Chapter 4: Communication skills

Hippocrates wrote:

Francis Macnab, Doctor of Divinity and patient, wrote: ‘The style of the doctor, the communication of the doctor and the person of the doctor at the level of primary contact and primary care can be crucial in a person’s life.’²

Much of the art of general practice lies in the ability to communicate.

Research continues to focus the ‘blame’ for communication breakdown on the doctor, ignoring the role of the patient.³

Communication can be defined as ‘the successful passing of a message from one person to another’.

There are five basic elements in the communication process:

• the communicator

• the message

• the method of communicating

• the recipient

• the response

Important principles facilitating the communication process are:

• the rapport between the people involved

• the time factor, facilitated by devoting more time

• the message, which needs to be clear, correct, concise, unambiguous and in context

• the attitudes of both the communicator and the recipient

These elements and principles can be seen emerging in various phases through the consultation, as illustrated in FIGURE 4.1.

Communication in the consultation^3,4

Communication in the consultation can be considered in the following sequence:

The doctor requires appropriate communication skills for complete diagnosis (physical, emotional and social) and competent management. It important to be aware of the patient’s cultural background and educational level and allow for these factors. The majority of interaction between doctor and patient occurs in the traditional consultation. This involves both verbal and non-verbal communication.

Prepare

The ‘prepare’ phase includes preparation done both well before the consultation and then just prior to the consultation. Well before consulting, the doctor should think about and prepare the physical environment. Comfort and privacy should be maximised, and distractions and interruptions minimised. The patient should be physically positioned to feel empowered (e.g. avoid talking across a desk or talking down to a patient on a bed).

As well as reviewing the environment, doctors should review themselves. They should do some self-reflection to consider what personal qualities, assumptions and values they have that may influence a consultation.

Just prior to the consultation, a review of the patient’s health record will improve the doctor’s awareness of important facts about the patient. Opening the file is actually when the consultation starts. Here, crucial clues can be found, such as:

• what happened at the last consultation

• what are the important medical issues for this patient

• any recent test results or correspondence that have arrived

• even the names of partners, parents or children who may come into the room with the patient

• brief notes on personal characteristics, likes/dislikes (e.g. has needle phobia)

When a record is examined well, the reasons for the consultation can often be anticipated prior to the formal start of the consultation, giving the doctor a wonderful opportunity to improve communication.

Increasingly in general practice we see patients as part of a team. The patient may previously have been seen by a practice nurse or a more junior doctor or medical student. This ‘teamlet model of primary care’.^5,6 has been shown to help elucidate patients’ concerns, as have ‘patient agenda forms’, which patients fill out prior to the consultation, prompting them to list what is on their agenda for the consultation.^6,7

At first contact, we usually call a patient from the waiting room into the consulting room. Having your eyes and ears ready and focused here can give you invaluable information. What is the person wearing? What is the significance of any badges, necklaces, rings or tatoos? What does his or her body language suggest? Who is accompanying the patient and how are they interacting with each other? Clues about their interests (e.g. a child’s T-shirt reflecting a favourite TV character), their cultural and social backgrounds (e.g. dress and appearance) and even their medical issues at hand (e.g. a limp, a bandage or carrying an X-ray folder or hospital letter) abound in this ‘pre-opener space’. Picking up on these clues early helps the doctor anticipate and reflect on issues before they emerge in the consultation, avoids communication breakdown, makes the patient feel that the doctor is interested in him or her and can make the doctor appear switched on and observant.

Open

When we get to the ‘opener’ (e.g. ‘What can I do for you today?’ or ‘Why have you come to see me today?’) and beyond, we should:⁸

• greet and address the patient by his or her preferred name (and anyone else entering the room)

• try to make the patient feel comfortable

• try to appear ‘unhurried’ and relaxed

• focus firmly on the patient

• use open-ended questions where possible

• make appropriate reassuring gestures

Gather

It is in the early stages of the consultation that silence (on the doctor’s part) can be golden. In what is termed active listening, we listen to more than the words—we are also alert to the messages buried in the words. We listen to the tone and rhythm and we look for the context of what we are hearing. We listen with understanding, in a relaxed, attentive silence. Note-taking, whether written or typed, should not become a barrier to appearing to listen; as it is done, it can be verbalised by the doctor, so the patient knows he or she is being heard. The computer should not be allowed to be the intrusive third person in the room.

