Basic communication skillsBasic communication skills

Herni SupraptiHerni Suprapti

the factors that influence the factors that influence

doctor-patient communicationdoctor-patient communication

some bad news some bad news

a relative has just dieda relative has just died failed some examsfailed some exams

First First the setting or situation is clearly the setting or situation is clearly

important important

SecondSecond how you feel at the time will how you feel at the time will

influence what you say, and so influence what you say, and so will the attitude of the other will the attitude of the other person person

The factors (patients) will The factors (patients) will influence how communicateinfluence how communicate

PersonalityPersonality UpbringingUpbringing Social classSocial class Ethnic Ethnic Cultural background Cultural background

Reactions to illness Reactions to illness include include

DenialDenial (Tidak Percaya) (Tidak Percaya) AngerAnger (Marah) (Marah) AnxietyAnxiety (Cemas) (Cemas) DepressionDepression (Depresi) (Depresi)

Factors influence Factors influence doctor-doctor-patientpatient communication communication

Patient-related factorsPatient-related factors

Doctor-related factorsDoctor-related factors

The interview settingThe interview setting

Patient-related factorsPatient-related factors

Physical symptomsPhysical symptoms Psychological factors related to Psychological factors related to

illness and medical care (e.g. illness and medical care (e.g. anxiety, depression, anger, denial)anxiety, depression, anger, denial)

Previous experience of medical carePrevious experience of medical care Current experience of medical careCurrent experience of medical care

Doctor-related factorsDoctor-related factors

Training in communication skillsTraining in communication skills Self-confidence in ability to Self-confidence in ability to

communicatecommunicate PersonalityPersonality Physical factors (e.g. tiredeness)Physical factors (e.g. tiredeness) Psychological factors (e.g. Psychological factors (e.g.

anxiety)anxiety)

The interview setting : The interview setting : requirementsrequirements

PrivacyPrivacy

Comfortable surroundingsComfortable surroundings

An appropriate seating An appropriate seating arrangementarrangement

Other factors that must be Other factors that must be taken into account are :taken into account are : the patient’s beliefs about the patient’s beliefs about

health and illnesshealth and illness the problem they wish to discussthe problem they wish to discuss their expectations of what the their expectations of what the

doctor will do (based on previous doctor will do (based on previous experience)experience)

how they perceive the role of the how they perceive the role of the doctordoctor

Doctor-related factorsDoctor-related factors medical studentmedical student doctordoctor easier than others to emphathise easier than others to emphathise

and communicate with patientsand communicate with patients other factors influence our other factors influence our

behaviour during a consultation behaviour during a consultation (Table 2.1)(Table 2.1)

medical student medical student

difficult initially when difficult initially when interviewing patients who are interviewing patients who are

much older than yourselfmuch older than yourself sensitive issuess such as sexual sensitive issuess such as sexual

behaviour are involvedbehaviour are involved

have less to give particular have less to give particular patientpatient

a medical student just before a medical student just before finalsfinals

a junior doctor at the end of a a junior doctor at the end of a long shiftlong shift

a GP who has already seen two-a GP who has already seen two-dozen patients earlier in the dozen patients earlier in the morningmorning

impair communicationimpair communication

TirednessTiredness

AnxietyAnxiety

Preoccupation with other Preoccupation with other concernsconcerns

The setting of the The setting of the interviewinterview Most consultations take place in Most consultations take place in

a hospital warda hospital ward the outpatient clinicthe outpatient clinic the GP’s surgerythe GP’s surgery

Privacy is essensial Privacy is essensial

The setting of the The setting of the interviewinterview A patient in a hospital bed A patient in a hospital bed

sensitive information sensitive information Mrs Smith in the bed next door can Mrs Smith in the bed next door can

hear every word through the curtainshear every word through the curtains

the patient can be moved the patient can be moved avoid interruptionsavoid interruptions LightingLighting Temperature Temperature

arrangement of seatsarrangement of seats

can influence how people can influence how people communicate with each other communicate with each other and and

give clues to how they perceive give clues to how they perceive their own and each other’s roles their own and each other’s roles in the encounterin the encounter

outpatient clinic / GP’s outpatient clinic / GP’s consulting roomconsulting room chairs and desk or a tablechairs and desk or a table

three possible ways of arranging three possible ways of arranging the seatingthe seating

