MEDICAL

COMMUNICATION SKILL
LECTURE
Theresia L. Toruan
Think back for a minute on your own life
experiences
Recall from your own interaction with your
doctor or dentist
The quality of the communication that
involved


Was it clear?
Was it sympathetic?
Were you left with the impression that you
were told as much as you wanted to
know?
Were you left with the impression that
your doctor was a good listener?

COMMUNICATION
Is an important component of patient care
Must gain an understanding of the
patients perspective on his or her illness
Carefully, not to be judgemental or
scolding,.may rapidly close down
communication
A Changing Paradigm
Paternalistic
Reductionist
Holistic and
Collaborative
Approach
Communication
skills of the
physician are
critical
Paternalistic approach

To deciding what should be done for a patient:

The physician knew best
Patient accepted the recommendation
Patient without question
SHARED DECISION MAKING
(holistic and collaborative
approach)
Advising to educate his or herself
To ask question

PHYSICIAN-PATIENT SATISFACTION
REDUCTION IN MEDICAL RISK
Communication Age
able to communicate
information

faster
more clearly
more widely
The basis for patient-physician alliance
Communication establishes the collaborative
nature of that alliance

shared decision-making
partnering


Medical communication.. own life experience!

Clear?
Sympathetic?
Left in the impression not told as much as wanted to know?
Left with the impression the doctor was a good listener?

Our experience with health and illness are significant to
our sense of health.
The benefits of good communication:
Good communication:

builds trust between patient and doctor;
may help the patient disclose information;
enhances patient satisfaction;
involves the patient more fully in health decision
making;
helps the patient make better health decisions;
leads to more realistic patient expectations;
produces more effective practice; and
reduces the risk of errors and mishaps.
Toronto Consensus Statement (1980): talking about
the importance of Medical communication Skill

and

Kalamazoo Consensus Treatment (1999): talking about
the Essential Element of the Medical Communication based
on the task approach
Essential element of Medical
Communication

1. Build a relationship
2. Open the discussion
3. Gather Information
4. Understand the patients perspective
5. Share information
6. Reach agreement on problems and plan
7. Provide closure
Essential Element of Medical Communication (cont..)
1. Build a Relationship
Fundamental communication task
Strong
Therapeutic
Effective relationship (idea, feelings, and
values of both)
Also relevant for work with the patient, family
and other support system
Is an ongoing task within and across
Essential Element of Medical Communication (cont..)
Mnemonic P E A R L S :
P..partnership, acknowledges that the physician and the patient
are in this together
E..empathy, expresses understanding to the patient
A..apology, acknowledges that the phycisian is sorry the patient
had to wait, that a laboratory test had to be repeated, etc
R..respect, acknowledges the patients suffering, difficulties, etc
L..legitimization, acknowledges that many patient are angry,
frustrated, depressed, etc
S..support, acknowledges that the physician will not abandon
the patient.
1. Build a Relationship. (cont)
Essential Element of Medical Communication
(cont)
2. Open the discussion
Physicians first greeting.
Physician show personal concern by offering
a handshake and warm smile.
Put the patient at ease in what could
otherwise to be unfamiliar, if not frightening
environment.
3. Gather Information
Shifting from a physician-centered to patient-centered interview
style
Physician interrupt patients an average of 18 seconds after the
patient begins to speak.
Patient rarely continued to express all their true concern once
they were interrupt
No more than 150 seconds was needed to express all their
concern at the beginning or the interview
Two words . What else?
Essential Element of Medical Communication (cont)
Five Communication Pattern :
Narrowly biomedical
Expanded biomedical
Biopsychosocial
Psychosocial
Consumerist.
Essential Element of Medical Communication (cont)
3. Gather Information (cont)
Five Communication Pattern (cont)
Example :
Physician : What bring you here?
Patient : I have headache
Physician : Where are the headache? How long do
they does? What do you do to relieve them?

This interview follows a physician centered and biomedical
model pattern.
Contrast the previous interview with the following interview.
Essential Element of Medical Communication (cont)
3. Gather Information (cont)
Five Communication Pattern (cont)

Example :
Physician : What brings you here today?
Patient : I have headache.
Physician : What else?
Patient : Well, I have problems on sleeping.
Physician : What else?
Patient : I am very worried about my son. He is
using drugs.

