CFM 1 o Subject matter which needs to be

NOVEMBER 03-10, 2014 presented and how it is being

Dr. Flores communicated
 INTENDED MESSAGE – verbal
and non-verbal
 UNINTENDED MESSAGE –
COMMUNICATION SKILLS given off beyond awareness
 CHANNEL OF TRANSMISSION
 The heart of the day to day activity of a
o Way of sending the message to one or
practicing physician is an effective doctor-patient
more senses
relationship.
 Written / oral / non-verbal
 The doctor-patient relationship can make or
 RECEIVER
break the outcome of interaction.
o Perceives the sender’s message
 The key to an effective doctor-patient
 FEEDBACK
relationship is communication.
o Allows evaluation of the interpretation of
 COMMUNICATION is a complex aspect of the
the message
relationship.
 Each participant sends and receives messages
FORMS OF COMMUNICATION
at multiple levels and through multiple modalities
1. Linguistic
simultaneously.
2. Paralinguistic
 A competent physician must accurately receive
3. Non-linguistic
and interpret patient messages and ensures that
*all 3 can occur simultaneously
the patient accurately receives and interprets the
physician’s message.
LINGUISTIC COMMUNICATION
 The use of effective communication can assist
- Messages that are conveyed through words
physicians to provide better care of their
which may relate to ideas or to describe
patients.
feelings or behaviors
- Interviewers exhibit 4 types of verbal
COMMUNICATION
responses:
- A process, through which information or
o Exploratory
ideas are being conveyed, transmitted or
o Clarifying
imparted by the use of signs, symbols or
o Affective
words to achieve certain understanding or
o Honest labeling
even changes in the behavior.
EXPLORATORY
FUNCTIONS OF COMMUNICATION
- Open-ended responses that encourage a
person to continue talking
 Establish relationship between the persons o Direct and indirect leads and probes
involved CLARIFYING
 Impart new information - Ensures that the message was indeed
 Reinforce knowledge received and allows a person to
 Direct the receiver in some ways as to: correct/check interpretation
o Change attitude and behavior o Paraphrase, perception check and
o Stimulate thoughts summary
o Provoke questions
o Reinforce attitude AFFECTIVE
- Attends to feelings, attitudes and values and
ELEMENTS OF COMMUNICATION fosters self-awareness
 SENDER o Reflecting feeling and probes
o Source/initiates communication HONEST LABELING
 MESSAGE - Speaking directly and honestly about the
issues
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GUIDES TO HONEST LABELING
 Rapport is already established
 Person is ready
 Choose words that shed light and not to
contribute to misinterpretation
 Speaking honestly does not mean speaking
brutally
 Painful or unwelcome interpretation should be
shared with compassion and sensitivity to the
effect such news may have to the receiver
WORD CHOICE
- Words have varying degree of precision and
conscious awareness
- The meaning of a particular word is intended
to convey, the meaning attached to the word
by the hearer and the interpretation given to
the entire communication may be very
different for each of the two parties in an
interchange.
DENOTATION – dictionary definition
CONNOTATION – meanings, images or feelings
that come to mind when a word is used but
that strictly speaking are not part of its formal
definition
WORDS THAT ARE BEST TO AVOID:
 Slang words
 Euphemisms carry out many connotations
 Medical jargons convey concepts that may be
misunderstood
PARALINGUISTIC COMMUNICATION
- Non-word messages conveyed through
speech
- Vocal messages affected by intonation,
pacing, sighs, grunts and pauses
- A person who has stopped speaking
because of overwhelming feelings must be
allowed a few moments of silence
NON-LINGUISTIC COMMUNICATION
- Facial expression
- Body placement
- Use of touch
- Physical arrangement
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1. FACIAL EXPRESSION
- Associated with strong conflicting feelings
that are not generally in the conscious
awareness of the person emitting them