Arrangement (a)Arrangement (a)

patient and doctor facing each patient and doctor facing each other across a deskother across a desk

is unlikely to make the patient is unlikely to make the patient feel at ease or facilitate feel at ease or facilitate discussiondiscussion

the doctor may feel in control of the doctor may feel in control of the interviewthe interview

Arrangements (b) and (c)Arrangements (b) and (c)

more informalmore informal

more likely to facilitate good more likely to facilitate good communicationcommunication

the distance between the the distance between the interviewer & the patientinterviewer & the patient Placing seats Placing seats

too closetoo close too fartoo far

4-9 feet4-9 feet

distance may change during the distance may change during the course of the interviewcourse of the interview

in a hospital bedin a hospital bed

standing over a patientstanding over a patient

draw up a chair so that you are draw up a chair so that you are on the on the same levelsame level as the patient as the patient

Beginning an interviewBeginning an interview

what made you feel at what made you feel at ease, you might have ease, you might have included :included : a comfortable settinga comfortable setting being greeted by name and a handshakebeing greeted by name and a handshake being shown where to sitbeing shown where to sit the interviewers introducing themselves the interviewers introducing themselves

and explaining the procedureand explaining the procedure an easy first questionan easy first question the interviewer appearing interested in the interviewer appearing interested in

your remarksyour remarks

An An unsatisfactoryunsatisfactory beginningbeginning is is likely to lead to an likely to lead to an unsatisfactoryunsatisfactory consultationconsultation

as the following case illustratesas the following case illustrates

How not to begin an How not to begin an interviewinterview

Mrs Francis, a shop assistant Mrs Francis, a shop assistant aged 31, attended medical aged 31, attended medical outpatients at her local hospitaloutpatients at her local hospital

Here is her story :Here is her story :

““When I went into the room which was big When I went into the room which was big and bare I felt lost. I didn’t know where to and bare I felt lost. I didn’t know where to sit, the doctor had his head down and was sit, the doctor had his head down and was writing, the nurse was on the telephone writing, the nurse was on the telephone and there were some medical students and there were some medical students talking to each other. I waited around and talking to each other. I waited around and wanted to run out the door. After what wanted to run out the door. After what seemed like ages the doctor told me to sit seemed like ages the doctor told me to sit down and asked what was wrong. I didn’t down and asked what was wrong. I didn’t know his name and I’m not sure that he know his name and I’m not sure that he knew mine, I’d been thinking about my knew mine, I’d been thinking about my problems and what I wanted to tell the problems and what I wanted to tell the doctor – but I forgot it all – he didn’t seem doctor – but I forgot it all – he didn’t seem very interested anyway. Hope I don’t have very interested anyway. Hope I don’t have to go again.”to go again.”

what was wrong with the way this what was wrong with the way this interview was conductedinterview was conducted

help the patient feel at ease, and help the patient feel at ease, and begin to build up a relationship begin to build up a relationship

that enables them to share the that enables them to share the story of their illness with you. story of their illness with you.

Beginning the interview involves Beginning the interview involves greeting the patient, introducing greeting the patient, introducing yourself and orientating the patient yourself and orientating the patient (Table 2.2).(Table 2.2).

Guidelines for Guidelines for conducting an interviewconducting an interview

Beginning the interviewBeginning the interview

The main part of the interviewThe main part of the interview

Ending the interviewEnding the interview

Beginning the interviewBeginning the interview Greet the patient by name (“Good Greet the patient by name (“Good

morning Mr Ricardson”) and shake morning Mr Ricardson”) and shake handshands

Ask the patient to sit downAsk the patient to sit down Introduce yourself (“I am Judy William, Introduce yourself (“I am Judy William,

as a medical student”)as a medical student”) Explain the purpose of the interview Explain the purpose of the interview

(“I would like to find out about your (“I would like to find out about your present problem”)present problem”)

Say how much time is availableSay how much time is available Explain the need to take notes and ask Explain the need to take notes and ask

if this is acceptableif this is acceptable

The main part of the The main part of the interviewinterview Maintain a positive atmosphere, warm manner, Maintain a positive atmosphere, warm manner,

good eye contactgood eye contact Use open questions at the beginningUse open questions at the beginning Listen carefullyListen carefully Be alert and responsive to verbal and non-Be alert and responsive to verbal and non-

verbal cuesverbal cues Facilitate the patient both verbally (“Tell me Facilitate the patient both verbally (“Tell me

more”) and non-verbally (using posture and more”) and non-verbally (using posture and head nods)head nods)

