and feedback
observation
Breaking bad news

21
Overview of the Module -
What is difficult about giving bad news:
There are personal, professional and social reasons why giving bad news to patients may be
difficult.
Why is it difficult to give bad news?

• The 'messenger' may feel responsible and fears being blamed
• Possible inhibition because of personal experience of loss
• Reluctance to change the existing doctor-patient relationship
• Fear of the patients emotional reaction
• Uncertainty as to what may happen next and not having answers to some questions
• To whom should bad news be given?

• Who should give bad news?
• When should bad news be given?
• How to give bad news?
The process of giving bad news

↓
Give information
↓
Check the patients understanding of the information
↓
Identify the patient's main concerns
↓
Elicit the patients coping strategies, personal resources and give realistic hope
There are some obvious things which should not be done:

• Not to give bad news at the end of physical examination while the patient is still
undressed
• Not to give bad news in corridors and over telephone
Breaking bad news

22
Practical session for giving bad news-
A patient is diagnosed as a case of parkinsonism. Procedure of giving the bad news-
Important steps that one must follow to give bad news:
5. Early in the day
6. Sufficient time
7. Ask what patient knows about it
8. Private comfortable room
9. Not during physical examination
10. Eye contact
11. Not to have stethoscope around neck
12. Create a personal and friendly situation
13. Reassurance
14. Responding to their concern
15. Referral
16. Feedback and handover to professional colleague
23
Breaking bad news

Summary:
• Giving bad news is among the most challenging of tasks in medical practice.
• The way bad news is given affects how people cope and adjust.
• Keep an open mind as to what is 'bad news'. Some patients are distressed by
seemingly good news, while others experience some relief on hearing bad news.
• Before giving bad news, consider to whom it should be given, who should give it,
when it should be given and what are the likely consequences of giving it.
• It helps to find out what the patient already knows and may want to be told. Making
assumptions about either of these can lead to serious problems in management.
• Giving bad news requires time, a setting free from distractions or interruptions,
empathy, active listening and humility to say that you may not have the answers to
certain questions.
• Elicit the patient's own resources for coping and instill realistic hope.
• Ensure that colleagues know what the patient has been told.
• Provide support for the patient's relatives and your professional colleagues.
Breaking bad news

24
Module – 4: Taking sexual history, conducting examination of such a patient, and

Focus of the Module
Introduction
25

examination of such a patient, and counseling
information
related to HIV
Breaking bad news


(party).

communication

do procedures
Basic skills of taking sexual history
Skills of counseling related to investigation for screening for HIV infection and treatment of
a patient having diagnosed as AIDS
Learning Objectives After completion of this module participants will be able to

