Communication Skills Prof Eiad Al- Faris Chairman, Department of Family Medicine

Communication Skills

Prof Eiad Al- FarisChairman,Department of Family Medicine

Communication SkillProf. Eiad Al- Faris


OutlineOutline DefinitionDefinition

Types of communicationsTypes of communications Why to learn communication skills?Why to learn communication skills? Exercise Exercise Characters of good communicatorsCharacters of good communicators Some specific skills e.g. ElicitingSome specific skills e.g. Eliciting How to learn communication skills?How to learn communication skills? ConclusionsConclusions


ObjectivesObjectives

Today’s session is important.

WHY?


ii

Definition

االتصا االتصا تعرف التالتتعرف::أنهاأنهابب

تبادل و نقل تبادل عملية و نقل عملية األفكاراألفكار

بين بين والمشاعر والمشاعرعن أكثر أو عن شخصين أكثر أو شخصينرموز استخدام رموز طريق استخدام طريقعليها متعارف عليها مشتركة متعارف مشتركةبين التفهم خلق بين بهدف التفهم خلق بهدف . .الطرفينالطرفين

االتصال عناصر االتصال تتكون عناصر تتكون::منمن

المرسلالمرسل –المستقبل المستقبل –الرسالة الرسالة –ال – ال التغذية ةةمرتدمرتدالتغذية

إدراكإدراك

مهاراتمهارات

خبرةخبرة

اهتمامات / اهتمامات / ميول ميول

قيمقيم

حاجاتحاجات

المرتدة المرتدة التغذية التغذية

التعبير أن الدراسات إحدى التعبير أثبتت أن الدراسات إحدى أثبتت: يلي كما يكون الرسالة :في يلي كما يكون الرسالة في

%%77 كلماتكلمات • %% 3838 قالبقالب•

مستوى – و مستوى قوة و ا لصوتلصوتااقوة ا ، لنغمةلنغمة،

الجسم • الجسم لغة %%5555لغةالوجه ،،الرموز الرموز ،،اإلشاراتاإلشارات))– الوجه تعابير ((تعابير


Piece of Cake?Piece of Cake?

visualverbaltonal

55%

7%

38%


Piece of Cake?Piece of Cake?

visualverbaltonal

55%

7%

38%


كلمات %7 %38 قالب لغةالجسم %55


Non verbal communicationNon verbal communication

❚ ❚ Eye contactEye contact ❚ ❚ Facial Facial expressionsexpressions ❚ ❚ Body languageBody language ❚ ❚ Tone of voiceTone of voice ❚ ❚ EmphasisEmphasis

Deliberate silenceDeliberate silence TimingTiming AppearanceAppearance TouchTouch Hand movementsHand movements

المختلفة المختلفة األشكال األشكاللالتصاالتلالتصاالت

الشفوي الشفوي االتصال االتصالالشخصية ** الشخصية المقابلة المقابلة

الهاتفي ** الهاتفي االتصال االتصال

التدريبية ** التدريبية الحلقات الحلقات

التحريري التحريري االتصال االتصالالتقاريرالتقارير**

المذكراتالمذكرات**

الرسائلالرسائل**

المختلفة المختلفة األشكال األشكاللالتصاالتلالتصاالت

تابع) تابع) ))

التصويري التصويري االتصال االتصالاالرشادية ** االرشادية اإلشارات اإلشارات

التعبيرية ** التعبيرية الصور الصور


Which is easier to read?Which is easier to read?

'The man gave the ball to the boy‘'The man gave the ball to the boy‘

'The ball was given to the boy by 'The ball was given to the boy by a man.' a man.'


it's important to:it's important to:

Use short sentences: Use short sentences: They force you to break your ideas into simple They force you to break your ideas into simple

understandable statements. understandable statements. Less than 20 words. Less than 20 words.

Use words readers understand. Use words readers understand.

Use subject-verb-object constructionsUse subject-verb-object constructions


http:// http:// www.LearnHowToWrite.com www.LearnHowToWrite.com





Why do we need to teach Why do we need to teach communication skills in communication skills in

medical schools?medical schools?

Any suggestion?Any suggestion?


Effect on Health OutcomeEffect on Health Outcome

Many studies reiterate that effective Many studies reiterate that effective communication and relationship-building communication and relationship-building are important in the delivery of high-are important in the delivery of high-quality health care.quality health care.

