Professionalism Patient-Centred Communication PDF

Professionalism, patient-centred communication and breaking bad news Prof. Denis Harkin MB MD FRCSI FEBVS Consultant Vascular Surgeon Chair of Medical Professionalism, RCSI Bahrain: Dr Kiara Verhagen Learning Objectives By the end of the lecture, learners will be...

Professionalism, patient-centred communication and breaking bad news Prof. Denis Harkin MB MD FRCSI FEBVS Consultant Vascular Surgeon Chair of Medical Professionalism, RCSI Bahrain: Dr Kiara Verhagen Learning Objectives By the end of the lecture, learners will be able to: 1. Define effective communication (including SBAR, active listening, non-verbal communication) 2. Describe impact of communication on patient safety (including miscommunications and human error) 3. Describe barriers to good communication (including disability, cross-cultural communication and incivility) 4. Discuss difficult discussions (PEARLS approach) and breaking bad news (SPIKES approach) 5. Apply your knowledge to common clinical communication scenarios Disclaimer & Fair Use Statement This talk may contain copyright material, the use of which may not have been specifically authorised by the copyright owner. This material is available in an effort to explain issues relevant to education or to illustrate the use and benefits of an educational tool. The material is distributed without profit for educational purposes. Only small proportions of the original work are being used and those could not-be-used easily to duplicate original work. This should constitute a “fair use” of any such copyrighted material (referenced and provided for in Irish Copyright and Related Rights Act 2000 and EU Directive 2001/29/EC). If you use any copyrighted material from this talk for the purposes of your own that go beyond “fair use”; you must obtain expressed permission from the copyright owner. Professionalism and Communication Good Professional Practice Eight Domains of Good Professional Practice ensure Patient Safety and Quality of Care: Professionalism Clinical Skills Relating to Patients Communication & Interpersonal Skills Collaboration& Teamwork Management (including Self-Management) Scholarship The Eight Domains of Good Professional Practice are provided for in the Rules for the Maintenance of Professional Competence (No2) in Statutory Instrument 171/ 2011. https://www.irishstatutebook.ie/eli/2011/si/171/made/en/print Medical Professionalism at RCSI Compassion Self Care Communication Medical Professionalism: “Values, behaviours and attitudes that Cultural Integrity Honesty promote professional relationships, Sensitivity public trust and patient safety” Patient Centred Service Evidence Based Advocacy Practice Personal and Professional Identity (PPId) Formation promotes Reflective Professionalism, Leadership and Practice Continuous Improvement Altruism Resilience. Working in Ethical Practice Partnership Communication The act of communicating with people. A process by which information is exchanged between individuals through a common system of symbols, signs, or behaviour. Patient-Centred Care The Institute of Medicine defines patient-centred care as: “Providing care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions”. Institute of Medicine (U.S.) Essence of Professionalism Caring patients physical, psychological and social Excellent care knowledge and communication Good Communication Essential Institute of Medicine (U.S.) and Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001. http://public.eblib.com/choice/publicfullrecord.aspx?p=3375215. http://www.oneviewhealthcare.com/the-eight-principles-of-patient-centered-care/ Personalised Care The Coalition for Collaborative Care has published a guide “Progress in Personalised Care and Support Planning”. To empower the person and improve the quality and value of care by focus on: Respect Information gathering Collaboration with the patient Recognizing the person is the expert. http://coalitionforcollaborativecare.org.uk/ Patient Centred Care by Communication Fostering healing relationships Enabling Responding patient self to patient management emotions Patient centred functions of communication Exchanging Engaging in information informed and about what collaborative patients want decision making and need Enabling Self-Care Self-Care, according to the World Health Organization (WHO), is: ‘the ability of individuals, families, and communities to promote health, prevent disease, maintain health, and to cope with illness and disability with or without the support of a healthcare provider.’ For a person to practice true self-care, they must utilize personal responsibility and self-reliance in a way that positively impacts their health in the current moment and in the future. https://www.who.int/health-topics/self-care#tab=tab_1 Empathy and Compassion Empathy is the ability to understand and share the experiences’ of another. point of view, To see things from their and to imagine yourself in their place. Compassion is the feeling or emotion, when a person is moved by the suffering or distress of another, and by the desire to relieve it; pity that inclines one to spare or to succour. ‘Walk a mile in someone else’s shoes’ Nightingale SD, Yarnold PR, Greenberg MS. Sympathy, empathy, and physician resource utilization. J Gen Intern Med. 1991;6:420–423. Linley PA, Joseph S. Therapy work and therapists’ positive and negative well-being. J Soc Clin Psychol. 2007;26:385–403. Cultural Awareness Cultural awareness (or cultural sensitivity, cross-cultural / intercultural awareness) refers to the awareness of our own cultural identity, values and beliefs and the knowledge and acceptance of other’s cultures. Cultural awareness brings a better understanding of ourselves and a better appreciation of those who are different. Cross-Cultural Communication (or intercultural communication) is the study of how verbal and nonverbal communication takes place among individuals from different backgrounds, geographies, and cultures. https://www.medicalcouncil.ie/ Cultural Awareness Cultural awareness is a reflective process to identify and understand your own cultural and professional: Background Values Beliefs Biases Assumptions Cultural awareness helps you understand how culture impacts your communication with others. Institute of Medicine; Nielsen-Bohlman L, Panzer A, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academy Press; 2004. American Association of Colleges of Nursing. Toolkit of resources for cultural competent education for baccalaureate nurses. 2008 http://www. aacn.nche.edu/education-resources/toolkit.pdf. Accessed March 22, 2016. Cross-cultural Communication Cross-cultural communication is the ability to successfully communicate with people from different cultures and with different languages than your own. The goal of cross-cultural communication in health care is to help improve quality and eliminate racial and ethnic health disparities. Institute of Medicine; Nielsen-Bohlman L, Panzer A, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academy Press; 2004. American Association of Colleges of Nursing. Toolkit of resources for cultural competent education for baccalaureate nurses. 2008 http://www. aacn.nche.edu/education-resources/toolkit.pdf. Accessed March 22, 2016. Cross-cultural Miscommunication Sources of Miscommunication Assumption of similarities (when one differs we take a negative view) Language differences (lack of understanding or misuse) Nonverbal misinterpretation (dress-code, gestures like nodding the head?) Preconceptions and Stereotypes (pre-defining characteristics of group) Tendency to evaluate (analyze behaviour by one’s own cultural norms) High anxiety (unfamiliarity with culture) Unconscious Bias Unconscious bias refers to a bias that we are unaware of and which happens outside of our control. It is a bias that happens automatically, triggered by our brain making quick judgements and assessments of people and situations, influenced by our background, cultural environment and personal experiences. Implicit bias questions the level to which these biases are unconscious especially as we are being made increasingly aware of them. Once we know that biases are not always explicit, we are responsible for them. We all need to recognise and acknowledge our biases and find ways to mitigate their impact on our behaviour and decisions. Protected Characteristics Equality legislation, it is against the law to discriminate against someone because of: age disability marriage and civil partnership pregnancy and maternity race (Irish Traveller) religion or belief Sex These are called protected characteristics. https://www.equalityhumanrights.com/en/equality-act/protected-characteristics Discrimination Unconscious bias is making quick judgements and assessments of people and situations, influenced by our background, cultural environment and personal experiences. Direct discrimination occurs when you treat a person less favourably than you treat (or would treat) another person because of a protected characteristic. Indirect discrimination occurs when you apply a provision, criteria or practice in the same way for all people or a particular group, but this has the effect of putting people sharing a protected characteristic within the general population at a particular disadvantage. Digital Communication and Social Media The advent of the World Wide Web (www.) in 1989, changed the way people personally and professionally communicate. It has connected the world and made it much easier to get information, share and communicate. Information and Misinformation Professionalism and Unprofessionalism Respect and Disrespect Consent and Confidentiality Globalisation and Privacy Ruffin M. Telemedicine: where is technology taking us? Physician Exec. 1995;21(12):43-4. Sir Timothy John Berners-Lee at CERN in 1989 invented the www. https://covid19.who.int/. Vraga EK, Bode L. Addressing COVID-19 Misinformation on Social Media Preemptively and Responsively. Emerging Infectious Diseases. 