communication Skill part 2

Dr Abdulsalam Saif Ibrahim

Consultant Pulmonary and ICU
( Alkhor Hospital)
• Initiating the Session
establishing initial rapport( great pt warmly and be name)
identifying the reasons for the patient’s attendance
• Gathering Information
exploration of problems Understanding the patient’s
perspective …… providing structure to the consultation
• Building the Relationship
developing rapport( active listening, detect & respond to
emotional issues …………involving the patient
• Explanation and Planning
providing the correct amount and type of information
aiding accurate recall and understanding
achieving a shared understanding: incorporating the pts
perspective
planning: shared decision making
options in explanation and planning
if discussing opinion and significance of problems
if negotiating mutual plan of action
if discussing investigations and procedures
• Closing the session
 Negotiating a management plan
Ascertain expectations
•What does patient know?
•What does patient want? Investigation? Management? Outcomes?
Advise on options
•Elicit patient's preferences
Develop a plan
•Involve patient
•Tailor preferred option to patient's needs and situation
•"Think family"
Check understanding
•Ensure that patient is clear about plan
•Consider a written summary
Advise on contingency management
•hat should patient do if things do not go according to plan?

•Agree arrangements for follow up and review

Three functions of the medical consultation

Build the relationship 1

Greet the patient warmly and by name
Active listening Detect and respond to
emotional issues

Collect data 2
Consider other factorsDo not interrupt patient
DevelopElicit patient's explanatory model
shared understanding

Agree a management plan 3

Make linksProvide information
Appropriate use of reassurance
Negotiate behaviour change
Negotiate a management plan
Responding to patient’s verbal and non verbal
cues

Aspects of interview style that aid assessment of

patients’ emotional problems

Active listening skills

Helping patients to change their behavior

 CLASS

Context

Listening skills

Acknowledgement

Empathy

Strategy

Summary
SPIKES

Setting

Perception

Invitation

Knowledge

Explore emotions and Empathy

Strategy and Summary

We are born to see, but
“

have to train ourselves to

observe”
Ask before you tell?
Don’t assume that the patients
already know!
Don’t acknowledge emotion before
you know the feeling?
• What are the objectives of the interview?

• The four E,s

• Engaging

• Empathizing

• Educating

• Enlisting
• Engaging the patient:
– joint the patient; elicit the agenda & sitting the
agenda

– Welcome and introduction

– Allow patient to talk uninterrupted as this is the

key technique in facilitating the interview

Example:(How things are going on since I saw

you? How are you?)
Empathy: create a setting that is
psychologically safe.
– Emotion handling is a learned skill that
consists of techniques:

Example: ( I do appreciate that not knowing

what is the nature of future is unpleasant to
you)( That should have been very upsetting)
It is difficult to know
• Educate the patient:-
– Assess the patient understanding

– Assume questions

– Assure understanding

– Get a feeling of the patient expectation so that you

can get to an agreement plan that is acceptable and
feasible to the patient, even if not perfect, which will
do better than a perfect plan which is not acceptable
• Enlistment:

– Decision making, adherence, and enrolling

the patient in his health care
– Enlistment is a crucial part of medical
interview

Example: (I want to propose to you that we set

together and see what we can do
• Expectation:
– Of medical condition: does that patient
think there is any wrong?
– Of treatment: what will it be like? Any
side effect?
– Of outcome: will every thing be normal
afterward?
• What are the techniques to achieve
those tasks?
CLASS
Context
Listening skills
Acknowledgment
Strategy
Summary
(CLASS) context or setting
– Starting with the first friendly handshake, non-verbal
communication is important to establish and maintain
patient confidence.

– Physical space – try to ensure privacy, sit down

• About 2 feet of space and no physical barriers between
you ( e.g across corner of desk or chair at beside bed)

• Good proximity at the bedside: insure privacy close the screen

separating the two beds

• Eye on same level as patient's

• Ideally the doctor should sit down talking to the patient

• If sitting on the patient bed ask his permission Example:

(There is no chair, is it Ok to set on the your bed?)
• Relative or friends
• Set relative/friend next to patient (not between you and patient)

• Have a box of tissue nearby if it is likely to be needed

Body language and eye contact

• Try to look relaxed and unhurried.

• Your own body language or positioning is a powerful communicator of

attentiveness

• Some doctors avoid sitting behind a desk to remove any barrier.

• If you lean forward slightly and look at the patient while he or she speaks,
your nonverbal communication says, "I'm interested in what you have to
say. Please continue.
• Maintain eye contact (except during patient's
distress): the patient may be sending you non-
verbal clue that you may not be noticing: you
may miss the likely diagnosis if you don't look.
• (The words and the non-verbal clues should
match)
• Pick up verbal cues and non-verbal cues
 (CLASS )Listening skills:
– Unlike hearing, which is the perception of
physical stimuli to our ears,
– listening is the active cognitive process of
interpreting what we hear, evaluating that
information, and deciding how that
information may be used.
• a) Open ended questions: questions that can be
answered in any way

(how are you?) How did that make you feel? How were
you doing recently?
• The open questions are the ideal questions used to start
the interview well and when you don't know what the
patient feel.
• Closed questions are a question that has one answer
(do you have shortness of breath?)
 b) Facilitating: encourage patient both
verbally and non verbally
• Pausing or silence when the patient
speaks: especially about important or
emotionally charged topic and especially in the
first few minutes of the interview.

