COMMUNICATION SKILLS

FOR HEALTHCARE PROVIDERS - An Overview

Prof. K. R. Sethuraman. MD, PGDHE,

(Formerly) JIPMER, Pondicherry. 605006. India.

Dean, AIMST University, Bedong, 08100, Malaysia.

Words of comfort, skillfully administered are the oldest therapy known to man. - Louis Nizer

Introduction

It is paradoxical that, at a time of Internet based global communication and �Cyber medicine," we are faced with breakdown in communication between patients and doctors. Increasing patient dissatisfaction, rising numbers of complaints and claims for malpractice and abandonment of conventional medicine for unproven alternatives are the major problems today. In a nation-wide household telephonic survey in US, physicians were rated lowest on communication skills and on attention to the costs. A similar survey among the physicians showed that they too rated their training the lowest in these same areas.

It is apparent that lack of proper training is why the public need for adequate information is not fully met by the doctors. The Toronto Consensus of 1991 stated that communication problems in clinical practice are common and that the quality of communication is related to health outcome for patients but that traditional medical education is ineffective at teaching communication. Teaching communication skills should be included at all levels of medical education and, even more importantly, should be a mandatory element of the medical curriculum and programmes of continuing medical education.

Ten Attributes of Effective Communication

Having never learnt the science of communication skills formally, most medical educators follow an intuitive approach to communicating with their patients. Later, they become positive or negative or mixed role models for their students to learn from. This can be corrected only when a critical mass of medical educators learn the great advances in communication science and apply it in clinical practice and in formal training of their students.

It is never too late to start. Identifying the top ten attributes of effective medical communication is a good point to start learning (1). They are listed below with examples from type-1 diabetes mellitus -

1. Accuracy: Valid content presented accurately. An example - informing a newly diagnosed type-1 diabetic about the nature of the disease and its therapy.

2. Availability: The message is available to the end user at the time of its need. An example - the patient should have appropriate information about self-injections at the time and the place of the act, i.e., at home and before breakfast. How can the doctor ensure it? Written information, like a handout is a good solution.

3. Timeliness: The message is conveyed when the audience is in need of and most receptive to it. The preceding example applies to this too.

4. Understandability: Follows the norms of clarity, choice of words appropriate for the patient. An example - the language used for an illiterate with diabetes should be far different from that used for a college student.

5. Culturally competent: The message, the medium and the mode of delivery are appropriate for the culture of the target group. An example - Misinformed diabetics are known to stop animal derived insulin on religious grounds. When talking about insulin, explain to a Hindu patient that non-bovine insulin is available and similarly tell a Muslim patient that non-porcine insulin is available.

6. Reliability: The patient feels he/she can rely on the source, and the message. This quality is fostered by rapport building, adequate knowledge of the subject and keenness shown by the doctor in clarifying the doubts of the patient.

7. Evidence based: The message and the communication method are evidence based. An example - Tell a patient reluctant to start on lifelong insulin injections why he/she should adhere to the advice using facts and figures in a caring - not scaring - way!

8. Balance: The presentation is balanced and covers the felt need vs. real need, benefit and risk, cost and benefit, natural history and outlook after intervention etc. An example - In real life practice, it may not be feasible for many a patient to follow the best possible anti-diabetic treatment for various non-medical reasons. While giving advice, a caring doctor should take the life-world of the patient into consideration (2).

9. Consistency: The message is internally consistent over time and externally consistent with other sources of unbiased information. Professional attitude and competence are two basic pre-requisites to achieve consistency. Listening to a well seasoned professional giving expert advice should be like listening to a live performance of a maestro.

10. Repetition: Repeated delivery to reinforce the message. �Tell them what you are going to say; say it; tell them what you have just said.� Important information should be introduced, elaborated upon and summarised thereby reinforcing the main points. A still more effective way is to get a feedback - ask the patients to repeat what you have just told them.

Doctor-Patient misunderstanding

Misunderstanding is the commonest cause of medical litigation (1, 2). Awareness of common reasons for doctor-patient misunderstanding may help one to nip the problem in the bud (3).

1. Patient information unknown to doctor

An easy example: not knowing that the female patient being prescribed a quinolone for �Honey moon cystitis� could be pregnant. Remember, by the time the next menstrual period is missed, she would have already Accuracy: Valid content presented accurately. An example - informing a newly diagnosed type-1 diabetic about the nature of the disease and its therapy.

2. Doctor information unknown to patient

In the preceding example, if the doctor had informed the patient that quinolone is a good choice for a non-pregnant woman, she might have informed him/her that she is not currently following any birth control measures and may even be pregnant.