- Frequent affective and clarifying responses
to bring non-word messages into the verbal
arena in order to understand them more
correctly and completely
2. BODY PLACEMENT
- Tells much about their feelings and the
nature of their relationship to those around
them
a. Personal Space – 3ft front, 1ft behind
b. Body position – inclined slightly forward
c. Sitting position – same eye level
d. Parallel movement – mirror image
e. Complementary movement – conveys
understanding and challenge
3. USE OF TOUCH
- Handshake, gentle touch
4. PHYSICAL ARRANGEMENT
COMMUNICATION PROCESS ATTITUDE &
SKILLS
 Every communication has 2 components, the
COGNITIVE and the affective or EMOTIONAL
tone.
 George Engel, MD – introduced the bio-
psychosocial approach model
 A physician who is bio-psychosocially oriented is
concerned with:
o Diseased organ
o Patient’s feelings and perceptions of his
illness
o Manner in which these feelings and
perceptions and the disease itself
interact with the larger family,
community and cultural systems to
which the patient belongs
 PATIENT-CENTERED
 FAMILY FOCUSED
 COMMUNITY ORIENTED
 If we understand that we do not see or hear
those which are not trained to see or hear, we
begin to focus our attention in listening.
 It is important to hear both cognitive and
affective components and respond to each of
them.
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  To address both, it is important to listen more o Appropriate body movement
and can be accomplished with the use of o Appropriate eye contact with speaker
ACTIVE LISTENING SKILLS. o Open and receptive facial expression
o Establishing a non-distracting
ATTITUDES environment
GENUINENESS 1. Attending
- Being honest and open about feelings, - Non-verbal communication
needs and ideas - Imparts willingness and readiness to listen
- Congruence or consistency in feelings, Lean Forward
actions and words Open Stance
- A genuine person can be himself with Voice of compassion
another so they know him as he truly is Eye contact
- A genuine person is aware of his innermost Relaxed
thoughts and feelings, accepts them and Sit at an angle
whenever appropriate, shares them
responsibly 2. Bracketing
- “What you see is what you get” - Form of psychological attending
- “Pagiging totoo” - A mental skill
- 3 ingredients: self-awareness, self- - Suspending own judgment and feelings;
acceptance and self-expression setting them aside for a while in order to
listen more fully to the patient
UNCONDITIONAL POSITIVE REGARD
- Choose to believe that there is something 3. Leading
good in a person regardless of the external  Indirect lead – open invitation by the MD to the
qualities patient to talk about whatever concerns him
- Involves accepting, respecting and “What can I do for you?”
supporting another person - Includes verbal anon-verbal encouragers
- Non-possessive love, willed love which are used to show that the listener is
- Non-judgmental listening and following what the speaker is
saying
EMPATHY o Verbal: “Yes,” “Go on,” “Uh-hmm,” “I
- Ability to put oneself in the shoes of the see”
other o Non-verbal: nodding, smiling, eye
- To be with, feel with and think with the other contact
- Ability to really see and hear another person - Encourages the speaker to continue talking
and understand him from his perspective  Direct lead – MD chooses the direction where
- Empathy is not the same as sympathy the conversation should go
- Feelings are neither right or wrong - Oftentimes it is based on the disease entity
that the MD is considering
ACTIVE LISTENING SKILLS
- It is also worthwhile to choose basing it on
what is most emotionally disturbing for the
Active because …
patient
 It calls for effortful listening (not just hearing) - Ask about …
 It requires you to communicate accurate o …what was said last
empathy and understanding to the person o …where the emotion was greatest
listened to o … what was repeated
- TMMATF (Tell me more about that feeling)
OPENING SKILLS
 Involves the listener giving his/her physical
attention to the speaker
o Attentive, open posture

