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COMMUNICATION SKILLS:
Doctor-Patient Communication
and Relationship
13/04/2013
Dr. Mohamed Salah Khalil (Ph.D-Neuropsychology)
Associate Professor-Consultant Clinical Psychologist
Coordinator of Postgraduate Clinical Psychology Program
1 DR. MOHAMED SALAH
What can studying communication
skills offer us as medical practitioners
13/04/2013
Increased Doctor Job Satisfaction
Decreased Conflict Within The Consultation
More Accurate And Efficient Interviews
Better Clinical Hypothesis Generation
Increased Patient Satisfaction
Increased Patient Understanding And Recall
Improved Compliance And Disease Outcome
Decreased Medico Legal Complaints
Actual Savings In Time
More Structure And Control Of The Difficult
Consultation
2 DR. MOHAMED SALAH
03/06/1434
2
Impacts of Good Communication Skill
13/04/2013
However, the most important findings that have
frequently been reported on the impact of
communication are in the following aspects:
Effective Diagnosis & Treatment Outcome
Patient’s Adherence
Doctor’s Competence & Self-Assertion.
Patient’s Satisfaction.
3 DR. MOHAMED SALAH
Patient Satisfaction
13/04/2013
From a psychological perspective, there is two
type of patient’s satisfaction:
Cognitive Satisfaction: How satisfied is the
patient with their understanding of the diagnoses,
treatment, and prognoses. This is related to the
doctor’s Verbal Behavior.
Emotional Satisfaction: This is related to the
doctor’s non-verbal behavior. The ability to show
care and concern by tone of voice, eye gaze, facial
expression, body movement and posture
4 DR. MOHAMED SALAH
03/06/1434
3
INTERVIEWING AND COMMUNICATION
SKILLS
13/04/2013
CORE COMMUNICATION SKILLS: Core
communication skills covers three dimensions:
Doctor -patient interpersonal skills
Information gathering skills
Information giving skills and patient education
Advanced Communication Skills
Skills for motivating patient adherence to treatment
plans
Other applications of core communication skills in
specific situations (e.g., dealing with anger, dependent
personality dis., breaking bad news).
5 DR. MOHAMED SALAH
The LEARN Mnemonic
13/04/2013
LISTEN actively with respect
ELICIT the health beliefs of the patient
ASSESS priorities, values and supports
RECOMMEND a plan of action with adequate
explanation and understanding
NEGOTIATE by involving the patient in next
steps and decisions
6 DR. MOHAMED SALAH
03/06/1434
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The SCANS Mnemonic
S= Setting, Situation
C = Centeredness, Co-operation
A= Active listening, Assessment, Acknowledgement, Agreement
N = Negotiation
S= Summary, Safety Net
13/04/20137 DR. MOHAMED SALAH
C
L
A
S
S
Techniques - The CLASS System
Context (Physical Setting)
Listening Skills
Acknowledgement
Strategy
Summary
13/04/20138 DR. MOHAMED SALAH
03/06/1434
5
Context (Physical Setting)
Privacy
Eye Level - Even
Personal Space
Body Language
Relaxed
Eye Contact
13/04/20139 DR. MOHAMED SALAH
Context (Physical Setting)
13/04/201310 DR. MOHAMED SALAH
03/06/1434
6
Techniques - The CLASS System
Context (Physical Setting)
Listening Skills
Acknowledgement
Strategy
Summary
13/04/201311 DR. MOHAMED SALAH
Listening Skills
• Open Questions
• Facilitating
• Clarifying
• Time & Interruptions
13/04/201312 DR. MOHAMED SALAH
03/06/1434
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Open-Ended Questions
Questions that have many answers
Closed questions have a specific answer
Examples:
How are you?
“How can I help you?’ “And then what happened?’
Tell me about your pain.”
Serve as an invitation
Beware – Patient may ramble awhile
13/04/201313 DR. MOHAMED SALAH
Effective Communication:
Verbal Strategies
4/13/2013DR. MOHAMED SALAH KHALIL14
Open Questions
Elicit information
How would you describe
your relationship with
your parents?
Closed Questions
Gather specific
information
Do you have a good
relationship with your
parents?