a) List Problems of Taking Sexual History
b) Identify Appropriate situations where sexual history is required
c) Take sexual history properly
d) Examine a patient completely
e) Counsel a patient with STD
f) Counsel a patient with HIV /AIDS
Lesson Plan
Pre-
Methods Trainers Trainees
Objectives Requisite Assessment
activity Activity
knowledge
A and B Personal Brainstorming Arrange & Participate and Informal
experience & group Facilitate comprehend
discussion
C STD and Presentation Lecture with Ask clarifying MCQ
modes of Multimedia questions
transmission
D Cl. Stigma & Video Demonstrate Observe and
Organ comprehend
Presentation
involvement
Demonstration
E and F STD Role Play Arrange Participate and
comprehend
HIV Role play and
Feedback
Taking sexual history, conducting examination of such a patient, and counseling related to HIV
27
Overview of the module –
Common assumptions and misconceptions about sexuality
• Elderly people don't have sex
• A married person couldn't possibly have a sexually transmitted disease
• Patients with sexual problems will recognize them and attend an STD clinic
• Young people under the legal age don't have sex
• Everyone understands the basics of reproduction
• Patients will raise the issue of sexual problems with their doctor if they have any
concerns
• The presence of sexual problems usually means that the patient also has
psychological problems
• All patients understand medical terms doctors tend to use when describing sexual
activities and the genitalia
• You can tell a person's sexual orientation by their appearance
Advantages and difficulties of taking a routine sexual history
Advantages:
• Sexual problems are seen as a normal part of the spectrum of problems discussed
with a doctor
• By talking about sexual issues, even when they are not seen as problems, one opens
the door for future consultations about sexual problems
• Discussion about sexual activities can be an opportunity for health promotion
Difficulties:
• It may be embarrassing for the patient and doctor
• The patient may misinterpret the purpose of the discussion and feel that their
lifestyle is being judged or condemned
• The patient may begin to worry about something that was not previously a problem
28
29
Counseling related to HIV:
Information patients should receive during HIV counseling:
• Testing allows the physician and patient to work together to control HIV infection
and prevent transmission of HIV to others.
• The risk of HIV transmission, including oral, vaginal and anal sex and needle
sharing should be discussed
• Condom use, sexual abstinence and drug treatment programs should be discussed
• Homosexual men and women need information about HIV transmission through oral
and anal sex, and about effective use of condoms.
• Women should be given information on latex and nonlatex condoms, and need to be
aware of the possibility that male sex partners also may engage in drug use or high-
risk sexual relations with other men
• Persons in some communities need to be reassured that testing is not harmful and
that they will receive medical services if they test positive for HIV.
• Drug users need to know that drug treatment provides a much greater chance of
survival
• The importance of obtaining test results as soon as possible should be emphasized.
Explicit procedures for testing, including rapid tests performed inside or outside the
clinical setting, should be discussed, and the need for confirmation of positive test
results should be explained.
• The meaning of HIV test results should be explained in explicit, understandable
language.
• Patients should be given information about where they can obtain further
information, counseling about HIV prevention, or other services.
Open-Ended Questions in Patient-Centered Counseling for Preventing HIV Infection
• What, if anything, are you doing that you think may be putting you at risk for HIV
infection?
• What are the riskiest things that you are doing?
• If your HIV test comes back positive, how do you think you may have become
infected?
• When was the last time you put yourself at risk for HIV infection? What was
happening then?
• How often do you use drugs or alcohol?
• How do you think drugs or alcohol influence your HIV risk?
• How often do you use condoms when you have sex?
30
Summary:
• Emerging medical and social problems, such as HIV/AIDS, confront us with
complex and sensitive issues which may need to be raised with patients.
• Cultural taboos, a fear of upsetting patients and lack of skills in sexual counseling
are obstacles to more open communication about sexual matters in health care
settings.
• There is a tendency to make assumptions about lifestyle and behaviour where
stereotypic views are held.
• Sexual problems invariably have an impact on other relationships.
• Special skills can be learned which can help in counseling patients about sexual
matters.
• The do's and don’ts of discussing sexual matters include:
- Be purposeful
- Don't make assumptions
- Don't stereotype
- Ask questions; don't judge people
- Use the patient's words and language
- Remain professional
- Address relationships
- Ask when you don't understand a term or activity
- Ask questions about sexual activities rather than lifestyle
- Address confidentiality and privacy.
31
Module – 5: Communication with patients’ family (party).

Focus of the Module
Introduction
32
Communication with patients’ family (party).

(a) The medical history and (b) giving
information
Breaking bad news


(party).

communication

do procedures
Communicating with the patient’s family, relatives or friends considering their views and
beliefs, social support, secrecy –related problems and confidential information.
Learning objectives:
a) Anticipate And address problems that affect other family members
b) Identify members to share information
c) Describe the steps of communication with family members
d) Communicates with a family
Lesson Plan
Pre-
Trainers Trainees
activity Activity
knowledge
Personal Brainstorming & Arrange & Participate and
A and B Informal
experience group discussion facilitate comprehend
Ask clarifying
C Nil Presentation Lecture with MCQ
multimedia questions
Video
Observe and
D1 C Presentation Demonstrate
comprehend
Demonstration
Arrange
Participate and
D2 C & D1 Role play role play and
comprehend
feedback

34
Anticipate and address

problems that affect Provide emotional and
other family members social support
Overcome difficulties Provide practical

Family
arising from secrets support
Provide information Provide understanding

about family history of of beliefs about illness
illness and treatment
Help avoid or overcome

compliance problems

35
Summary:
• Illness not only has an impact on individuals but also affects the close family and
relatives.
• Family members usually provide practical and emotional support, so it is important
to address their personal concerns and their role in care-giving.
• Do not make assumptions about who the patient defines as 'family'.
• Drawing a family tree provides a graphic representation of relationships and clues to
patterns of illness between generations.
• The patient's family can influence treatment compliance.
• Secrets can create an impasse in care and interfere with personal and professional
relationships.
• The use of hypothetical and future-oriented questions helps to overcome an impasse.