(Roter 1987, Betakis 1991, Stewart 1995).(Roter 1987, Betakis 1991, Stewart 1995).



Stewart 1995, in a review of several studies about Stewart 1995, in a review of several studies about effective physician-patient communication and effective physician-patient communication and health outcome concluded that health outcome is health outcome concluded that health outcome is positively affected by:positively affected by:

Probing the thoughts, feelings, and expectations Probing the thoughts, feelings, and expectations of patients.of patients.

Encouraging them to ask questions, and Encouraging them to ask questions, and allowing patients to share in the decision making. allowing patients to share in the decision making.



These effects are documented in:These effects are documented in: The reduction of anxiety.The reduction of anxiety. The reduction of psychological distress.The reduction of psychological distress. Pain relief.Pain relief. Symptom resolution.Symptom resolution. Mood improvement.Mood improvement. Reduction of high blood pressure.Reduction of high blood pressure.

(Stewart 1995).(Stewart 1995).



Improved communication has also been shown Improved communication has also been shown to:to:

Increase satisfaction of patients.Increase satisfaction of patients. Decrease in the duration of treatment.Decrease in the duration of treatment. Decrease in the intake of painkillers.Decrease in the intake of painkillers. Decrease in hospital stay.Decrease in hospital stay.

( Van Dalen 2001, Eisenthal 1976, steward 1984, Mumford ( Van Dalen 2001, Eisenthal 1976, steward 1984, Mumford 1982, Egbert 1962).1982, Egbert 1962).


““The Toronto consensus statement The Toronto consensus statement stressed that the main complaint of stressed that the main complaint of patients is related to patients is related to ““communication problems and not communication problems and not to clinical competency.to clinical competency.””

(Simpson 1991)(Simpson 1991)


The association between specific The association between specific communication patterns and law suits was communication patterns and law suits was found in a study done on primary care found in a study done on primary care physicians.physicians.

( Levinson 1997).( Levinson 1997).


““The main remarks made by patients in the The main remarks made by patients in the primary health care centers in Riyadh was primary health care centers in Riyadh was that that ““physicians were not listening enough physicians were not listening enough to their complaints.to their complaints.””

( Saeed 2001)( Saeed 2001)


The magnitude of the problem of poor The magnitude of the problem of poor communication is demonstrated by:communication is demonstrated by:

The increase in patientThe increase in patient’’s complaint.s complaint. The increasing number of law suits against The increasing number of law suits against

doctors and hospitals.doctors and hospitals. The tendency of patients to keep changing The tendency of patients to keep changing

physicians and hospitals.physicians and hospitals. Patients non-adherence to medical regimen.Patients non-adherence to medical regimen.

(Meryn 1998, Simpson 1991, Vincent 1994).(Meryn 1998, Simpson 1991, Vincent 1994).





ExcerciseExcercise

Communication SkillProf. Eiad Al- Faris 3131

ExerciseExerciseQ1.Q1. Describe each patient in 1-2 words Describe each patient in 1-2 words

1

43

2


ExerciseExerciseQ2.Q2. How do you think his doctor may feel about him or How do you think his doctor may feel about him or

her?her?

1

43

2


ExerciseExerciseQ3.Q3. What is your first objective in dealing with these patients? What is your first objective in dealing with these patients?

1

43

2


Common answers:Common answers:

1.1. This pt is This pt is arrogantarrogant and he needs and he needs control control

2.2. This pt is This pt is angryangry and may be and may be dangerous,dangerous, he he

needs needs control control

3.3. This pt is This pt is abusingabusing her doctor and she needs her doctor and she needs

controlcontrol

4.4. This pt is This pt is carelesscareless, she needs , she needs control control


The Tip of The IcebergThe Tip of The Iceberg


Illness Behavior Illness Behavior The Tip of The IcebergThe Tip of The Iceberg

5%5% of the patients of the patients visiting their physiciansvisiting their physicians

1%1% of them need of them need referral to hospital out referral to hospital out patientpatient

