Behavioral Dentistry Second Year

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COMMUNICATION SKILLS:
Doctor-Patient Communication
and Relationship
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Dr. Mohamed Salah Khalil (Ph.D-Neuropsychology)
Associate Professor-Consultant Clinical Psychologist
Coordinator of Postgraduate Clinical Psychology Program
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What can studying communication
skills offer us as medical practitioners
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Increased Doctor Job Satisfaction
Decreased Conflict Within The Consultation
More Accurate And Efficient Interviews
Better Clinical Hypothesis Generation
Increased Patient Satisfaction
Increased Patient Understanding And Recall
Improved Compliance And Disease Outcome
Decreased Medico Legal Complaints
Actual Savings In Time
More Structure And Control Of The Difficult
Consultation
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Impacts of Good Communication Skill
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However, the most important findings that have
frequently been reported on the impact of
communication are in the following aspects:
Effective Diagnosis & Treatment Outcome
Patient’s Adherence
Doctor’s Competence & Self-Assertion.
Patient’s Satisfaction.
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Patient Satisfaction
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From a psychological perspective, there is two
type of patient’s satisfaction:
Cognitive Satisfaction: How satisfied is the
patient with their understanding of the diagnoses,
treatment, and prognoses. This is related to the
doctor’s Verbal Behavior.
Emotional Satisfaction: This is related to the
doctor’s non-verbal behavior. The ability to show
care and concern by tone of voice, eye gaze, facial
expression, body movement and posture
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INTERVIEWING AND COMMUNICATION
SKILLS
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CORE COMMUNICATION SKILLS: Core
communication skills covers three dimensions:
Doctor -patient interpersonal skills
Information gathering skills
Information giving skills and patient education
Advanced Communication Skills
Skills for motivating patient adherence to treatment
plans
Other applications of core communication skills in
specific situations (e.g., dealing with anger, dependent
personality dis., breaking bad news).
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The LEARN Mnemonic
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LISTEN actively with respect
ELICIT the health beliefs of the patient
ASSESS priorities, values and supports
RECOMMEND a plan of action with adequate
explanation and understanding
NEGOTIATE by involving the patient in next
steps and decisions
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The SCANS Mnemonic
S= Setting, Situation
C = Centeredness, Co-operation
A= Active listening, Assessment, Acknowledgement, Agreement
N = Negotiation
S= Summary, Safety Net
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C
L
A
S
S
Techniques - The CLASS System
Context (Physical Setting)
Listening Skills
Acknowledgement
Strategy
Summary
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Context (Physical Setting)
Privacy
Eye Level - Even
Personal Space
Body Language
Relaxed
Eye Contact
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Context (Physical Setting)
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Techniques - The CLASS System
Context (Physical Setting)
Listening Skills
Acknowledgement
Strategy
Summary
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Listening Skills
• Open Questions
• Facilitating
• Clarifying
• Time & Interruptions
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Open-Ended Questions
Questions that have many answers
Closed questions have a specific answer
Examples:
How are you?
“How can I help you?’ “And then what happened?’
Tell me about your pain.”
Serve as an invitation
Beware – Patient may ramble awhile
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Effective Communication:
Verbal Strategies
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Open Questions
Elicit information
How would you describe
your relationship with
your parents?
Closed Questions
Gather specific
information
Do you have a good
relationship with your
parents?
Combining Open and Closed Questions

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Facilitating
Sending an “I’m with you” message
May encourage development of hope
Simple gestures or phrases:
Nodding, smiling
“Tell me more”
Uh-huh
Pausing appropriately
Repeating a keyword the patient uses
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Clarifying
Know exactly what the patient is saying
Examples:
“Let me see if I’ve got this straight…”
“So what you’re saying is…”
“Do you mean ____ or ___ ?”
Use a translator, social worker or other facilitator
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Paraphrasing and Reflection
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patient: Everything is boring. There’s nothing new
going on, nothing exciting. All my friends are
away. I wish I had money to do something
different.
Paraphrase: With your friends gone and no money
around, there is nothing for you to do right now.
Reflection: You feel bored with the way things are
for you right now.
WHAT ABOUT NON-VERBAL?
It’s not what you say - it’s the way that you say it!
There are several other positive non-verbals that can be
used to indicate we are listening supportively - often known
under the mnemonic S.O.L.E.R.
Sitting Square on to the patient with an Open position,
Leaning slightly forward with Eye contact in a Relaxed
posture.
The most important is eye contact followed by facial
expression and inflection of voice.
