COMMUNICATION

THE CENTRAL ACT

IN FAMILY MEDICINE

مهارات لالتصال Dr. Duaa Hiasat

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Objectives:

1. To increase the audience self-awareness

about their own communication style

2. To increase the audience understanding of

their patient’s communication style

Communication

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My Goal is that : at the end of this presentation You’ll

know

1. Why good doctor-patient communication is important.

2. What creates good communication.

3. What you can do as a doctor to create that good communication

4. To apply more effective skills in establishing and maintaining doctor-patient relationship.

• Appropriate communication skills helps doctors to

feel less frustrated and more satisfied in their work .

It reduces conflict by preventing the misunderstanding

which is so often the source of difficulties between

doctors and patients.

(Levinson et al 1993).

Communication Skills

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“The good clinician treats the disease, but the great

clinician treats the patient”

William Osler

(Canadian Physician, 1849-1919)

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WHY STUDY COMMUNICATION SKILLS?

• One of 4(core) essential components of clinical competence

1. Knowledge

2. Communication skills,

3. Problem solving, and

4. Physical examination.

• All are inextricably linked(ال ينفصم):

• outstanding expertise in any one alone is not sufficient.

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Communication CYCLE

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6 Steps of Communication Process

1. Idea occurs

2. Message coded

4. Message received

5. Message decoded

6. Feedback

3. Message sent

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Communication barrier

Anything that gets in the way of clear communication during these steps

• Physical disabilities

• Psychological attitudes and prejudice

• Cultural diversity

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1. Ideas occur

Possible problems:

• The message is ill-conceived

• It is vague or incomplete;

• Associated with critical emotions e.g. shame or anxiety

Solution

Put your patient at ease –Create rapport

2. Message coded

Possible problems:

• The wrong language may be choose

• The tone is inappropriate.

• Solution

• Interpret patient’s cues

• Watch your voices tone-Talk in a non-threatening tone of voice.

• Respect culture differences

3. Message sent through medium

Possible problems may include:

• Interruption

– Doctors interrupt their patients after 18 seconds.

– Doctors very often assume that the first complaint mentioned is the only one that the patient has brought. (Beckman 1984).

Solution

Improve your listening skills

4. Message received

•Possible problems:

• Hearing problems

• Psychological

Solution

• Speak slowly.

• Use nonverbal communication

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• Questioning Paraphrasing مقتبسا

• Reflection انعكاس Probing تحقيق

• Confrontation مواجهة Mirroring المتطابق

• Interpretation ترجمة Summarizing تلخيص

Mastering varieties of skills to use them if needed:

If one skill doesn't work the other may work

Verbal Communication Skills

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5. Message decoded

• Possible problems: 1. The sender has send incomplete or ambiguous message

e.g.. He has used jargon or technical terms.

It is only Fungal infection

Give explanation to any medical term Solution

6. Feedback

Possible problems:

1. Passive listening

2. Blocking

3. Lecturing

4. Premature Reassurance

Health Care workers should:

•Allow patients to express their fears or anger.

•Encourage them to talk about their feelings.

•Avoid arguing.

•Remain calm.

•Talk in a non-threatening tone of voice.

•Provide quality care.

Communication Skills

Nonverbal communication

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Verbal Communication

• Much of the communication process in the clinical interview is verbal interchange.

• Some aspects of verbal communication play an important role in establishing and maintaining rapport

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Funnel of Verbal

Communication

Skills

•We want to balance between

facilitation and active listening

in one hand …on the other

hand focusing and using time

effectively .

•This funnel will help to

maintain this balance

•To organize The flow of

facilitation and active listening

Verbal communication Facilitation & Active Listening

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?سالماتVerbal Communication Skills

Questionining

: Use open-ended questions. How is the pain?- كيف هو األلم

Probing تحقيق :

or “I’d like to hear about…”

Confrontation مواجهة : “You look sad… أنت تبدو حزينة ” OR

“ You look anxiouse

“Tell me more قل لي أكثر”

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Questioning :

• Indirect Qs (Open-ended Qs)

• Direct Qs (Yes or No)

• Suggestive Qs

VERBAL Communication

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Closed Questions -Yes/No

• No chest pain, shortness of breath, or nausea, right?