5 5 per per 10001000 need need hospital admissionhospital admission


Ratio of Medical Ratio of Medical Consultation to Consultation to

Symptoms EpisodeSymptoms Episode


Headache Headache 1: 601: 60 Changes in energy, tirednessChanges in energy, tiredness

nerves, depression, or irritability nerves, depression, or irritability 1 : 741 : 74 Aches or pains in joints,Aches or pains in joints, muscles, legs or armsmuscles, legs or arms 1: 181: 18 Women’s complaint’s like Women’s complaint’s like Period painPeriod pain 1 : 101 : 10 Stomach aches or painStomach aches or pain 1 : 111 : 11 BackacheBackache 1 : 38 1 : 38 Cold, flu, or running noseCold, flu, or running nose 1 : 12 1 : 12 Sore throatSore throat 1 : 91 : 9 SleeplessnessSleeplessness 1 : 311 : 31 OthersOthers 1 : 81 : 8

Total Total 1 : 181 : 18

The Tip of The The Tip of The IcebergIceberg

Why?Why?


It is simpleIt is simpleI can manageI can manage

OneOne Headache episode Headache episode 5959 Headache episode Headache episode

The Tip of The Iceberg … Why??


Patient’s Ideas :Patient’s Ideas :

The Real Reason:


Patient’s Concerns :Patient’s Concerns :

The Real Reason:


I am a patientI am a patient I am weakI am weak I am worried I am worried I need helpI need help

This is a very basic fact:This is a very basic fact:

Patients are Patients are not not ordinary customersordinary customers


Patients use verities of ways to express Patients use verities of ways to express their weakness and worriestheir weakness and worries

1

43

2


Patient’s Needs & ExpectationsPatient’s Needs & Expectations

Understanding Explanation

Reassurance

Empathy

The Real Reason:


First Facts:First Facts:

This answers reflect:This answers reflect:

Judgmental attitudeJudgmental attitude

Lack of empathyLack of empathy

Very little consideration for patient’s behaviorVery little consideration for patient’s behavior

The majority of doctors think & feel this wayThe majority of doctors think & feel this way


Second Facts:Second Facts:

If doctors think & feel negativeIf doctors think & feel negative

They communicate according to their feelingsThey communicate according to their feelings

Let us deal with our thinking & Let us deal with our thinking &

feelings firstfeelings first


Summary:Summary:

Symptoms (Symptoms (presenting complaintpresenting complaint) are ) are

not the only reason for patient seeking not the only reason for patient seeking

medical help;medical help; The The real reasonsreal reasons are: are:

Patient’s Patient’s believes & worriesbelieves & worries

Needs & expectationsNeeds & expectations

Patients are Patients are notnot ordinary customers, they ordinary customers, they

need need very special communicationvery special communication

skillsskills

How are you going to apply this How are you going to apply this

exercise in your practiceexercise in your practice??

Illness BehaviorIllness Behavior


Try to exercise seeing the full picture of your patient:

1. Presenting complaint2. Believes & worries3. Needs & expectations


I am a patientI am a patient I am weakI am weak I am worriedI am worried I need helpI need help


Without considering Without considering illness behaviorillness behavior

Patient’s actionPatient’s action Doctor’s reaction Doctor’s reaction

ArrogantArrogantControl the situation Control the situation

AbusingAbusing

AngryAngry

AggressiveAggressive

Control the situation Control the situation




When you see the full When you see the full picturepicture

Patient’s actionPatient’s action Doctor’s reaction Doctor’s reaction

PatientPatientUnderstanding & empathyUnderstanding & empathy

PatientPatient

PatientPatient

PatientPatient

Understanding & empathyUnderstanding & empathy




HOUSE KEEPINGHOUSE KEEPING The mood to consult.The mood to consult.

Enthusiasm and curiosity.Enthusiasm and curiosity.

The desk .The desk .

A cup of tea. A cup of tea.

Stretch your legs. Stretch your legs.

Take a deep breathTake a deep breath..




Characters of good Characters of good communicatorscommunicators


❚ ❚ Know what they want to sayKnow what they want to say

❚ ❚ Establish and maintain Establish and maintain relationshipsrelationships

❚ ❚ Understand others perspectiveUnderstand others perspective

❚ ❚ Active listenersActive listeners

❚ ❚ Understand and clarify Understand and clarify messagesmessages


Why Dr A sees only 20 pts, Why Dr A sees only 20 pts, while Dr B comfortably sees while Dr B comfortably sees 30?30?