2021;27(2):396-403. doi:10.3201/eid2702.203139. Cross-cultural RESPECT The RESPECT Model provides a framework to help you remain: Open Show respect Build trust with patients from diverse cultures. Office of Minority Health. Guide to providing effective communication and language assistance services. The RESPECT Model. Think Cultural Health Web site: https://hclsig.thinkculturalhealth.hhs.gov Effective Communication Effective communication is the process of exchanging ideas, thoughts, opinions, knowledge, and data so that the message is received and understood with clarity and purpose. When we communicate effectively, both the sender and receiver feel satisfied. Five Cs of Effective Communication Communication occurs in many forms, including verbal and non-verbal, written, visual, and listening. It can occur in person, on the internet (on forums, social media, and websites), over the phone (through apps, calls, and video), or by mail. Clarity: Know what you want and express it clearly Conciseness: Keep your message direct, simple and to the point Compellingness: Make your request persuasive and appealing Curiosity: Listen to the other person's needs and interests Compassion: Show empathy and respect for the other person Verbal & Non-verbal Communication “The most important thing in communication is to hear what isn’t being said” – Peter F Drucker Look Listen and Feel (Practice Active-Listening) The Mehrabian Conjecture (55/38/7 Formula) Albert Mehrabian, a researcher of body language, who first broke down the components of a face-to-face conversation. He found that communication is 55% nonverbal (body- language), 38% vocal (tone and inflection), and 7% words. He claimed that in face-to-face conversation up to 93 percent of communication, does not involve what you are actually saying. Mehrabian A. Nonverbal communication. Aldine-Atherton; 1972. Dunbar RIM, Robledo JP, Tamarit I, Cross I, Smith E. Nonverbal Auditory Cues Allow Relationship Quality to be Inferred During Conversations. J Nonverbal Behav. 2022;46(1):1-18. doi: 10.1007/s10919-021-00386-y. Epub 2021 Oct 22. PMID: 35250136; PMCID: PMC8881250. Kinesics or Body Language Kinesics Communication involves the physical cues that are visible and send a message about your attitude towards the other person, your emotional state and your relationship with the environment. These include: Body posture Body motion Gestures Facial expressions Eye contact Haptic or Touch Haptic communication is communicating by touch and is used when we come into physical contact with other people. We use handshakes to gain trust and introduce ourselves However, physical contact may: give comfort, make uncomfortable, be unsafe (COVID-19) or may even be inappropriate? Active Listening Effective listening is listening to the words of the speaker and the meaning of the words. Active listening is a process in which the listener takes active responsibility to understand the content and feeling of what is being said and then checks with the speaker to see if they heard what the speaker intended to communicate. Listening attentively and responding empathically so a person feels heard Levitt, DH 2001, ‘Active Listening and Counselor Self-efficacy: Emphasis on one Micro-skill in Beginning Counselor Training', The Clinical Supervisor, vol.20 pp.101–115 Active Listening Active listening is: Demonstrating clear interest in a speaker’s message through non-verbal signals. Refraining from judgment and reflecting the speaker’s message using verbal paraphrasing: ‘Correct me if I’m wrong, but what you’re saying is…’ Asking the speaker to elaborate on their beliefs, feelings, and experiences. Phrases to Embrace “Tell me more about that...” “Just to make sure that I understand, what you’re saying is...” “How did you feel when that happened?” Jahromi, VK, Tabatabaee, SS, Abdar, ZE & Rajabi, M 2016, ‘Active Listening: The Key of Successful Communication in Hospital Managers’, Electronic Physician, vol. 8(3), pp.2123–2128 Listening to Patients The “18 Second” Paper Primary care physicians (Michigan, USA) Physicians interrupted after only 18 seconds. Patients allowed to completed opening statement of concerns on only 23% visits. This controlled style, premature interruption of patients, results in loss of relevant information. