communication Skill part 2

Dr Abdulsalam Saif Ibrahim

Consultant Pulmonary and ICU

( Alkhor Hospital)

• Initiating the Sessionestablishing initial rapport( great pt warmly and be name)identifying the reasons for the patient’s attendance

• Gathering Information exploration of problems Understanding the patient’s

perspective …… providing structure to the consultation• Building the Relationshipdeveloping rapport( active listening, detect & respond to

emotional issues …………involving the patient• Explanation and Planning

providing the correct amount and type of informationaiding accurate recall and understandingachieving a shared understanding: incorporating the pts perspectiveplanning: shared decision makingoptions in explanation and planningif discussing opinion and significance of problemsif negotiating mutual plan of actionif discussing investigations and procedures

• Closing the session

Negotiating a management plan

Ascertain expectations •What does patient know? •What does patient want?   Investigation? Management? Outcomes?

Advise on options •Elicit patient's preferences

Develop a plan •Involve patient •Tailor preferred option to patient's needs and situation •"Think family"

Check understanding •Ensure that patient is clear about plan •Consider a written summary

Advise on contingency management •hat should patient do if things do not go according to plan?

•Agree arrangements for follow up and review

Three functions of the medical consultation

1 Build the relationshipGreet the patient warmly and by nameActive listening Detect and respond to emotional issues

2 Collect data Do not interrupt patientConsider other factors

 Elicit patient's explanatory modelDevelop shared understanding

3 Agree a management plan Provide information Make links

 Appropriate use of reassurance Negotiate behaviour change

Negotiate a management plan 

Responding to patient’s verbal and non verbal

cues

Aspects of interview style that aid assessment of

patients’ emotional problems

Active listening skills

Helping patients to change their behavior

CLASS

Context

Listening skills

Acknowledgement

Empathy

Strategy

Summary

SPIKES

Setting

Perception

Invitation

Knowledge

Explore emotions and Empathy

Strategy and Summary

“We are born to see, but have to train ourselves to observe”

Ask before you tell?Don’t assume that the patients already know!Don’t acknowledge emotion before you know the feeling?

• What are the objectives of the interview?

• The four E,s

• Engaging

• Empathizing

• Educating

• Enlisting

• Engaging the patient:

– joint the patient; elicit the agenda & sitting

the agenda

– Welcome and introduction

– Allow patient to talk uninterrupted as this is

the key technique in facilitating the interview

Example:(How things are going on since I

saw you? How are you?)

Empathy: create a setting that is

psychologically safe.

– Emotion handling is a learned skill that

consists of techniques:

Example: ( I do appreciate that not knowing what

is the nature of future is unpleasant to you)(

That should have been very upsetting) It is

difficult to know

• Educate the patient:-

– Assess the patient understanding

– Assume questions

– Assure understanding

– Get a feeling of the patient expectation so that you

can get to an agreement plan that is acceptable and

feasible to the patient, even if not perfect, which will

do better than a perfect plan which is not acceptable

• Enlistment:

– Decision making, adherence, and enrolling

the patient in his health care

– Enlistment is a crucial part of medical

interview

Example: (I want to propose to you that we

set together and see what we can do

• Expectation:

– Of medical condition: does that patient

think there is any wrong?

– Of treatment: what will it be like? Any

side effect?

– Of outcome: will every thing be normal

afterward?

• What are the techniques to achieve those tasks?

CLASSContextListening skillsAcknowledgmentStrategySummary

(CLASS) context or setting– Starting with the first friendly handshake, non-verbal

communication is important to establish and maintain

patient confidence.

– Physical space – try to ensure privacy, sit down

• About 2 feet of space and no physical barriers

between you ( e.g across corner of desk or chair at beside

bed)

• Good proximity at the bedside: insure privacy close the

screen separating the two beds

• Eye on same level as patient's

• Ideally the doctor should sit down talking to the patient

• If sitting on the patient bed ask his permission Example:

(There is no chair, is it Ok to set on the your bed?)

• Relative or friends

• Set relative/friend next to patient (not between you and patient)

• Have a box of tissue nearby if it is likely to be needed

Body language and eye contact

• Try to look relaxed and unhurried.

• Your own body language or positioning is a powerful

communicator of attentiveness

• Some doctors avoid sitting behind a desk to remove any

barrier.

• If you lean forward slightly and look at the patient while he

or she speaks, your nonverbal communication says, "I'm

interested in what you have to say. Please continue.

• Maintain eye contact (except during patient's

distress): the patient may be sending you non-

verbal clue that you may not be noticing: you

may miss the likely diagnosis if you don't look.

• (The words and the non-verbal clues should

match)

• Pick up verbal cues and non-verbal cues

(CLASS )Listening skills:

– Unlike hearing, which is the perception of

physical stimuli to our ears,

– listening is the active cognitive process of

interpreting what we hear, evaluating that

information, and deciding how that

information may be used.