• “Not been suicidal, right?”

Open Ended Questions

• Where is the pain.?

• How is the pain?

• What it looks like?

• When is usually coming?

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؟ …سالمات •

كهمني أكثر ؟•

كيف حانك انيىو ؟•

كيف ممكن أفيدك ؟ •

بماذا تشعر ؟ •

استعمال أداة االستفهاو كيف أوماذا •

حدثني أكثر عن نفسك : )طهب انمزيد من انتىضيح ، مثم قىل • ؟...ماذا أيضا ؟ ، أشرح ني، صفه ني...

How can I help you ? What can I do for you ?

Tell me more …. What else?

Examples of Open-Ended Questions

؟ …سالمات

؟ …كلمني أكثر

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Closed-ended questions: • Useful in clarifying information & gathering factual

data

• Can be answered by “Yes” or “No”.

• Their value is extremely limited in obtaining reliable information

• Effective in generating specific & quick responses to a clearly defined topic (e.g., asking about red flags)

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Mirroring المتطابق :

Restate using patient’s words

Dr: What makes your

headache worse?

Pt: I notice that it’s the worst

when I am under stress

Dr: It’s worst when you are

under stress?

Verbal Communication Skills

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Paraphrasing- مقتبسا :

Restate in your own words

Dr: What makes your

headache worse?

Pt: I notice that it’s the worst

when I am under stress.

Dr: If you are under stress it

gets worse?

Verbal Communication Skills

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Reflection- انعكاس:

Reflect the pt’s comment or

pt’s question back to him

Pt: “is it cancer dr.?”

Dr: “Do you think it is really

cancer !...”

Interpretation -: ترجمة try

to link the story together, to

fine out

Verbal Communication Skills

the significant of every part of patient's story 28

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Summarizing- تلخيص

Summarize the patient’s

main points. to keep on

track

Summarize to move to the

next point

Facilitation & Active Listening

Verbal Communication Skills

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Paralanguage

Paralanguage is the voice effect that accompanies or modifies talking and communicates meaning, includes:

• Velocity(fast, slow, hesitate)

• Tone

• Volume

• Sighs and gruntsتتنهد وهمهمات

• Pauses and inflections

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Verbal and Vocal information. There is a real difference between verbal and

vocal information.

• The verbal message refers to the words literally transmitted.

• The vocal message includes the emotional quality, the tone of voice, and the frequency and length of pauses information that is lost when the words

are written.

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Metacommunication

•communicating about communicating

–“Do you follow me?”

–“You seem worried; is that right?”

–“I’m not sure I get what you’re saying.”

–“Is it ok if I ask you some questions about that?”

Some tips

• Use of appropriate vocabulary

• Phrasing questions in simple language appropriated to the patients level of understanding

• Avoid of medical jargon

• The patients cultural level and education should be considered.

• Ask their patient to volunteer their ideas

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Non Verbal Communication

• Non verbal communication is often ignored.

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Personal appearance

• Personal appearance is a significant part of nonverbal communication. Patients consider house staff who wear white coats with conventional street clothes as more competent than those who wear scrub suits.

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If white coats are worn, the patient sees only the collar, tie, and shoes, and it is therefore important to keep these items neat.

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Non Verbal Communication

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Non Verbal Communication has been classified as

• Body language

• Physical characteristics

• Paralanguage

• Touching

• Artifacts and

• Environmental factors

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Body Language

• Specific gestures and their interpretation are of importance only when judged in the context of the circumstances surrounding them.

• A single gesture has clinical relevance only as part of a sequence of actions.

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Higher patient satisfaction is associated with a physician’s forward body lean and rotation of the torso toward the patient

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• Patient also responds more favorably to the physician who his chin in his hands and gazes directly at the patient

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• Physicians whose communication styles have been considered patient oriented have been observed to change body position more frequently than physicians whose conversations were physician centered.