Use specific (closed) questions when Use specific (closed) questions when appropriateappropriate

Clarify what the patient has told youClarify what the patient has told you Encourage the patient to be relevantEncourage the patient to be relevant

Ending the interviewEnding the interview

Summarise what the patient has Summarise what the patient has told you and ask if your told you and ask if your summary is accuratesummary is accurate

Ask if they would like to add Ask if they would like to add anythinganything

Thank the patient Thank the patient

The main part of the The main part of the interviewinterview

QuestioningQuestioning ListeningListening Facilitating Facilitating

are three of the key skills that are three of the key skills that enable us to communicate enable us to communicate effectively with otherseffectively with others

Asking questionsAsking questions

the the purposespurposes of interviewing a of interviewing a patient is to patient is to obtain informationobtain information about the condition for which about the condition for which they are seeking helpthey are seeking help

The information must be The information must be accurateaccurate, , completecomplete and as and as relevantrelevant as possible as possible

medical students & doctors medical students & doctors often :often : ask too many ask too many questions and questions and do do

not allownot allow the patient to tell their the patient to tell their story in their own wordsstory in their own words

ask questions that are ask questions that are too longtoo long, , too complicated and confusingtoo complicated and confusing

ask questions in such a way that ask questions in such a way that they may bias the answers given they may bias the answers given

ignore questions that patients ignore questions that patients may askmay ask

So it must be concluded that So it must be concluded that asking questions is a valuable asking questions is a valuable skill that needs to be learntskill that needs to be learnt

Open and closed questionsOpen and closed questions

Open questionsOpen questions

obtain a great deal of information and obtain a great deal of information and also allows the patient to tell their own also allows the patient to tell their own storystory

sould be used as much as possible, sould be used as much as possible, particularly at the start of the interviewparticularly at the start of the interview

e.g. ‘would you please tell me how you e.g. ‘would you please tell me how you have been feeling in the past few days?’ have been feeling in the past few days?’

closed questionsclosed questions

Asking spesific (i.e. closed) Asking spesific (i.e. closed) questions gives the patient little questions gives the patient little choice in the way they answer and choice in the way they answer and ussually elicits a ‘yes’ or a ‘no’ussually elicits a ‘yes’ or a ‘no’

‘‘Have you been feeling unwell Have you been feeling unwell today?’today?’

Case example 2.2Case example 2.2

A patient’s response to open and A patient’s response to open and closed questionsclosed questions

Mr Clark is an accountant aged Mr Clark is an accountant aged 47 years. 47 years.

He comes to the accident and He comes to the accident and emergency department following emergency department following an attack of the chest pain. an attack of the chest pain.

He is seen first by Dr Yated :He is seen first by Dr Yated :

Dr YatesDr Yates I see from your notes that you have had some chest I see from your notes that you have had some chest

pain. Do you still have the pain ?pain. Do you still have the pain ? Mr ClarkMr Clark

No, not nowNo, not now Dr YatesDr Yates

Was it tight or dull ?Was it tight or dull ? Mr ClarkMr Clark

It seemed a very dull painIt seemed a very dull pain Dr YatesDr Yates

Did it go down your arm ?Did it go down your arm ? Mr ClarkMr Clark

No, I don’t think soNo, I don’t think so Dr YatesDr Yates

Did it get worse when you exercise ?Did it get worse when you exercise ? Mr ClarkMr Clark

No, it didn’tNo, it didn’t

Mr Clark is seen by Dr Mr Clark is seen by Dr Vale :Vale : Dr ValeDr Vale

I understand that you have had pain. Would you I understand that you have had pain. Would you please tell me more about it ?please tell me more about it ?

Mr ClarkMr Clark Well, it was in my chest and it came on when I was Well, it was in my chest and it came on when I was

sitting at my desk. It was a funny dull pain that sitting at my desk. It was a funny dull pain that stayed in the middle of my chest. I’ve had it a few stayed in the middle of my chest. I’ve had it a few times recently, always when I’m at worktimes recently, always when I’m at work

Dr ValeDr Vale Can you tell me what brings it on ?Can you tell me what brings it on ?

