Communication Skills Doctor-Patient Relationship PDF

INTERPERSONAL SKILLS & DOCTOR-PATIENT RELATIONSHIP DR. Tabassum Alvi Associate Professor Psychiatry/Behavioural Sciences Majmaah University What and why  WHY IN MEDICINE? Communication error leads to 60% to 70% of preventable hospit...

INTERPERSONAL SKILLS & DOCTOR-PATIENT RELATIONSHIP DR. Tabassum Alvi Associate Professor Psychiatry/Behavioural Sciences Majmaah University What and why  WHY IN MEDICINE? Communication error leads to 60% to 70% of preventable hospital deaths (The Joint Commission on Accreditation of Healthcare Organizations) “Oh my Sustainer! Open my heart and Make my task easy for me And loosen the knot from my tongue So that they might understand my Speech” Surah Taha (16:25-29--Al Quran M A P S O F O U R M I N D  OBJECTIVES At the end of session students should be able to a. Explain the basic principles of communication skills b. Discuss the role of doctor-patient relationship in clinical care c. Discuss communicating with special groups; e.g., mentally ill, children, elderly and gender, hard of hearing and blind d. Describe stages of grief. e. Use appropriate strategies to break bad new.  Assignment WRITE ABOUT YOUR OWN INTERPERSONAL SKILLS WITH FRIEND AND FAMILY ND HOW CAN YOU IMPROVE ?  DEFINITION “The imparting or exchange of information by speaking, writing or using any other medium” APT (2002), vol. 8, p. 166  Communication Model Context (stimuli) Sender Thought Process Message Receiver What, When, Why, (Medium) Thought process Whom, where & How Taking meaning out Verbal & Non Verbal & Encoder Plan to respond decoder  TYPES OF COMMUNICATION Verbal Nonverbal Written WHAT IS MORE IMPORTANT?  Types of communication Verbal Non verbal Symbol Based Gesture Based Largely Learnt Largely Innate Consciously Controlled Partial Control Higher Risk of Deception Relatively Uncontaminated  ACTIVE LISTENING Level of seating Being friendly, warm, and attentive Smiling naturally (not forced) Attentive posture Listening carefully Nodding Active questions and answers. Use Paralinguistics Eye contact Matching facial expression Speaking slowly and clearly; pronounce words correctly  NON-VERBAL COMMUNICATION BODY LANGUAGE: Facial expression Most expressive part of the body Eye contact Look directly at the person when speaking to them POSTURE : Serve as a form of feedback Posture Open: Arms comfortably at your sides or in your lap, facing the other person and leaning forward in your chair demonstrates receptiveness, friendliness and interest Posture Closed: Arms are rigid or folded across chest, leaning back in your chair, turning away to avoid eye contact, Conveys anger.  EMPATHY The process of identifying with someone else’s feelings. Sensitivity to another’s feelings and problems. No judgement BEING IN THE OTHER PERSON’S SHOES Three components of empathy Cognitive Emotional Compassionate  THREE TYPES OF EMPATHY Cognitive: “Simply knowing how the other person feels and what they might be thinking. Sometimes called perspective-taking. Emotional: “When you feel physically along with the other person, as though their emotions were contagious.” Compassionate: “With this kind of empathy we not only understand a person’s thoughts and feel with them, but are spontaneously moved to help, if needed.” NEGATIVE VERBAL COMMUNICATION Pay attention to others in service-oriented workplaces Avoiding eye contact Interrupting patients as they speak Rushing through explanations or instructions Treating the patient impersonally Making patients feel they are taking up too much time Forgetting common courtesies Showing boredom Stereotypes Judging Defensive Challenging Rejecting DOCTOR-PATIENT RELATIONSHIP  Therapeutic Communication Skills Therapeutic communication is the ability to communicate with patients in terms they can understand as well as communicate with other team members using the appropriate technical terms. Being silent – allows the patient time to think without pressure Accepting without bias GENUINE AND OPEN Giving recognition Be thoughtful and kind in your actions  FUNDAMENTAL ELEMENTS Right to receive information Right to make decisions Right to courtesy, respect, responsiveness, and timely attention Right to confidentiality Right to continuity of health care Right to have available adequate health care (Issued June 1992 based on the report "Fundamental Elements of the Patient-Physician Relationship)  Information Care The Essential Questions What is wrong with me? Is there a risk of the illness spreading to those around me or passing it to my off-springs? Is there an effective treatment for my problem? Is the treatment safe / are there any serious side effects or dangerous effects of the treatment effects Alternative treatments available? How long will I take to recover? Is there any abstinence? BASIC STEPS IN INFORMATIONAL CARE Patient’s knowledge and expectations must be assessed prior to and after the communication of significant information to see what and how much has been retained. Evidence Based Facts should be provided. Positive and negative effects of medicine expressed. Avoid false hopes. Discuss prognosis of disease in range. Summarize Check for information retained.  GRIEF Five Stages of Grief by Elisabeth Kubler Ross & David Kessler At first grief feels like being lost at sea: No connection to anything. The anger becomes a bridge over the open sea, a connection from you to them.  DENIAL Denial is the first of the five stages of grief Denial and shock help to cope and make survival possible. World becomes meaningless and overwhelming. Life makes no sense. As one is beginning to be stronger the denial is beginning to fade. ANGER Anger is a necessary stage of the healing process. The more one truly feel it, the more it will begin to dissipate and the more healing. The truth is that anger has no limits. It can extend not only to your friends, the doctors, your family, yourself and your loved one who died, but also to God. You may ask, “Where is God in this? Underneath anger is pain Usually, we suppress anger than feeling it. The anger is just another indication of the intensity of your love.  