3. Conflicting information

This may be due to doctor-to-doctor variation or mismatch between verbal and non-verbal messages. Two doctors in the same unit or from different specialities may give different views on diagnosis, treatment or prognosis confusing patients and their relatives. A single doctor can cause similar confusion if the verbal output (�You are doing fine�) does not match the non-verbal output as body language (signs of nervousness of deception). Body language is subconscious and unless one is a well-trained actor, reveals the truth. Patients instinctively believe doctors� body language more than their spoken words.

4. Disagreement about attribution of causation or nature of illness

This is known as the �knowledge gap� between doctors and patients. Patients see their illness from their life-world: �Why me? Why now? How will it affect my life?� are their main worries. So non-medical explanations based on astrology, religion, faith etc seem perfectly logical for them. Meanwhile, doctors are concerned about bio-medical questions like, �What is the diagnosis? How can I help?� For example, while the doctor struggles to determine the cause of stroke in a young patient, he may �know� that loss of power in his right hand is punishment for stealing money from his mother�s cash box.

5. Failure of communication about doctor's decision

For medical reasons, doctors make several decisions for their patients based on implied trust. But if the outcome is unacceptable to the patients or their relatives, they may accuse the doctor of �playing God.� In the Internet based information era, where any one can access latest medical information in an instant, the doctors need to reorient themselves to shared decision making.

6. Relationship factors

Also known as �Dysfunctional Dyad,� this refers to a vitiated relationship between a doctor and a patient. In this situation, it is very difficult to treat a patient. The doctor concerned should have capacity to negotiate with the hostile, reticent or paranoid patient and take him or her back to a fiduciary relationship based on trust. There are advanced skills like �mental judo� to achieve this transition (1, 2).

Good Doctor-Patient Relationship

It is difficult to define this complex relationship. According to many studies, the necessary ingredients for goodness are:

Mutual trust

Honesty, and devotion to patient-care

Social orientation

Non-judgmental attitude

Friendliness and empathy

Conveying interest and a desire to help

Giving patients compliments

Making inoffensive personal remarks, laughing or making jokes

Being multi-facetted and multi-dimensional, doctor-patient relationship is one of the most complex social relationships. If a doctor and a patient are glad to see each other in a clinical dyad, then it marks a satisfactory relationship.

Teaching and Learning of Communication skills (1, 6)

It is a distinct Art to talk Medicine in the language of non-medical man. - E. H. Goodman

With proper teaching learning, it is not difficult to acquire communication skills. One should realise that communication is not merely as a set of skills and that communicating well is not just a matter of learning discrete pieces of surface behaviour. It is an observable manifestation of appropriate attitude, which may be much more difficult to explicitly convey and instantly acquire. It requires development of appropriate professional and ethical attitude as well as cultivation of relevant behavioural skills.

Appropriate methods for imparting these skills, in order of increasing difficulty and effectiveness include-

Case study - It is relatively easy to collect clinical vignettes, which are of educational value in the area of doctor-patient communication. Students can peruse handouts of such case studies and learn the dos and don�ts.

Narrative - This refers to vignettes presented by a seasoned teacher to a group of students, who then react to the narrative and also seek clarifications on communication skills. This is a lively and interactive method of teaching and learning. It does not require equipments or high tech gadgets. However, a committed and experienced teacher is a must.

Video trigger - Vignettes can be acted out as skits and recorded on videotape. These skits are shown to students and meant to provoke them and trigger a group discussion. The video-skits can be also culled from small parts of films like Anand (for topics like cancer, dying patient, empathy, etc) or Patch Adams (patient-orientation, trust-building, caring etc). A moderator is required to initiate the session and conduct the group discussion after each trigger.

Role-play - If actors are available, (from among the staff and students) then live role-play can be arranged rather than the video triggers. The impact is more provided and one does not need the gadgets for recording and playing back the video skits. Like the previous methods, role-play also needs group discussion following each skit. The discussion also �debriefs� the role-players and brings them back to their usual selves.

Simulation role-play - In contrast to the previous method, which is merely a passive observation of role-plays, in simulation method, each student by turns, is involved in the role-play. They may play the role of a doctor, a patient or a caretaker of the patient, depending on the skit. Each student is actively involved in the communication process and acquires skills by actual experience and also by feedback given by the observers who use a checklist and rate each performance. This is time consuming and need a lot of preparation but gives individual learning experience.

Simulation with video recording and corrective feedback - This is similar to the previous method with the addition of video recording of the performance of every student in the simulation role-play. The feedback session is very effective as the student can observe his/her own action objectively and correct his/her mistakes. This is the most effective teaching-learning method but needs a well-equipped communication skills laboratory.

