Medical Communication

Introduction
Tjakra W. Manuaba
Suryawisesa
Wawan Tirtha Yasa

Medicine

Underlying Premises
- Communication is a core clinical skills

essential to clinical competence.

Communication is a learned skill that needs
to be taught.
Communication skills need to be taught
effectively.
Communication skills teaching and learning
is different.
Facilitator know the what and the how
of communication skills teaching.

Underlying Premises
- Communication skills teaching and learning
need to be evidence based.
- Unified approach to communication skills
teaching in medicine is needed.
- Communication skills teaching should cross
cultural and national boundaries.
- Coordinated approach to communication
skills teaching throughout medical education
is necessary.

An inquiring, analytical mind;

an unquenchable thirst for new
knowledge; and a heartfelt
compassion for the ailing these
are prominent traits among the
committed clinicians who have
preserved the passion for
medicine
Lois DeBakey

Communications is
A Complex Phenomenon
Per definition it varies,
emphasize on
verbal or non verbal, which
include
content, process,
informational, relational, and
cultural or social aspect
of communication

What is
Is theCommunication
act by which information is shared
between humans. Such encounter might
cover:
Desires
Needs
Perceptions
Knowledge
Affective states

What is Effective
Communication
Reciprocal

Interactive process responsibility that

message has been received & understood
HCP (Health Care Provider) messages
are tailored exactly to the personality,
needs and abilities of the patients, to
encourage the engagement of the patient
Verify that messages received and
understood
Chance supporting agreed action

The ability to communicate well

with patients to build up a
trusting relationship within which
curing relieving and comforting
can take place, is a great challenge
Why good medical communication
is important? better care for our
patients
Sir Charles Fletcher

Medical Communcation
Medical communication is the usual
communication encounter between doctor and
the patient
It can be classified according to the purpose of
the interview into 4 types
History taking
Consultation
Obtaining Informed Consent
Breaking bad news

Medical Students before

Graduation should be able to
Demonstrate The Communication
Skills:

Have the ability to obtain accurate history,

that essential to patient health problem
Have the ability to communicate well
orally or writing with patients, families,
colleagues, and others with whom
physicians must exchange information
Compassionate treatment of patients and
respect for their privacy and dignity
Have enough and skills in Medical or non
Medical sciences related to health problem

DOCTORS PATIENTS
RELATIONSHIP.
Not anymore paternalism
Should be partnership basis.
Doctor-Patient collaboration vs
health problem
Equal

The most frequent patients complaints

about doctors
Doctors would not listen
Doctors would not give information
Doctors showed lack of concern &
lack of respect for the patients
Lloyd and Bor, 1996.

Essentials of Patient Care

Physician

Patient

Art & Science of Medicine

Communication
Medical History
Physical Exam.
Literature & Art in Medicine

Hagen & Pauly 2006

Communication Skills
To diagnose and treat diseases
To establish/ maintain a therapeutic
relationship
To offer information and educate

Communication Skills
You must demonstrate
- Respect
- Genuineness
- Empathy

These skills can be learned with practice

Respect
Remember that every patient could
be you, your mom, your brother or
your boy/ girlfriend
How would he or she feel waiting for
the doctor to come into the room?

Respect
Introduce yourself to the patient/ family
Explain who you are and your role
Shake hands, but dont force physical
contact if patient is uncomfortable
Call the adult patient MrMrsMs (do
not use first name)

Respect
Maintain privacy
Keep doors and curtain closed
Acknowledge and greet others in the
room
Maintain a professional appearance
clean, neat, conservative, name tag
(professional authority)

Respect
Make sure the patient is comfortable
Sit at the patient level
Be aware of the patients personal space
(can vary among cultures)
Continue to consider the patient comfort
during history taking and physical
examination

Respect
Appear interested and ready to listen
Use your posture to do this
- S -- Sit square to the patient
- O -- Open to the patient
- L -- Lean toward the patient
- E -- Eye contact with the patient
- R -- Relax

Genuineness

The ability to be yourself in

relationship despite your professional

role

Genuineness
It is OK to laugh at patients jokes
If patients spouse has died you
might say: I am sorry to hear that.
How are you doing?
Show your true interest in the patient

Empathy
Is the ability to understand the patients
experiences and feeling accurately as well
as to demonstrate that understanding to
the patient
Is an active process
Is more than sympathy, or feeling sorry for
someone

Empathy
If you are empathetic you will maximize
your ability to gather accurate and
objective data about patients thoughts
and feelings

Empathy
Observe the patient
Pay attention to the patients nonverbal
communication
Is the patient looking away, fidgeting or
leaning away from you while he or she
talks?