• a) Open ended questions: questions that can be

answered in any way

(how are you?) How did that make you feel? How were

you doing recently?

• The open questions are the ideal questions used to start

the interview well and when you don't know what the

patient feel.

• Closed questions are a question that has one answer

(do you have shortness of breath?)

b) Facilitating: encourage patient both

verbally and non verbally

• Pausing or silence when the patient

speaks: especially about important or

emotionally charged topic and especially in the

first few minutes of the interview.

Examples: Nodding, smiling, saying ( hmm hmm)

– Tell me more about that , go on etc

– Yes, I see

• C)Repetition (checking)

– This is underused and very powerful facilitating

technique: it means using a key word from the

patient last sentence in you first sentence(Repeat

the patient's own words

"Not well since your mother died“

if he speaks about an abnormality or pain

repeat his own words etc

d) Clarifying:

• Making overt any ambiguous or awkward topic:

(so what you are saying is)

(Let me see if I've got this straight)

( do you mean that you have shortness of breath)

(What do you mean when you say you always feel

tired?"

• E) Handling time and interruption

– pagers and phones: acknowledge the patient

privacy before you pay attention to interruption

and tell him who is with you as you answer

– Tell the patient about any time constraint and

clarify when discussion will resume

– Do not read notes while taking patient's

history

• Responding to patients' "cues"

Verbal cues

– State your observation "You say that recently you have

been feeling fed-up and irritable"

Non-verbal cues

– Comment on your observation "I can hear tears in your

voice"

– Ask a question "I wonder if that upsets you more than you

like to admit?"

(CLASS) Acknowledgment

• Acknowledge emotions and explore them is

the central skill of being perceived as

supportive.

• Often it is not possible to reassure patients

about the diagnosis or outcome of disease, but

it is always possible to provide support and to

show personal concern for them.

the empathic response:

• identify the emotion

• identify the cause or source of the emotion

• respond in a way that show you have made the

connection between the first two steps

( that must be very upsetting) ( that must felt

awful) (this information has obviously came as

quit a shock) (this is very distressing)

• If you are not sure what the patient is feeling, use

open ended and direct questions until you are.

( how did you feel?) then use empathic response.

• The empathic response is a technique or skill not a

feeling,

- It is not necessary for you to experience the same

feeling as the patient

- Or to agree with the patient's view or assessment

normalizing

- is often useful after acknowledgment as it

helpful after you have shown that you have

heard what the patient is worried about

- it is often unhelpful if you do it before or instead

of acknowledgment

( many patient say) ( most people have that

feeling)

- this doesn't mean you agree with the patient

• Acknowledgment validates and legitimizes the

patient feeling regarding their treatment or

response to what is happening

– “This is clearly worrying you a great   deal,"

– "You have a lot to cope with," etc

• Surveying the field :Repeated signals that

further details are wanted:

• Offering support "I am worried about you,

and I want to know how I   can help you best

with this problem"

• Touch: touching the patient can be very important part

of your non-verbal communication skill and may help

the patient feel less isolate, however not all patients like

to be touched,.

Two rules

1. Only touch a neutral are of the body (hand or

forearm)

2. Touch briefly and see if the patient appreciates it

• an empathic response is an intellectual

response to an emotional situation. It allows

you the clinician a bet of separation from the

patient, which allows you to be supportive

without becoming overwhelmed by the patient

emotional burden

• An empathic response to your own

emotions:

– When confronted with a difficult situation that upset

you ( the doctor) you may express that to the patient

that describe rather than display your feeling and

explain rather than exhibit them

(I found it frustrating when I try to explain to

you while you are taking aside)

CLASS STRATEGY

• Negotiating a management plan

The ideal management plan is one that reflects

current best evidence on treatment, is tailored to

the situation and preferences of the patient, and

addresses emotional and social issues.

• Both patient and doctor should be involved in

developing the plan, although one or the other

may have the greater input depending on the

nature of the problem and the inclinations of the

patient

Negotiating a management plan • Ascertain expectations • What does patient know? • What does patient want? Investigation? Management?

Outcomes? • Advise on options • Elicit patient's preferences • Develop a plan • Involve patient • Tailor preferred option to patient's needs and situation • "Think family" • Check understanding • Ensure that patient is clear about plan • Consider a written summary • Advise on contingency management • What should patient do if things do not go according to

plan • Agree arrangements for follow up and review

• The forming of management strategy is the central spine of clinical practice.

• Communication skills are not a substitute for the correct management. They are essential adjunct to the management plan and not a substitute for making the right decisions.

• The management strategy is: A reasonable management plan that the patient understands s and will follow is better than an ideal plan that will be ignored by your patient

Steps in developing management plan:

• 1) Think what is best medically, further

diagnostic investigations, treatment options,

most suitable, side effects, likely outcome,

who else should be involved in this patient

care?

• 2) assess patient expectation of condition,

treatment and outcome

The expectation of the patient

• Expectation of illness: does the patient ever think there is any thing wrong?

• Expectation of treatment: what will it e like? Any side effects?