Mr ClarkMr Clark Well, I was thinking about that. I’ve been very Well, I was thinking about that. I’ve been very

busy at work recently, and it seems to happen busy at work recently, and it seems to happen when I feel worried about somethingwhen I feel worried about something

the the advantagesadvantages of using open of using open questions and questions and

the the disadvantagesdisadvantages of closed of closed questionsquestions

Dr Vale obtained considerably Dr Vale obtained considerably more informationmore information by using open by using open questions than Dr Yates, who questions than Dr Yates, who used closed questionsused closed questions

open style question is open style question is preferable because :preferable because : more relevant information can be more relevant information can be

obtained in a given timeobtained in a given time the patient feels more involved in the patient feels more involved in

the interviewthe interview the patient can express all the the patient can express all the

concern and anxieties about their concern and anxieties about their problems; these may be missed if problems; these may be missed if closed questions are asked.closed questions are asked.

open questions : some open questions : some disadvantagesdisadvantages

the interview may take longer the interview may take longer and be more difficult to controland be more difficult to control

some of the information may not some of the information may not be relevantbe relevant

recording answers may be more recording answers may be more difficultdifficult

closed style of questioning :closed style of questioning : the information obtained is the information obtained is

restricted to the questions askedrestricted to the questions asked the interview is controlled by the the interview is controlled by the

interviewer who decides the interviewer who decides the content of the questionscontent of the questions

the interviewer has little the interviewer has little opportunity to express their opportunity to express their concern and feelings. This may concern and feelings. This may make them feel frustatedmake them feel frustated

Closed questionClosed question

obtain specific information that the obtain specific information that the patient has not given patient has not given

when the patient is shy or withdrawnwhen the patient is shy or withdrawn when it is necessary to obtain a when it is necessary to obtain a

limited amount of factual limited amount of factual information in a limited period of information in a limited period of timetime painful arm after a fallpainful arm after a fall

Probing questionsProbing questions

help a patient to think more help a patient to think more clearly about an answer they clearly about an answer they have givenhave given

Probing questions may be Probing questions may be used to :used to : Clarify : What do you mean by Clarify : What do you mean by

that ?that ? Justify : What makes you think Justify : What makes you think

that ?that ? Check accuracy : You definitely Check accuracy : You definitely

took three tablets a day ?took three tablets a day ?

Questions to be avoidedQuestions to be avoided

Complex questions Complex questions Leading questionsLeading questions

The questions should be The questions should be easily understood easily understood asked in such a way that does not asked in such a way that does not

influence the patient’s responseinfluence the patient’s response

Complex questionsComplex questions

confuse both the patient and the confuse both the patient and the interviewerinterviewer

Ex : ‘Did your vomiting start Ex : ‘Did your vomiting start yesterday or today and have you yesterday or today and have you had diarrhoea?’ had diarrhoea?’

only one part of the question only one part of the question would be answeredwould be answered

Leading questionsLeading questions

the person responding to give the person responding to give the answer that the interviewer the answer that the interviewer expects or wantsexpects or wants

3types of leading 3types of leading questionquestion ConversationalConversational : :

to open or stimulate conversationto open or stimulate conversation e.g. ‘Aren’t we having awful weather this e.g. ‘Aren’t we having awful weather this

year?’.year?’. SimpleSimple : :

influence the patient to agree with the influence the patient to agree with the interviewer’s viewpoint and should not be interviewer’s viewpoint and should not be usedused

e.g. ‘You don’t sleep well do you?’.e.g. ‘You don’t sleep well do you?’. SubtleSubtle : :

to influence the repondentto influence the repondent should be avoidedshould be avoided

the wording of a question can the wording of a question can influence the answerinfluence the answer

a study of the frequency of a study of the frequency of headaches in a group of headaches in a group of individualsindividuals

‘‘Do you get headaches Do you get headaches frequently and, if so, how often?’ frequently and, if so, how often?’ the average response was 2.2 the average response was 2.2

headaches per week. headaches per week.

‘‘Do you get headaches Do you get headaches occasionally and, if so, how occasionally and, if so, how often?’ often?’ the average reponse was 0.7 the average reponse was 0.7

headache per week.headache per week.

