Chapter 1

Doctor-patient communication

Vivian (Weiwei Liu)

Public health and Management
Department
Consultation Styles

It’s serious isn’t it

doctor?
 “Ideal Patient”
Permitted to:

Regarded as being in need of care

In Return :
Seek help from and cooperate with a doctor
 “ Ideal Doctor”
Apply a high degree of skill and knowledge

Act for the good of the patient

Remain objective and emotionally detached

 Conflict of Interest
Interests of patient v society

Interests of patient v other patients

Problems of confidentiality
 Types of D-P Relationship
Physician control
Patient Control Low High

Low Default Paternalist

High Consumerist Mutuality

Doctor patient communication
skills-6 steps
 Start
 Active listening to the patient
- listening to the patient what causes the illness
- Observation of verbal and nonverbal language
- Patience to feel and express
 Collection of medical history
 Physical examination
- Let the patients know what the doctor expected?
Diagnosis, treatment and prognosis
- To ensure patient understanding of their main
health problems
- Need for patient participation and cooperation
- Discussion of self-care and medication

After treatment
- Clarify what to do next?
 Step 1: Start
 Self introduction, greeting patients
 Pay attention to the patient’s health status
- Showing care and respect
 Identify patient and escort
- In order to call their name in the following conversation
 Sit down with the patient to make eye
contact, avoid:
- Don’t turn your back on patients
- Only focus on the text material or on the computer for recording
- Ensure that attention is not dispersed (e.g. telephone
interference, other viewers walk by)
Cases:
 Establish harmonious relationship
- Doctor:” before we discuss your disease, I want to know
some of your personal things.”
- patient:” doctor, what do you mean?”
- Doctor: “tell me what you think of the most important
thing is to yourself. Where do you live? With whom?
How’s your work? How about your spare time? Etc..)

 Make a promise of secrecy to the

patient
 Step 2: Active listening
 Listen to
- Pay attention to the  Verbal
speaker
- Eye contact
communication
- Fast response - Speed and tone
- For the scene language
 Nonverbal - Express sympathy and
communication concern
- Body language
- Facial expressions
- Gesture
Encourage patients to tell their issues, to
identify the main problem:
 “Which one of the question is the most troubling you?”
 What kind of goal do you want to achieve today?”

Ensure the patient will not be interrupted

 A recent survey shows, family physicians interrupt their
patients in every 23 seconds.
 If not interrupted, the patient average talk time < 90
seconds.
 Active listening-
nonverbal language
Physicians need to observe the patient
emotion
 Body language, facial expressions, the speed and tone
- whether the patient being anger, worry, frustration
 Medical indicia, such as hot crimson, fatigue, pain
spasm
 Active listening-
mirrored feedback method
Listen carefully and let the patients know
you’re listening
Mirror feedback method is used to show that you’re
understanding what is told
 “That is to say you feel very tired for more than
one month.”
 “That must be stressful.”
 “Yes, I know that you fear… … ”
 “Of course, I agree… … ”
The initiative to encourage patients to
clarify in detail
 “Please go on, tell me more.”
 “Could you explain what you said dizziness refers
to?”

Think more initiative sentences~

 Step 3: Collection of
medical history
 Theeffective use of “open” and “closed”
questions

 Open-ended questions was used to get

more information or to explore unexpected
discovery
 “How do you feel after dinner every time?”
 “Does this problem affect your daily activities?”
 The use of extended words, such as” can you tell me some
more about that?”
 Nomatter what the patient says, to maintain
a calm and reliable voice
- Even though you are very busy, you should let the patient talk
fast to keep up with your speed
- Use tone to the patients to show you care

 Let the patient correction

- Medical history
- Open and closed issues
- Previous diagnosis

 To control the conversation and schedule

Step 4: Physical examination
 Tell the patient what you are doing

 Explain possible discomfort, such as cold,

pain and oppression.
Step 5: Diagnosis, treatment and
prognosis
 Recognize from patient’s need
 Put forward specific request or
response
request need
Consultation with the patient
treatment plan:
 Discuss the various options, negotiate a mutually
acceptable plan;
 Encourage patients to express their own ideas;
 Recognizing the patient’s return, risk and perceived
barriers;
 Patients are encouraged to participate in the
implementation of the plan.
Explain the process of identifying
patients understand:
 Clear and well organized, avoid jargon and terminology,
use of a clear explanation;

 Let the patient “mirrored feedback” your statement, to

determine whether or not to understand;

 Giving clear medication instructions:

- Write down the dose, whether to eat and the possible side-
effects of information
- Explain to the patient directly or to his/her family member.
 Step 6: Summary
Make a positive conclusion
 Provide a more realistic hope
- Good prognosis;
- If patient happen to meet a poor prognosis, provide
effective pain control

Give a clear follow-up guidance

 Make appointment to review
 When and how to take medicine?
 Need to use the written explanation
Use of facial expressions and gestures to
show your care
 Handshake
 Pat on the shoulder
 Greetings to the patient’s accompanies

Accurately tell the patient what will happen in

the final diagnosis step
 “Use the medicine before dinner.”
 “As soon as you feel……Immediately come to examine.”
A few cases for thought
 Case 1: Autonomy and family
member
A patient’s son insisted that the doctor should
not tell his mother that she has been
diagnosed with chronic leukemia, otherwise he
will take her home against medical advice.
 The mother seems to be generally passive and
submissive to the son’s decisions related to
her health care
 How should the patient’s right be addressed?
 Case 2: Demand of medical
treatment
 A patient with mental illness demanded to be treated
with the newest psychiatric drugs
 The doctor assessed and found that the patient was
not suffering from significant side effect from the
existing drug, which is also one of the newer drugs
that had passed the patent period (cheap generic
drug is locally available)
 What is the extent of patient right in this case?
Dealing with refusal of treatment

 When mentally competent and properly

informed, the patient’s refusal must be
respected. [Principle of respect for autonomy]

 Assess mental capacity Treatments can be

provided to mentally incapacitated persons
based on ‘best interests’ principle [Principle
of beneficiary]
Resolving ethical dilemma related to
autonomy – advice for clinicians
 Listen carefully – do not jump to conclusion
of “patient not cooperative” too easily
 Gather more information relevant to the case
situation
 Consider your own bias and assumptions
 Explore reasonable options of compromise
 Involve minders and friends trusted by
patient as appropriate
Conclusion
listening feeling

request need

• To improve the diagnosis efficiency

• To establish relations of cooperation
• Enhanced patient participation and compliance
• Improving patient satisfaction