SOFTENSOFTENSS SmileSmileOO Open PostureOpen Posture FF Forward Forward Lean Lean TT TouchTouchEE Eye ContactEye ContactNN NodNod


عنه الله رضى جابر عنه قال الله رضى جابر :: قال

عليه الله صلى الرسول رأيت عليه ما الله صلى الرسول رأيت ماوجهي في تبسم إال مرة وجهي وسلم في تبسم إال مرة وسلم


Examples of good Examples of good communication skillscommunication skills


The three skills that improved patients’ The three skills that improved patients’

disclosure of sensitive information were. disclosure of sensitive information were.

Asking questions about psychological Asking questions about psychological

issues.issues.

Making supportive statements.Making supportive statements.

Listening attentively .Listening attentively .

)Am J Ped 1994(.)Am J Ped 1994(.





1.Initiating the session1.Initiating the session 2- Skills for Eliciting2- Skills for Eliciting 3- Nonverbal Cues3- Nonverbal Cues )4( Influencing Skills)4( Influencing Skills 5- Explaining Skills5- Explaining Skills 6- Skills for Sharing Understanding6- Skills for Sharing Understanding 7- Relationship building7- Relationship building 8.8.


Active listening.Active listening. Explain your findings.Explain your findings. Discuss prognosis.Discuss prognosis. Outline the plan.Outline the plan. Involve the patient in the plan.Involve the patient in the plan. Educate the patient.Educate the patient.

Conclusion )Cont’d(Conclusion )Cont’d(FIVE SIMPLE STEPS TOFIVE SIMPLE STEPS TO

EFFECTIVE COMMUNICATIONEFFECTIVE COMMUNICATION


1.Initiating the session 1.Initiating the session

Greet him with Greet him with appropriate appropriate warmth.warmth.

General Questions General Questions e.g e.g


1.Initiating the session 1.Initiating the session )cont()cont(

A- ‘What can I do for A- ‘What can I do for

you? you?

B- ‘What do you want to B- ‘What do you want to

talk about/discuss today?’ talk about/discuss today?’


1.Initiating the session 1.Initiating the session )cont()cont(

C- ‘What do you want C- ‘What do you want usus to to

talk about/discuss today?’talk about/discuss today?’

D- SalamatD- Salamat

E- How can I help you E- How can I help you


1. Initiating the session 1. Initiating the session )cont()cont(

A hypertensive patient coming for follow-A hypertensive patient coming for follow-up appointment, up appointment,

‘‘Hello, well now?’ with a smile and a Hello, well now?’ with a smile and a raised eyebrow.raised eyebrow.

‘‘It’s your blood pressure, isn’t it”It’s your blood pressure, isn’t it”



2- Skills for Eliciting2- Skills for Eliciting

At the start, the patient has the leadAt the start, the patient has the lead

Delay making your hypothesis. Delay making your hypothesis.

Say as little as possible. Say as little as possible.

Avoid stopping the flow.Avoid stopping the flow.

Try to generate several possible hypotheses. Try to generate several possible hypotheses.

Do not judge too quickly and by appearances.Do not judge too quickly and by appearances.

Do not reassure the patient too soonDo not reassure the patient too soon


2- Skills for Eliciting2- Skills for Eliciting )Cont’d( )Cont’d(

A. Active ListeningA. Active Listening

)with genuine interest()with genuine interest(



i. Reflectioni. Reflection

‘ ‘You look sad today’.You look sad today’.

‘‘That must have been very frightening’, ‘That must have been very frightening’, ‘

How did that make you feel?(. How did that make you feel?(.




ii. Show understanding, empathy and ii. Show understanding, empathy and

sensitivity: sensitivity:

‘‘I know’, ‘I feel like that sometimes, it’s I know’, ‘I feel like that sometimes, it’s

terrible’ terrible’

‘‘I know, I hate blood tests, too, etc.(.I know, I hate blood tests, too, etc.(.



iii.iii. Actively encourage the Actively encourage the

other person to talk by other person to talk by

nodding, smiling and nodding, smiling and

echoing significant words. echoing significant words.




iv-Repeat tentively, in your own words, iv-Repeat tentively, in your own words,

your understanding of their story.your understanding of their story.

v-Give encouragement such as ‘v-Give encouragement such as ‘

vi- Check what the patient has said.vi- Check what the patient has said.