• Expectation of the outcome?Will every thing be normal afterwards?The expectation of the patient will affect any plan or strategy and the patient's satisfaction with the medical interview and outcome

• Be alert for the mismatch between the patient

perception or expectation of the situation and

the medical facts

– The concept of mismatch between expectation and medical facts is very important.

Medical condition

Not serious

possibly serious

Probably serious

Definitely serious

category

Actual

Perceived

MatchConcernedill

Actual

Perceived

MatchNeeds assurance

Actual

Perceived

MismatchUnware or denial

Actual

Perceived

MismatchOver anxiety

Actual

Perceived

Under prepared

Actual

Perceived

Overly concernedHandle carefully(possible serious

• 3) Propose a strategy: based on wither you &

the patient are reading from the same page

after assuming the patient response.

• 4) Assess patient response (e.g. what stages of

actions are there in the pre – implementation ,

implementation and or reinforcement face

Think family When interviewing an individual

• Ask how family members view the problem • Ask about impact of the problem on family function • Discuss implications of management plan for the family

When a family member comes in with patient • Acknowledge relative's presence • Check that patient is comfortable with relative's presence • Clarify reasons for relative coming

Ask for relative's observations and opinions of the problem

• Solicit relative's help in treatment if appropriate • If patient is an adolescent accompanied by an adult

always spend part of consultation without the adult present

• Never take sides

Summary And Closure

• Ending the interview has three main components:

• 1) a precise summary of main topics you have discussed

• 2) any important issues or questions that you ought to

discuss even if you don't have time to discuss them in

this interview , they can be on the agenda for the next

meeting

• 3) A clear contract for the next contact

(I will see you next week and we will see how the tablets

work)

• 1: Key tasks in communication with patients

• Eliciting (a) the patient's main problems; (b)

the patient's perceptions of these; and (c) the

physical, emotional, and social impact of the

patient's problems on the patient and family

• Tailoring information to what the patient wants

to know; checking his or her understanding

• Eliciting the patient's reactions to the

information given and his or her main

concerns

• Determining how much the patient wants to

participate in decision making (when

treatment options are available)

• Discussing treatment options so that the

patient understands the implications

• Maximizing the chance that the patient will

follow agreed decisions about treatment and

advice about changes in lifestyle

Breaking bad news

– Bad news is any news that seriously and adversely

change the patient’s view of his or her future.

– Bad news is the gap between patient’s expectation

and reality of the patient’s medical condition.

– You cannot tell how bad any bad news is and how

badly it may affect the patients unless you have

already some idea of what the patients perception

and expectation of the situation, therefore before

you tell ask(find out what the patient/s know or

thinks ?)

Breaking Bad news ( Mnemonics)

• SPIKES

Setting

Perception

Invitation

Knowledge

Empathy

Summary

S-Setting:

Listening skills

Getting the setting- the right physical contact of

the interview (sitting down, body language,

eye contact etc.)

Listening skills (open questions to start with, not

interrupting, facilitation techniques etc

P- Patient Perception

– Ask patient to say what he or she knows or suspects

about his medical problem e.g. what did you think when

you know that you have..? or did you think it might be

serious?

• As patient replies:

– Listen to level of comprehension and vocabulary when

the patient has clear comprehension, your task will be

easier than when the condition is not clear.

– Accept denial by patient

– Use the patient vocabulary on explanation: ( so you are

concerned about that lesion in the chest x-ray)

I- Invitation:What he or she would like to know?

– Are you the sort of person who wants to know everything

even if it turn to be serious?

– are you the kind of person who wants to know the

diagnosis?

– How would you like me to handle the information about your

condition?

– Before I tell you the result , did you think that there is

something serious?

• Accept the right of the patient not to know, but offer

to answer questions as patient wishes later.

K: Knowledge (giving medical facts) 

– Aligning- using language intelligible to patient,

starting at the level he/ she finished at.

– Give information at chunks

– Check reception: confirm that patient understands

– Respond to patient reaction as they occur

– As you talk you listen

– As you listen you acknowledge and respond

E: Explore emotions and empathizes

1. Identify the emotions

2. Identify the cause or source of the emotions

– Respond in a way that shows you have made the

connection between 1 and 2

– The empathic response is a technique or skill- not a

feeling. It is not necessary for you to experience the

same feeling as the patient or agree with the

patient's view or assessment.

• Explore: Does that makes sense so far?

• If the patient asks: What's going to happen to me?

You may respond by saying ( that's very fair

question…. We may not be able to tell today. It

may take months to have a clear picture. ( I

cannot tell you today, but only after

treatment. .etc)

• Acknowledge the patient emotion (it is distressing

not to know what things are going to be)(that

must have been very upsetting)

S: Strategy and Summary

• Involve the patient's support system( family,

religious people, friends, social services etc.)

in the strategy

• At end of interview agree on strategy and

summarize and clarify

• Other major questions

• Clear contact for next contact

Thank you