Combining Open and Closed Questions
03/06/1434
8
Facilitating
Sending an “I’m with you” message
May encourage development of hope
Simple gestures or phrases:
Nodding, smiling
“Tell me more”
Uh-huh
Pausing appropriately
Repeating a keyword the patient uses
13/04/201315 DR. MOHAMED SALAH
Clarifying
Know exactly what the patient is saying
Examples:
“Let me see if I’ve got this straight…”
“So what you’re saying is…”
“Do you mean ____ or ___ ?”
Use a translator, social worker or other facilitator
13/04/201316 DR. MOHAMED SALAH
03/06/1434
9
Paraphrasing and Reflection
4/13/2013DR. MOHAMED SALAH KHALIL17
patient: Everything is boring. There’s nothing new
going on, nothing exciting. All my friends are
away. I wish I had money to do something
different.
Paraphrase: With your friends gone and no money
around, there is nothing for you to do right now.
Reflection: You feel bored with the way things are
for you right now.
WHAT ABOUT NON-VERBAL?
It’s not what you say - it’s the way that you say it!
There are several other positive non-verbals that can be
used to indicate we are listening supportively - often known
under the mnemonic S.O.L.E.R.
Sitting Square on to the patient with an Open position,
Leaning slightly forward with Eye contact in a Relaxed
posture.
The most important is eye contact followed by facial
expression and inflection of voice.
13/04/2013DR. MOHAMED SALAH18
03/06/1434
10
Time & Interruptions
Acknowledge that the patient is your primary
concern
Records/Pages & phone calls: defer or avoid
Clarify time constraints
Plan a continuation of the discussion
Don’t interrupt
13/04/201319 DR. MOHAMED SALAH
Acknowledgement
The Empathic Response
Touch
Normalize
13/04/201320 DR. MOHAMED SALAH
03/06/1434
11
13/04/2013
Empathy
• "Empathy means demonstrating an
understanding of the patient's pain and distress
while maintaining an objective and observant
stance."
Being Seen
Being Heard
Being Accepted
The Empathic Response
A verbal technique that acknowledges you have
heard the patient’s emotional content.
No requirement to feel the emotion.
Steps:
1. Identify the emotion – open-ended questions
2. Identify its cause
3. Respond in a way that shows you understand the
connection between 1 and 2
13/04/201322 DR. MOHAMED SALAH
03/06/1434
12
THE MNEMONIC “NURSE”
The Duke team uses the mnemonic “NURSE” to
label five types of continuer statements:
Name: State the patient's emotion
Understand: Empathize with and legitimize the
emotion
Respect: Praise the patient for strength
Support: Show support
Explore: Ask the patient to elaborate on the
emotion
13/04/2013DR. MOHAMED SALAH23
Empathy
Example:
“I understand that you are worried about the
consequences of your injury.”
Let the patient know that you understand his or her
problem as if it had oc-curred to you.
Support:
“It must have been a terrible experience for you”.
Let the patient know that you comprehend his or her
feelings.
Normalizing : Tell the patient that his response is
appropriate and normal
13/04/201324 DR. MOHAMED SALAH
03/06/1434
13
Touch
May be a very important part of your non-
verbal communication skills.
Helps the patient feel less isolated
Three rules:
1. Only touch a neutral area (hand or forearm)
2. Touch briefly, and see if the patient appreciates
it
3. Never to opposite sex
13/04/201325 DR. MOHAMED SALAH
Strategy: Creating the Plan
Think what is best medically
Assess the whole patient
Propose a strategy
Assess the patient’s response & modify accordingly
A reasonable plan the patient will follow is better
than an ideal plan the patient will ignore.
Any plan is far better than no plan.
13/04/201326 DR. MOHAMED SALAH
03/06/1434
14
Summary
Summarize main points
Any urgent questions?
Any thing else!
Plan next contact:
• Time
• Setting
13/04/201327 DR. MOHAMED SALAH
Core Communication Skills
A) INTERPERSONAL
13/04/2013
Non-verbal communication
Skills in non-verbal communication like eye contact, physical proximity,
and facial expression need to be improved to enhance patient’s
satisfaction and adherence to treatment. This should convey to the
patient that the Health practitioner is attentive and interested.
Avoid Overreacting
Some patients may appear demanding, dependent or even at times,
adversarial. It is the physician's responsibility to not overreact to these
situations. This can be achieved by establishing limitations (boundaries)
on what can be provided and suggesting appropriate ways for the
patients to contact them.