Standardised patient (SP) encounter - It should be possible in any teaching unit to collect a few patients willing to spend some time in helping students to learn new skills. The moderator has to standardise the patient first by training them to give consistent responses in every encounter with a student. Individually each student is allowed to communicate with such a patient on specific areas like eliciting sexual history, advising to curb drinking or give up smoking etc. Using a checklist, an observer rates the performance and gives a corrective feedback. If the SP is educated and observant, even he/she can be trained to give a useful feedback to the students. In Indian setting, this is more feasible than video-recorded feedback and is a very effective alternative.

Organising a Module on Communication Skills

Workshop method may be the most suitable method as it is flexible, practical problem oriented and can mix and match several of the methods discussed above. The workshop can include any or all of the following learning units related to doctor-patient communication and prudent physician behaviour1, 3.

Information sharing: models & methods (1, 4, 5)

Questioning skills

Listening skills

Answering skills

Non-verbal behaviour

Rapport building skills

Counselling skills

Skills of persuasion

Reassurance of the worried well

Talking with the parents of young patients

Dealing with the elderly

Communicating prognosis, hope and risk

Dealing with chronic diseases and dying

Integrating Religion, Faith and Culture in health care

Non-compliance and deception

Dealing with patient dissatisfaction

Negotiating skills

Patient-centeredness in Decision making

Prudent and �Mindful� practice

Effective use of Telecommunication in health care

Formal evaluation may not be possible within the existing curriculum for the post-graduate studies. However, for undergraduates, it is easily possible to allot some weightage in the internal assessment for proficiency in these skills. Objective structured clinical examination (OSCE) may be an objective method of evaluating these skills (7). Simulated patients (role-players) or standardised patients (real patients trained to give consistent responses) could be used as subjects for OSCE.

An example of a successful module

At JIPMER, Pondicherry, an annual orientation programme is being conducted for interns since 1993 on �Quality Care.� Modules on oral and written communication and on medical ethics are incorporated in this 3-day workshop conducted after one month of internship. The art and practice of oral communication are conveyed in two parts over three hours.

The first part is on �Patient personality types� and focuses on their recognition from non-verbal and verbal output. This session lasts 90 minutes and is based on one-minute skits done as live or video role-plays. Each skit focuses on a type of personality. It acts as a trigger to initiate discussion into the unique nature of such a personality and how a doctor should handle them in clinical practice. Up to eight triggers are shown during this session. A faculty from management school also takes part in moderating the discussion and in giving scientific input.

The second part is on �Seven common errors in clinical practice.� This is again based on seven one-minute skits shown live or as a video record. Each skit depicts a common communication error committed by novices in the field or by negative role models. Each skit triggers a discussion on what went wrong and a demonstration of better ways of communication.

A session on medical ethics complements the former by shaping the attitudes of the impressionable interns. It is an intense session in workshop mode. Six to nine case studies highlighting important aspects of medical ethics are thrashed out in small group discussions. This is followed by a plenary session, wherein a member of each group presents the group deliberations to the whole audience. Ten faculty members guide the whole process with the help of a faculty from the law college who gives input on legal medicine.

Since 1993, eight batches of interns, totalling more than 500 have undergone this training. Their unanimous (100%) feedback has been to continue this �eye-opener� programme for future batches and that the session on oral communication was quite useful and relevant to their needs.

Summary

Health care is still based on fiduciary relationship that is fostered by sharing of ideas and feelings. Educators can and should empower the next generation of medical professionals by imparting effective training to them on communication skills and appropriate behaviour. It is obvious that a brief overview like this cannot mention all the details needed to prepare a training module on communication and behavioral skills. The bibliography appended below lists some very useful resources for preparing such a module.

References

1. Sethuraman KR. Communication Skills in Clinical Practice (Doctor-Patient communication), 2001. Jaypee Brothers, Post Box 7193, New Delhi -110002. India

2. Sethuraman KR. Trick or Treat - a survival guide to healthcare, 2000. EQUIP Society, P.B. No 8, Pondicherry - 605006. India

3. Communication - oral and written, in - Interns� Orientation Manuals (1993 to 2001), National Teacher Training Centre (NTTC), JIPMER., Pondicherry 605006. India.

4. Siegfried Meryn, Improving doctor-patient communication Not an option, but a necessity (Editorial) BMJ 1998; 316:1922-1930.

5. Kaplan SH, Greenfield S, Gandek B, Rogers WH, Ware JE. Characteristics of physicians with participatory decision-making styles. Ann Intern Med 1996; 124:497-504.

6. Sethuraman KR, Santosh Kumar (1997) - Implementing innovations in Clinical Skills Training. National Teacher Training Centre (NTTC), JIPMER, Pondicherry. 605006 - India.

7. Sethuraman KR. Objective Structured Clinical Examination (OSCE), 2000. Jaypee Brothers, Post Box 7193, New Delhi -110002. India