ListeningListening

patients appreciate and respons patients appreciate and respons positivelypositively

is one of the most obvious is one of the most obvious components of the communication components of the communication processprocess

active or effective listening is one of active or effective listening is one of the most difficult skills to acquirethe most difficult skills to acquire

The first step is receiving the The first step is receiving the message from the other person.message from the other person.

listeninglistening Listening involves Listening involves

receiving informationreceiving information being ‘in tune’ with the speaker being ‘in tune’ with the speaker responding appropriatelyresponding appropriately

This is active or effective This is active or effective listeninglistening

The key features of active The key features of active listening are :listening are : gathering & retaining the gathering & retaining the

information accuratelyinformation accurately understanding the implications for understanding the implications for

the patient of what is being saidthe patient of what is being said responding to verbal and non-verbal responding to verbal and non-verbal

signals or cuessignals or cues demonstrating that you are paying demonstrating that you are paying

attention and trying to understandattention and trying to understand

Picking up cuesPicking up cues

A patient may be unable or A patient may be unable or unwilling to articulate their real unwilling to articulate their real concern and feelings. concern and feelings.

it is important that their verbal it is important that their verbal and non-verbal cues are picked and non-verbal cues are picked up.up.

verbal cuesverbal cues Dr StoneDr Stone

Hello Mrs Fine, come and sit down. How can I help Hello Mrs Fine, come and sit down. How can I help today?today?

Mrs FineMrs Fine I thought I’d come to see you, doctor, about my I thought I’d come to see you, doctor, about my

headachesheadaches Dr StoneDr Stone

Perhaps you could tell me more about these Perhaps you could tell me more about these headachesheadaches

Mrs FineMrs Fine Well, they’re really bad, and getting worse. They Well, they’re really bad, and getting worse. They

started soon after my mother died and now they’re started soon after my mother died and now they’re making me feel dizzy. I’m really worried about themmaking me feel dizzy. I’m really worried about them

Dr StoneDr Stone Could you tell me why you are worried about them ?Could you tell me why you are worried about them ?

Dr Stone has picked up one of the Dr Stone has picked up one of the verbal cues. verbal cues.

The other cue is that Mrs Fine The other cue is that Mrs Fine relates the symptoms to her relates the symptoms to her mother’s death, and Dr Stone mother’s death, and Dr Stone should go on to explore her should go on to explore her reaction, e.g. ‘Could you tell me reaction, e.g. ‘Could you tell me more about how you felt after your more about how you felt after your mother’s death?’mother’s death?’

Non-verbal cuesNon-verbal cues a lot of information about ourselves a lot of information about ourselves

and our feelings in our body language and our feelings in our body language – the way we dress, our posture, – the way we dress, our posture, gestures and facial expressionsgestures and facial expressions

When you interview a patient, you can When you interview a patient, you can learn a good deal by watching them learn a good deal by watching them enter the room (their appearance, enter the room (their appearance, posture, gait, etc). posture, gait, etc).

be sensitive to their body language be sensitive to their body language during the interview.during the interview.

non-verbal cues :non-verbal cues : Eye contactEye contact : :

difficulty in maintaining eye contactdifficulty in maintaining eye contact feels depressedfeels depressed embarrassed about what they are sayingembarrassed about what they are saying uninterested in the conversationuninterested in the conversation

excessive eye contact : anger & aggressionexcessive eye contact : anger & aggression PosturePosture : :

the confident person : sit uprightthe confident person : sit upright the patient depressed : sit slouched with the patient depressed : sit slouched with

head bent forward.head bent forward.

non-verbal cues :non-verbal cues : GesturesGestures : :

the angry patient with clenched fists or the angry patient with clenched fists or the anxious patient who wrings their the anxious patient who wrings their hands or taps their feet continously.hands or taps their feet continously.

FacialFacial expressionsexpressions : : sadness, anger & happinesssadness, anger & happiness

The way the voice is usedThe way the voice is used : : tone, timing, emphasis on certain words tone, timing, emphasis on certain words

and vocalisation other than with words. and vocalisation other than with words. (Paralinguistics.)(Paralinguistics.)

Demonstrating active Demonstrating active listeninglistening show the patient that you are listening carefully. show the patient that you are listening carefully.

use of use of eye contacteye contact posture (e.g. sitting slightly forward facing the patient)posture (e.g. sitting slightly forward facing the patient) nodding your headnodding your head saying ‘hmm – go on’saying ‘hmm – go on’

active listening : active listening : asking questions directly related to asking questions directly related to following on from the patient’s last statement.following on from the patient’s last statement.

