Basics of Communication and Interviewing skills in Family Medicine

The duties of the Doctor are:

• Make the care of your patient your first concern
• Protect and promote the health of patients and the public
• Provide a good standard of practice and care
• Treat patients as individuals and respect their dignity
• Work in partnership with patients
• Be honest and open and act with integrity
• Communication is central to fulfilling these duties satisfactorily.

Doctors with good communication skills identify patients' problems more accurately. Their patients adjust better psychologically and are more satisfied with their care. Doctors with good communication skills have greater job satisfaction and less work stress.

Definition

• Derived from the Latin word – “communis” which means common, to share, to impact, to transmit
• It's the process of sharing information or the process of generating information and transmitting meanings
• Communication is the exchange of meaning between and among individuals through a shared system of symbols that have the same meaning for both the sender and the receiver of the message
• Symptoms are a form of communication – the way a patient conveys feelings of illness, distress, or discomfort

Patient-related factors

• Physical symptoms (e.g. Pain, anxiety...)
• Psychological factors related to illness and/or medical care (e.g. anxiety, depression, anger, denial)
• Previous experience of medical care
• Current experience of medical care

Physician-related factors

• Training in communication skills
• Self-confidence in ability to communicate
• Personality
• Physical factors (e.g. tiredness)
• Psychological factors (e.g. anxiety)

• Privacy
• Comfortable surroundings (Neat, cool…)
• An appropriate seating arrangement (Below are 2 sitting arrangements, option b is acceptable while option a is not acceptable)
• Most consultations take place at a reasonable distance, too far may indicate disinterest, too close may be intimidating.

Option a

×

Option a

Option b

×

Option b

Communicating effectively with patients involves the core skills of; questioning, active listening, and facilitating.

These skills can be learned and need to be practiced.

The features of a patient-centered consultation are:

• Exploring the patient’s experience of illness
• Exploring the patient’s knowledge of his or her illness
• Allowing patients to express their beliefs about their illness, e.g. what caused it
• Allowing patients to express their concerns about the impact of their illness on their life
• Treating the patient as a partner when discussing treatment.

The acronym FIFE is a simple effective method of being patient-centered in our consultation:

• F - Understand the Fears of the patient (e.g. "I think I may go blind from this red eye")
• I - Explore the patient’s Idea of the cause of the illness (e.g. "My mother in-law is the cause")
• F - Determine how the illness affects the patient’s Functioning (e.g. "I can’t see well to work")
• E - Clarify the patient’s Expectation from the consultation (e.g. "I want an injection that will cure me").

Verbal Communication

• Speak in a clear, audible tone of voice
• Avoid using any medical technical language or jargon (without adequate explanation)
• Use language the patient will understand
• Adopt a similar tone, pitch, and pace in your speech to that of the patient

Non-verbal Communication (SOLER)

• S - Sit facing the patient - indicates involvement
• O – Open, friendly posture and body language
• L – Lean towards the patient a little when speaking and listening – indicates engagement
• E – Maintain regular eye contact (as much as is comfortable for the patient); don’t stare or look away a lot
• R – Relax and smile appropriately

• Anger is a common and normal reaction
• Often due to a loss of control, feelings of powerlessness
• Can be justified – e.g. due to late/missed diagnosis, medical errors, fatalities, poor quality care, inadequate pain control, excessive waiting times, rudeness, etc.

Simple Steps (Do’s and Dont's)

• Stay calm – all anger is self-limiting!
• Acknowledge it – name it
• Focus on the issue – take it seriously and pay full attention to what the patient is saying
• Don’t take it personally – this is not about you; they’re acting this way because their needs haven’t been met; visualize the person’s comments going ‘through’ you
• Don’t get defensive – don’t challenge them or criticize them; more important to try and understand the root cause of the anger
• Don’t get into an argument or yell back
• Acknowledge and explore negative emotions – make the patient feel that you have heard what they said and not judged them, e.g., “You’re clearly very angry about what happened in the hospital due to……”
• Listen actively – maintain eye contact, listen without interrupting, later on you can paraphrase, ask clarifying questions, e.g., “I know this has upset you a great deal."

• One of the physician’s most difficult duties and the greatest test of the doctor-patient relationship.
• Often results in a conspiracy of silence by physicians.
• The House Officer or Registrar is saddled with it.
• Training in communication skills facilitates it and improves patient satisfaction and reduces physician’s stress.
• Bad news is “any information which adversely and seriously affects an individual’s view of his or her future” or “any information that drastically alters a patient’s view of the future for the worse” (Baile et al 2000).
• “If done well they will never forget you, but if badly done they will never forgive you”.

What Patients and Relatives Require

• Prognostic information (Kutner’s Study)
• Honesty
• Hope
• Expression of feelings
• More time to talk
• Availability/Accessibility

Possible Reactions by patients

• Anger
• Denial
• Fear
• Anxiety
• Depression
• Loss of self-esteem
• Risk of assault
• Litigations
• etc

When Breaking Bad News

• Attitude of the physician is important
• Privacy of the environment, clarity of the message, keeping eye contact, empathy, listening, no interruptions, ability to answer questions, etc.
• Many protocols for breaking bad news; SPIKES, RELATE, SPEAK THE TRUTH, SAAIQ, etc.

SPIKES Protocol:

• S – Setting up the interview
• P – Patient’s Perception
• I – Invitation to ascertain how much the patient wants to know
• K – Knowledge and information giving
• E – Emotion management
• S – Strategy and Summary of the key points

• Breaking Bad News is an assignment that you should have skills for.
• Do not break bad news on the telephone except in very exceptional circumstances. Leave it for your senior colleagues.
• Show Empathy
• Do not cause harm
• Avoid litigations

• Greet the patient by name ('Good morning, Mr. Ajayi') and shake hands, if it seems appropriate
• Ask the patient to sit down
• Introduce yourself ('I am Dr………')
• Explain the purpose of the interview ('I would like to find out about your present problem')
• Say how much time is available
• Explain the need to take notes and ask if this is acceptable
• Maintain a positive atmosphere, warm manner, and good eye contact
• Use open questions at the beginning
• Listen carefully
• Be alert and responsive to verbal and non-verbal cues
• Facilitate the patient both verbally ('Tell me more') and non-verbally (using posture and head nods)
• Use specific (closed) questions when appropriate
• Clarify what the patient has told you
• Encourage the patient to be relevant

Ending the Interview

• Summarize what the patient has told you and ask if your summary is accurate
• Ask if the patient would like to add anything
• Give an appropriate appointment where necessary
• Thank the patient