36
Module - 6: How to take informed consent
Focus of the Module
Introduction
37
How to take informed consent (a) The medical history and (b) Giving
information
Breaking bad news


(party).

communication

do procedures
Obtaining and documenting informed consent complying with regulatory requirements

Preparation of the written informed consent form
a) List examples where written consent is necessary
b) List component information of a informed consent
c) Prepare a informed consent form
Lesson plan
Pre-
Trainers Trainees
activity Activity
knowledge
A Informal
Experience Group discussion Facilitate comprehend
Ask clarifying
B NIL Presentation Lecture with MCQ
Multimedia Questions
Write, Present Written
C B Practice Writing Feedback
and Discuss Assignment

39
Basic elements of informed consent
Sample consent form
¾ Informed consent in clinical research is described as a process by which a subject

voluntarily confirms his or her willingness to participate in a particular trial, after
having been informed of all aspects of the trial that are relevant to the subject’s
decision to participate.
¾ In a clinical situation, informed consent is the process by which a fully informed
patient can participate in choices about her health care.
Types of interventions that require informed consent:
¾ Surgery
¾ Anesthesia
¾ Other invasive procedures
These signed forms are really the culmination of a dialogue required to foster the patient's
informed participation in the clinical decision
Informed consent in special situation:

If the patient is determined to be incapacitated/ incompetent to make health care decisions, a
surrogate decision maker must speak for him/ her.
Elements of full informed consent:

¾ The patient's diagnosis, if known;
¾ The nature and purpose of a proposed treatment or procedure;
¾ The risks and benefits of a proposed treatment or procedure;
¾ Alternatives (regardless of their cost or the extent to which the treatment options are
covered by health insurance);
¾ The risks and benefits of the alternative treatment or procedure;
¾ The risks and benefits of not receiving or undergoing a treatment or procedure.
¾ Assessment of patient understanding
¾ The acceptance of the intervention by the patient
40
Informed consent form:
A consent form should contain
¾ Clear and simple language
¾ Indications for the procedure
¾ Probable procedure
¾ Additional Procedures that may have to be performed
¾ Major complications
¾ Signature of Patient or relatives and witness with Date and Time

41
Summary:
¾ Informed consent is needed in clinical research and various clinical situations
¾ The moral doctrine of IC is derived from a respect for the patient's autonomy. The
physician's goal is not to minimize liability, but help patient make the best decision.
¾ Informed consent should be obtained after explaining the full procedure/treatment,
risk and benefits of the procedure/treatment and alternatives available
¾ Incapacitated/ incompetent to make health care decisions, a surrogate decision
maker must speak for him/ her.
¾ The patient's consent should only be "presumed", rather than obtained, in emergency
situations when the patient is unconscious or incompetent and no surrogate decision
maker is available.
¾ Information and consent may be compared to the two sides of the same coin. These
are the two important pillars that coincide and are joined giving weight to the
medical responsibility, as far as concerns consent to the health intervention
42
Module – 7: Challenging consultations: special problems in doctor-patient
communication.

Focus of the Module
Introduction
43
Challenging consultations: special problems

in doctor-patient
information
Breaking bad news


(party).

communication

do procedures
Ways of communicating effectively with patients who:
- Are withdrawn and appear difficult to engage in conversation
- Are anxious
- Are angry and aggressive
- Having hearing and /or speech problems
At the end of the session trainees will be able to
a) Identify a difficult patient
b) Describe measures to be adopted in a case of a difficult patient
c) Successfully manages a difficult patient
Lesson Plan
Pre-
Trainers Trainees
activity Activity
knowledge
A Informal
experience group discussion facilitate comprehend
Ask clarifying
B Nil Presentation Lecture with MCQ
multimedia questions
Write, present Written
C B Practice writing Feedback
and discuss Assignment
Challenging consultations: special problems in doctor-patient communication

45
Guidelines for helping the uncommunicative patient:
• Be prepared to spend time over the consultation
• Do not become bored, frustrated or angry
• Observe the patient carefully: be alert and respond to their verbal and non-verbal
cues
• Show empathy by your own body language (e.g. lean forward and maintain eye
contact)
• Explain the purpose of the interview: why you want the information
• Use facilitatory language, e.g. 'I can see that you're finding it difficult to talk about
this'
• Use more closed questions than open questions, if this seems appropriate
Guidelines for helping the anxious patient

• Be calm and prepared to spend time with the patient
• Explain that most patients feel some anxiety and that this is appropriate
• If the patient is talking too much, try to keep them to the point by summarizing what
they have told you and explaining what further information you need and why you
need it
• Be specific about what you may want them to do during and after the consultation
• If the patient presses you for the cause of their symptoms and seeks reassurance,
explain that you are a student and refer them to their own doctor
Guidelines for dealing with the angry or aggressive patient