FacilitationFacilitation essential part of effective listeningessential part of effective listening the aim : to help the patient to talk the aim : to help the patient to talk

as fully as possible about problemsas fully as possible about problems

Ex : verbal facilitation :Ex : verbal facilitation : ““Please go on and tell me more about Please go on and tell me more about

your pain.”your pain.” ““Yes, I understand – please continue.”Yes, I understand – please continue.”

give the patient time to respond give the patient time to respond after you have spoken. after you have spoken.

Non-verbal : adopting an Non-verbal : adopting an appropriate postureappropriate posture lean slightly forward towards the lean slightly forward towards the

patientpatient maintain eye contact maintain eye contact nod your head at appropriate timesnod your head at appropriate times

ClarificationClarification

ask the patient to clarify ask the patient to clarify something they have said. something they have said.

This can be done in several ways :This can be done in several ways : ““Please tell me exactly when your Please tell me exactly when your

abdominal pain started.”abdominal pain started.” ““Can you describe the pain in more Can you describe the pain in more

detail?”detail?” ““What do you mean by ‘dizziness’?”What do you mean by ‘dizziness’?”

ReflectionReflection what they have just said may what they have just said may

help them to proceed with their help them to proceed with their storystory

particularly when they may be particularly when they may be finding it difficult to go on finding it difficult to go on because of their feelingsbecause of their feelings

Helping the patient to be Helping the patient to be relevantrelevant

your time as efficiently as your time as efficiently as possible. possible.

helping the patient not to stray helping the patient not to stray from the main point of the from the main point of the interview. interview.

interrupt at an appropriate point interrupt at an appropriate point and try to redirect the interview. and try to redirect the interview.

Helping the patient to be Helping the patient to be relevantrelevant

For example :For example : ““What you’ve just told me about What you’ve just told me about

your job is interesting, but I’d like your job is interesting, but I’d like to hear more about the headaches to hear more about the headaches you’ve been having.”you’ve been having.”

““It would help me to know more It would help me to know more about the circumstances that bring about the circumstances that bring on your chest pain.”on your chest pain.”

SilenceSilence make us feel uncomfortablemake us feel uncomfortable can be a temptation to rush in with can be a temptation to rush in with

another questionanother question

Silences are valuableSilences are valuable giving the patient time to reflect on what has giving the patient time to reflect on what has

been saidbeen said use them yourself to observe the patient, to use them yourself to observe the patient, to

reflect on the interview so far and to plan the reflect on the interview so far and to plan the next stagenext stage

SummarisingSummarising

summarise what the patient has told summarise what the patient has told youyou

e.g. ‘I’d like to make sure that I’ve e.g. ‘I’d like to make sure that I’ve understood you correctly. You told me understood you correctly. You told me that …’. that …’.

Summarising serves several important Summarising serves several important functions :functions :

check the accuracy of the patient’s story : check the accuracy of the patient’s story : opportunity to correct any misunderstandingsopportunity to correct any misunderstandings

review the patient’s story and deduce what else review the patient’s story and deduce what else needs to be explored, and it allows you to ‘buy needs to be explored, and it allows you to ‘buy time’ if you get stuck and can’t think of what to time’ if you get stuck and can’t think of what to ask next.ask next.

help the patient to carry on discussing their help the patient to carry on discussing their problems – it is one method of facilitation.problems – it is one method of facilitation.

help you to keep the patient ‘on track’.help you to keep the patient ‘on track’. let the patient know that you have been listening let the patient know that you have been listening

carefully and are interestedcarefully and are interested It is an appropriate way to close an interviewIt is an appropriate way to close an interview

Ending an interviewEnding an interview Summarise what the patient has told youSummarise what the patient has told you Ask them to check the accuracy of what Ask them to check the accuracy of what

you have saidyou have said Ask them if you have left out any Ask them if you have left out any

information that they feel is importantinformation that they feel is important Enquire if they would like to add anythingEnquire if they would like to add anything End by thanking the patient, e.g. ‘Thank End by thanking the patient, e.g. ‘Thank

you for talking to me; our time is now up’.you for talking to me; our time is now up’.

