Communication Skills PDF

# Communication Skills While communication seems like the most basic and innate part of being human, effective communication is a vital tool in clinical settings as it forms the basis of the doctor-patient interaction. The doctor and patient undertake a joint voyage, many a times into an unknown te...

# Communication Skills While communication seems like the most basic and innate part of being human, effective communication is a vital tool in clinical settings as it forms the basis of the doctor-patient interaction. The doctor and patient undertake a joint voyage, many a times into an unknown territory of disease. Problems may arise when the two travelers find it difficult to communicate or understand each other. While the physician is expected to know the patient's language, the patient is often unaware of medical jargon. As the service provider, the responsibility for effective communication lies with the physician. The tools that can be employed to make this communication effective and skillful are: ## Attending and Listening Attending is the act of truly focusing on the patient. It involves a conscious effort by the doctor to be aware of what the other person is saying and trying to imply. This may only be possible if the interaction with the patient is done in a setting of exclusivity. Standing on a patient's bedside with fellow students, amidst the traffic in a ward, attending to mobile calls simultaneously, or eating/drinking while talking to the patient may signal that you are not exclusively attending to the patient and/or his family member. A screen next to the bed, or a relatively quiet corner of the ward meant for interaction of patients with the students may provide a setting that allows for more effective communication. ## Active Listening This is a process that goes beyond merely hearing and making notes of what the patient says. It involves a simultaneous focus on the linguistic and the paralinguistic aspects of speech. The linguistic aspect refers to the words and verbal aspect of the speech. Paralinguistics refers to nonverbal features of speech such as timing, volume, pitch, accent, fluency, pauses and 'ums' and 'errs'. These are important as they indicate how the person is feeling beyond just the spoken word. An understanding of body language of the patient is important for a doctor to communicate with the patient. Body language refers to the way a patient expresses himself through the use of non-verbal cues such as facial expressions, proximity to the doctor, use of gestures, body position, movements and eye contact. It should be borne in mind that body language expressions are only cues and not 'clinical signs'. These cues should be pointed out to the patient to draw his attention to them, to understand his feelings or their meaning to him, e.g. "I notice that you look angry, how are you feeling at the moment?", or "your eyes filled up with tears when you told me the name of your father." This is more rational than making the wrong assumption about his gestures or body language. This is essential as methods of non-verbal communication vary in patients and their family members, according to their upbringing, culture and background. Active listening also involves customizing your style and language to match that of your patients or anybody you are listening to. This can be done by using the same language as the patient wherever possible. Another important aspect of active listening is respecting the pauses and silences of the patient. This would mean not immediately jumping in and talking whenever the patient pauses for breath or reflects silently. ## Verbal techniques These are pivotal in making the communication effective and thus contribute towards the therapeutic process. These are vital skills for the doctors and can be mastered through practice. Any verbal communication in a clinical setting involves the following components: ### Questions These can be closed or open ended. - **Closed ended questions** elicit a yes/no or a fixed response e.g. "What is your name?" "Are you married?" "Do you get nausea after taking your meals"? These questions are vital at the start of an interaction both, to collect data as well as establish familiarity and comfort with the patient. - **The open ended questions** do not elicit a particular answer. They are intended to encourage patients to talk more about their story or to expand more upon their issues. Questions are usually used for exploration of a particular aspect, for obtaining further information, to clarify any details and to encourage a patient to talk. E.g. "What brings you to the hospital today" or "Kaisay aana hua?" or even simply "Jee, kahiye." It is important to start an interaction with the patient or his family members with an open ended query, such as "What brings you to the hospital?" "What can I do for you"? This gives the patient a chance to open the conversation, with what s/he considers most significant. Leading questions are those that prompt the patient to answer in a certain way. These lead to skewed information as we tend to give the answer that we feel the person is looking for. These should be avoided as should value laden ones. Some examples of these are e.g. "Don't you think your pain radiates into the left arm?" or "Do you feel ashamed of your short stature?" Moreover 'why' questions should be used sparingly e.g. "Why do you think you have developed shortness of breath?" An effective communication therefore revolves around questions starting with what, when, where and how. ### Funneling This refers to the use of questions to guide the conversation from a broader area to a more specific one. These should follow open ended questions. This technique helps the interviewer move from general statements by the patient to specific areas of clinical relevance e.g. "Now that you have described your complaint of feeling weak and lethargic, can you describe which specific part of the body you were referring to?" ### Paraphrasing It refers to the process of repeating the last few words the patient said and summarising what the patient has communicated so far, in your own words, and then ask him or her to validate if you have understood it correctly, e.g. "you have told me about the weakness in your legs and lethargy that you feel after walking for only few yards. Is that right?" "Aap ne bataya k aap kai maiday mai 2 haftay se jalan ho rahi hai jo khanay k baad barh jaati hai, kya aisa he hai?" ### Selective reflection Reflection is a technique to bring out the feelings attached to various symptoms and problems that a patient has stated. It refers to the method of repeating back to the client a part of something s/he said that was emphasised in some way or which seemed emotionally charged. e.g. "How does it feel when you start to feel fatigued only walking for a few minutes? You told me earlier, that you were once an athlete who could easily run a mile." ### Empathy building This refers to statements made by the doctor that make the patient see that his or her feelings have been well understood. It helps the patient understand that his/her feelings are valid and that the doctor would have felt the same if s/he was in the patient's place. It is important here to refrain from expressing sympathy instead, which would imply that the doctor feels sorry for the patient's plight. "I can imagine how difficult it must be for you to live with your pain for such a long time" is an empathetic statement, which is highly desirable; a statement such as "Poor you, I really feel bad hearing your story" is an expression of sympathy which may not have the desired therapeutic effect and also undermine the effectiveness of communication. ### Checking for understanding From time to time during the session the doctor needs to summarise patient's statements or ask the patient to comment on the summary, to ensure if s/he has understood the problem and its associated feelings correctly. An effective communication based on the above principles is bound to form a bond and a relationship between the patient and the doctor in which both feel understood and connected. It is this feeling of mutual understanding that is traditionally described by patients as "Half my illness was relieved after talking to my doctor." While the principles of effective communication should be part of all clinical interactions between a doctor and his patient, the best use of these principles is in counselling individuals, couples, family members or groups. ## Factors that improve communication - Use of minimal prompts - Sit squarely in relation to the patient - Open body position in relation to the patient - Leaning slightly towards the client - Maintaining reasonable eye contact - Relaxed attentive health professional - Listen and respond to feelings - Note all paralinguistic and nonverbal cues ## Factors that obstruct communication - Lack of exclusivity - Preoccupied or anxious health professionals - Uncomfortable seating - Lack of attention to non-verbal cues during active listening - Offensive remarks or judgement by the health professional - Frequent interruptions - Selective listening - Day dreaming or dosing off during the communication