Object: Medical communication and behavior

What is the communication process?

• The sharing of meaningful information between two or more people with the goal of the receiver understanding the sender's intended message. 

• Nowadays, the effective communication is an absolute must, because it commonly accounts for the difference between success and failure or profit and loss, prosper carrier or bad image etc.

• Effective communication is the most critical component of total quality management.

Elements of a communication process

• The communication process is made up of four key components: encoding, medium of transmission, decoding, and feedback.

• The communication process begins with the sender and ends with the receiver. If a sender relays a message through an inappropriate channel, its message may not reach the right receivers. That is why senders need to keep in mind that selecting the appropriate channel will greatly assist in the effectiveness of the receiver's understanding. Effective communication leads to understanding.

Elements of a communication process

• After the appropriate channel or channels are selected, the message enters the decoding stage of the communication process. Decoding is conducted by the receiver. Once the message is received and examined, the stimulus is sent to the brain for interpreting, in order to assign some type of meaning to it.

• The receiver begins to interpret the symbols sent by the sender, translating the message to their own set of experiences in order to make the symbols meaningful.

• Successful communication takes place when the receiver correctly interprets the sender's message.

Elements of a communication process

• Feedback is a key component in the communication process because it allows the sender to evaluate the effectiveness of the message.

Feedback ultimately provides an opportunity for the sender to take corrective action to clarify a misunderstood message.

"Feedback plays an important role by indicating significant communication barriers: differences in background, different interpretations of words, and differing emotional reactions" (Bovee & Thill, 1992).

What are barriers in the communication process?• factors that have a negative impact on the communication process.

• Some common barriers include:- the use of an inappropriate medium (channel),

- incorrect grammar, - inflammatory words, - words that conflict with body language, and technical jargon.

- Noise etc. 

Barriers to patient-physician communication

• Speech disability or language articulation.• Foreign language spoken.• Disphonia.• Time constrains on physician or patient.• Unavailability of physician or patient to meet face –to-face.

• Illness.• Altered mental state.• Medication effects.• Psychological or emotional distress.• Gender differences.• Racial or cultural differences.• Other.

Types of errors most frequently encountered during the establishment and development of doctor-patient relationship:

• Inappropriate attitude features of the doctor: rush, impatience, fatigue, boredom, raised voice.

• Excess of or lack of authority with the patient.• Underestimating difficult patients, with increased psychogenic tendencies.

• Engaging in conflict situations.• Acceptance of insufficient communication with the patient.

• Polimedication as an expression of the doctor’s submission to pa tient’s insistence.

Deficiencies in doctor-patient communication:

• Failure to appropriately greet the patient, introducing oneself and explaining one’s actions.

• Failure to get easily accessible information, mainly due to fears and expectations.

• Accepting imprecise information, failure in seeking clarifications.• Failure to verify with the patient what the doctor understood from the situation.

• Failure to elicit questions or to appropriately answer to questions• Neglecting obvious clues or clues not provided verbally or in a different manner by the patient.

• Avoiding information concerning the patient’s personal, family, social status, including problems in these areas.

• Failure to elicit information about the patient’s feelings and the perception of the illness.

• Directive style with closed questions, frequent interruption and failure to make the patient speak freely.

• Rushed focusing without testing theories.• Failure to provide appropriate information concerning the diagnosis, treatment, side effects or prognosis, or in verifying the patient’s understanding of these issues.

• Failure to understand the patient’s viewpoint.• Poor comforting.

Important moments in a medical consultation

1. Starting the interview Research has shown the importance of listening to patients’ opening statements without interruption.

Doctors often ask about the first issue mentioned by their patients, yet this may not be what is concerning them most. Once a doctor has interrupted, patients rarely introduce new issues.

If uninterrupted, most patients stop talking within 60 seconds, often well before. The doctor can then ask if a patient has any further concerns, summarize what the patient has just said.

Important moments in a medical consultation

2. Detecting and responding to emotional issues

Even when their problems are psychological or social, patients usual ly present with physical symptoms. They are also likely to give verbal or non-verbal cues. Verbal cues are words or phrases that hint at psychological or social problems. Non-verbal cues include changes in posture, eye contact, and tone of voice that reflect emotional distress.

Important moments in a medical consultation

•3. Check understanding• Ensure that patient is clear about plan.• Consider a written summary.• Questions that cannot be answered in one word require patient to ex pand.

• Move towards closed questions at the end of a section of the consultation.

• Repeat back to patient to ensure that you have un der stood.

• Encourage patient both verbally (“Go on”) and non-ver bally (nodding).