Empathy
Do not interrupt patients
In one study 69% physician interrupted
patients within 18 seconds
77% of patients didnt get to fully explain
their problem

Empathy
Enhance empathy by the way you
respond to what the patient says
Show the patient you have been listening
to the content of their problem
Show the patient you understand their
perspective on the problem

Empathy
Do not ignore what the patient says
Avoid minimizing his or her
symptoms
Instead, reflect back to the patient

CLINICAL EXAMPLE

The following dialogue illustrates the use of empathy by a physician when a

mother initially refused to grant consent for her son to have a diagnostic
lumbar puncture when meningitis was suspected clinically.
Physician: What concerns you about the spinal tap?

Mother: I refuse to give consent.

Physician (remaining calm and showing genuine interest): Tell me more

about why you are worried.

Mother: I think my son will get better without that long needle

Physician: you are concerned about the length of the needle. (The physician
reflects to the mother her concern about the needle; this conveys to her his
understanding of the problem. He purposefully avoids lecturing about the
known safety of the needle)

 Mother: Yes I am concerned. It could make him bleed into his back
Physician: what do you mean? ( again, the physician tries to understand the fear
rather than repeat his explanation of the procedure)
Mother: My neighbors father had a bad time with headaches after spinal tap, and
Johnny is sick enough already.
Physician: So you dont want your sick children to suffer more discomfort. It is
difficult for you to put him in that painful situation. (The physician must not only
understand the fear but also verbalize that understanding to parent so that the
parent knows the physician understands)
Mother: Yes, I am confused. Maybe it wouldnt hurt him like it did my neighbors
father. How long is the needle? (Now the mother relaxes and is able to listen to the
physician and follow his advice.
JAMA, October 2, 1991-vol 266, no 13

Reassurance

To solve problem

To form & maintain

relationship

Communication
To alleviate distress
To give
information

To Convey Feelings

To persuade

To make Decision
Communication Purposes (Lloyd & Bor, 1996)

Factors Influence Doctors Patients

Communication
Patient Related Factors
- Physical Symptoms
- Psychological Factors anxiety, depression, anger, denial
- Previous Experience of medical care
- Current experience medical care
- PTSD
Doctors Related factors
- Training in communication skills
- Self Confidence in ability to communicate
- Personality
- Physical factors (tiredness)
- Psychological (anxiety, PTSD)
The Interview Setting: Requirements
- Privacy
- Comfortable surrounding
- An appropriate seating arrangement

Thank you

Medical Interview
(History taking)

Beginning an Interview?

Patients Expression ease

the interview
A comfortable setting
Being greeted by name & handshake
Being shown where to sit
The interviewer introducing her/himself &
explaining the procedure
An easy first question
The Interviewer appearing interesting in your
remarks

PLEASE NOTICE THE BARRIER BETWEEN DOCTOR PATIENT!

PLEASE NOTICE THE POSITION OF DOCTOR PATIENT.

IT IS CLOSER, FAMILIAR, AND THERE IS NO BARRIERBETTER.

RELAXING & CORRECT POSITION DURING MEDICAL INTERVIEW.

EQUAL (LEVEL) EYE CONTACT.

Guidelines For Conducting an Interview

Beginning The Interview

- Greet the patient (by names) & shake hands
- Ask patient to sit down
- Introduce yourself as the doctor
- Explain the purpose of the interview
- Say how much time available
- Explain the need to take notes and ask if this is acceptable

The Main Part of The Interview

- Maintain positive atmosphere, warm manner, good eye contact
- Listen carefully
- Be alert to verbal and non-verbal cues
- Facilitate patients verbally and non verbally
- Use specific questions when appropriate
- Clarify what patient has told you
- Encourage patient to be relevant

Guidelines For Conducting an

Interview

Ending The Interview

Summarize what patient has told you
and ask if your summary is accurate.
Ask if they would like to add anything
Thank the patient

Bad News

Inevitable part of medical practice

Not widely taught in medical schools
Studies how patients/ families cope with bad news
not the process of breaking bad news
Bad news is a relative concept & should depend
on patients interpretation of information &
their reaction to it where patients feel the
news will adversely affect their future

BREAKING BAD NEWS.