Examples: Nodding, smiling, saying ( hmm hmm)

– Tell me more about that , go on etc

– Yes, I see
• C)Repetition (checking)
– This is underused and very powerful facilitating
technique: it means using a key word from the
patient last sentence in you first sentence(Repeat
the patient's own words

"Not well since your mother died“

if he speaks about an abnormality or pain

repeat his own words etc
 d) Clarifying:

• Making overt any ambiguous or awkward topic:

(so what you are saying is)

(Let me see if I've got this straight)

( do you mean that you have shortness of breath)

(What do you mean when you say you always feel tired?"
• E) Handling time and interruption
– pagers and phones: acknowledge the patient
privacy before you pay attention to interruption
and tell him who is with you as you answer
– Tell the patient about any time constraint and
clarify when discussion will resume

– Do not read notes while taking patient's

history
• Responding to patients' "cues"

Verbal cues
– State your observation "You say that recently you have
been feeling fed-up and irritable"

Non-verbal cues
– Comment on your observation "I can hear tears in your
voice"
– Ask a question "I wonder if that upsets you more than you
like to admit?"
 (CLASS) Acknowledgment
• Acknowledge emotions and explore them is the
central skill of being perceived as supportive.

• Often it is not possible to reassure patients

about the diagnosis or outcome of disease, but it
is always possible to provide support and to
show personal concern for them.
 the empathic response:
• identify the emotion

• identify the cause or source of the emotion

• respond in a way that show you have made the

connection between the first two steps

( that must be very upsetting) ( that must felt

awful) (this information has obviously came as
quit a shock) (this is very distressing)
• If you are not sure what the patient is feeling, use open ended and
direct questions until you are.( how did you feel?) then use
empathic response.

• The empathic response is a technique or skill not a feeling,

- It is not necessary for you to experience the same feeling as the
patient

- Or to agree with the patient's view or assessment

normalizing

- is often useful after acknowledgment as it helpful

after you have shown that you have heard what
the patient is worried about

- it is often unhelpful if you do it before or instead

of acknowledgment

( many patient say) ( most people have that feeling)

- this doesn't mean you agree with the patient

• Acknowledgment validates and legitimizes the
patient feeling regarding their treatment or
response to what is happening
– “This is clearly worrying you a great   deal,"

– "You have a lot to cope with," etc

• Surveying the field :Repeated signals that
further details are wanted:
• Offering support "I am worried about you,
and I want to know how I   can help you best
with this problem"
• Touch: touching the patient can be very important part
of your non-verbal communication skill and may help
the patient feel less isolate, however not all patients like
to be touched,.

Two rules

1. Only touch a neutral are of the body (hand or

forearm)

2. Touch briefly and see if the patient appreciates it

• an empathic response is an intellectual
response to an emotional situation. It allows
you the clinician a bet of separation from the
patient, which allows you to be supportive
without becoming overwhelmed by the patient
emotional burden
• An empathic response to your own
emotions:
– When confronted with a difficult situation that upset
you ( the doctor) you may express that to the patient
that describe rather than display your feeling and
explain rather than exhibit them

(I found it frustrating when I try to explain to

you while you are taking aside)
 CLASS STRATEGY
• Negotiating a management plan
The ideal management plan is one that reflects current
best evidence on treatment, is tailored to the situation
and preferences of the patient, and addresses emotional
and social issues.

• Both patient and doctor should be involved in

developing the plan, although one or the other may
have the greater input depending on the nature of the
problem and the inclinations of the patient
 Negotiating a management plan
• Ascertain expectations
• What does patient know?
• What does patient want? Investigation? Management?
Outcomes?
• Advise on options
• Elicit patient's preferences
• Develop a plan
• Involve patient
• Tailor preferred option to patient's needs and situation
• "Think family"
• Check understanding
• Ensure that patient is clear about plan
• Consider a written summary
• Advise on contingency management
• What should patient do if things do not go according to
plan
• Agree arrangements for follow up and review
• The forming of management strategy is the
central spine of clinical practice.

• Communication skills are not a substitute for

the correct management. They are essential
adjunct to the management plan and not a
substitute for making the right decisions.

• The management strategy is:

A reasonable management plan that the
patient understands s and will follow is better
than an ideal plan that will be ignored by your
patient
Steps in developing management plan:
• 1) Think what is best medically, further
diagnostic investigations, treatment options,
most suitable, side effects, likely outcome,
who else should be involved in this patient
care?
• 2) assess patient expectation of condition,
treatment and outcome
 The expectation of the patient

• Expectation of illness: does the patient

ever think there is any thing wrong?