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984 Nov;101(5):692-6. doi: 10.7326/0003-4819-101-5-692. PMID: 6486600. Barriers Use the correct medium or platform Effective communication requires you to consider whether you need to meet in-person or if Zoom would suffice. Is your message casual enough to use WhatsApp, or would a formal email be more efficient and thorough? You might assess the priority level and the type of communication needed. For a university lecture, do students prefer to be online or meet in person? To break-bad-news to a family, and would it be fruitful to conduct it in a private interview room, or on a busy ward? WHO Principles for Effective Communications The World Health Organisation (WHO) follows 6-principles to ensure its’ communication is effective and improves healthcare outcomes: 1. Accessible to decisions-makers 2. Actionable by decisions-makers 3. Credible and trusted by decisions-makers 4. Relevant to decisions-makers 5. Timely to enable decision-making 6. Understandable to decision-makers https://www.who.int/about/communications/principles “They may forget what you said, but they will never forget how you made them feel” Carl W. Buehner 1971 (LDS Church), often incorrectly attributed to Maya Angelou (Poet) The essential insight is that a skilled communicator must be aware of the emotional valence of his or her words. Patient Safety Communication and Patient Safety Joint Commission’s (TJC’s) Sentinel Event Database, communication was identified as a leading root cause of sentinel events in USA 12 122 sentinel events between 1995 and 2015 in USA Ineffective Team Communication root cause 66% Medical Errors Clinician’s ability to explain, listen, and empathize can have an overpowering effect on patient satisfaction and experience of care. TJC for the US National Patient Safety Goals 2017) is to “improve the effectiveness of communication among caregivers.” The Joint Commission. Sentinel Event Data Root Causes by Event Type. The Joint Commission Web site. http://www.jointcommission.org/. Institute for Healthcare Communication. Impact of Communication in Healthcare. Institute for Healthcare Communication Web site. http://healthcarecomm.org/about-us/impact-of-communication-in-healthcare/ The Joint Commission. 2017 National Patient Safety Goals Slide Presentation. The Joint Commission Web site. https://www.jointcommission.org/npsg_presentation/. Communication and Patient Safety The NHS (UK) has over a million patient–clinician contacts every 36 hours. NHS Improvement (NHSI) commissioned report More Than Words: Spoken Communication and Patient Safety in the NHS. Critical communication domains: Communication Environment Information Exchange Attitude and Listening Aligning and Responding Creating the preconditions for effective team communication Communicating with unique groups Iedema R, Greenhalgh T, Russell J, et alSpoken communication and patient safety: a new direction for healthcare communication policy, research, education and practice?BMJ Open Quality 2019;8:e000742. doi: 10.1136/bmjoq-2019-000742 Communication Environment Ideal environment would be “caring surroundings” where physicians and patients “feel psychologically and physiologically safe”. Ideal “I found the clinic a very pleasant place, lovely building and staff were really nice, from the front desk to the consultant, I do not feel concerned at all” Not Ideal “It took me ages to find the room, nobody seemed to know the way, and the corridor was really dark and quite dirty, the consultant barely gave me time to sit down, I am not sure I would like to go back there for treatment” Less effective and safe Iedema R, Greenhalgh T, Russell J, et alSpoken communication and patient safety: a new direction for healthcare communication policy, research, education and practice?BMJ Open Quality 2019;8:e000742. doi: 10.1136/bmjoq-2019-000742 Information exchange Spoken communication is effective when accurate and appropriate information is exchanged between the right people at the right time. Ideal “Stitch scissors please, in my right hand” Not Assumptions specific Not Ideal “When your ready, can you just cut the “7/0 prolene”, you know that way Mr Nice like us to do it, right?” Jargon Conflicting information Iedema R, Greenhalgh T, Russell J, et alSpoken communication and patient safety: a new direction for healthcare communication policy, research, education and practice?BMJ Open Quality 2019;8:e000742. doi: 10.1136/bmjoq-2019-000742 Attitude and listening Effective communication with respect, commitment, positive regard, empathy, trust, receptivity, honesty and an ongoing and collaborative focus on care. Ideal “Dr Naughty has been nothing but kind, honest and helpful” Lack of patient-doctor collaboration Not Ideal “She wouldn’t even let me speak, she didn’t seem to notice the diagnosis of cancer had destroyed me… even after seeing me break-down in tears She just said “Yes, OK, perhaps we will pick this up again later”… she didn’t come back… what a horrendous bed-side manner!” Lack of Empathy Expectations and Compassion Partnership Iedema R, Greenhalgh T, Russell J, et alSpoken communication and patient safety: a new direction for healthcare communication policy, research, education and practice?BMJ Open Quality 2019;8:e000742. doi: 10.1136/bmjoq-2019-000742 Aligning and responding Aligning and responding, is critical for nurturing the clinician–patient relationship, develop mutual trust, confidence and “common ground”. It’s an ongoing process. Ideal “I haven’t stopped the smoking but have cut back… Right, good well done… The cost frightens me more than cancer… You’re right there, the cigarettes have got very expensive… I remember when you