Communication skills

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Learning Objectives
▪To discuss the basics of communication skills in clinical
encounters.
▪To discuss the management of difficult patients.
▪To discuss the steps for delivering bad news to
patients.

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Relevance of
communication skills

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Why are Communication Skills
Important?
▪Conducting a medical interview is a core clinical skill of
doctors especially primary health care providers.
▪ Effective doctor-patient communication is directly linked to
improved patient satisfaction, adherence, and health
outcomes.
▪A good doctor-patient relationship is especially important in
the management of chronic diseases.
▪Patients who are well-informed about their disease and
involved in the decision making, are more adherent to the
medical recommendations and willing/able to carry out
more health – related behavior.

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The Basics of
Communication skills

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Basic Communication Skills in a
Medical Encounter (1)
▪Preparing the stage: organizing the setting of the clinic, making sure
that you have what you need for the encounter.
▪The Opening: greeting the patient and engaging in informal discussion.
▪Asking: use open-ended questions to know the reason of presentation
of the patient. Avoid leading and judgmental questions.
▪Clarification: this is used to clarify unclear information provided by the
patient.
▪Facilitation: to encourage patients to proceed in telling their story. It
can be both verbal (and then what…) or non-verbal (nodding your
head).
▪Reflection: use reflective statements on what patients said to
encourage them to answer specially sensitive questions.

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Basic Communication Skills in a
Medical Encounter (2)
▪Confrontation: it helps to clarify information given by the patient. This
includes for example asking for explanation to non-clear information,
showing the contradictions in the messages of the patient.
▪Summarizing: to summarize the information provided by the patient.
▪Preparing the patient for physical exam: need to explain to the patient
about the content of the exam.
▪Congruence: to be genuine in dealing with the patient. Your verbal and
non-verbal messages should not be contradictory.
▪Negotiation: this helps reaching common ground with the patient.
▪Closing: at the end of the encounter.

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The Art of Communication

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Steps to Follow when
Communicating with Patients
▪Focus on the Patient
▪Establish a connection with the patient
▪Assess the patient’s response to illness and suffering
▪Communicate to foster healing
▪Use the power of touch
▪Laugh a little
▪Show some empathy

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Step 1- Focus on the Patient
▪Prepare for the encounter before the patient enters into your clinic.
This will set the stage for what comes next.
▪Make sure first that you are ready to receive the patient; your mind is
set and free.
▪Check the patient medical record.
▪Get to know your patient: check previous encounters.

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Step 2: Establish a Connection with
the Patient
▪Use the first few minutes of the encounter to connect with the patient
– short non-medical social interaction.
▪Build a rapport with the patient. This can provide some clues to the
patient’s emotional state.
▪Set the agenda of the encounter with the patient: reason for coming,
additional issues that the patient would like to discuss, agree on what
can be done during this encounter and if there is a need to set another
appointment for the remaining issues.
▪Setting the agenda with the patient will increase his/her satisfaction .

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Step 3: Assess the Patient’s
Response to Illness & Suffering
▪Assess how the patient is responding to his/her illness. This can uncover
important clinical clues.
▪Assess the suffering level of the patient, which can be both physical and
psychological.

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Step 4 – Communicate to Foster
Healing
▪Include the following in your communication with the patient:
o Congruence : to be authentic and avoid putting a façade.
o Acceptance: show that you value the person that the patient is even if you
do not agree with his/her actions.
o Understanding : try to relate and be sensitive to what the patient is
experiencing.

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Step 5 – Use the Power of Touch
▪A warm handshake or a pat on the shoulder can help calm worried
patients.
▪Make sure to be culturally sensitive.

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Step 6 – Laugh a Little
▪Humor can be helpful sometimes in establishing rapport. Make sure
that the patient accepts the humor well and does not lack a sense of
humor.
▪Humor can relieve anxiety , enhance healing, and decrease frustration.

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Step 7 – Show Some Empathy
▪Empathy is an important part of communication.
▪It is important as well that you express your understanding of the
situation of the patient. This would encourage sharing by the patient of
more personal and clinical information that would help in his/her
management.

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Patient-centered medical
interviewing

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Patient-Centered Approach
▪Patient-centered care is an essential element of high quality care.
▪Patient-centered approach has three main goals:
oTo elicit the patient’s perspective on the illness
oTo understand the patient’s psychosocial context
oTo reach shared treatment goals based on the patient’s values.