• Expectation of treatment: what will it e

like? Any side effects?

• Expectation of the outcome?

Will every thing be normal afterwards?
The expectation of the patient will affect
any plan or strategy and the patient's
satisfaction with the medical interview
and outcome
• Be alert for the mismatch between the patient
perception or expectation of the situation and
the medical facts

– The concept of mismatch between expectation and

medical facts is very important.
Medical Not serious possibly Probably Definitely category
condition serious serious serious

Actual  Match

Concerned

Perceived ill

Actual  Match

Needs

Perceived assurance
Actual  Mismatch
Unware or

Perceived denial
Actual  Mismatch
Over anxiety

Perceived
Actual  Under
prepared

Perceived
Actual  Overly
concerned

Perceived Handle
carefully(possi
ble serious
• 3) Propose a strategy: based on wither you &
the patient are reading from the same page
after assuming the patient response.
• 4) Assess patient response (e.g. what stages of
actions are there in the pre – implementation ,
implementation and or reinforcement face
 Think family
When interviewing an individual
• Ask how family members view the problem
• Ask about impact of the problem on family function
• Discuss implications of management plan for the family

When a family member comes in with patient

• Acknowledge relative's presence
• Check that patient is comfortable with relative's presence
• Clarify reasons for relative coming

Ask for relative's observations and opinions of the

problem
• Solicit relative's help in treatment if appropriate
• If patient is an adolescent accompanied by an adult always
spend part of consultation without the adult present
• Never take sides
 Summary And Closure

• Ending the interview has three main components:

• 1) a precise summary of main topics you have discussed

• 2) any important issues or questions that you ought to

discuss even if you don't have time to discuss them in this
interview , they can be on the agenda for the next meeting

• 3) A clear contract for the next contact

(I will see you next week and we will see how the tablets
work)
• 1: Key tasks in communication with patients

• Eliciting (a) the patient's main problems; (b) the

patient's perceptions of these; and (c) the
physical, emotional, and social impact of the
patient's problems on the patient and family

• Tailoring information to what the patient wants

to know; checking his or her understanding

• Eliciting the patient's reactions to the

information given and his or her main concerns
• Determining how much the patient wants to
participate in decision making (when treatment
options are available)

• Discussing treatment options so that the

patient understands the implications

• Maximizing the chance that the patient will

follow agreed decisions about treatment and
advice about changes in lifestyle
 Breaking bad news
– Bad news is any news that seriously and adversely
change the patient’s view of his or her future.

– Bad news is the gap between patient’s expectation

and reality of the patient’s medical condition.
– You cannot tell how bad any bad news is and how
badly it may affect the patients unless you have
already some idea of what the patients perception and
expectation of the situation, therefore before you
tell ask(find out what the patient/s know or thinks ?)
Breaking Bad news ( Mnemonics)
• SPIKES

Setting

Perception

Invitation

Knowledge

Empathy

Summary
S-Setting:
Listening skills

Getting the setting- the right physical contact of

the interview (sitting down, body language,
eye contact etc.)

Listening skills (open questions to start with, not

interrupting, facilitation techniques etc
P- Patient Perception
– Ask patient to say what he or she knows or suspects about
his medical problem e.g. what did you think when you know
that you have..? or did you think it might be serious?

• As patient replies:
– Listen to level of comprehension and vocabulary when the
patient has clear comprehension, your task will be easier
than when the condition is not clear.

– Accept denial by patient

– Use the patient vocabulary on explanation: ( so you are

concerned about that lesion in the chest x-ray)
 I- Invitation:What he or she would like to know?
– Are you the sort of person who wants to know everything even if it turn to be serious?

– are you the kind of person who wants to know the diagnosis?

– How would you like me to handle the information about your condition?

– Before I tell you the result , did you think that there is something serious?

• Accept the right of the patient not to know, but offer to answer questions
as patient wishes later.
K: Knowledge (giving medical facts) 
– Aligning- using language intelligible to patient,
starting at the level he/ she finished at.
– Give information at chunks

– Check reception: confirm that patient understands

– Respond to patient reaction as they occur

– As you talk you listen

– As you listen you acknowledge and respond

E: Explore emotions and empathizes
1. Identify the emotions

2. Identify the cause or source of the emotions

– Respond in a way that shows you have made the
connection between 1 and 2
– The empathic response is a technique or skill- not a
feeling. It is not necessary for you to experience the
same feeling as the patient or agree with the
patient's view or assessment.
• Explore: Does that makes sense so far?

• If the patient asks: What's going to happen to me?

You may respond by saying ( that's very fair question….
We may not be able to tell today. It may take months to
have a clear picture. ( I cannot tell you today, but only
after treatment. .etc)

• Acknowledge the patient emotion (it is distressing not to

know what things are going to be)(that must have been
very upsetting)
S: Strategy and Summary
• Involve the patient's support system( family,
religious people, friends, social services etc.)
in the strategy
• At end of interview agree on strategy and
summarize and clarify
• Other major questions

• Clear contact for next contact

Thank you