could smoke yourself to death for a few pounds… Ah, those were the days, but cutting back will help… your right doctor, I shall try that” Tuning into the patients mood and humour Not Ideal “I am 92 and have been smoking all my life… that young doctor just kept going on about smoking kills and Neoplasms… I don’t even know what those things are… I don’t think I need to worry at 92” Iedema R, Greenhalgh T, Russell J, et alSpoken communication and patient safety: a new direction for healthcare communication policy, research, education and practice?BMJ Open Quality 2019;8:e000742. doi: 10.1136/bmjoq-2019-000742 Creating the preconditions for effective team communication A team communicates effectively when team members feel “psychologically safe”, valued and sufficiently confident to raise concerns or point out problems. Ideal “Dr Dream, was very nice… I called him about a sick patient last night… he listened and gave clear advice… he came in to the hospital and assessed the patient with me… he even asked my advice on treatmentl… once the patient was stable he took me for a cup or tea… and at the morning handover thanked me for recognising the sick-patient and for all my hard work… I felt really valued” Young doctor is uncertain and should feel able to ask advice Not Ideal “Dr Nightmare, literally growled at me when I rang last night to discuss an admission… he said he would see all the admissions on the morning ward round… then hung-up… I have never been so embarrassed and lost” Iedema R, Greenhalgh T, Russell J, et alSpoken communication and patient safety: a new direction for healthcare communication policy, research, education and practice?BMJ Open Quality 2019;8:e000742. doi: 10.1136/bmjoq-2019-000742 Communicating with unique groups Greater care needs to be taken when communicating with groups such as: Children and young people People with problems understanding spoken English (eg, limited-English speakers, people with a hearing impairment, learning disabilities or cognitive impairment) People who are distressed or have mental health conditions Be culturally aware and sensitive Ideal “I know your name, ethnicity and religion… I know the things you like to do and talk about… I know you are vegetarian and have talked through the menu options that may suit you or whether we can arrange food to be brought in” Lack of Respect or Patient-Centredness Not Ideal “I didn’t know you were blind and vegetarian… I left the beef-pie… and didn’t think to ask why you hadn’t eaten anything” Iedema R, Greenhalgh T, Russell J, et alSpoken communication and patient safety: a new direction for healthcare communication policy, research, education and practice?BMJ Open Quality 2019;8:e000742. doi: 10.1136/bmjoq-2019-000742 Communication Techniques Ask-Tell-Ask Ask-Tell-Ask is a collaborative communication method that includes: Asking patients open-ended questions, assessing their existing knowledge, before sharing information. https://ce.mayo.edu/special-topics-in-health-care/content/effective-communication-healthcare-and-cross-cultural-workshops-2020 Ask-Tell-Ask Ask-Tell-Ask is a shift from a directive paradigm (telling patients what to do) to a collaborative paradigm (asking patients what they are willing to do). Ask permission to start a conversation Ask what the patient thinks about their health Ask questions to find out what the patient already knows Tell the patient information in a way that is easy to understand Ask to gauge the patient’s understanding A collaborative and participatory relationship between the patient and doctor is one of the most successful factors in promoting healthy behaviours. http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo/ConnieDavis-WhatIsAskTellAsk.aspx Let’s practice Tell-Tell-Tell. First, pick a personal health issue that you have want to improve. Perhaps, you want to get more sleep or you want to spend more time in your garden. Directions: Pair up with a partner. You and your partner will practice the tell-tell-tell. The bad coach will ask their partner, “What do you want to work on?” The bad coach will then ONLY tell: Why engaging (or not engaging) in this behaviour is risky The benefits of changing (or starting) the behaviour How to change (or start) the behaviour You have 3 minutes to be a bad coach. Remember, you may only ask the question, “What do you want to work on?” and then you must tell-tell-tell. Three minutes may seem like a long time to tell – because it is! We want you to feel uncomfortable as you only tell for four minutes. Switch roles and repeat directions above. Teach-back Teach-back is a communication strategy to Explain a new confirm that you explained information in a concept way that your patient understood. Asks patients to explain back to: Ask again for the patient to explain it Ask the patient to explain it back or back or show you show you Check their understanding Help them remember Clarify and explain information that the patient misunderstood Agency for Healthcare Research and Quality (AHRQ). Implementation quick start guide: teach-back. http://www.ahrq.gov/sites/default/files/ wysiwyg/professionals/quality-patient- safety/patient-family-engagement/pfeprimarycare/TeachBack-QuickStartGuide.pdf. Accessed June 11, 2018. Situation-Background-Assessment-Recommendation Situation-Background-Assessment- Recommendation (SBAR) Easy to use Structured form of communication Enables information to be transferred accurately between individuals Identify-SBAR (Online Virtual Clinics) https://www.england.nhs.uk/wp-content/uploads/2021/03/qsir-sbar-communication-tool.pdf Situation-Background-Assessment-Recommendation SBAR can be used anywhere, including: inpatient or outpatient urgent or non urgent communications conversations between clinicians, nurse to doctor or doctor to doctor or others conversations with peers – change of shift report communication between different disciplines, eg care home to ED escalating a concern Patients moving between NHS services or social care, eg care home & in/out hospital https://www.england.nhs.uk/wp-content/uploads/2021/03/qsir-sbar-communication-tool.pdf Communicating Distressing or Bad News Difficult, Distressing or Bad News Bad News is information that adversely alters one’s expectations for the future. From an early stage, doctors find themselves in situations where they must convey difficult, distressing or bad news to patients and/or relatives. Having someone deliver the news well can make the person receiving it feel respected and supported going forward. Relationship PEARLS To build a relationship with your patients use the technique PEARLS Partnership Empathy Apology / Acknowledgement Respect Legitimisation Support https://ce.mayo.edu/special-topics-in-health-care/content/effective-communication-healthcare-and-cross-cultural-workshops-2020 Delivering Bad News Delivering, denotes a one-way transaction, in which a product or service is provided by one party to another. Paternalism, rather than Partnership “Delivered”, like a pizza? Breaking Bad News Breaking, implies a transaction is conducted bluntly, even forcibly. Perhaps without Compassion “Broken”, like an egg? Distressing SPIKES SPIKES can be used in numerous situations to deliver bad news, from a new diagnosis to a medical error.. S - Setting P - Perception/Perspective I - Invitation K - Knowledge E - Empathy/Emotion S - Summary/Strategy Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer. The oncologist. 2000 Aug 1;5(4):302-11 Emotional Reactions Emotional Reactions Patient and Family (Receiver) Student and Doctor (Conveyor) Consider your own emotional reaction: Self-conscious, Inexperienced, Culturally naive? Fear about managing your emotions Concern about your communication Kübler-Ross E, Kessler D (2014). On grief & grieving : finding the meaning of grief through the five stages of loss. New York: Scribner. ISBN 978-1476775555.  Key points Communicating with patients about bad news is a 2-way process between carer and patient and family Effective communication about bad news entails several discreet elements which may be memorized but should be delivered fluidly Numerous verbal and non-verbal communication techniques may enhance the effectiveness of communication of bad news Poor communication of bad news can have long-term negative consequences for patients and families "A time to keep silence, and a time to speak" - Ecclesiastes 3:7. Conclusions By the end of the lecture, learners will be able to: 1. Define effective communication (including SBAR, active listening, non-verbal communication) 2. Describe impact of communication on patient safety (including miscommunications and human error) 3. Describe barriers to good communication (including disability, cross-cultural communication and incivility) 4. Discuss difficult discussions (PEARLS approach) and breaking bad news (SPIKES approach) 5. Apply your knowledge to common clinical communication scenarios Thank You Acknowledgements Dr Shaista Salman, Dr Aine Ryan, Mr Eric Clarke. Bibliography American Board of Internal Medicine Foundation. American College of Physicians–American Society of Internal Medicine Foundation. European Federation of Internal Medicine Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243–246. https://www.medicalcouncil.ie/news-and-publications/reports/guide-to-professional-conduct-and-ethics-for-registered-medical- practitioners-amended-.pdf Understanding medical professionalism W Levinson, S Ginsburg, F Hafferty, C Lucey.Lange http://www.cochrane.org/, http://group.bmj.com/products/evidence-centre, http://www.acponline.org/clinical_information/guidelines/guidelines HSE National Healthcare Communication Programme Modules Building Relationships https://www.hse.ie/eng/about/our-health-service/healthcare-communication/module-1-making-connections/ Gathering information https://www.hse.ie/eng/about/our-health-service/healthcare-communication/module-2/ Challenging Consultations https://www.hse.ie/eng/about/our-health-service/healthcare-communication/module-3/