This interview follows a patient-centered and
biopsychosocial pattern
Essential Element of Medical Communication (cont)
3. Gather Information (cont)
4. Understand the Patients Perspective
Explore contextual factors (e.g., family, culture, gender,
age, socioeconomic status, spiritually)
Explore beliefs, concern, and expectation about health and
illness
Acknowledge and respond to to the patients ideas,
feeling, and values
Essential Element of Medical Communication (cont)
5. Share Information
Use language the patient can understand
Check for understanding
Encourage questions
Essential Element of Medical Communication (cont)
6. Reach Agreement on Problems and Plan
Essential Element of Medical Communication (cont)
7. Provide Closure
Ask whether the patient has other issues or
concern
Summarize and affirm agreement with the plan
of action
Discuss follow up
Essential Element of Medical Communication (cont)
Special Medical Communication
End-of-life communication
Bad News
Old Patient
Family caregivers
End-of-life communication
Reflection:
And I came to understand that this was medicine,
and this was so much greater than my nave ideas
of complete cures and miraculous recoveries, which
are too few and far between; that the true practice
of medicine is not the miraculous cure of a disease
but the total care of a person.
Special Medical Communication (continue)
Bad News
Mnemonic S P I K E S protocol for breaking bad news.
S..etting and listening skills
P..erception by patient of condition and seriousness
I..nvitation from patient to give information
K..nowledge - giving medical facts
E..xplore emotions and empathize as patient
responds
S..trategy and Summary
Special Medical Communication (cont)
Old Patient
Working Memory Capacity Diminish
Hearing and Vision lost
Reflective listening
Create Hope
Special Medical Communication (cont)
Family Caregivers
Understand that illnes and disability are a
family affair. Let the patient know
Be sensitive about place talking to caregivers
about difficulty subjects. Not appropriate in
waiting room and corridors.
Special Medical Communication (cont)
EMPHATY
Of all the element involved in effective
communication: the most powerful
1880, psychologist Theodore Lipps: einfuhlung
(in-feeling)
To describe: emotional appreciation of
anothers feeling
Being a psychiatric or mental health expert is not necessary for using
emphatetic communication
The only requirement is an awareness of opportunities for emphaty as
they arise during the interview with the patient

In emphaty, we borrow anothers
feelings to observe, feel, and understand
them - - but to take them onto ourselves
By being a participant-observer, we came
to understand how the other person feels
EMPHATY versus SYMPHATY?
Empathy
Key skill used to built doctor patient-relationship
Empathic processes affect how the physician (observer)
thinks, feels (intrapersonal outcomes), and behaves
(interpersonal outcomes) with the patient (target)
The process of understanding a persons subjective
experience
Balance curiosity to leading to a deeper understanding of
another human being
The capacity to understand another person experience from
within that person s frame of reference
The ability to put oneself in anothers shoes
Empathy (cont)
Begins to look something like:
Touch the patient on the arm
Look them in the eye
If the patient stop talking, repeat the last word that they said
to show you are listening and interested.
Doing so without also developing a genuine interest in the
resulting connection can lead to an empty charade
Effectively teaching useful approaches to physician-
patient relationship
Empathy (continue)
Deepened understanding of Empathy
For one year now, I have been trying to come to terms
with the notion of sacred, esteemed, professional doctor-
patient relationship. Somehow, I had gotten the idea in my
head that this relationship should be somehow devoid of
emotions. It took a women like nurse Cindo and a patient
like Mr. Lanang to help me to realize that it might actually be
okay, normal, and human to cry and to express emotions
about a wonderful dying patient
Active Listening

The most important skill of medical communication
to learn.
Involves two way tramsmission of verbal and non-
verbal behaviour between doctor and patient.
The aim is to encourage the patient to continue their
opening statement as far as possible without
interruption.
Closely linked to the doctors capacity to recognize
emotional factors contributing to illness and distress.
Active Listening (cont)
Mnemonic S O L E R , positive non-verbals that can
be used to indicatephysician are listening supportively.
Ssitting square on to the patient with an
Oopen position
L leaning slightly forward with
Eeye contact in a
R relaxed posture
Collaboration in Health Care
Involves coordination of individual actions in
Cooperating in planning
Working together
Sharing of goal, planning, problem solving, decision
making and responsibility

Can happened between two people who
represent the same or different disciplines.
Collaboration in Health Care (cont)
Nurse-Physician Collaboration
Nurse Practitioner-Physician Collaboration
Social Worker-Physician Collaboration
Pharmacist-Physician Collaboration
Physician-Physician Collaboration
The Impact of Poor Communication
Poor communication:
decreases confidence and trust in medical care;
deters the patient from revealing important information;
causes significant patient distress;
leads to the patient not seeking further care;
leads to misunderstandings;
leads to the misinterpretation of medical advice;
underlies most patient complaints; and
predicts negligence claims.

These difficulties may lead to poor or sub-optimal outcomes for the
patient.
Doctor-related Obstacles
The doctor may be:
inadequately trained in communication skills;
lacking in sensitivity or empathy;
unwilling to recognise patient autonomy;
unaware of problems arising from differences in
language and culture;
affected by time pressures; or distracted by external
or personal factors.

Patient-related obstacles
The patient may be:
affected by the condition, illness or medication;
anxious, embarrassed or in denial about the medical condition;
inexperienced in identifying and describing symptoms;
intimidated by health care settings;
overawed by the doctors perceived status;
disadvantaged by differences in language and culture;
confused by the use of medical jargon;
reluctant to ask questions; or
concerned about time pressures.

All of these factors may impede the patients capacity to provide, take
in and retain information.
COMMUNICATION
Its a series of learned skill

Experience is a poor teacher: it needs
observation plus well intentioned,
constructive, detailed and
descriptive feedback plus rehearsel
to effect change