Allowing the patient to talk (without interruption), and even leaving a slightly prolonged pause, often provides enough space for the patient’s concerns to emerge. This is especially the case with psychosocial issues.⁹

This ability to elicit patient concerns is unfortunately not one that doctors have always done well. Stewart¹⁰ summarises the evidence in this area:

This evidence is of course in relation to doctors as a whole and not just general practitioners, but it does illustrate how important and at times difficult effective communication in medical consultations can be.

Three techniques that have been demonstrated^8,11 to improve how we elicit patient concerns are:

• facilitation

• the open-to-closed cone

• summarisation

Facilitation refers to comments or behaviours by the doctor that encourage the patient to keep talking. This could include a head-nod, a ‘hmm’ at the right time, or ‘Tell me more about that’. The open-to-closed cone is a gradual narrowing of focus from an indirect non-directive exploration to a more direct exploration. It is often difficult to resist the urge to ‘dive in’ and explore the initial concern raised and narrow the cone too quickly.^6,12

After each problem or concern is elicited, the doctor should continue to explore to ensure there are not any more. What are the patient’s concerns (e.g. headache, depressed mood) and needs (e.g. a prescription, a referral or a form to be filled out)?⁹ The doctor does not take too much control of the conversation, does not direct the topic away from the patient’s concerns and hence helps to demonstrate empathy as well as a real interest in the patient. Using a patient-centred approach leads to improved patient trust and satisfaction, more appropriate prescribing and more efficient practice.⁶

Summarisation is when the doctor provides the patient with an explicit verbal summary of the information gathered thus far in the consultation.¹¹ This helps to orientate the patient, acknowledging to him or her that the doctor has taken on board what they have said, and reflecting back to the patient the doctor’s understanding of it.

If we initially ‘limit ourselves to triage questions’ and wait until ‘all the cards are on the table’,⁹ it reduces the chance of patient concerns being missed. The value of a question like ‘Is there anything else today?’, and repeatedly making such an enquiry until we receive a ‘no’ in response, will help ensure we have obtained a complete understanding of the patient’s agenda.⁹

Non-verbal communication

Non-verbal communication or body language is a vital feature of the communication process. Human communication takes place through the use of gestures, postures, position and distances (non-verbal communication or body language) more than by any other method. Non-verbal cues comprise the majority of the impact of any communicated message (see TABLE 4.1).¹³

Recognition of non-verbal cues in our communication is important, especially in a doctor–patient relationship. Charles Darwin in his ‘Expression of the Emotions in Man and Animals’ (1872) concluded that there is a unique pattern of non-verbal actions for each emotion, such as snarling as a sign of aggression. The ability to identify non-verbal cues improves communication, rapport and understanding of the patient’s fears and concerns. Recognising body language can allow doctors to modify their behaviour, thus promoting optimum communication.

Interpreting body language

The interpretation of body language, which differs between cultures, is a special study in its own right, but there are certain cues and gestures that can be readily understood. Examples illustrated include: the depressed patient (see FIG. 4.2); barrier-type signals, often used as a defensive mechanism to provide comfort or indicate a negative attitude (see FIG. 4.3); and a readiness gesture, indicating a desire to terminate the communication (see FIG. 4.4).

Having noted the non-verbal communication, the doctor must then deal with it. This may require confrontation—that is, diplomatically bringing these cues to the patient’s attention and exploring the associated feeling further.

The patient’s perspective

To be truly patient-centred, it is not enough merely to find out the patient’s concerns and needs—we also need to explore his or her ideas, beliefs and expectations.⁸ What is the patient’s perspective on his or her concerns and needs? What does the patient expect of you and from the consultation? What are the priorities?

To best meet this challenge, doctors should be vigilant for verbal and non-verbal cues that suggest frustrations, fears and anxieties.³ A shuffle in a chair or a stiffening in posture may give a clue as to the emotional context a patient places on a particular issue. The issue is therefore not only whether we have listened, but whether we have understood.⁹

The patient’s feelings and perspectives can also be further elicited by reflective statements. Examples of these include:

• you seem very sad today

• you seem upset about your husband

• it seems you’re having trouble coping

• you seem to be telling me that …

• your main concern seems to me to be …

Discovering the patient’s beliefs about illness will allow us to make statements to them that are congruent with those beliefs. This is especially important in mental health, where illness beliefs are often emotionally laden and unpredictable.