Important moments in a medical consultation

• Read referral letter or notes, or both, before seeing patient.

• Encourage patients to discuss their presenting concerns without interruption or premature closure.

• Explore patients’ presenting complaints, concerns, and understanding (beliefs).

• Inquire about disability.• Inquire about self care activities.• Show support and empathy.• Use silence appropriately.• Use non-verbal communication such as eye contact and nods.

Three functions of effective medical consultation

•1 Build the relationship• Greet the patient warmly and by name.• Detect and respond to emotional issues.• Active listening.•2 Collect data• Do not interrupt patient.• Elicit patient’s explanatory model.• Consider other factors.• Develop shared understanding.•3 Agree a management plan• Provide information.• Appropriate use of reassurance.• Negotiate a management plan.• Make links.• Negotiate behaviour change.

Communication benefits to patient

• Worry about health (health anxiety) is a common cause of distress and disability in those with and without serious disease. Reassurance is therefore a key component of starting treatment.

• The first step is to elicit and acknowledge patients’ expectations, concerns, and illness beliefs.

• This is followed by history taking, examination, and if necessary investigation.

• The psychological factors of beliefs and attitudes about illness and treatment are major determinants of outcome. Hence, strategies that increase understanding, sense of control, and participation in treatment can have large benefits.

Mismatch of expectations and experiences

• What patients want What some patients get

• To know the cause. No diagnosis.• Explanation and information Poor explanation that does not

• address their needs and concerns.

• Advice and treatment. Inadequate advice.• Reassurance. Lack of reassurance.

• To be taken seriously by a competent doctor. Feeling that doctor is uninterested.

• You: ascertain expectations• What does patient know?• What does patient want? - Investigation? Management? Outcomes?

Showing your understanding of patients’ concerns

• Relay key messages such as, “The symptoms are real,” “We will look after you,” and “You’re not alone”.

• Take patients seriously and make sure they know it.• Don’t dismiss presenting complaints, whether or not relevant pa tho logy is found.

• Explain your understanding of the problem, what it is, what it isn’t, treatment, and the future.

• Consider offering a positive explanation in the absence of relevant physical pathology.

• Avoid mixed messages.• Encourage and answer questions.• Share decisions.• Communicate the management plan effectively, both verbally and in writing.

• Provide self care information, including advice on lifestyle change.

• Avoid medical jargon and terms with multiple meanings.• Involve relatives.

There are some strategies to help patients to change their behaviour.

• Explore motivation for change• Build rapport and be neutral.• Help draw up list of problems and priorities.• Is problem behaviour on patient’s agenda? If not, raise it sensitively.• Does patient consider the behaviour to be a problem? Do others?

• Clarify patient’s view of the problem• Help draw up a balance sheet of pros and cons.• Empathize with difficulty of changing.• Reinforce statements that express a desire to change.• Resist saying why you think patient ought to change.• Summarize frequently.• Discuss statements that are contradictory.

• Promote resolution if no change is wanted negotiate it, when, and how to review• Enable informed decision making.• Give basic information about safety or risks of behaviour.• Provide results of any examination or test.• Highlight potential medical, legal, or social consequences.• Explain likely outcome of potential choices or interventions.• Get feedback from patient.• Give patient responsibility for decision.

Iatrogenesis• Is the adverse effects or complications caused by or resulting from medical treatment or advice.

A psychological iatrogenesis can be caused by:

• Absence of confidential contact.• Neglecting.• Misses in speech of the doctor, it is especial at the first occurring.

• The unreasonable use of medical terminology.

• Patient-physician communication produces a therapeutic effect for the patient, (as has been validated in controlled studies).

• Patients, who understand their doctors are more likely to acknowledge health problems, understand their treatment options, modify their behavior accordingly, and follow their medication schedules.

• In fact, effective patient - physician communication can improve a patient's health as quantifiably as many drugs, perhaps providing a partial explanation for the powerful placebo effect seen in clinical trials.

!!!• Based on emerging literature on the value of effective communication, medical students and postgraduates are increasingly given instruction on techniques for:

• listening, • explaining, • questioning, • counseling, and • motivating patients.

!!!• During the typical 15- or 20-minute patient-physician encounter, the physician makes nuanced choices regarding the words, ques tions, silences, tones, and facial expressions he or she chooses.

• These choices either enhance or detract from the overall level of excellence of the physician's delivery of care.

!!!• The physician who can communicate bad news in a direct and compassionate way will not only help the patient cope, but will also strengthen the therapeutic relationship, so that it endures and further extends the healing process.