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Mirroring When good rapport exists between two people,

each will mirror the other’s movements. Some people unconsciously

rapport with another by mirroring that person’s movements or body posture

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Touch A close personal interest in the patient can be

communicated by the appropriate use of touch. The most socially acceptable method in Western countries is a handshake, enabling the physician to establish early contact with the patient , a firm handshake is most acceptable.

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• Usually, the limp or “wet dishrag” handshake indicates lack of interest or insincerity, especially if it is rapidly withdrawn.

• A moist palm is a sign of nervousness or apprehension.

• The “halfway there,” fingers-only handshake indicates reluctance or indecision.

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However, the handshake continues to be modified culturally, and a person should be extremely wary of misinterpreting another person’s handshake without understanding his or her cultural background.

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• Touching can be an effective method for communicating concern or compassion and can break down some of the defensive barriers to communication.

• Caution should be exercised, however, not to use it excessively or earlier than is socially permissible.

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• When there is congruence(انسجام)between the verbal and nonverbal message—when the gesture conveys the same message as the spoken word—communication and its meaning are probably in agreement.

• When a person indicates something different from the other, however, the non verbal message usually is more accurate. Unless body language, tone of voice, and words spoken all match, look more closely for the reason

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• The magic of touch can be good medicine, especially when combined with concern, support, and reassurance. Stroking, التمسيد a special kind of touching, describes a physical or symbolic recognition of a person’s finer attributes. A stroke may be a kind word, a warm gesture, or a simple touch of the hand. Infants deprived of touch and stroking suffer mental and physical deterioration. Adults also require stroking to maintain a

healthy emotional state

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Body Language • The astute-smart physician will cultivate

observational skills that enable the detection of hidden or subtle clues to diagnosis contained in the patient’s nonverbal behavior

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• Attempts by the patient to mask feelings can be detected readily by observing body behavior. True feelings are more likely to leak through conscious efforts to conceal feelings.

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• On the other hand a physician’s attempt at deception will be detected by patients and can destroy confidence and damage rapport.

• Positive verbal communication (e.g., “You’re looking better today”) accompanied by negative nonverbal cues will be

• interpreted by the patient as insincere.

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Body Position

• The body position when sitting can show various degrees of tension or relaxation.

• The tense person sits erect with a fairly rigid posture

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• A person who is moderately relaxed has a forward lean of approximately 20 degrees and a side lean of up to 10 degrees.

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• Figure 12-2 Joseph Califano (left), Secretary of Health, Education and Welfare,mirrors his boss, President Jimmy Carter, through his posture and gestures.(From Key MR [ed]: The Relationship of Verbal and Nonverbal Communication. New York,Mouton Publishers, 1980, p v.) 59

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Head Position

Typically,

• the head is held forward in anger

• back in defiance, anxiety, or fear.

• down or bowed in sadness, submissiveness, shame, or guilt.

• tilted to one side indicates interest and attention

• The erect head indicates self-confidence and maturity.

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Head is held forward in anger

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Eye & Face

• Feelings , attitudes, emotions

• Sarcastic comments

• Eyes lying

• may be smiling, although inwardly sad or angry.

• . As Shakespeare wrote, “I saw his heart

in his face” (The Winter’s Tale,Act I, Scene II

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Head Position Guilt sadness, submissiveness, shame, or guilt.

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Face

• When listening to a patient, the physician should show interest and concern by an attentive position, which is best illustrated by sitting forward in the chair with an interested,

attentive facial expression and the head slightly tilted

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• The human face can create more than 7000 expressions using44 muscles (Cleese, 2001); some say 10,000 expressions are possible (Ekman, 2003).Darwin (1872) proposed that cultures throughout the world express similar emotions or states of mind with remarkably uniform body movements.