Establishing Boundaries
Frequent phone calls, unscheduled visits, and unrealistic expectations,
are ways in which some patients lose perspective of the shared
responsibility of their care. Doctors need to establish boundaries for
patients in a way that doesn't belittle them.
28 DR. MOHAMED SALAH
03/06/1434
15
13/04/2013
Core Communication Skills
Active listening: (Well-timed silence and eye
contact)// POSTURE, GESTURE, AND FACIAL
EXPRESSION ---- culturally acceptable
Empathy, respect, interest, warmth and support
(THESE ARE THE CORE FACTORS IN
RAPPORT BUILDING.-------
Language: Avoid medical jargon.
Non-verbal communication
Avoid Overreacting
Establishing Boundaries
Closing the interview
Core Communication Skills
13/04/2013
Information gathering skills
Using an appropriate balance of open to closed
questions
Silence You need to learn to use silence appropriately as a
way to encourage express themselves more fully, raise
difficult topics and remember important
Clarifying patient expectations about the consultation
Clarifying the information given by the patient
Sequencing of events
Directing the flow of information
Summarizing
30 DR. MOHAMED SALAH
03/06/1434
16
Information Giving Skills And Patient
Education
13/04/2013
Providing clear and simple information
Using specific advice with concrete examples.
Putting important things first. Research suggests that what is said first
is remembered.
Using repetition.
Summarizing.
Categorizing information to reduce complexity and aid recall.
Using tools.
Checking patient understanding of what has been said. Repeating
instructions, using diagrams, written instructions, and sometimes-
technical aids to explain difficult concepts are useful.
31 DR. MOHAMED SALAH
Advanced Communication Skills
13/04/2013
Skills for motivating patient adherence to treatment plans
The list below includes skills for the promotion of behaviour. Realistic compliance
with treatment plans may require patients to make significant changes in their diet,
lifestyle or daily routine on a short term or long term basis.
Providing a rationale for behavior change
Providing examples of role models
Allowing opportunities for verbal rehearsal of the details of the treatment
Feedback (positive reinforcement of constructive behaviour changes already
achieved since earlier consultations)
Finally, doctors should be aware about the clinical, communication and interpersonal
skills that are required when dealing with difficult patients, (e.g., overdependent,
dramatizing and exaggerating, aggressive, and antisocial personalities,).
32 DR. MOHAMED SALAH

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Doctor patient communication and relationship

  • 1. 03/06/1434 1 COMMUNICATION SKILLS: Doctor-Patient Communication and Relationship 13/04/2013 Dr. Mohamed Salah Khalil (Ph.D-Neuropsychology) Associate Professor-Consultant Clinical Psychologist Coordinator of Postgraduate Clinical Psychology Program 1 DR. MOHAMED SALAH What can studying communication skills offer us as medical practitioners 13/04/2013 Increased Doctor Job Satisfaction Decreased Conflict Within The Consultation More Accurate And Efficient Interviews Better Clinical Hypothesis Generation Increased Patient Satisfaction Increased Patient Understanding And Recall Improved Compliance And Disease Outcome Decreased Medico Legal Complaints Actual Savings In Time More Structure And Control Of The Difficult Consultation 2 DR. MOHAMED SALAH
  • 2. 03/06/1434 2 Impacts of Good Communication Skill 13/04/2013 However, the most important findings that have frequently been reported on the impact of communication are in the following aspects: Effective Diagnosis & Treatment Outcome Patient’s Adherence Doctor’s Competence & Self-Assertion. Patient’s Satisfaction. 3 DR. MOHAMED SALAH Patient Satisfaction 13/04/2013 From a psychological perspective, there is two type of patient’s satisfaction: Cognitive Satisfaction: How satisfied is the patient with their understanding of the diagnoses, treatment, and prognoses. This is related to the doctor’s Verbal Behavior. Emotional Satisfaction: This is related to the doctor’s non-verbal behavior. The ability to show care and concern by tone of voice, eye gaze, facial expression, body movement and posture 4 DR. MOHAMED SALAH