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Sequence of Patient-Centered
Medical Interviewing
▪Introduce and build rapport
▪Elicit the patient’s agenda
▪List all of the patient’s agenda items
▪Negotiate the agenda
▪Start discussing the patient’s concerns with open-ended questions
▪Ask direct questions to elicit details about the chief concern, and perform a
review of systems
▪Elicit the patient’s perspective
▪Empathize
▪Summarize
▪Transition

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Difficult Encounters

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Difficult Encounters
▪Difficult encounters account for around 15% to 30% of visits to family
doctors.
▪Disparity between the expectations, perceptions or actions of patient
and doctor characterizes difficult encounters.
▪Doctors who have most difficulty with patient relationships are more
likely to report job dissatisfaction and burnout symptoms.
▪Different factors interplay and might result in difficult encounters.
These are classifies as doctors- related factors, patients-related factors,
situation-related factors or a combination.

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Doctors- Related Factors
▪Every doctor brings to each patient encounter his/her background,
personality and experience.
▪Examples of encounters that can put the doctors on alert include the
following:
oPatients asking doctors for specific tests/treatments after
searching the Internet --- might surprise or threaten the
doctor.
oPatients presenting with recurrent symptoms related to
lifestyle factors despite receiving adequate counseling --- might
lead the doctor to question his/her ability to influence
behavior change.

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 Doctors- Related Factors
Attitudes Conditions Knowledge Skills
- Emotional burnout - Anxiety / - Inadequate - Difficulty
- Insecurity depression training in expressing empathy
- Intolerance of - Exhaustion/ psychosocial - Easily frustrated
diagnostic overworked medicine - Poor
uncertainty - Personal health - Limited communication
- Negative bias issues knowledge of the skills
toward specific - Situational patient’s health
health conditions stressors condition
- Perceived time - Sleep deprivation
pressure

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 Patients- Related Factors
Behavioral issues
- Angry/argumentative/rude
- Demanding/entitled
- Drug-seeking behavior
- Highly anxious
- Hypervigilance to body
sensations
- Manipulative
- Manner in which patient
seeks medical care
- Non-adherence to
treatment for chronic
medical conditions
- Not in control of negative
emotions
- Reluctance to take
responsibility for his or her
health
- Self-saboteur
Conditions Psychiatric Disorders
- Addiction to alcohol or drugs - Borderline personality
- Belief systems foreign to disorder
physician’s frame of reference - Dependent personality
- Chronic pain syndromes disorder
- Conflict between patient’s and - Underlying mood
physician’s goals for the visit disorder
- Financial constraints causing
difficulty with therapy adherence
- Functional somatic disorders
- Low literacy
- Multiple (more than four)
medical issues per visit
- Physical, emotional, or mental
abuse
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Situation-Related Factors
▪Prioritizing patho-physiological complaints rather than addressing
psychological needs of patients as a result of condensed clinic
schedules.
▪Easy access of patients to health information (internet for example),
triggering several questions from patients with an increased need to
more in-depth discussions.

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Management of Difficult
Encounters
▪Doctors play a crucial role in the management of difficult encounters.
Doctors need:
o To avoid prejudging and to acknowledge that the symptoms of the
patients are valid.
o To conduct a thorough assessment of the patients' distress.
Undiagnosed and untreated psychopathologies can be common in
difficult patients. History of abuse, difficult family or social situations
can be detected as well.
o To be empathetic. Empathy helps them suspend judgment and
ensure that they are perceived as healers and allies rather than just
service providers.
o To follow the principles of effective communication.
▪The CALMER method is another approach to difficult medical encounter s.

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The CALMER Approach to Difficult Medical Encounters
Element Approach
Catalyst for change - Identify the patient’s status in the stages of change model
(pre- contemplation, contemplation, preparation /
determination, action, maintenance, relapse)
- Recommend how the patient can advance to the next stage
Alter thoughts to - Identify the negative feelings elicited by the patient
change feelings - Clarify how these feelings influence the encounter
- Strategize how to reduce your own negativity and distress
Listen and then make - Remove or minimize barriers to communication
a diagnosis - Improve working relationships
- Enhance probability of accurate diagnoses
Make an agreement - Negotiate, agree on, and confirm a plan for health
improvement
Education and follow - Set achievable goals and realistic time frames, and ensure
up follow-up
Reach out and - Ensure a strategy for your own self-care
discuss feelings

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Counterproductive Strategies
▪To ignore the problem or to export it to another doctor will not solve it.
▪To accuse the patient of being problematic might trigger patient anger.
▪To tell the patient that there is nothing wrong with him/her might
trigger the patient to come more frequently to prove that the problem
is real.