• Is the patient agitated, restless or ready to explode? What does their behaviour
communicate to you? \
• Show willingness to talk and listen. Acknowledge their anger or annoyance. Never
redefine their behaviour as fear or anxiety, even if they seem to manifest these
feelings
• Keep a safe distance: neither too close, nor too far away
• Do not: interrupt their outburst; caution a swearing person about their choice of
words; threaten them in any way
• Ask open rather than closed questions. Encourage them to talk: talking is preferable
to violent behaviour
• Do not make agreements or promises that cannot be kept; be reasonable and honest
46
• Help the patient to feel they have choices: people are most often aggressive when
they feel they have few or no choices
• Do not talk to them from behind: this can be threatening and unnerving. Also, do not
attempt to touch them: any movement could seem threatening. On the other hand, do
not bock their path: ensure they have an escape route
• Do not take personal offence at what might be said; this could make you aggressive
or defensive and so escalate violence
• Never let down your guard until the incident is over. Fatigue, or a sense that the
argument is ending, could lead you to take risks and so start up the problem again
• If security staff are summoned, try to supervise their actions so that you maintain
some control over the situation
How not to respond to a person with communication difficulties:

• Repair language (to someone who is stuttering): 'What you are trying to say is: "Will
I go home this week?". The answer is "Yes".'
• Tell them what to do and think: 'If you don't say anything, we must assume you don't
want to go on the day trip. So you'll have to stay behind and sit in the day centre.'
• Avoidance: 'Leave her alone; she doesn't understand what we're saying. You'll only
upset her.'
• Speak louder: there is a tendency to increase the volume of speech rather than use
different words, believing that the louder we speak, the more easily the other person
will understand us
• Use another person as conduit for communicating (in front of the patient): 'What is
he saying? Can you understand?' [under your breath and exasperated]: 'I give up!'
• Become impatient and angry: 'Look, I've got a busy clinic. If there's something else,
speak to one of the nurses.'
• Offer meaningless reassurance (after incomprehensible sounds from a patient):
'Don't worry, we'll take care of everything for you.'

47
Summary:
• When communicating with patients who seem withdrawn, anxious or angry, try to
understand the underlying reasons for their behaviour and adapt your style to
facilitate communication.
• Notions of 'appropriateness’ or 'normality' are not fixed: they depend on the
individual culture and life experiences of both doctor and patient.
• When confronted by an angry patient, do not do anything that may escalate the
threat of violence.
• Act conservatively; try to prevent situations from becoming worse by being attentive
and concerned.
• Do not avoid patients with a disability, especially those whose hearing, speech and
memory is impaired. Use both verbal and non-verbal forms of communication
creatively.
• Use an interpreter where necessary. It can be helpful and important to ask the
interpreter to translate exactly what the patient has said.
• Check that the patient has understood what has been said.
• Allow time for communicating with patients who have the difficulties discussed in
this chapter.

48
Module – 8: Counseling for seeking permission to do procedures

Focus of the Module
Introduction
49
Module – 8 Introduction to basic communication
skills.
Counseling for seeking permission to do
procedures (a) The medical history and (b) giving
information
Breaking bad news


(party).

communication

do procedures
At the end of this module, Trainees will be able to
a) Identify where consent is required
b) List information to be given to the patient about the procedure
c) List steps of taking consent
d) Take consent from a simulated patient
Lesson Plan
Pre-
Trainers Trainees
activity Activity
knowledge
A Personal Brainstorming Participate and Informal
experience & group Arrange & comprehend
discussion facilitate
B Knowledge Brainstorming Ask clarifying MCQ
about & group questions
procedure discussion
C Nil Presentation Presentation / Comprehend Written
handouts and
and discuss Assignment
discussion
D C Role play Arrange Participate Observation
role play
with checklist

51
Counseling for Seeking Permission to do Procedures
To perform any procedure for either diagnostic or therapeutic purpose first priority is to
give adequate information so that patient can take decision voluntarily.
Guidelines for giving information:

¾ Describe what information you plan to give based on
Results of the physical examination
Results of test
Diagnosis (or provisional diagnosis)
Cause of the problems
Necessary further investigations
Treatment planned
Prognosis
¾ Summarize your understanding of patients problem
¾ Find out their understanding of the condition
¾ Outline the structure of the rest of the interview and discuss about
Diagnosis
Further investigation
Treatment
¾ Use appropriate language
¾ If relevant, use drawing to supplement the information
¾ Give the most important piece of information first
¾ Explore the patients view on information given
¾ Negotiate management
¾ Check the patients understanding of what has been said
Patient’s safety during a procedure may be assured by maintaining following steps-

