Communication Skills

In Clinical Medicine

Prepared and presented by

Marc Imhotep Cray, M.D.
Marc Imhotep Cray, M.D.
 Communication Matters!
Communication impacts:
 Diagnosis
 Adherence
 Patient satisfaction
 Physician satisfaction
 Malpractice litigation

Marc Imhotep Cray, M.D. 2

 In Fact...
According to defense attorneys, communication
breakdown is most important event leading to
a patient's decision to litigate
 35% Physician communication

 35% Physician attitude

 10% Patient financial incentives

 20% Other

Physician scores on a national clinical skills

examination as predictors of complaints to medical
regulatory authorities.
JAMA. 2007 Sep 5;298(9):993-1001.

Marc Imhotep Cray, M.D. 3

Communication is Not "Just Talking"
 Communication is most commonly used
medical procedure
 Communication skills are not innate or fixed
 Communication skills can be learned and improved
 Physicians can improve health outcomes by
learning how and when to use specific
communication techniques

Richards T. Chasms in communication.

BMJ. 1990 December 22; 301(6766): 1407–1408.
PMCID: PMC1679819

Marc Imhotep Cray, M.D. 4

 Physician Tasks- The Two Fs

Biomedical Tasks
 Find it!

 Fix it!

Marc Imhotep Cray, M.D. 5

 Physician Tasks :
The Four Es
Communication Tasks
 Engage the patient!

 Empathize with the patient!

 Educate the patient!

 Enlist the patient in his/her own health care!

Poor Communication Between Doctors Costs

Patients’ Lives, Apr 30, 2013
www.thedoctorschannel.com/view/poor-
communication-between-doctor

Marc Imhotep Cray, M.D. 6

 The First E - Engagement
 Is the interview an inquiry
or an inquisition?
 Who is in charge of the
inquiry process?
 What does interruption say
about roles?
 How many complaints are
"normal?"
Clarke AR, Goddu AP et.al. Med Care. 2013 Nov;51(11):1020-6.
Thirty years of disparities intervention research: what are we doing
to close racial and ethnic gaps in health care?
doi: 10.1097/MLR.0b013e3182a97ba3.

Marc Imhotep Cray, M.D. 7

Agree Upon an Agenda for the Visit
 Ask - "Is there anything else you would
like to talk about?"
 Ask - "Is there anything else you were
wondering about?"
 Ask - "What were you hoping we'd
accomplish today?"

Marc Imhotep Cray, M.D. 8

Pay Attention to Two "Voices"
Physicians have a "voice,"
the voice of medicine.
This voice...
 Wants to obtain a history
 Asks close-ended questions
to get "facts"
 Constructs a differential
diagnosis
Marc Imhotep Cray, M.D.
Patients have a “voice”, the
voice of experience.
This voice...
 Wants to tell the "story" of
the illness
 Is concerned with the
personal meaning of the
illness
 Speaks in response to
open-ended questions
9
Translate, Bridge, Funnel
 Translate - Converse in one "voice"
while thinking in another
 Bridge - Acknowledge when topics are
being changed and give the reasons for
the changes
 Funnel - Direct the flow of conversation
by asking for information about topics of
specific concern

Marc Imhotep Cray, M.D. 10

Outcomes of Successful Engagement(1)

Develop a more accurate Increase the likelihood of

diagnosis adherence
 Obtain more information  Establish an improved
about the illness. physician-patient
 Understand the effect of relationship.
the illness upon the  Discover the health
patient. belief system of the
patient

Marc Imhotep Cray, M.D. 11

Outcomes of Successful Engagement(2)
Establish an effective relationship
 Create an opportunity for partnership.

 Demonstrate interest in the patient's

point of view
 Provide the patient with an opportunity
to tell their story

Marc Imhotep Cray, M.D. 12

 The Second E - Empathy

 Being Seen
 Being Heard
 Being Accepted

Marc Imhotep Cray, M.D. 13

Being Seen Techniques
N.B. See new patients with their clothes on at
the beginning of the interview
"See" the patient - acknowledge...
 Facial and bodily expressions of feelings.