Understanding the patient’s perspective also needs to be considered in a cultural context. Culture can have many dimensions, including ethnicity, age, gender, sexuality, community and religious beliefs. Being culturally competent by showing an interest in, respect for and sensitivity to that culture will help us achieve a shared understanding of where the patient is coming from and how he or she is seeing things.⁸

Communicating during the physical examination or procedure

In the same way that we obtain consent for surgical procedures, we should also fully inform the patient of what we plan to do and obtain consent in any physical interaction with the patient. Physical examination can be very confrontational for some patients and this can be underestimated by the doctor. There may be factors of which the doctor is unaware that may make examination particularly difficult for the patient, such as unpleasant previous experiences, cultural, gender or sexual issues surrounding touch, or phobias about medical procedures or needles.

As well as preparing the patient, explaining during the examination or procedure what is happening and what we are observing and finding will help the patient feel valued and respected. We should also continue to keep an ear out for any further patient concerns being raised.³

If we are fully eliciting the patient’s concerns and needs and are consulting using a patient-centred approach, a point is reached in the consultation where the information flow will need to go in the opposite direction—from doctor back to patient (in fact, in most consultations this flow often moves repeatedly back and forth). How we deliver this information is critical to patient communication.

When we are communicating information to a patient, it will be best understood and accepted when the information is congruent with the patient’s beliefs. If these beliefs are helpful, we should recognise them and reinforce them. For instance, ‘I agree with you; I think stress might be contributing to your pain here.’

Four techniques that will help maximise patient understanding are:

• signposting

• ‘chunk and check’

• avoiding jargon

• using visual and physical techniques to communicate⁸

Signposting is a technique whereby the doctor explicitly states what he or she has done and/or is about to do (e.g. ‘Andrew, I have finished examining you, now I would like to explain what I think the issues are’ or ‘Mrs Jones, I have two matters I would like to discuss: first …’). Signposting helps orientate the patient, which further helps him or her to relax and focus better on what you are saying.

Chunk and check is where the doctor provides a chunk of information to the patient and then immediately checks the patient’s understanding of what has been said. Chunk and check works best when the chunks are small, as this information is often new to the patient and best digested in small grabs. It is frequently surprising to find how far away the patient’s understanding is from what we intended to communicate, so this technique informs the doctor of any misunderstanding and hence provides an early opportunity to correct this.

Jargon is a barrier to communication in many professions (think accountants or IT technicians) and medicine is rife with jargon. However, jargon is not a dirty word. The way we are educated and the way doctors and other health professionals continue to communicate with each other is expedited by using jargon—it makes our communication more efficient by having a technical language to use.

On the other hand, when dealing with patients, using jargon not only impairs the patient’s understanding, but can also be alienating and intimidating. What actually constitutes jargon is also often underestimated. While a doctor will usually realise that ‘acute myocardial infarction’ or ‘cholecystectomy’ are jargon, more subtle forms of jargon could include words such as ‘complication’, ‘rare’ or ‘tumour’. A patient’s understanding of such words may be very different from the doctor’s, so checking this understanding will help protect against this. What is jargon will also vary from patient to patient. Factors such as age, education, language skills and cultural background can affect which forms of language and words are beyond the patient’s understanding. The patient needs to have the cognitive and communicative capacity to understand the message.¹⁴

Visual and physical methods of conveying information given (or plans made) can include diagrams, models, patient hand-outs or information sheets.⁸ Having ready access to electronic visual materials or websites on a desktop computer can also help. Videos on websites such as YouTube can be used to illustrate how the body functions, how a disease manifests, or a particular medical procedure, and directing patients to reputable and reliable information sources on the web or elsewhere (before they find unreliable information themselves) will help avoid misinformation and extend the communication beyond the consultation.

Negotiate and agree on a plan

Looking beyond patient-centred communication, we can then think about planning: what do we intend to do, how we are going to decide this, who is going to do it? The preferred technique for this is shared or collaborative decision making.^14,15 The aim should be to have such collaboration at all stages of the consultation. But because patients can often feel intimidated, it is a challenge for the doctor to make the patient feel comfortable enough to do so.¹⁶

To enable this collaboration, the doctor and patient should treat each other’s concerns with respect; this will lead to a shared responsibility for agenda setting.⁹ Such collaboration, when done well, can lead to a coming-together of thinking that has been called a shared mind.¹⁴ Strategies that will help achieve this include finding common ground, reaching consensus on a treatment plan and establishing a mutually acceptable follow-up plan.¹³ ‘This is what I would suggest, what do you think?’ As a way of thinking, a shared mind involves a doctor being mindful of the patient’s values, thoughts and feelings (as well as those of his or her own), and seeing where the two connect.¹⁷