2-Skills for Eliciting2-Skills for Eliciting )Cont’d( )Cont’d(


2-Let the 2-Let the patient answer a patient answer a question before question before you ask another you ask another question.question.


)B( Make good questions.)B( Make good questions. Ask open questions,….. Ask open questions,…..

Ask closed questions,…..Ask closed questions,…..

Example:Example:

I was wondering, whether …’,I was wondering, whether …’,

‘ ‘Sometimes I find, occurred to me that some people Sometimes I find, occurred to me that some people

‘‘I’ve known cases where …’, ‘I had a patient once I’ve known cases where …’, ‘I had a patient once

…’.…’.




C. Actively search for the patient’s C. Actively search for the patient’s beliefs, ideas, concerns, expectations beliefs, ideas, concerns, expectations and feelings and the effects of these.and feelings and the effects of these.


DD)) Explain why you are asking a question. Explain why you are asking a question. ‘ ‘The reason I asked about wind and bloating The reason I asked about wind and bloating

was that I was …………was that I was …………

E( Use silence.E( Use silence.




3- Nonverbal Cues3- Nonverbal Cues Assessing the patient’s mental state.Assessing the patient’s mental state.

Look for the minimal cues.Look for the minimal cues.

Watch the patient’s facial expression.Watch the patient’s facial expression.

We obtain further clues by listening to We obtain further clues by listening to

their vocabulary, figures of speech, their vocabulary, figures of speech,

metaphors and imagery.metaphors and imagery.

Dr. Desmond video


i.i. Use presuppositions Ex: ‘Do you think you Use presuppositions Ex: ‘Do you think you will find it easier to stop smoking all at will find it easier to stop smoking all at once, or gradually cut down over a once, or gradually cut down over a fortnight?’ fortnight?’

ii.ii. Use the ‘My friend technique’. For Use the ‘My friend technique’. For example, ‘I remember someone else who example, ‘I remember someone else who did what you are thinking of and found out did what you are thinking of and found out …..…..

)4( Influencing Skills)4( Influencing Skills )Cont’d( )Cont’d(


Iv- Reframe statements/questions.Iv- Reframe statements/questions.

e.g‘attention-seeking.’e.g‘attention-seeking.’

What if he were labeled What if he were labeled

‘attention-needing’? ‘attention-needing’?

)4( Influencing Skills)4( Influencing Skills )Cont’d( )Cont’d(


v.v. Compliance:Compliance:

When patients are more likely When patients are more likely

take a treatment such as take a treatment such as

simvastatin? simvastatin?

A.A. It reduces their risk of another It reduces their risk of another

heart attack by a third heart attack by a third

B.B. IIt reduces their risk from 12% to t reduces their risk from 12% to

8%. 8%.

C.C. The NNT to prevent 1 attack is 25.The NNT to prevent 1 attack is 25.


5- Explaining Skills5- Explaining Skills

One way vs Two ways processesOne way vs Two ways processesi.i. Use short words / sentences specific(.Use short words / sentences specific(.ii.ii. The order of information .The order of information .iii.iii. Repeat imp pieces.Repeat imp pieces.

iv.iv. The patient’s language. The patient’s language.


v. v. Provide ‘explicit categorizationProvide ‘explicit categorization: :

vi. vi. Use leaflets, tapes, websites, …. Use leaflets, tapes, websites, ….



Feedback and patient’s understanding.Feedback and patient’s understanding.

Too much information.Too much information.

Patient staring out of the window is a Patient staring out of the window is a

sign of ?sign of ?



iii-Break iii-Break information information down into down into manageable manageable segments.segments.


6- Skills for Sharing Understanding.6- Skills for Sharing Understanding.

Similar phrases to the pt.Similar phrases to the pt.

Share a little of yourself e.g ‘I had an Share a little of yourself e.g ‘I had an

operation once’ or ‘Migraines are bloody operation once’ or ‘Migraines are bloody

awful, aren’t they?’awful, aren’t they?’

Show understanding and empathy.Show understanding and empathy.


7- Relationship building.7- Relationship building.

Environment: Environment: SOFTENSOFTEN

Be friendly and attentive, Be friendly and attentive,

An informal style.An informal style.