 Mode of dress and physical presentation

 Notable physical characteristics

Eliminate physical barriers - desks, charts, etc.

Marc Imhotep Cray, M.D. 14

Being Heard Techniques
 Use the language of the patient.
 Give feedback to the patient
 Ask for feedback from the patient.
 Invite the patient to tell his/her story;
welcome the story:
 Feelings

 Values

 Thoughts

Marc Imhotep Cray, M.D. 15

 But There's a Problem...
 Physicians acquire more than
13,000 new words during
their training
 They use them with patients
 Adapt to the patient's "voice"
(language, beliefs, etc.)
 This requires concentration

Marc Imhotep Cray, M.D. 16

Being Accepted Techniques
 If you must judge, judge the behavior not
the person
 Communicate your understanding of the
patient's feelings and values (do so in a
way that they can correct you)
 Use appropriate self-disclosure

Marc Imhotep Cray, M.D. 17

 Steps in Communicating Empathy
 Recognize the emotional moment
 Pause to question: "What's going on here?"
 Name the emotion you believe is present.
 Communicate your understanding of the
emotion and validate its presence
 Respect the patient's efforts with the emotion
 Offer support and partnership

Marc Imhotep Cray, M.D. 18

Outcomes of Establishing an
Empathic Connection
 Reduced anxiety related to isolation or
abandonment
 Improve adherence
 Increased level of connection:
1) Increased patient satisfaction
2) Increased physician satisfaction
 Reduced physician frustration

Marc Imhotep Cray, M.D. 19

 The Third E - Education
Assume the following
questions and answer
them as a matter of
course:
 What has happened to me?
 Why has it happened to me?
 What is going to happen to
me?
Can Doctors Really Educate Patients in 15 Minutes?
Aug 17, 2012
http://www.thedoctorschannel.com/view/can-doctors-
really-educate-patients-in-15-mins/
Marc Imhotep Cray, M.D. 20
Mysteries of the Medical World
 What are you (they) doing for me (to me)?
 Why are you (they) doing this rather than
that?
 Will it hurt me or harm me? How much?
How long?
 When and how will you know what all this
(tests, procedures, etc.) means?

Marc Imhotep Cray, M.D. 21

 Patient Survey(1)
In a telephone survey of 1000 randomly
selected adults:
 25% reported they had stopped seeing
a physician at some time because of
communication problems
 60% reported they wanted physicians to
do a better job explaining options
Patient-physician communication: why and how.
J Am Osteopath Assoc. 2005 Jan;105(1):13-8.

Marc Imhotep Cray, M.D. 22

 Patient Survey (2)
 50% said, "Ask if the patient has more
questions"
 48% said, "Ensure the patient understands
what the physician has said"
 47% said, "Explain what the physician is
doing"

Marc Imhotep Cray, M.D. 23

 The Fourth E - Enlistment
 The challenge is to enlist the patient as an
active decision maker and participant in
her/his health care
 Active decision making can not be assumed
 Adherence can not be assumed
 Physician action influences both
participation and adherence

Marc Imhotep Cray, M.D. 24

 The Price of Failure
 Patients do not adhere to physicians'
recommendations at least 30% of the time

 Non-adherence with prophylactic

medication among asymptomatic patients
can be more than 50%

Marc Imhotep Cray, M.D. 25

What's Going On?!?
 3 billion new prescriptions
are written in U.S. each
year
 Up to 50% will never be
filled or taken
 Up to 50% of those filled
will only be partially taken

Generation Rx How prescription drugs are altering American lives, minds, and body
J Clin Invest. 2006 February 1; 116(2): 287. doi:10.1172/JCI27774

Americans Skimping on Medication, Sep 14, 2012

http://www.thedoctorschannel.com/view/americans-skimping-on-medication/
Marc Imhotep Cray, M.D. 26
American Prescription Drug Use
“The average number of prescriptions drugs per person,
annually, in 1993 was seven

The average number of prescriptions drugs per person,

annually, in 2000 was eleven

The average number of prescriptions drugs per person,

annually, in 2004 was twelve”

Generation Rx How prescription drugs are

altering American lives, minds, and body
J Clin Invest. 2006 February 1; 116(2): 287.

