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 Clinical
Communication

Professor Craig Jackson

Prof. Occupational Health Psychology
Head of Psychology
BCU
Clinical Communications Outline

Benefits for clients

Benefits for clinicians

Demerits

Skills

Shut up and listen

Clinical Communications Outline

“ The good clinician treats the

disease, but the great
clinician treats the patient”

William Osler
Relatively new area

Communication was a “wet skill”

Now part of curriculum

Seen as important ( not more important than clinical skill) . . .

. . . Clinical skills viewed as worthless without communication

Communication skills not universal

Different types of communication

Depends on therapists’
Training
Philosophy
inclination
Theoretical position

Psychodrama

Holotropic breathwork

CBT

RET
“ Hello Chris”

Covert naturalistic experiment

8 sessions with psychotherapist

Was NOT psychotherapy

Pseudo hypnotherapy

Distractions

. . . . . iPad
Not the “breathy voice” again

Sounds too “American”

. . . Too controlled

. . . Too therapeutic

. . . Too effortful

. . . Not naturalistic
Benefits for Clinicians & Clients

Time saving

Effective & efficient

Reduces Stress & Burnout

Reduces litigation

Clients more satisfied

Best predictor of resolution

(e.g. Chronic headache; Headache study group Ontario (1986)

Shorter care needed

(coronary care patients with emotional support - 2 days less bed time)
Mumford et al 1982
Benefits for Clients

Positive evaluations

Both Clinician and Client agree on reason for consultation

Clinician asks client about ideas, concerns or health beliefs

Clinician takes time to achieve a shared understanding with client

Positive consultations take no longer than negative ones

(Arborelius & Bremberg 1992)

Improved outcomes
A Meeting of Experts

Any clinical consultation is a meeting of two experts

Clinician - Skills & Knowledge

Client - Their body & Experience

But sometimes, people just want to be told what to do . . .

It’s all subjective of course

Clients rating their clinicians

Not knowledge based

Not skills based

Based on communication and subtle cues

They might be wrong . . . but their perception is everything

Medspeak

Jargon

Sets boundaries - reminds of power relationships

Lay person Clinician

“ Sick” Illness Vomit

“ Nerves” Anxiety Neurology
“ Chronic” Severe Long duration
“ Acute” Severe Sudden onset
“ Diet” Calorie restriction Intake
“ Drugs” Narcotics Medication
“ Stomach” Abdomen Organ
“ History “ The past Previous disease
Interruptions & Redirections

Consultations start with client

Appearing rushed

Checking watch

Fidgeting

Monitoring email

28% of clinicians interrupt client in first opening

Mean of 23 seconds ( Marvel et al 1999 )

Average of 2 interruptions per consultation

Mean of 12 seconds in home consultations ( Rhoades et al 2001 )
Valerie: HIV patient in 1985
Useful sources

90% of info comes from taking a history

10% (or less) from case files and records

Visual metaphor

Might come in bits and pieces

Communication Skills: General Manner

1. Responds to cues
2. Active Listening
3. Use Empathy
4. Offer Support
5. Non-judgemental
6. Avoid personal beliefs
7. Simple language
8. Use appropriate body language
9. Questioning style
10. Information giving
11. Information gathering
Information Gathering

Appropriate language

Ordered and Methodological

Comprehensive / Succinct

Coaxing

Use triangulation . . . “So you said that . . . Therefore . . .”

Offer partners or collaborators to input

Props e.g. clipboard, notes, questionnaire

Information Gathering . . . Don’t rely on symptoms
“ Doorknob concerns”

“ By the Way” syndrome ( Robinson 2001 )

Clients often reveal real reason only when comfy

Real reason is not the first reason hey give

Psychosocial issues

Worries about future

Their own ideas

Social context of their problem

Barry et al 2000
Information Giving

Convey info

Check understanding

Control of consultation (allows it to vary)

Signpost change of direction

Summarises / indicates next steps

Recognise and respond to client’s concerns and anxieties

Consultation General Skills

1.Gives name and explains role; checks patient’s name

2.Gives greeting appropriate to culture (handshake not always needed)
3.Non-verbal behaviour appropriate to culture (eyes not always
needed)
4.Establishes purpose of interview
5.Clarifies why interview is taking place:
- from client’s perspective
- from clinician’s perspective
6.Checks that patient is happy to proceed
7.Establishes desired outcome of interview
8.Establishes baseline knowledge/understanding
9.Uses open questions
10.Listens
11.Confirms what s/he has learned
Some natural cynicism from medical circles
Case Summary of a counselling client

Date Symptoms Referral Investigation Outcome

1980 (18) Abdominal pain GP --> surgical OP Appendictomy Normal

1983 (21) Pregnancy GP --> obs and gynae Termination

(boyfriend in prison) OP

1985-7 Bloating, abdominal GP --> Gastro and All tests normal IBS diagnosis
(23-25) blackouts (divorce) neurology OP unexplained syncope

1989 (27) Pelvic pain GP --> obs and gynae Sterilised Pain persists for 2 years
(wants sterilisation) OP

1991 (29) Fatigue GP --> infectious Nothing abnormal Diagnosis of ME by patient

diseases unit and self help group

1993 (31) Aching muscles GP --> rheumatology Mild cervical Pain clinic - Tryptizol
clinic spondylosis

1995 (34) Chest pain, breathless A&E --> chest clinic Nothing abnormal Refer to
psychiatric services (child truanting) poss hyperventilation
Summary

Clinicians expected to be good communicators

Clinical skill does not make up for communication lacking

Communication does not replace clinical skills

Getting it right worthwhile

Rewards

Getting it right takes time and experience

Clinical supervision essential

Case reviews essential

Communication without Knowledge
Communication without Knowledge
Some References

Makoul, G. (2001). Essential elements of communication in medical encounters:

the Kalamazoo consensus statement. Academic Medicine, 76(4) : 390-393.

RSM forum on Communication in Healthcare (2004). Core curriculum for

communication skills in medical schools. In E. McDonald (ed). Difficult
Conversations in Medicine. Oxford: Oxford University Press. pp 209-211.

Simpson, M et al. (1991). Doctor-patient communication: the Toronto consensus

statement. British Medical Journal. 303(6814): 1385-1387.

Von Fragstein, M. et al. (2008) UK consensus statement on the content of

communication curricula in undergraduate medicine education. Medical Education
42(11): 1100-1107.