Plueral pronouns to indicate partnership. Plueral pronouns to indicate partnership.


‘‘I hope you agree. Shall we meet again in two I hope you agree. Shall we meet again in two

weeks to see how you are getting on?’weeks to see how you are getting on?’

Use self-disclosure to establish trust and Use self-disclosure to establish trust and

common ground. common ground.

‘‘Yes, I know you must be frightened. I am Yes, I know you must be frightened. I am

terrified of the dentist.’terrified of the dentist.’



Make comments that are provisional Make comments that are provisional

Respond descriptively.Respond descriptively.



‘‘What about my knees, doctor?’ Which?What about my knees, doctor?’ Which?

A.A. ‘‘I think you have some wear and tear, I think you have some wear and tear,

possibly a little early arthritis’ orpossibly a little early arthritis’ or

B.B. ‘‘You’re too fat and that’s why you have You’re too fat and that’s why you have

knee pain’.knee pain’.



A- I think that since your heart A- I think that since your heart attack, your heart has been under a attack, your heart has been under a little strain. You will feel betterlittle strain. You will feel better with some fluid tablets, but you will with some fluid tablets, but you will need some time off work so that need some time off work so that your heart can recover. your heart can recover.

Which is better frWhich is better from tom the following two:he following two:


Which is better for the Which is better for the following two:following two:

I will make you an appoint for some I will make you an appoint for some rehab which will help you and get you rehab which will help you and get you back to work quicker. Here is a back to work quicker. Here is a leaflet about what I mean. leaflet about what I mean.


B.B. You must stay off work until I tell You must stay off work until I tell

you. Go for rehabilitation treatment, you. Go for rehabilitation treatment,

this will be good for you, and here are this will be good for you, and here are

some water tablets to take every some water tablets to take every

morning.morning.

• So make comments that are related to So make comments that are related to

the problem )s( rather than to the problem )s( rather than to

controlling the patient.controlling the patient.


Learn to recognize the effect of your own Learn to recognize the effect of your own

behaviour on your patient.behaviour on your patient.

Learn to recognize, interpret and Learn to recognize, interpret and useuse your your

feelings.feelings.

Learn to deal with your own stress.Learn to deal with your own stress.

Most patients don’t mind waiting if…..Most patients don’t mind waiting if…..



Can Communication Skills Be Can Communication Skills Be Taught?Taught?

Communication skills of physicians can be Communication skills of physicians can be changed and this change can endure changed and this change can endure (Maguire 1990, Roter 1993(. (Maguire 1990, Roter 1993(.

Important changes in physicianImportant changes in physician ’’s behavior s behavior and in their communication skills have and in their communication skills have been demonstratedbeen demonstrated

( Levinson 1993(. ( Levinson 1993(.


Many medical colleges in the world and Many medical colleges in the world and an increasing number of nursing schools an increasing number of nursing schools have included communication skills have included communication skills courses in their undergraduate as well as courses in their undergraduate as well as postgraduate curriculum. postgraduate curriculum.


The general medical council in the UK The general medical council in the UK and the association of American medical and the association of American medical colleges recommended that colleges recommended that communication skills training should be communication skills training should be an integral part of any medical curriculum an integral part of any medical curriculum (GMC 1993, AAMC 1999(. (GMC 1993, AAMC 1999(.





How to learn communication How to learn communication skills?skills?

Unconscious ignorance

Conscious ignoranceConscious knowledge

Unconscious knowledge


How to learn communication How to learn communication skills?skills?

Feedback is essentialFeedback is essential Experiential learning is the way to learnExperiential learning is the way to learn


Feedback methodsFeedback methods

Self assessment of a videotape or Self assessment of a videotape or audiotapeaudiotape

By colleaguesBy colleagues By tutorsBy tutors






??


SUMMARY SUMMARY


ConclusionsConclusions


Communication skills are not Communication skills are not an optional extra; without an optional extra; without appropriate communication appropriate communication skills our knowledge and skills our knowledge and intellectual efforts are easily intellectual efforts are easily wastedwasted

Sliverman, Kurtz & Droper 1998Sliverman, Kurtz & Droper 1998


THANK YOUTHANK YOU


Documents

Communication Skills Prof Eiad Al- Faris Chairman, Department of Family Medicine