Marc Imhotep Cray, M.D. 27

The Poor Adherence Myth
Myth - "Poor adherence can be attributed to
patient characteristics."
In fact, no consistent relationship has been shown
between adherence and...
 Age
 Gender
 Social economic status
 Marital status
 Personality traits (introverted, gregarious, etc.)

Marc Imhotep Cray, M.D. 28

Factors Affecting Adherence
 The objective severity of the disease does
not affect adherence;
 what the physician believes has limited impact
 The subjective perception of the
seriousness of the disorder does affect
adherence;
 what the patient believes is critical

Marc Imhotep Cray, M.D. 29

What Does Affect Adherence?
 The patient's perception of the seriousness
of the disease
 The patient's perception of the efficacy of
the treatment
 The duration of the treatment and the illness
 The complexity of the regimen
 The relationship with the physician

Marc Imhotep Cray, M.D. 30

Enlistment Techniques
To improve adherence physicians must:
 Demonstrate compassion

 Communicate:

 Personal concern for the patient.

 Personal interest in the patient's future well-
being
 Activate patient motivation
 Share responsibility with the patient

Marc Imhotep Cray, M.D. 31

 Assume a Self Diagnosis
 The patient has an internal belief system
which explains to the patient what is
happening with his or her health
 This includes
 cause of a health problem,
 meaning (consequences and symbolism) of
the problem, and
 how the problem might be resolved

Marc Imhotep Cray, M.D. 32

To Improve Adherence, the
Physician Must Be Willing to...

 Discover the patient's beliefs:

“cause, meaning and cure”

 Discuss the patient's beliefs

Read: Davey G and Parry E. Chapter 1: People and the environment, Pgs. 1-7.
In: Principles of Medicine in Africa. Mabey D et. al. Eds. Cambridge: Cambridge
University Press, 2013.

Marc Imhotep Cray, M.D. 33

Enlistment Technique
 Ask - "This is what I think is
going on.
 (State your explanation.)
 How does my explanation fit
with what you have been
considering?"

Walker J, Leveille SG et.al.

Inviting patients to read their doctors' notes: patients
and doctors look ahead: patient and physician surveys.
Ann Intern Med. 2011 Dec 20;155(12):811-9.

Marc Imhotep Cray, M.D. 34

Outcomes of Enlistment
 Increased likelihood of adherence.
 Empowerment of the patient: motivation.
 Greater range of choices for physician
and patient.
 Partnership between physician and
patient.
 Increased patient and physician
satisfaction

Marc Imhotep Cray, M.D. 35

There is a Need to End-
How to Disengage
Summarize diagnosis, treatment, and
prognosis
Review next steps:
 Future visits, phone calls, etc.
 Tests, referrals, etc.
 Say good-bye, express hope

Marc Imhotep Cray, M.D. 36

 Selected References
PubMed
A communication skills course for preclinical students: evaluation of general practice based
teaching using group methods.
Kendrick T, Freeling P. Med Educ. 1993 May;27(3):211-7.
http://www.ncbi.nlm.nih.gov/pubmed/8336570

Effects of communication skills training on students' diagnostic efficiency.

Evans BJ, Stanley RO, Mestrovic R, Rose L. Med Educ. 1991 Nov;25(6):517-26.
http://www.ncbi.nlm.nih.gov/pubmed/1758333

Teaching communication skills: a skills-based approach. Wagner PJ, Lentz L, Heslop SD.Acad
Med. 2002 Nov;77(11):1164.
http://www.ncbi.nlm.nih.gov/pubmed/12431944

Simpson M, Buckman R, Stewart M, Maguire P, Lipkin M, Novack D, Till J. Doctor-patient

communication: the Toronto consensus statement.
BMJ. 1991 Nov 30;303(6814):1385–1387.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1671610/

Kerr DN. Teaching communication skills in postgraduate medical education.

J R Soc Med. 1986 Oct;79(10):575–580.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1290495/
Marc Imhotep Cray, M.D. 37