  • 3. 03/06/1434 3 INTERVIEWING AND COMMUNICATION SKILLS 13/04/2013 CORE COMMUNICATION SKILLS: Core communication skills covers three dimensions: Doctor -patient interpersonal skills Information gathering skills Information giving skills and patient education Advanced Communication Skills Skills for motivating patient adherence to treatment plans Other applications of core communication skills in specific situations (e.g., dealing with anger, dependent personality dis., breaking bad news). 5 DR. MOHAMED SALAH The LEARN Mnemonic 13/04/2013 LISTEN actively with respect ELICIT the health beliefs of the patient ASSESS priorities, values and supports RECOMMEND a plan of action with adequate explanation and understanding NEGOTIATE by involving the patient in next steps and decisions 6 DR. MOHAMED SALAH
  • 4. 03/06/1434 4 The SCANS Mnemonic S= Setting, Situation C = Centeredness, Co-operation A= Active listening, Assessment, Acknowledgement, Agreement N = Negotiation S= Summary, Safety Net 13/04/20137 DR. MOHAMED SALAH C L A S S Techniques - The CLASS System Context (Physical Setting) Listening Skills Acknowledgement Strategy Summary 13/04/20138 DR. MOHAMED SALAH
  • 5. 03/06/1434 5 Context (Physical Setting) Privacy Eye Level - Even Personal Space Body Language Relaxed Eye Contact 13/04/20139 DR. MOHAMED SALAH Context (Physical Setting) 13/04/201310 DR. MOHAMED SALAH
  • 6. 03/06/1434 6 Techniques - The CLASS System Context (Physical Setting) Listening Skills Acknowledgement Strategy Summary 13/04/201311 DR. MOHAMED SALAH Listening Skills • Open Questions • Facilitating • Clarifying • Time & Interruptions 13/04/201312 DR. MOHAMED SALAH
  • 7. 03/06/1434 7 Open-Ended Questions Questions that have many answers Closed questions have a specific answer Examples: How are you? “How can I help you?’ “And then what happened?’ Tell me about your pain.” Serve as an invitation Beware – Patient may ramble awhile 13/04/201313 DR. MOHAMED SALAH Effective Communication: Verbal Strategies 4/13/2013DR. MOHAMED SALAH KHALIL14 Open Questions Elicit information How would you describe your relationship with your parents? Closed Questions Gather specific information Do you have a good relationship with your parents? Combining Open and Closed Questions
  • 8. 03/06/1434 8 Facilitating Sending an “I’m with you” message May encourage development of hope Simple gestures or phrases: Nodding, smiling “Tell me more” Uh-huh Pausing appropriately Repeating a keyword the patient uses 13/04/201315 DR. MOHAMED SALAH Clarifying Know exactly what the patient is saying Examples: “Let me see if I’ve got this straight…” “So what you’re saying is…” “Do you mean ____ or ___ ?” Use a translator, social worker or other facilitator 13/04/201316 DR. MOHAMED SALAH
  • 9. 03/06/1434 9 Paraphrasing and Reflection 4/13/2013DR. MOHAMED SALAH KHALIL17 patient: Everything is boring. There’s nothing new going on, nothing exciting. All my friends are away. I wish I had money to do something different. Paraphrase: With your friends gone and no money around, there is nothing for you to do right now. Reflection: You feel bored with the way things are for you right now. WHAT ABOUT NON-VERBAL? It’s not what you say - it’s the way that you say it! There are several other positive non-verbals that can be used to indicate we are listening supportively - often known under the mnemonic S.O.L.E.R. Sitting Square on to the patient with an Open position, Leaning slightly forward with Eye contact in a Relaxed posture. The most important is eye contact followed by facial expression and inflection of voice. 13/04/2013DR. MOHAMED SALAH18
  • 10. 03/06/1434 10 Time & Interruptions Acknowledge that the patient is your primary concern Records/Pages & phone calls: defer or avoid Clarify time constraints Plan a continuation of the discussion Don’t interrupt 13/04/201319 DR. MOHAMED SALAH Acknowledgement The Empathic Response Touch Normalize 13/04/201320 DR. MOHAMED SALAH
  • 11. 03/06/1434 11 13/04/2013 Empathy • "Empathy means demonstrating an understanding of the patient's pain and distress while maintaining an objective and observant stance." Being Seen Being Heard Being Accepted The Empathic Response A verbal technique that acknowledges you have heard the patient’s emotional content. No requirement to feel the emotion. Steps: 1. Identify the emotion – open-ended questions 2. Identify its cause 3. Respond in a way that shows you understand the connection between 1 and 2 13/04/201322 DR. MOHAMED SALAH