BARGAINING Before a loss, it seems like person can't do anything if only your loved one would be spared. “Please God, ” you bargain, “I will never be angry at my wife again if you’ll just let her live.” “What if I devote the rest of my life to helping others”. Person want life returned to what it was; we want our loved one restored. We want to go back in time. I will do anything not to feel the pain of this loss. We remain in the past, trying to negotiate our way out of the hurt.  DEPRESSION Empty feelings present themselves, and grief enters our lives on a deeper level, deeper than imagined. This depressive stage feels as though it will last forever. Depression is not a sign of mental illness. It is the appropriate response to a great loss. withdrawn from life, left in a fog of intense sadness, wondering if there is any point in going on alone? No experience depression after a loved one dies would be unusual.  ACCEPTANCE Acceptance is often confused with the notion of being “all right” or “OK” with what has happened. Most people don’t ever feel OK or all right about the loss of a loved one. This stage is about accepting the reality that our loved one is physically gone and recognizing that this new reality is the permanent reality. It is the new norm with which we must learn to live needs readjustment. We must learn to reorganize roles, re-assign them to others or take them on ourselves. We can never replace what has been lost, but we can make new connections, new meaningful relationships, new inter- BREAKING BAD NEWS  BIO PSYCHOSOCIAL MODEL It is a comprehensive addressing of all the aspects of informational care, and principles of effective communication and counseling  IMPORTANCE OF TELLING NEWS To decrease uncertainty To complete left over work Needs management Prepare for grief Advance direction Enhance mutual support by family Accidental finding will damage doctor- patient relationship Other sources can mislead person  What is doctor’s role? Be honest Be warm Be aware of religious & cultural values Use basic counseling skills Serve as a series of continuous support & encouragement as long as possible  What is doctor’s role ? Encourage questions & legitimate hope that a full valuable life can still be lived. Prepared to receive patient's anger. Prepared to have professional competence challenged. Prepared not to have all answers.  Who to say? Senior doctor, fully trained in art of communication.  When to say? As soon as diagnosis is certain  How to say? Introduce yourself Introduction of subject Straight forward way Feel concerned with patient Use familiar language & simple words  How to say? Indicate facts Give time for questions Following disclosure patient should be given private place & time to be with relatives. Give few minutes alone to patient to express his feelings freely  How to say? Soften bad news with good new Patient are appreciative of any information that provides hope (no falsified hope) Avoid technical jargon Don’t try to give precise prognosis Make sure of next appointment arrangement within 24-48 hours  What further be done? Continue dialogue Instill hope i.e. full & valuable remaining life is possible Encourage patient to talk about meaning of illness and life If patient has failed to ask greater details involve him in decision making.  What further be done? Mobilize coping mechanism Frequent short interviews Provide information to make intelligent decision about own treatment. Ask patient to write down questions  What further be done? Do make an offer to introduce the patient to another patient with similar condition Provide leaflets or written information Explanation should be clear & not only technical STEP – 1: SEATING AND SETTING: Exclusivity Involvement of significant others Seating arrangements Appear attentive and calm Listening mode Availability  STEP 2: PERCEPTION The principle involved in this step is “before you tell, ask". What does he or she thinks about his medical condition. Example 1) What did you think was going on with you when you felt lump? 2) What have doctors told you about all this so far?  STEP 2: PERCEPTION Note the language and vocabulary of the patient. If the patient is in denial, try not to confront him in the first interview.  STEP 3: INVITATION Most patients want to know all about their illness but assumption towards that should be avoided. Obtaining overt permission respects the patient’s right to know or not to know. STEP 3: INVITATION Would you like me to give you details about what is going on ? or Would you prefer I tell you about the treatment I am prescribing to you? STEP 4: KNOWLEDGE Before you break bad news, give your patient a warning to prepare him. Use same language as it maintain a therapeutic relationship with the patient.  STEP 4: KNOWLEDGE Avoid scientific and technical language. Give information in small bits and clarify whether he understands Emotions and reactions arise during the interview, acknowledge them and respond to them.  STEP 5: EMPATHY It comprise of 3 components. 1) One needs to listen and identify the emotion and acknowledge them. 2) Identify the source of that particular emotion. 3) Respond by showing that you understand the emotiona expression of the patient.  STEP 6: SUMMARIZE Recapitulate the information of all that has been discussed and give your patient an opportunity to voice any major concerns or questions.  STEP 7: PLAN OF ACTION Clear plan for the next steps that need to be taken regarding management of the issues. DISCUSS COMMUNICATING WITH SPECIAL GROUPS 1 Mentally ill 2 Difficult children 3 Elderly hard of hearing 4 Silent 5 Breaking Bad News  Assignment WRITE ABOUT YOUR OWN INTERPERSONAL SKILLS WITH FRIEND AND FAMILY ND HOW CAN YOU IMPROVE ? THANK YOU