¾ Verification of appropriate patient
¾ Marking exact site
¾ “Time out” immediately before starting

52
Summary:
Before doing procedure patient has every right to know-
¾ Detailed of diagnosis and prognosis
¾ Uncertainties of diagnosis and planned further investigation
¾ Option for treatment
¾ Purpose and associated risk of the procedure
¾ Advice if a proposed treatment is experimental
¾ How and when the patients condition will be reassessed
¾ Name of the doctor, whether a trainee or student will be included
¾ Right to seek 2nd option
¾ Cost of treatment

53
References:
1. Kurtz SM, Silverman J D, Draper J. Teaching and learning communication skills in
medicine. 2nd ed. Oxford: Radcliffe, 2005.
2. Silverman J D, Kurtz SM, Draper J. Skills for communicating with, patients. 2nd ed.
Oxford: Radcliffe, 2005.
3. Lloyd M, Bor R (1996). Communication Skills for Medicine. Churchill Livingstone,
New York
4. Curriculum for Under-graduate Medical Education in Bangladesh 2002. Approved by
Bangladesh Medical & Dental Council. Edited by: Centre for Medical Education.
5. Tekian A (2002). Have newly graduated physicians mastered essential clinical skills?
Medical Education 36:406-407
6. Interneeship Logbook. 2003. Prepared and adopted by BMDC
7. Albanese M (2000). The decline and fall of humanism in medical education. Medical
Education 34: 596-597.
8. Frich J C and Fugclli P (2003) Medicine and the Arts in the Undergraduate Medical
Curriculum at the University of Oslo Faculty of Medicine, Oslo, Norway. Academic
Medicine 78: 1036-1038
9. Willis S C, Tones A & O' Neill P A (2003). Can undergraduate education have an
effect on the ways in which pre-registration house officers conceptualize
communication? Medical Education 37: 603-608.
10. Chan CSV, Wun Y T, Chcung A, TA Dickinson T A, KW Chan K W et al (2003)
Communication skill of general practitioners: any room for improvement? How much
can it be improved? 37:514-526
11. Anderson R & Schiedermayer D (2003) The Art of Medicine through the Humanities:
an overview of a one-month humanities elective fourth year students Medical
Education 37:560-562.
54

Publication Module On Health Communication

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Communication Skills in

Prepared & published by BCPS and DGHS

Professor Md. Abul Faiz

The module on “Communication Skills in Medicine” is indeed a well-prepared document

Professor T.I.M. Abdullah-Al-Faruq

List of other contributors:

Module- 1: Introduction to basic communication skills 1-11

Module- 3: Breaking bad news 19-24

Module- 4: Taking sexual history, conducting examination of such

Module- 5: Communication with patient’s family 32-36

Module- 6: How to take informed consent 37-42

Module- 7: Challenging consultations: special problems in

Module- 8: Counseling for seeking permission to do procedures 49-54

Objectives of the Module:

Breaking bad news

Taking sexual history, conducting

Communication with patient’s family

How to take informed consent?

Challenging consultations: special

Counseling for seeking permission to

Introduction to basic communication kills

Introduction to basic communication kills

Initiating the session

Building the relationship

Explanation and planning

Closing the session

Introduction to basic communication kills

Explanation and planning

• Providing the correct type and amount of information

Closing the session

Introduction to basic communication kills

• Initiating the session

Introduction to basic communication kills

Using appropriate non-verbal communication

What do we mean by Non-verbal Communication

Introduction to basic communication kills

Introduction to basic communication kills

• The ability to communicate effectively and sensitively is central to all medical

• Communication skills can and should be taught:

Introduction to basic communication kills

Learning Objectives of the Module

Focus of the Module

Breaking bad news

Taking sexual history, conducting

Communication with patients’ family

How to take informed consent

Challenging consultations: special

Counseling for seeking permission to

(a) The medical history and (b) Giving information

(a) The medical history and (b) Giving information

Establish a relationship with Gather information

Make a diagnosis if possible

Explain and discuss this with Formulate a management plan

(a) The medical history and (b) Giving information

Modifications of history taking sequences are necessary in following situations:

Some special practical hints for taking a history:

(a) The medical history and (b) Giving information

(a) The medical history and (b) Giving information

(a) The medical history and (b) Giving information

Learning Objectives of the Module

Breaking bad news

Breaking bad news