1. COMMUNICATION SKILLS IN CLINICAL PRACTICE Dr. Syahnaz Mohd Hashim Department of Family Medicine, Faculty of Medicine, PPUKM
2. What is communication?"the successful passing of a message from one person to another"2
3. Important principles facilitating the communication process Rapport between the people involved 2. The time factor, facilitated by devoting more time 3. The message, needs to be clear, correct, concise, unambiguous and in the context 4. The attitudes of both the communicator and the recepient 1.3
4. Communication in the consultation The doctor requires communication skills for complete diagnosis: - Physical - Emotional - Social4
5. If you are the patient, what will be your opinion on this doctor?5
6. Important positive behavior At first contact Address patient by his or her preferred name Make the patient feel comfortable Be 'unhurried' and relaxed Focus firmly on the patient Use open-ended questions where possible 6
7. Open-ended questions "How are you feeling today? "Anything I could help you with?" "Tell me more about your problem?"7
10. Listening Isan active process described by Egan.."One does not listen with just his ears: he listens with his eyes, mind, his heart and his imagination. He listens to the words of others, but he also listens to the messages that are buried in the words. He listens to the voice, the sounds, the gestures and to the silence" 10
11. Listening includes four essential elements Checking facts 2. Checking feelings 3. Encouragement 4. Reflection " You seem very upset today" " It seems you're having trouble coping" 1.11
12. Communication Tips Check if what was said is what you understood ◦ Rephrasing: "Let me say it as I understand it: . . . ." ◦ Further Questioning: "How is that pain?" ◦ Asking for clarification: "Do you mean to say that . . . . . " ◦ Asking for elaboration: "Can you tell me more about it?" 12
13. Non verbal communication IMPACT OF THE MESSAGE % Words alone7Tone of voice38Non verbal communication/Body language55Body language include use of gestures, postures, position and distance 13
14. Barriers to effective communication ◦ ◦ ◦ ◦ ◦Authoritative attitude (usually on the side of the medical/health professional.) Asking only Closed questions patients equate it to Interrogation Closed body posture Lack of or no eye contact Distancing, i.e.: sitting too far apart that the patient feels removed14
15. Barriers to effective communication ◦Appearing too busy & too rushed◦Not listening & constantly interrupting patient◦Writing soon after opening the interview, before listening to patient◦Environmental interference, e.g. lack of privacy, people coming in and out of room, too hot/cold, too noisy, children interfering15
16. Using medical jargon16
17. "What to achieve in a 15 min consultation" 7 Tasks of Consultation 1.Define the reason for patient's attendance2.Consider other problems3.Achieve a shared understanding of the problems17
18. 4.With the patient, choose an appropriate action/management plan for each problem5.Involve the patient in the management & encourage patient to accept appropriate responsibility6.Use time and resources appropriately7.Establish and maintain a relationship which helps achieve other tasks 18
19. Patient Centered InterviewingFocus on eliciting symptoms and signs of illness19
20. What is your opinion to this doctor?20
21. Shows genuine interest in; Patientsas individuals Their reasons for seeking help Their perceptions of what might be wrong Their feeling about the problems The impacts of this problems on their daily lives and well-being21
22. Advantages of patient centered consultationEmphasispatient perspective on health including his/ her perceive needs/ concerns/ preferences and beliefs.Encouragespatient to express what is most important to himAllowspatient to leadGreaterpatients compliance with advice and treatments ◦ promotes patient's health awareness22
23. Other advantages Greaterpatient satisfactionsDoctor-patientinteractions itself can be therapeutic enhanced feeling of trust and understandingClinicaldecision making process and disclosure of psychosocial problems are facilitated 23
24. Four Windows of Consultation (Stott and Davis, 1979)"The exceptional potential in each primary care consultation".A. Management of Acute problemsB. Modification of BehaviourC. Management of ComorbiditiesD. Prevention of Diseases / Promotion of Health24
25. Ending an Interview Summarizewhat the patient has told youAskthem to check the accuracy of what you have saidAskthem if you have left out any information which they feel is importantEnquireif they would like to add anything 25
26. Closethe interview in the positive manner and write management plan: - when is the next follow up visit - What is the patient suppose to do - What will you have to do. Endby thanking the patient◦ E.g. Thank you for talking to me. Our time is now up.26