  • 12. 03/06/1434 12 THE MNEMONIC “NURSE” The Duke team uses the mnemonic “NURSE” to label five types of continuer statements: Name: State the patient's emotion Understand: Empathize with and legitimize the emotion Respect: Praise the patient for strength Support: Show support Explore: Ask the patient to elaborate on the emotion 13/04/2013DR. MOHAMED SALAH23 Empathy Example: “I understand that you are worried about the consequences of your injury.” Let the patient know that you understand his or her problem as if it had oc-curred to you. Support: “It must have been a terrible experience for you”. Let the patient know that you comprehend his or her feelings. Normalizing : Tell the patient that his response is appropriate and normal 13/04/201324 DR. MOHAMED SALAH
  • 13. 03/06/1434 13 Touch May be a very important part of your non- verbal communication skills. Helps the patient feel less isolated Three rules: 1. Only touch a neutral area (hand or forearm) 2. Touch briefly, and see if the patient appreciates it 3. Never to opposite sex 13/04/201325 DR. MOHAMED SALAH Strategy: Creating the Plan Think what is best medically Assess the whole patient Propose a strategy Assess the patient’s response & modify accordingly A reasonable plan the patient will follow is better than an ideal plan the patient will ignore. Any plan is far better than no plan. 13/04/201326 DR. MOHAMED SALAH
  • 14. 03/06/1434 14 Summary Summarize main points Any urgent questions? Any thing else! Plan next contact: • Time • Setting 13/04/201327 DR. MOHAMED SALAH Core Communication Skills A) INTERPERSONAL 13/04/2013 Non-verbal communication Skills in non-verbal communication like eye contact, physical proximity, and facial expression need to be improved to enhance patient’s satisfaction and adherence to treatment. This should convey to the patient that the Health practitioner is attentive and interested. Avoid Overreacting Some patients may appear demanding, dependent or even at times, adversarial. It is the physician's responsibility to not overreact to these situations. This can be achieved by establishing limitations (boundaries) on what can be provided and suggesting appropriate ways for the patients to contact them. Establishing Boundaries Frequent phone calls, unscheduled visits, and unrealistic expectations, are ways in which some patients lose perspective of the shared responsibility of their care. Doctors need to establish boundaries for patients in a way that doesn't belittle them. 28 DR. MOHAMED SALAH
  • 15. 03/06/1434 15 13/04/2013 Core Communication Skills Active listening: (Well-timed silence and eye contact)// POSTURE, GESTURE, AND FACIAL EXPRESSION ---- culturally acceptable Empathy, respect, interest, warmth and support (THESE ARE THE CORE FACTORS IN RAPPORT BUILDING.------- Language: Avoid medical jargon. Non-verbal communication Avoid Overreacting Establishing Boundaries Closing the interview Core Communication Skills 13/04/2013 Information gathering skills Using an appropriate balance of open to closed questions Silence You need to learn to use silence appropriately as a way to encourage express themselves more fully, raise difficult topics and remember important Clarifying patient expectations about the consultation Clarifying the information given by the patient Sequencing of events Directing the flow of information Summarizing 30 DR. MOHAMED SALAH
  • 16. 03/06/1434 16 Information Giving Skills And Patient Education 13/04/2013 Providing clear and simple information Using specific advice with concrete examples. Putting important things first. Research suggests that what is said first is remembered. Using repetition. Summarizing. Categorizing information to reduce complexity and aid recall. Using tools. Checking patient understanding of what has been said. Repeating instructions, using diagrams, written instructions, and sometimes- technical aids to explain difficult concepts are useful. 31 DR. MOHAMED SALAH Advanced Communication Skills 13/04/2013 Skills for motivating patient adherence to treatment plans The list below includes skills for the promotion of behaviour. Realistic compliance with treatment plans may require patients to make significant changes in their diet, lifestyle or daily routine on a short term or long term basis. Providing a rationale for behavior change Providing examples of role models Allowing opportunities for verbal rehearsal of the details of the treatment Feedback (positive reinforcement of constructive behaviour changes already achieved since earlier consultations) Finally, doctors should be aware about the clinical, communication and interpersonal skills that are required when dealing with difficult patients, (e.g., overdependent, dramatizing and exaggerating, aggressive, and antisocial personalities,). 32 DR. MOHAMED SALAH