Communication Skills W1 PDF

Introduction Role and importance of communication  Aim of the subject the doctor‐patient relationship key of clinical communication effective teaching and assessment of clinical communication key  Introduction to the Doctor–Patient Relationship ...

Introduction Role and importance of communication  Aim of the subject the doctor‐patient relationship key of clinical communication effective teaching and assessment of clinical communication key  Introduction to the Doctor–Patient Relationship  The doctor is a healer, witness to suffering, interpreter of symptoms, educator, advocate, and a provider of treatment, comfort and access to services. Hippocratic Oath of ancient times embodies the virtues and values within the relationship, the ‘medical ideal’ is varyingly shaped by the social, scientific, technological and political contexts of the day  cc  rise of the scientific paradigm and dominance of the biomedical model The scientific approach to medicine during the 19th century had a major impact on the role of the doctor r. Medical care was revolutionised by the discoveries of the circulation of the heart and vascular system, the germ theory of disease and cell theory with its application to the effects of disease on tissues and organs The body was increasingly seen as a machine, and the disease, not the patient’s experience of illness, became the object of study and treatment importance in the diagnostic process was recognised by the Canadian physician William Osler, who revolutionised training by insisting that students learned from seeing and talking to patients on the wards. His admonition ‘listen to your patient, he is telling you the diagnosis’  From the late 19th century, psychoanalysis and talking therapies emerged to study the mind and explain conversion of psychological traumas to physical symptoms and expressions of unhappiness Whilst therapeutic alliance in the doctor–patient relationship was crucial to the healing process, the power resided with the doctor.  healthcare as a right In the UK in 1945, the creation of a National Health Service (NHS) by Aneurin Bevan brought about healthcare free at the point of need. This was a hugely significant historical moment, enshrining health as a right, and consultation rates increased enormously Doctors now treated people from all socio‐economic groups who were grateful, powerless and uncritical. The formers’ success was dependent on approval from hospital superiors and not patients.  Challenges to the biomedical model and rise of the biopsychosocial model In the mid‐20th century, sociology and psychology, new fields of discourse, joined the debate about the doctor–patient relationship. The American sociologist Talcott Parsons in 1951 referred to the ‘sick role’, in which patients were regarded as passive victims but were expected to want to get better by following the advice of the expert doctor Recognising different contexts, the physicians Thomas Szasz and Marc Hollender described three basic models of doctor–patient relationship: : activity‐passivity - the physician does something to an inert or unresponsive patient;  guidance‐cooperation. - in which the physician tells the patient what to do and the patient complies mutual participation, whereby the physician helps the patient to help him‐ or herself and the patient participates as a partner In all situations however, ‘compliance’, essentially meaning obeying doctors’ orders, was expected In the name of reducing anxiety, the truth was often withheld from patients, and doctors made decisions about treatment This ‘benign paternalism’ was the cornerstone of the relationship. Indeed one might characterise it psychodynamically, or in transactional analysis terms, as a parent–child type of relationship  New approach Patient- doctor relationship was discussed in a new light in the angle of “dynamic psychology and a new approach was established George Engel advocated the need for a new medical model that linked science and humanism and used the term ‘bio‐psychosocial‐cultural’ This integrated information concerning what was the matter with the patient and what mattered to the patient Anyone in a therapeutic relationship, such as a doctor or therapist, needed to demonstrate unconditional positive regard, openness, warmth and a willingness to listen and understand the person The goal was to empower the person to fulfil his or her potential. Rogers’ work was hugely important in the 1960s, defining a basis for the doctor–patient relationship, specifying both underlying attitudes and skilled behaviours.  