27. HOW TO BREAK BAD NEWS?
28. Why we need to know "How to Break Bad News"? Important Practicalpart of the medical job& useful in daily clinical workRemember… If we do it badly, the patients or family members may never forgive us. If we do it well, they will never forget us.28
29. What is bad news? "Any news that drastically and negatively alters the patient's view of his or her future"29
30. The 10-step Protocol 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.Prepare the physical set-up Get to know the patient Identify patient's support systems Find out how much the patient already knows Find out how much the patient wants to know Give a "Warning shot" Share the information – Break the news gently! Respond to patient's feelings – Acknowledge distress & support ventilation of feelings Identify concerns, prioritize & answer all questions Planning & follow-through / follow-up 30
31. 1. Prepare the physical set-up Checkyour facts! Do it in person, never over the phone! Find a private room to ensure privacy & confidentiality Turn-off your hand phone & pager Prevent any interruptions! Have enough chairs & tissue (for tears) If there are visitors, ask the patient who they are and what relationship? 31
32. 2. Get to know the patient Establishrapport Introduce self & other staff/students (if any) Start with "normal" courtesies & considerations (drink, washroom) Does he/she have a spouse, children, work, etc.? Open with an open question, e.g.: ◦ "How are you feeling at the moment?" ◦ "How are things today?" ◦ "Do you feel well enough to talk a bit?" 32
33. 3. Identify patient's support systems Howdid he/she come?◦ By car, by bus, taxi, friend brought him/her? Anyone that came with him/her? ◦ Alone, spouse, best friend, etc.?Askpermission to draw "genogram". Not just of family ties but also draw a genogram of "Support persons" 33
34. Prepare setting, identify support34
35. 4. Find out how much the patient already knows •How much do you understand about your illness? . .. . . . . . . . . . . PAUSE . . . . . . . . . .! •What did your previous doctor tell you about your condition? . . . PAUSE!•What have you been thinking about this nausea/unsteadiness/breast lump . . . PAUSE!•Have you been very worried about this illness? 35
36. 5. Find out how much the patient wants to know •Would you like me to explain what is happening?•Would you like me to tell you the full details of the diagnosis?•Would you like to know exactly what is going on, OR•Would you prefer me to give you the outline only? 36
37. 6. Give a "Warning shot" Iam afraid that the news is not very good."Well,the situation does appear to be more serious than that . . ."Maaf,saya rasa berita yang saya akan sampaikan agak tidak begitu baik.Sayaberat hati untuk memberi tahu. . . . . . Silence . . . . . , Mirroring . . . . . 37
38. 7. Share the information Break the news GENTLY Breakthe news gently, but not so much that it is not clear.Usesimple language, i.e.: avoid medical jargon◦ You have carcinoma of the mammary gland vs. You have cancer of the breast. ◦ Cancer barah ◦ Tumor (non-malignant) ketumbuhan38
39. The treatment isn't working. The cancer has come back. The scan shows that the cancer has spread. The biopsy result shows it is cancerous. We were not able to resuscitate him. Anchor the news on something firm. Checkfor patient's understanding frequentlyReinforce Mayand clarify information frequentlyneed to draw a picture for clarity39
40. Patient's reactions40
41. 8. Respond to patient's feelings – Acknowledge distress & support ventilation of feelings Patient says: Iam so sorry, it is very hard, it is so cruel. . . . . . . Silence . . . . ., Mirroring . . . . .WAIT. . . . Until the patient talks again. "Let the storm pass by"41
42. 9. Identify concerns, prioritize & answer all questions Patient may ask:Am I going to die? What happens next? Is there any more treatment? Who is going to look after my kids? Answer all questions as honest & as best as you can. 42
43. Never say: "There is nothing more that we can do." It is not true! Further chemotherapy probably won't help anymore, but there are lots of ways we can make you comfortable.43
44. 10. Planning & Follow through Identify patient's support systems. ◦ Who have you got at home? ◦ Can I phone anyone for you? ◦ How are you going to get home?This is where your "Support Genogram" will help a lot. 44
45. Remember.. A mentally competent and informed patient has the right to: •Accept or reject any treatment offered•React to the news and express his own feelings in any way he chooses.45
46. How to write a referral letter?46
47. Why do we write? 1. Part of continuing good clinical care (i.e. good quality referral letters) 2. Interphase between healthcare professionals in primary and secondary / tertiary care 3. Flexible means of info transfer between healthcare professionals 47
48. What should be heading? Officialclinic/hospital letterheadLEGIBLEHANDWRITING! / typedPatient'sbiodata (NRIC/Hospital R/N)Date/time Toletter was writtenwhom the letter is written 48
49. What should be the content? Patient'sproblem as a title before the main text Brief & relevant history, including current medication Past medical history Allergies Social circumstances± Any treatment tried to date & outcomes, current drug treatment 49
50. What else? Anyinvestigations to date (with a copy of the results) State what was told to the patient in cases of a potentially serious diagnosis Reason for the referral second opinion exclusion of a serious diagnosis treatment failure50
51. Very importantly… Bepolite & grammatically correct.Ensurecopy is kept in the medical records51
52. Example of Referral letter To: Bandar Tasek Selatan Kindly see the above named who has uncontrolled hypertension. Seen here at A&E BP 180/100. ECG : Normal Asymptomatic. Kindly do the needful. 52
53. To: Medical Officer-in –charge, Pusat Perubatan Primer UKM, BTS DearColleague,Kindly see the above named a 59 yr old /C/ Female who has background history of uncontrolled hypertension X 6 years-on PRN GP follow-up. She does not know her antihypertensive medications & compliance is poor. Seen here at A&E BP 180/100. Pulse rate: 66 bpm. ECG : Normal.Asymptomatic. Kindly do the needful. (Kindly see her for regular monitoring of her hypertension.) TQ.Dr XOX (Official Stamp)53
54. THANK YOU FOR YOUR ATTENTION54
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