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• This doctor signals attentiveness and seriousness by holding

• very still, cocking her head, and looking intently at the speaker

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Smile

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Hands

• The hands will be droopy and flaccid with sadness, fidgety or grasping in anxiety, and clenched in anger

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• Notice the manner in which the arms are crossed. Are they relaxed in the normal position of comfort, or are they in a hugging posture, reflecting insecurity or sadness and indicating a need for reassurance

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Gestures

• The thumbs-up sign in the United States means “good going,” but in some Islamic countries, it is the equivalent ofan upraised middle finger.

• Similarly, the extended hand withpalm forward means “stop” in the United States, but in West Africa, it is an insult greater than the upraised middle finger

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• The eyes are probably the principal organs of expression.They are so important to a person’s appearance that when anonymity is desired, only the eyes need to be coveredIn most cultures, good rapport is enhanced when one’sgaze meets the other’s 60% to 70% of the time. When we talk,we maintain eye contact about 40% of the time and 80%

when listening.

• One trait of good

listeners is that

they constantly look

at the speaker.

•at the speaker

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• Sincerity is expressed with the eyes. The best method for

• conveying sincerity is frequent eye contact, a technique

• most appropriately used when listening to the other person.

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Detecting Lying In addition to looking up and to the right to create an

image or a fact, a person who is lying is also likely to do the

following: • Cover the mouth with hand. • Rub or flick the nose. • Scratch the neck. • Pull at the ear, or rub behind the ear. • Rub one eye.

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Detecting Lying

Scratch the neck Pull at the ear, or rub behind the ear

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Key Points

• Listening is a key element for any successful interview.

• Building bridges of understanding helps to manage the various difficulties of the interview.

• Being sensitive to various forms of diversity, including disabilities, religious issues, and

ethnicity, will enhance communication and

participation by the patient.

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Conclusion

• The art of interviewing is a skill that is learned, developed,

• and enhanced through clinical practice. It is an ongoing process

• that will change as the physician engages people of different

• ages from a variety of circumstances and with a variety

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Final Message and Recommendations

1. It is time to change our doctor-patient

relationship to adult to adult relationship

(maturity style)

2. Try to correct all the myths and respond to

patient needs

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Final Message and Recommendations

3. Reassurance need effective doctor-

patient relationship

4. Apply the basic principles of effective

doctor-patient relationship will help

you mastering any doctor-patient

encounter

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The power of your positive attention

A physician simply making contact by observing to the

baby’s mother: “I can see she has your eyes,” or “He’s

snuggled right into you, isn’t he?” engaged the

mothers more than other far more complicated

interventions.

Brazelton et al.

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The Nuggets

• 1. A good doctor-patient relationship is key to good health outcomes (it helps you do good!)

• 2. Good relationships with patients are the main source of satisfaction for satisfied physicians (they make you happy!)

• 3. A good doctor-patient relationship reduces errors and the likelihood of being sued whether or not there is an error. (Hence you earn a living!)

Summary 1. Good communication basics include making direct

eye contact, using open nonverbal communication, and facing the patient rather than your laptop.

2. Building rapport begins the minute you meet the patient.

3. Knowing background about the patient (e.g., job information) can help you make a diagnosis and may affect how you deliver information.

4. Being emotionally present will help you make a genuine connection to your patient.

5. Avoiding jargon and using “teachback” can help address literacy challenges.

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References

1. Communication Skills for PhysiciansFayza Rayes MBBCh. Msc. MRCGP (UK)

2. Rakel - Textbook of Family Medicine, 7th Edition

3. Rayes F. (2007), Consultation Skills-Course Manual

4. Kurtz S, Silverman J, Benson J, et a.2nd edition (2004) Skills for Communicating with patients. Oxford. Radcliffe.

5. Auguste H. Fortin, Robert C. Smith, Francesca C. Dwamena, Richard M. Frankel. Smith's Patient Centered Interviewing: An Evidence-Based Method, 3rd Edition (2012)

6. Tate P .6th edition (2009). The Doctor’s Communication Handbook. Raddiffe Medical Press, London

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