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Note to Doctors
▪Doctors need to practice effective self-management. This includes:
o acknowledging and accepting their own emotional responses to patients
o attempting to ensure personal well-being

▪Doctors who experience ongoing difficulties with difficult patients may

need professional support such as Balint group, or the help of a
psychotherapist.

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Breaking Bad News

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What is “Bad News”?
▪The term “Bad news” is defined as "any information likely to alter
drastically a patient's view of his or her future…" or that "…results in a
cognitive, behavioral, or emotional deficit in the person receiving the
news that persists for some time after the news is received“.
▪The definition depends heavily on the patient’s beliefs and perceptions.
▪Family doctors encounter many situations that involve breaking bad
news: telling a young man that he has a sexually transmitted infection,
telling a middle-aged woman that her magnetic resonance image raises
the possibility of multiple sclerosis, telling the parents of a child that the
symptoms of polydipsia and weight loss suggest diabetes mellitus.

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Relevance to Family Doctors
▪It is crucial for family doctors to know the basics of breaking bad news.
▪Evidence shows that the attitude, communication skills and empathy of
doctor while delivering the bad news plays an important role in the
coping and bereavement abilities of patients and their families.
▪The specialty of Family Medicine emphasizes the importance of
understanding the psychosocial context of patients’ lives, and the
trusting relationships that doctors develop with their patients over the
years. This helps in determining the best way to deliver bad news and to
predict how bad news can be accepted.

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Frameworks for Breaking Bad News
▪Different Frameworks cited in the literature:
oSPIKES
oABCDE
oGUIDE
oBREAKS

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1. Baile WF, Buckman R, Lenzi R, et al.
SPIKES—a six-step protocol for deliver
bad news: application to the patient with
cancer. Oncologist 2000; 5:302.
2. Rabow MW, McPhee SJ. Beyond
breaking bad news: how to help patients
who suffer. West J Med 1999; 171:260.
3. Back AL. (2013) Vital Talk (1.0) [Mobile
Application Software] Retrieved
from http://vitaltalk.org.
4. Narayanan V, Bista B, Koshy C.
"BREAKS" protocol for breaking bad
news. Indian J Palliat Care 2010; 16:61.
Summary of the Steps
▪Preparation and Setting
▪Perception: Asking the patient/family what they understand or perceive
▪Sharing the “bad news” itself
▪Attending to emotions as they arise
▪Planning and discussing next steps

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Preparation and Setting
▪Secure a private and quiet setting.
▪Avoid interruptions.
▪Make sure to allocate enough time for the discussion.
▪Ask the patient who he/she would like to be present during the
discussion.

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Perception: Asking the Patient/Family what
they Understand or Perceive
▪Ask the patient/family what they already know about his/her condition.
▪This helps the doctor to build on what the patient/family know and fill
in the gaps.
▪Use active listening techniques such as leaning in, eye contact, open
posture.

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Sharing the Bad News Itself
▪Can start with giving a “warning shot” such as “I am sorry, I have some
bad news”.
▪Use simple and direct language. Avoid medical jargon.
▪Keep the news brief; provide information in small chunks allowing time
for the patient/family to understand.
▪After delivering the information, pause and give time to patient/family
to process this information. This might be a period of 10 seconds of
silence or more.
▪Avoid being blunt or insensitive while delivering the news.

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Attending to Emotions as They Arise
▪Expect the emotional response of the patient/family to the news.
▪Be quiet and listen. Try not to break the silence unless it is taking too
long. It can help then to ask the patient/family “what is it like for you to
hear this news?”, helping them to begin processing the news.
▪It is important to give the patient/family a “realistic hope” and avoid
any false hope.
▪Be empathetic in dealing with strong emotions (use the NURSE
acronym).

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NURSE Acronym for Dealing with Strong
Emotions
Acronym Request Example
N Name It sounds like you are frustrated
U Understanding I cannot imagine what it would be like to be
in this situation
R Respect You are asking all the right questions and
doing an amazing job of being an advocate
for your husband
S Support I will be around to answer any of your
questions
E Explore Tell me more about what you are thinking

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Planning and Discussing Next Steps
▪Discuss the plan with the patient/family. Discuss follow up
appointments, upcoming tests, referrals to other specialists etc.
▪Guide the patient/family in this new journey.
▪Check if the patient/family have any other questions.

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Important Note to Doctors
▪Delivering bad news can be tough on doctors as well.
▪Issues of counter-transference can develop, which might trigger poorly
understood feelings.
▪It is important to seek support or advice as needed. A formal or
informal debriefing session can be of help.

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