EmpathyEmpathy

means putting yourself in other means putting yourself in other person’s placeperson’s place

The doctor can The doctor can demonstrate empathy by :demonstrate empathy by :

looking at the patient and adopting looking at the patient and adopting an appropriate posturean appropriate posture

indicating that you understand what indicating that you understand what is happening to them, e.g.:is happening to them, e.g.:

PatientPatient My father died from a heart attack My father died from a heart attack

seven years ago whilst I was on holiday seven years ago whilst I was on holiday in Francein France

DoctorDoctor That must have been a distressing time That must have been a distressing time

for youfor you

doctor-centred style of doctor-centred style of communicationcommunication the doctor the doctor

has taken the dominant role in a has taken the dominant role in a consultation with a patientconsultation with a patient

paying little attention to the patient’s paying little attention to the patient’s concerns and understanding of their concerns and understanding of their illnessillness

not involving the patient in decisions not involving the patient in decisions about their treatmentabout their treatment

Patient-centred consultationsPatient-centred consultations

many patients want to know more many patients want to know more about their illness and be involved in about their illness and be involved in treatment decisionstreatment decisions

leads to greater satisfaction and leads to greater satisfaction and compliance with treatmentcompliance with treatment

Doctor & patient-centred Doctor & patient-centred interviewing stylesinterviewing styles Mrs Fraser works as a clerk in an office. She Mrs Fraser works as a clerk in an office. She

has been referred to her local hospital by has been referred to her local hospital by her GP because she has had a persistent her GP because she has had a persistent cough and wheeze for the past 6 months. cough and wheeze for the past 6 months. She has tried to stop smoking but is finding She has tried to stop smoking but is finding this difficult. Her cough is worse when she this difficult. Her cough is worse when she is at work and she is worried that it is is at work and she is worried that it is brought on by the air conditioning in the brought on by the air conditioning in the office. She is afraid that she may have to office. She is afraid that she may have to leave her job, which she depends on to leave her job, which she depends on to support herself and her three children.support herself and her three children.

Doctor-centred styleDoctor-centred style Dr EliotDr Eliot

Your doctor says that you have a cough, how long have you Your doctor says that you have a cough, how long have you had it for and is there anything else wrong ?had it for and is there anything else wrong ?

Mrs FraserMrs Fraser I’ve had it for 6 months and sometimes I wheezeI’ve had it for 6 months and sometimes I wheeze

Dr EliotDr Eliot Do you smoke ?Do you smoke ?

Mrs FraserMrs Fraser Well I’ve been trying to stop and now I only smoke two Well I’ve been trying to stop and now I only smoke two

cigarettes in the eveningcigarettes in the evening Dr EliotDr Eliot

Your symptoms are probably due to your smoking. I strongly Your symptoms are probably due to your smoking. I strongly advise you to stop smoking. I’ll arrange for you to have a chest advise you to stop smoking. I’ll arrange for you to have a chest X-ray and other tests and I’ll see you in 1 month’s timeX-ray and other tests and I’ll see you in 1 month’s time

Patient-centred stylePatient-centred style Dr EliotDr Eliot

Your doctor says that you have a cough. Please could you tell me more about it Your doctor says that you have a cough. Please could you tell me more about it and about any other symptoms you may have ?and about any other symptoms you may have ?

Mrs FraserMrs Fraser Well I’ve had this cough for about 2 months now and sometimes I feel short of Well I’ve had this cough for about 2 months now and sometimes I feel short of

breath, particularly in the morningbreath, particularly in the morning Dr EliotDr Eliot

Could you tell me if you bring up any sputum when you cough ?Could you tell me if you bring up any sputum when you cough ? Mrs FraserMrs Fraser

Yes, sometimes I do in the morning but I think that’s because I smoke, although I Yes, sometimes I do in the morning but I think that’s because I smoke, although I am trying to cut down. Also, I wheeze particularly when I’m at work and I think am trying to cut down. Also, I wheeze particularly when I’m at work and I think that’s due to the air conditioningthat’s due to the air conditioning

Dr EliotDr Eliot You seem to have two concerns. First, you want to stop smoking and I am sure You seem to have two concerns. First, you want to stop smoking and I am sure

that is important for your health. Second, you are worried about your work. How that is important for your health. Second, you are worried about your work. How do you think that I can help ?do you think that I can help ?

Mrs FraserMrs Fraser Well I would like some help to smoking and I wonder if you could write a letter to Well I would like some help to smoking and I wonder if you could write a letter to

the doctor at work because I’ve had quite a lot of time off work recently. I’m the doctor at work because I’ve had quite a lot of time off work recently. I’m really scared that I will lose my job and get behind with the mortgage.really scared that I will lose my job and get behind with the mortgage.

