Communication

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Why effective communication?

• Planning patient care

• Transfer of information
• Consent

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Do we need to develop communication
skills?

• Patients have a right to information

• Information should be presented ..in a manner easy to follow

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Barriers to effective communication
• Barriers from patient’s perspective
• Patients may think that physicians are too busy.
• Don’t want to be a burden.
• Can’t explain how they feel.
• Fear breaking down, crying, losing control.
• Believe doctors, nurses and other HCP are primarily concerned with
physical aspects of care.
• Anxious about having their worst fears confirmed

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Barriers from the health care professionals’
perspective

• Frightened of upsetting the patient.

• Getting blamed ––by patient /relatives or colleagues.
• Frightened of difficult questions.
• Saying the wrong thing
• Can’t handle the patients’ or their own emotions
• “Not part of my job”
• Lack of training in communication skills.
• ‘‘Not enough time ’’
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The way forward

• Acknowledge / be aware barriers exist

• Employ techniques to overcome patients / relatives barriers
Use
• Methods that promote patient disclosure and therefore facilitate
communication.
• Verbal and non verbal aspects

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How much is communicated by body
language?

• Studies show that during interpersonal communication

• 7% of the message is verbally communicated by the words used.

• 93% non-verbal communication:

• 38% is through vocal tones and
• 55% is through facial expressions or other body language

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Cardiff six point toolkit

• comfort
• language
• question style
• listening
• reflection
• summarising

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1. Comfort
• Prepare for consultation..
• The setting- privacy, comfort and time
• Physical barriers, equality
• Accepting appropriate distress
• Avoid inappropriate remarks.

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2. Language
• Verbal and non-verbal
• Same verbal language
• Medical terminology, jargon

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3.Listening
• Silence is a valuable tool in communicating.
• It helps by:
• Allowing the patient time to assimilate news.
• Demonstrating the patient is being listened
• Giving the patient time to react.
• Giving the patient time to ask questions.

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How to listen effectively
• Allow the patient to talk (80% Vs 20%)
• Engage in active listening- verbal and non-verbal

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4. Question style

• The question style is crucially

important. As a general rule, the
more open the question the
greater the amount of
information

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Question styles
• How have things been? (Open)
• Can you tell me more about the
pain? (Focused)
• Start with open Qs
• Avoid multiple Qs
• Avoid leading Qs

• Does the skin over the area feel

sensitive? (Direct)

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5. Reflection
• ‘Good use of reflection is important. It really makes the patient feel
you are listening to them.’
• Patient: I’ve been feeling tired all the time doctor.
• Doctor: (Pause) Tired all the time?
• Patient : Yes. I’m normally full of life but recently I’ve had no energy. Is
this to do with the cancer?

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6. Summarizing

• Doctor: Let me just recap what you’ve been telling me Mr J. From

what I understand you have noticed that you have been losing weight
and you’ve found it difficult to swallow.
• ►Mr J: Yes doctor. That’s a bad sign isn’t it?

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Special situations that require communication
skills
• Breaking bad news
• Discussing prognoses, end of life decisions
• Counseling
• Difficult scenarios- dealing with anger, denial, ETC

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Robert Buckman's Six Step Protocol for
Breaking Bad News
1. Getting started.
The physical setting ought to be private, with both physician and
patient comfortably seated.
 ask the patient who else ought to be present, and let the patient
decide--studies show that different patients have widely varying views
on what they would want.
It is helpful to start with a question like, "How are you feeling right
now?" to indicate to the patient that this conversation will be a two-
way affair.

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2. Finding out how much the patient knows.
By asking a question such as, "What have you already been told
about your illness?" you can begin to understand what the patient has
already been told ("I have lung cancer, and I need surgery"), or
how much the patient understood about what's been said ("the
doctor said something about a spot on my chest x-ray"),
the patient’s level of technical sophistication ("I've got a T2N0
adenocarcinoma"),
the patient's emotional state ("I've been so worried I might have
cancer that I haven't slept for a week").
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3. Finding out how much the patient wants to know.
It is useful to ask patients what level of detail you should cover.
 For instance, you can say, "Some patients want me to cover every medical
detail, but other patients want only the big picture--what would you prefer
now?“

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4. Sharing the information.
 Decide on the agenda before you sit down with the patient, so that you have the relevant
information at hand.
The topics to consider in planning an agenda are: diagnosis, treatment, prognosis, and support or
coping.
For a patient on a medicine service whose biopsy just showed lung cancer, the agenda might be:
a) disclose diagnosis of lung cancer;
b) discuss the process of workup and formulation of treatment options ("We will have the cancer
doctors see you this afternoon to see whether other tests would be helpful to outline your treatment
options").
Give the information in small chunks, and be sure to stop between each chunk to ask the patient if he
or she understands ("I'm going to stop for a minute to see if you have questions").
Long lectures are overwhelming and confusing.
Remember to translate medical terms into patient’s, and don't try to teach pathophysiology.
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5. Responding to the patient's feelings.
If you don't understand the patient's reaction, you will leave a lot of
unfinished business, and you will miss an opportunity to be a caring
physician.
• Learning to identify and acknowledge a patient's reaction is
something that definitely improves with experience, if you're
attentive, but you can also simply ask ("Could you tell me a bit about
what you are feeling?").

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6. Planning and follow-through.
At this point you need to synthesize the patient's concerns and the
medical issues into a concrete plan that can be carried out in the
patient's system of health care.
Outline a step-by-step plan, explain it to the patient, and contract
about the next step.
 Be explicit about your next contact with the patient ("I'll see you in
clinic in 2 weeks")
Give the patient a phone number or a way to contact the relevant
medical caregiver if something arises before the next planned
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• What if the patient starts to cry while I am talking?
In general, it is better simply to wait for the person to stop crying
 It is nice to offer tissues if they are readily available (something to
plan ahead);
try not to act as if tears are an emergency that must be stopped, and
don't run out of the room--you want to show that you're willing to
deal with anything that comes up.

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Bedside rules
• Avoid jokes and laughter in front of patients
• Keep patient privacy and confidentiality
• Respect your collegues.Never backbite your collegues with
patients/relatives
• Show confidence in all your actions

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