The Accreditation Council for Graduate Medical Education recommends that

physicians become competent in five key communication skills:

• 1. listening effectively; • 2. eliciting information using effective questioning skills;

• 3. providing information using effective explanatory skills;

• 4. counseling and educating patients;• 5. making informed decisions based on patient information and preference.

• 6. Tell the truth. • 7. Watch the patient's body and face. • 9. Be prepared for a paient reaction.

Some skills that will help doctor to deal in a good way

the medical consultation• 1. Assess what the patient already knows. Before providing information, find out what a patient already knows about his or her condition.

• 2. Assess what the patient wants to know. Not all patients with the same diagnosis want the same level of de tail in the information offered about their condition or treatment.

• 3. Be empathic. Empathy is a basic skill physicians should develop to help them recognize the indirectly expressed emotions of their patients.

• 4. Slow down. Physicians who provide information in a slow and deliberate fa shion allow the time needed for patients to comprehend the new information.

• 5. Keep it simple. Physicians should avoid engaging in long monologues in front of the patient. Far better for the physician to keep to short statements and clear, simple explanations.

Communication traps to avoid:• Using highly technical language or jargon when communicating with the patient.

• Not showing appropriate concern for problems voiced by the patient.

• Not pausing to listen to the patient.• Not verifying that the patient has understood the information presented.

• Using an impersonal approach or displaying any degree of apathy in communications.

• Not becoming sufficiently available to the patient.

A “perfect” doctor• Good listener• …….

A “perfect” patient • Will be mindful of the doctor's limited time. • Will be concise in his communication, preparing carefully for meetings with his practitioner.

• Will ask the meaning of words and concepts he doesn't understand.

• If interrupted, will ask the doctor to stop and listen respectfully.

• Will ask his doctor what to expect next. • Will know which questions to ask the doctor, and which to save for others.

• Become as knowledgeable as possible. • Take good care of yourself. • Set goals. • Have pertinent data with him. • Take notes. • Repeat what his doctor say. • …

Difficult patients• are persons who can vex even the most mild-mannered physicians, by the spectrum of challenging behavior.

• Some types of difficult paients:• “A universal pain” pacient.• The fearful patient. • The “drug seeker”. • The angry patient. • All in the family. “When you have a patient who is terminally ill, in particular, it’s usually the family who has the more unrealistic expectation of what can be done,”

• The no-can-do-er patient. • Emotionally needy patient.

Strategies to deal with difficult persons

•Make sure you:• Observe: Notice a patient's words, voice or attitude to pick up on rising anger levels. "Worries and loss of control often are triggers of aggression," says Simms, who urges nurses to trigger a sense of capability in patients, not one of vulnerability.

• Connect: Uncover and directly address a patient's underlying fee lin gs with comments such as, "You sound worried. What can we do to help?" Establishing a personal connection can go a long way toward gaining cooperation, Kuhn says.

• Show Respect: Make eye contact, and try to approach patients at eye level. Always address patients as Mr. or Mrs., and speak in a friendly manner.

• Slow Down: Rushing can be counterproductive, especially when caring for those with hysterical and emotive patients.

• Recruit Help: Enlist relatives to help break the isolation, create solutions and provide support.

• Be Informed: Know your employer's patient bill of rights, as well as its policies and procedures for dealing with difficult patients.

Strategies to deal with difficult persons

•Avoid:• Bullying: Don't use your caregiver status to threaten patients.

• Making Assumptions: Most patients are not intentionally abusive or disruptive. They often are responding to an irritation, vulnerability, cognitive impairment, inability to express them or loss of identity.

• Putting Up Walls: Distance just fuels patients' anger. • Tolerating Disruptive Behavior: Clearly explain what is unacceptable to avoid problems later.

• Taking It Personally: "You can't expect that everyone at work will act pleasantly. So, interpersonal mishaps or confrontations are guaranteed when you work with the public."

Communication & Manipulation

• AT WHAT POINT COMMUNICATION BECOMES MANIPULATION?• Dictionary.com  defines ‘manipulate’ as: to manage or influence skillfully, especially in an unfair manner: to manipulate people’s feelings.

• The Chambers English Dictionary defines ‘manipulate’ as: to turn to one’s own purpose or advantage.

• So the key factor is not the number of influence techniques used, but the intention of the speaker. Influencing the audience for your own selfish interests is considered manipulation, and has a negative connotation.

• The practical exercise

!!! • The audience’s own interest is the magical ingredient of any presentation. If you can always clearly act in the audience’s interest, you will never be accused of manipulation, no matter how many influence techniques you use. And if you can find a way to meet their needs while also meeting yours, then everybody wins.