The features of a patient-The features of a patient-centred consultation are :centred consultation are :

Exploring the patient’s experience of illnessExploring the patient’s experience of illness Allowing the patient to express their beliefs Allowing the patient to express their beliefs

about their illness, e.g. what caused it.about their illness, e.g. what caused it. Allowing the patient to express their concerns Allowing the patient to express their concerns

about the impact of their illness on their lifeabout the impact of their illness on their life Treating the patient as a partner when Treating the patient as a partner when

discussing treatmentdiscussing treatment

practising the principles of practising the principles of good communication :good communication : Helping the patient to feel at ease Helping the patient to feel at ease

and adopting an empathic approachand adopting an empathic approach Using open questionsUsing open questions Picking up and responding to verbal Picking up and responding to verbal

cues by listening actively to what the cues by listening actively to what the patient is sayingpatient is saying

Picking up and responding to non-Picking up and responding to non-verbal cuesverbal cues

Is patient-centred interviewing always Is patient-centred interviewing always appropriate ?appropriate ? is appropriate in the majority of is appropriate in the majority of

consultations and leads to better consultations and leads to better outcomes for the patient and doctor. outcomes for the patient and doctor.

some patients prefer doctor-centred some patients prefer doctor-centred consultations, i.e. they want the consultations, i.e. they want the doctor to take a more paternalistic doctor to take a more paternalistic approach and to ‘take charge’ of the approach and to ‘take charge’ of the consultation and their treatment.consultation and their treatment.

TouchTouch

is a powerful means of communication that is a powerful means of communication that we use to express a whole range of we use to express a whole range of emotions – tenderness, love, anger, etc. emotions – tenderness, love, anger, etc.

touch can convey concern and empathy, touch can convey concern and empathy, and it can have a therapeutic effect in itselfand it can have a therapeutic effect in itself

touch must be used appropriately and with touch must be used appropriately and with due regard to the sensitivities of the patient due regard to the sensitivities of the patient and to professional codes of conduct.and to professional codes of conduct.

When should touch be used in the When should touch be used in the doctor-patient encounter ?doctor-patient encounter ? Shaking a patient’s hand on meeting at the Shaking a patient’s hand on meeting at the

start of an interview is socially appropriatestart of an interview is socially appropriate

Putting your arm around a distressed Putting your arm around a distressed person to comfort themperson to comfort them

placing your hand on the arm of a patient placing your hand on the arm of a patient who is having difficulty expressing their who is having difficulty expressing their thoughts and emotions conveys empathy, thoughts and emotions conveys empathy, and this often helps the person to continueand this often helps the person to continue

two general guidelines two general guidelines when touching patients :when touching patients : Try to assess the patient’s likely response Try to assess the patient’s likely response

to being touched; you can pick up clues to being touched; you can pick up clues from the way in which they relate their from the way in which they relate their story, their posture and other aspects of story, their posture and other aspects of body language.body language.

If you feel uncomfortable about touching If you feel uncomfortable about touching patients, it is probably advisable not to do patients, it is probably advisable not to do it – you might communicate your anviety it – you might communicate your anviety to the patient.to the patient.

Communication during the Communication during the physical examinationphysical examination touching during a physical examinationtouching during a physical examination

Remember that the patient is likely to be Remember that the patient is likely to be very conscious of their vulnerability and very conscious of their vulnerability and the power of the doctor as they lie on the the power of the doctor as they lie on the couch waiting to be examined. They may couch waiting to be examined. They may also feel embarrased and anxious about also feel embarrased and anxious about what may be found. Try to put them at what may be found. Try to put them at ease. ease.

guidelines :guidelines : respect the patient’s sensitivity and respect the patient’s sensitivity and

modestymodesty a blanketa blanket

Explain what you are going to do. Do they Explain what you are going to do. Do they have any concerns about this ?have any concerns about this ?

Be careful not to instil anxiety at this stage Be careful not to instil anxiety at this stage by your facial expressions, or by spending by your facial expressions, or by spending a long time on one part of the examination a long time on one part of the examination without explanationwithout explanation

Avoid causing discomfort if possible by Avoid causing discomfort if possible by watching the patient’s expressions or by watching the patient’s expressions or by saying, ‘Please tell me if I hurt you’.saying, ‘Please tell me if I hurt you’.