CONDITIONING
PLANNING
EXPLANATION

Conditioningfamilies
step by step.
Family learns to accept
the bad situation

Why is it difficult to break bad News

The messenger may feel responsible and fears being blamed

Not knowing how best to do it

Possible inhibition because of personal experience of loss

Reluctance to change the existing doctor-patient relationship

Fear of upsetting the patients existing family roles/ structure

Not knowing the patient, their resources & limitation

Fear of the implications for the patient (disfigurement, pain, social and
financial losses)

Fear of the patients emotional reaction

Uncertainty as to what may happen next and not having answers to some
questions

Lack of clarity about ones own role as a health care provider

Lloyd and Bor, 1996

Managing difficult situation in breaking bad news

To whom should bad news be given

Who should give bad news
When should bad news be given
How much bad news should be given
Should you give hope and reassurance
along with bad news

How to convey bad news

Personal preparation
The Physical Setting
Talking to patient and responding to

concerns
Arranging for follow-up or referral
Feed and handover to colleagues

KEY CORE SKILL FOR BREAKING BAD NEWS

EXPLANATION & PLANNING.

Preparation
Summarizing
Negotiating the Agenda
Listening
Picking up Cues
The use of Silence
Discovering the patients concern and ideas
Encouraging the expression of feeling
Picking up the non verbal cues

A six step protocol for

delivering bad news

 Diseases recurrence
Spread of disease
Failure of treatment
Irreversible side effects
Revealing positive result of genetic test
Hospice care and resuscitation

Definition
Any information which adversely and seriously
affects an individuals view of his or her future
(Buckman R)
Bad news is always in the eye of the beholder,
such that one cannot estimate the impact of
the bad news until one has first determined the
recipients expectations or understanding

BBN why is it important?

A frequent but stressful task:
BBN to cancer patient described as hitting the patient head or

dropping a bomb.
Can be stressful when clinician is inexperienced, patient is young, or

there are limited prospects for successful treatment

Patient want the truth:

Survey published 1982 of 1251 americans:
96% wished to be told if they had a diagnosis cancer
85% wished in cases graved prognosis, to be given realistic estimate of how
long they had to live.

Clinical outcomes: many patient desire accurate information

to assist them in making important QOL decision.

What are the barriers to

breaking bad news?

Tesser: the bearer of bad news often

experiences strong emotions such as

anxiety, a burden of responsibility for the
news, and fear of negative evaluation.
A reluctance to deliver bad news MUM
effect.

How can a strategy for BBN help

the clinician and the patient?
A Six steps strategy for breaking bad news:
Complex clinical tasks may be considered as a series of steps
Goals of the bad news interview:
1. gathering information from the patient. This allows the physician to
determine the patient knowledge and expectations and readiness to
hear the bad news.
2. provide intelligible information in accordance with the patient
needs and desires.
3. to support the patient by employing skill to reduce the emotional
impact and isolation experienced by the recipient of BN.
4. To develop a strategy in the form of treatment plan with the input

The six steps of SPIKES

STEP1. SETTING UP the interview:
Arrange for some privacy
Involve significant others
Sit down
Make connection with the patient:
Maintain eye contact
Touching the patient arm or holding a hand

Manage time constraints and interruptions

 STEP 2. P- ASSESSING THE PATIENTS PERCEPTION

Before you tell, ask.
Open ended question: to test how the patient perceives
the medical situation
Ex What have you been told about your medical
situation so far? Or
What is your understanding of the reasons we did the
MRI?
Correct misinformation and tailor the Bad News

 STEP 3: I Obtaining the patients invitation

Majority of patients express a desire for full information
about diagnosis, prognosis, and detail of illness, some
patient do not.
Shunning information is a valid psychological coping
mechanism, and may be more likely to be manifested
as the illness becomes more severe.
How would you like me to give information about the
test results?