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 4. Focusing
- patients in emotional pain sometimes
bring up a lot of things one after the
other
- in such cases, ask the patient to choose
what is more important to him
- TMI/TME (Too much
information/emotion)
- Enumerate the issues brought up, then
ask which one is the heaviest, or which
one the patient wants to talk about first
- Focus on
> most difficult issue
> heaviest emotion
5. Probing
- Questions you ask to find out more
about how the patient is reacting to what
is being discussed
- Ask open-ended questions
o Avoid yes and no questions;
“why” questions
- Probe where the emotion is heaviest
o What was repeated
o HDTMYF (How did that make
you feel?)
o TMMATF (Tell me more about
that feeling)
6. Attentive silence
- One of the hardest skills to acquire
- Uncomfortable with silence  feel the
compulsion to jump in and fill in the
silence
- There are times when silence is the
most appropriate response
o The speaker is searching for a
response
o The speaker is emotionally
distressed
- Silence allows the person to experience
distress, regain composure and continue the
communication
7. Reflecting
a. Reflecting content – paraphrasing and
perception check
 BREVITY & CLARITY – saying in 10
words what the client said in a
hundred
 ACCURACY – walang dagdag,
walang bawas
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 A paraphrase that is made into a
question
o “…is that it?”
o “…did I get you right?”
o “…Tama po baa ng
pagkaintindi ko?”
b. Reflecting feeling
 Feelings are neither right nor wrong
 It is the feeling you do not
acknowledge that will take control of
your life
 Behind every feeling is a perception
for a misperception
o “It seems that you feel…
MAD, GLAD, SAD,
AFRAID.”
(4 basic emotions)
c. Reflecting experience
Reflecting Non-verbals
 Point out the non-verbal behavior for
its meaning
 Actions (non-verbal messages) may
say more than what is being shared
verbally
PRINCIPLE OF ADULT LEARNERS
You cannot give insight to another, he has to
make the realization himself.
OPENING SKILLS:
 FIRST HALF OF THE PATIENT-DOCTOR
ENCOUNTER, the MD
o Brings out the patient’s perceptions and
frame of reference
o Sees the situation from the patient’s
perspectives rather than from his own
 Helps the patient become aware of his
perception
 Helps the patient to understand how such a
perspective results in the symptoms, feelings
and behaviors which the patient experiences
 However, very often the patient’s point of view is
not enough; his perceptions and perspectives
may in some ways be distorted and
unproductive
 It is the role of the MD to challenge the distortion
and incongruence with reality
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CLOSING SKILLS
1. Interpretation
a. Interpretative statement
b. Interpretative question
c. Fantasy or metaphor
2. Confrontation
a. Challenging discrepancies
b. Challenging distortions
c. Feedback and opinion
3. Summarizing
4. Goal setting
INTERPRETATION
- Involves sharing your “hunches” with the patient
as to what is behind the experiences, behaviors
and feelings
- Goal of all interpretative effort is to increase self-
interpretation by the patient
- The more the patient knows about him/herself,
the more he/she will be able to change his
behavior
FORMS OF INTERPRETATION
1. Interpretative statemene
a. Declarative statement about
hunches
2. Interpretative question
a. Makes interpreting less risky
3. Fantasy or Metaphor
GUIDELINES FOR INTERPRETATION
1. Look at the basic message(s) of the patient
2. Paraphrase
3. Add your understanding of what the messages
mean to him in terms of your theory
4. Keep the language simple and close to the
patient’s message
5. Avoid wild speculations
6. Offer tentative ideas on what their words and
behaviors mean
7. Solicit patient’s reactions to your interpretation
8. Teach the patient to do his own interpreting
CONFRONTATION
- Enables the MD to
o Challenge the discrepancies,
distortions, smoke screens and games
that the patient is using – knowingly or
unknowingly
o To keep himself and others from
seeing his problems clearly
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o Thus getting in the way of problem-
managing actions
- May be perceived as offensive and may lead
to:
o Defensive behavior
o Non-compliance
o Loss of the patient
o Loss of practice
FORMS OF CONFRONTATION:
CHALLENGING DISCREPANCIES
 Between what the patient thinks or feels
and what he says
 Between what he says and what he
does
 Between what he is and what he wishes
to be
 Between his expressed values and his
actual behavior
1. Challenging Distortions
- Some patients cannot face the situation as it
is so that they distort it in various ways
your 2. Feedback and Opinion
- MD’s reaction to the therapeutic
interchange; his own perception of the
problem
GUIDE IN GIVING FEEDBACK:
1. Patient must be ready
2. Describe the behavior before giving your
reaction to it, which may be thru sharing
your feeling
3. Give feedback about the behavior rather
than judgment about the person
4. Give feedback in small amounts so that the
patient can experience its full impact
5. Feedback should be a prompt response to
current or to specific behavior, not
unfinished emotional business from the past
6. Give feedback on the things the patient can
change
7. Give positive feedback
8. Ask for reactions to your feedback
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SUMMARIZING GIVING ADVICE AND SHARING PERSONAL
- Tying together into one statement several EXPERIENCE
ideas and feelings at the end of a discussion
or interview INFORMATION GIVING
- Broader than paraphrase 1. Advising – based on experience
- Gives focus or direction to counselling 2. Informing – based on expertise
process **MDs should not pretend to know everything
- Help clients view their situation in a more
focused way, clarify and begin to set goals GUIDELINES:
- Do not add new ideas to the summary 1. Clear and relevant
- Decide if it would be more helpful to let the 2. Do not overwhelm patients
patient summarize for you 3. Do not push your own values
4. Be informed
GOAL SETTING 5. Phrase advise in the form of tentative
- Most important part of the session since it ties all suggestions
the processes together
- Characteristics: HELPER SELF-SHARING
o Specific and measurable  Doctor reveals something about his own
o Realistic personal life
o Hierarchical
o Desired by the person GUIDELINES:
o Tailored to him 1. Selective and focused
o Frequently evaluated 2. Not a burden to the patient
3. Done sparingly
STEPS FOR GOAL SETTING
1. Identify and affirm strengths  Communication flows out of basic attitudes as
2. Discuss resources well as through specific methods and skills
3. Identify the needs/wants in terms of  The person who has mastered the skills but
behavior one would like for himself or from lacks genuineness, love and empathy will find
others his expertise irrelevant.
4. Help patient decide which alternatives he
would like to try

CLOSING SKILLS
LATTER HALF OF THE CONSULTATION PROCESS:
 MD helped the patient to see the situation from a
more realistic point of view
 MD helped the patient to set reasonable goals
toward the resolution of his problem

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