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Time & Interruptions
Acknowledge that the patient is your primary
concern
Records/Pages & phone calls: defer or avoid
Clarify time constraints
Plan a continuation of the discussion
Don’t interrupt
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Acknowledgement
The Empathic Response
Touch
Normalize
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Empathy
• "Empathy means demonstrating an
understanding of the patient's pain and distress
while maintaining an objective and observant
stance."
Being Seen
Being Heard
Being Accepted
The Empathic Response
A verbal technique that acknowledges you have
heard the patient’s emotional content.
No requirement to feel the emotion.
Steps:
1. Identify the emotion – open-ended questions
2. Identify its cause
3. Respond in a way that shows you understand the
connection between 1 and 2
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THE MNEMONIC “NURSE”
The Duke team uses the mnemonic “NURSE” to
label five types of continuer statements:
Name: State the patient's emotion
Understand: Empathize with and legitimize the
emotion
Respect: Praise the patient for strength
Support: Show support
Explore: Ask the patient to elaborate on the
emotion
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Empathy
Example:
“I understand that you are worried about the
consequences of your injury.”
Let the patient know that you understand his or her
problem as if it had oc-curred to you.
Support:
“It must have been a terrible experience for you”.
Let the patient know that you comprehend his or her
feelings.
Normalizing : Tell the patient that his response is
appropriate and normal
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Touch
May be a very important part of your non-
verbal communication skills.
Helps the patient feel less isolated
Three rules:
1. Only touch a neutral area (hand or forearm)
2. Touch briefly, and see if the patient appreciates
it
3. Never to opposite sex
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Strategy: Creating the Plan
Think what is best medically
Assess the whole patient
Propose a strategy
Assess the patient’s response & modify accordingly
A reasonable plan the patient will follow is better
than an ideal plan the patient will ignore.
Any plan is far better than no plan.
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Summary
Summarize main points
Any urgent questions?
Any thing else!
Plan next contact:
• Time
• Setting
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Core Communication Skills
A) INTERPERSONAL
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Non-verbal communication
Skills in non-verbal communication like eye contact, physical proximity,
and facial expression need to be improved to enhance patient’s
satisfaction and adherence to treatment. This should convey to the
patient that the Health practitioner is attentive and interested.
Avoid Overreacting
Some patients may appear demanding, dependent or even at times,
adversarial. It is the physician's responsibility to not overreact to these
situations. This can be achieved by establishing limitations (boundaries)
on what can be provided and suggesting appropriate ways for the
patients to contact them.
Establishing Boundaries
Frequent phone calls, unscheduled visits, and unrealistic expectations,
are ways in which some patients lose perspective of the shared
responsibility of their care. Doctors need to establish boundaries for
patients in a way that doesn't belittle them.
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13/04/2013
Core Communication Skills
Active listening: (Well-timed silence and eye
contact)// POSTURE, GESTURE, AND FACIAL
EXPRESSION ---- culturally acceptable
Empathy, respect, interest, warmth and support
(THESE ARE THE CORE FACTORS IN
RAPPORT BUILDING.-------
Language: Avoid medical jargon.
Non-verbal communication
Avoid Overreacting
Establishing Boundaries
Closing the interview
Core Communication Skills
13/04/2013
Information gathering skills
Using an appropriate balance of open to closed
questions
Silence You need to learn to use silence appropriately as a
way to encourage express themselves more fully, raise
difficult topics and remember important
Clarifying patient expectations about the consultation
Clarifying the information given by the patient
Sequencing of events
Directing the flow of information
Summarizing
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Information Giving Skills And Patient
Education
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Providing clear and simple information
Using specific advice with concrete examples.
Putting important things first. Research suggests that what is said first
is remembered.
Using repetition.
Summarizing.
Categorizing information to reduce complexity and aid recall.
Using tools.
Checking patient understanding of what has been said. Repeating
instructions, using diagrams, written instructions, and sometimes-
technical aids to explain difficult concepts are useful.
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Advanced Communication Skills
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Skills for motivating patient adherence to treatment plans
The list below includes skills for the promotion of behaviour. Realistic compliance
with treatment plans may require patients to make significant changes in their diet,
lifestyle or daily routine on a short term or long term basis.
Providing a rationale for behavior change
Providing examples of role models
Allowing opportunities for verbal rehearsal of the details of the treatment
Feedback (positive reinforcement of constructive behaviour changes already
achieved since earlier consultations)
Finally, doctors should be aware about the clinical, communication and interpersonal
skills that are required when dealing with difficult patients, (e.g., overdependent,
dramatizing and exaggerating, aggressive, and antisocial personalities,).
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