STEP 4. K GIVING KNOWLEDGE AND INFORMATION TO THE

PATIENT:
UNFORTUNATELY IVE GOT SOME BAD NEWS TO TELL YOU OR
IAM SORRY TO TELL YOU THAT
FIRST: Start at the level of comprehension and vocabulary of the patient
SECOND: try to use nontechnical words spread instead of metastasized,
sample of tissue instead of biopsy
THIRD: avoid excessive bluntness you have very bad cancer and unless
you get treatment immediately you are going to die
FOURTH: Give information in small chunks and check periodically as to the
patient understanding
FIFTH: when prognosis is poor, avoid phrases such as there is nothing
more we can do for you

 Step 5: E addressing the patient Emotions with empathic

responses.
An emphatic response consists of four step:
FIRST Observe any emotion: tearfulness, sadness, silence, shock
SECOND identify the emotion experienced by the patient
Third Identify the reason for emotion.
Fourth after you have given the patient a brief period of time to express
his or her feelings, let the patient know that you have connected the
emotion with the reason for the emotion by making a connecting
statement.
An example:

 Doc: Im sorry to say that the x ray shows that

the chemo doesnt seem to be working [pause].

Unfortunately, the tumor has grown somewhat.
Patient: Ive been afraid of this ! [Cries]
Doctor: [Moves his chair closer, offers the patient

a tissue, and pauses] I know that this isnt what

you wanted to hear. I wish the news were better.

o th e r e m o tio n s ( I a ls o w is h th e n e w s w e re b e tte r ). It c a n
b e a s h o w o f s u p p o rt to fo llo w th e e m p a th ic re s p o n s e w ith
a v a lid a tin g s ta te m e n t, w h ic h le ts th e p a tie n t k n o w th a t
th e ir fe e lin g s a re le g itim a te (T a b le 3 ).

p o w e rfu l w a y s o f p ro v id in g th a t s u p p o rt [6 4 -6 6 ] (T a b le 2 ).
It re d u c e s th e p a tie n ts is o la tio n , e x p re s s e s s o lid a rity , a n d
v a lid a te s th e p a tie n ts fe e lin g s o r th o u g h ts a s n o rm a l a n d to
b e e x p e c te d [6 7 ].

T a b le 2 . E x a m p le s o f e m p a th ic , e x p lo r a to r y , a n d v a lid a tin g r e s p o n s e s
E m p a th i c s ta te m e n ts

E x p lo r a t o r y q u e s ti o n s

V a l i d a t in g r e s p o n s e s

I c a n s e e h o w u p s e ttin g th is is to y o u .

H ow do you m ean?

I c a n u n d e rs ta n d h o w y o u fe lt th a t w a y .

I c a n te ll y o u w e re n t e x p e c tin g to h e a r th is .

T e ll m e m o re a b o u t it.

I g u e s s a n y o n e m ig h t h a v e th a t s a m e re a c tio n .

I k n o w th is is n o t g o o d n e w s fo r y o u .

C o u ld y o u e x p la in w h a t y o u m e a n ?

Y o u w e re p e rfe c tly c o rre c t to th in k th a t w a y .

I m s o rry to h a v e to te ll y o u th is .

Y o u s a id it frig h te n e d y o u ?

Y e s , y o u r u n d e rs ta n d in g o f th e re a s o n fo r th e
te s ts is v e ry g o o d .

T h is is v e ry d iffic u lt fo r m e a ls o .

C o u ld y o u te ll m e w h a t y o u re
w o rrie d a b o u t?

It a p p e a rs th a t y o u v e th o u g h t th in g s th ro u g h
v e ry w e ll.

I w a s a ls o h o p in g fo r a b e tte r re s u lt.

N o w , y o u s a id y o u w e re c o n c e rn e d a b o u t
y o u r c h ild re n . T e ll m e m o re .

M a n y o th e r p a tie n ts h a v e h a d a s im ila r
e x p e rie n c e .

T a b le 3 . C h a n g e s in c o n f id e n c e le v e ls a m o n g p a r tic ip a n ts in w o r k s h o p s o n c o m m u n ic a tin g b a d n e w s
B r ea k in g b a d n ew s

F ello w s
p -v a lu e

P la n th e d is c u s s io n in a d v a n c e
C re a te a c o m fo rta b le s e ttin g
E n c o u ra g e fa m ily /frie n d p re s e n c e

.0 1 0
.0 3 7
.1 0 1 *

F a c u l ty
t sc o r e

p -v a lu e

t sc o r e

- 3 .0 8 7
- 2 .3 7 7
- 1 .7 9 2

.0 0 1
.0 0 7
.3 9 6

- 4 .0 1
- 3 .0 8
.8 7 *

Conclusions Bad News

Doctors do need communication skill
If Doctors have more times, bad news should be
given step by step by conditioning patients
and family
Doctors should convey bad news without delay
Bad News should be carefully and systematically
prepare, by learning the background of the
patient and family