impact on doctors of the limitations of the biomedical model doctors struggle with patients where they could find no diagnosis or satisfy the patient. Balint was the first to coin the term ‘Patient‐centred medicine’, to describe the belief that each patient ‘has to be understood as a unique human being’ The two ‘realities’ in the doctor–patient relationship were defined by Elliot Mishler in the terms ‘medicines world’ and patients’ ‘lifeworld’. The world concept and language in each differed The patient is the one who moves in and out of the healthcare setting trying to maintain his or her narrative in the ‘lifeworld’, and problems arise when the patient is ignored or blocked by doctors’ use of the voice of medicine The biopsychosocial concept of health, or ‘Whole Person Health’, was affirmed in the World Health Organisation’s Alma‐Ata Declaration in 1978, a major milestone of the 20th century, defining health as ‘a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity’ studying the doctor–patient relationship  studying the doctor–patient relationship She identified how mothers frequently left the consultation without having expressed their main concerns or questions. Half had not received an explanation of the cause of their child’s symptoms and doctors often used jargon that families did not understand. The concept of ‘evidence‐based medicine’ was beginning to emerge  Evidence-based research Research on the doctor–patient interaction burgeoned from the 1980s with audio‐ and videotaping now enabling observation of the process. High control styles were common, and interruption of patients only 18 seconds into the consultation, as reported by Howard Beckman and Richard Frankel, led to important information being missed Patients often misinterpreted what doctors were intending to convey, and understanding of terminology, anatomy and disease was poor clinicians avoided emotionally challenging situations by using distancing tactics, and in so doing, mental health problems often remained undiagnosed and untreated This highlighted how doctors’ own emotions and psychological needs were central in the doctor–patient relationship, as well as the skills they did or did not possess. Hence such studies on the doctor–patient relationship revealed how communication and partnership might be threatened.. From their review of research, a strong message emerged; within the relationship, doctors needed to use their power wisely, not to control but to ‘find common ground’, show care, and guide and empower patients in collaborative relationships and shared decision making to improve outcomes  patient‐centredness and models of the doctor–patient relationship  The psychodynamic models were highly relevant to the underlying doctor–patient relationship. Notably, Eric Berne’s channels of communication identified verbal and nonverbal behaviour embodying ‘parent’, ‘adult’ and ‘child’ (superego, ego and id) states The ‘parent’ relationship maps particularly to the paternalistic approach, whilst the ‘adult’ relationship embodies respect for patient autonomy and partnership. John Heron described ‘authoritative’ and ‘facilitative’ interventions, both of which were appropriate, depending on context (Heron 1976). Additionally he identified inappropriate and potentially ‘harmful’ interventions that he termed ‘perverted’. At the end of the 20th century, the concept of ‘concordance’ was proposed This was a radical shift in the consultation dynamic, which traditionally demanded that both parties act to avoid tension or conflict that could jeopardise the encounter in the immediate and long term It involved honest sharing of ideas and real negotiation ‘so that both doctor and patient together can proceed on the basis of reality and not of misunderstanding, distrust or concealment’  training on the doctor–patient relationship Postgraduate training was important to promote best practice by clinicians and to develop trainers for the expanding undergraduate and postgraduate teaching. In the USA, the American Association of Medical Colleges established a Task Force on the Doctor and Patient in the 1980s and launched a national facilitator training programme to promote knowledge, attitudes and skills relating to the medical interview across all specialities  public inquiries in the 21st century: trust in the doctor–patient relationship In 2005 in the UK, the Royal College of Physicians’ report on professionalism restated the values of integrity, compassion, altruism, continuing improvement, excellence, working in partnership with members of the wider healthcare team, personal responsibility and accountability that underpin the science and practice of medicine the patient in the patient‐doctor relationship: the Internet and of knowledge Arguably the most profound effect on the doctor–patient relationship has come from the explosion of information available to the public in the 21st century.. The potential for patients themselves to influence the interaction has been supported not only by information from a myriad of websites but also formal training aimed at improving patients’ ability to be more skilful in handling the consultation to express their ideas  Focus on patients’ ability and desire for involvement in their healthcare recognised the importance of ‘health literacy’, defined as ‘the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health’ These patient factors affect the doctor–patient encounter. Some authors warned of potential risks of ‘victim blaming’ in the individual responsibility model, which could damage the doctor–patient relationship Patients’ dependency and need for support differ, requiring a flexible approach by clinicians in promoting patient engagement and self‐care Iona Heath argued that if not balanced with unconditional positive regard, nonjudgement and compassion, expectations of patient responsibility could be detrimental and oppressive