This mindfulness of each other’s position can help the negotiation of what happens in the consultation and also avoid communication breakdowns. For instance, what shall we deal with today, and what should be delayed or rolled over to another consultation?⁹ It can also help repair a communication breakdown. For example, if a patient is heading off at a tangent, if we are mindful of where he or she is coming from and what is important to that person, it will enable us to gently bring him or her back to the topic we feel is more pressing.

One technique that uses this principle is called an empathic bridge.⁹ This is where we anchor the conversation in the patient’s experience by reflecting or paraphrasing. From this anchor, we then manoeuvre the conversation back to where it needs to be (e.g. ‘It sounds like your pumpkin soup recipe is something special. It is a pity you managed to cut your finger while making it today. Now let’s have a look at that cut’).

Another aspect of the doctor–patient relationship that enhances collaborative decision making, particularly in general practice, is shared experiences.¹⁸ GP–patient relationships evolve over time, and a shared experience such as helping a patient through a difficult pregnancy, a major illness or even doing a home visit can enrich the relationship, deepen the connection and trust between doctor and patient, and lead to greater collaborative decision making.

Close

How should we close a consultation? If we follow the principles of patient-centred communication and remember that we should keep our focus on the patient’s concerns and needs, it soon becomes apparent.

First, is the patient aware of the imminent closure? Anxious and distressed patients may have no idea how long they have been ruminating about their concerns through the consultation, and be unaware that the waiting room full of people is actually starting to concern you. In such situations, letting them know in advance that closure is being planned (and why) will allow them to not feel pushed out of the room.

Secondly, making sure that there are no further disclosures of concerns or needs to come (yet again) will reduce the risk of what has been termed the ‘doorknob presentation’—the raising of a patient concern that happens as the doctor puts his or her hand on the doorknob to leave the room (this has also been called the ‘Oh, by the way doctor’ syndrome in the USA, the ‘à propos, docteur’ in France, and ‘tussen haakjes’ in Denmark, which translates to ‘between two brackets’ or, as we may say, ‘parenthetically’).⁹

Thirdly, summarising the critical points of the consultation and planned actions and expectations will provide a final opportunity to identify gaps between what the doctor and patient are respectively thinking. We should also prepare a safety net by considering any possible unexpected outcomes to what is being planned (e.g. what a parent should watch out for and what to do if things worsen with the febrile infant patient).

Finally, we should thank and say farewell to the patient with an appropriate parting statement. Does this include a handshake? This may be determined by your style, the patient’s style and cultural issues.

Use of relationship-building skills

During the consultation and throughout a doctor–patient relationship over many consultations (and potentially, in general practice, over decades), effective communication is underpinned by using skills that develop the interpersonal relationship between doctor and patient.^3,8

These skills include the doctor paying attention to non-verbal behaviour on display, as mentioned above, such as appropriate eye contact, posture, position and movement. Verbal cues such as the speed of speech, volume and tone can also be used. If using a computer or taking written notes, the doctor should do so in a fashion that does not interfere with dialogue or rapport. Also, given that patients are often highly emotionally invested in what we say, consulting in a manner that reflects confidence (without stepping over into arrogance) will help build trust.

Rapport, which originates from an old French word that literally means ‘to carry back’, can be engendered by fostering connections back and forth with the patient. Displaying empathy for the patient’s situation or feelings, acknowledging his or her view or efforts, and dealing sensitively with embarrassing or disturbing topics such as pain or grief, will engender rapport. We can show we are willing to provide emotional support by overtly expressing our concern or understanding, or a willingness to help or offer partnership.^8,16 An offer such as ‘I am really keen to help you with this situation’ can go a long way.

Connections that build rapport can also happen away from medical issues, and are often more powerful. This is where the ‘clues’ that we were looking for at the beginning of the consultation can come into play. If a short interplay can happen between doctor and patient about something the patient is passionate about or interested in, which has nothing to do with the medical issues at hand, the patient will feel that he or she is respected as a person, not just as a medical presentation to be solved. Examples of such clues that could be picked up and explored by the doctor could be a favourite toy being held by a child, a book that a patient carries into the room, or the doctor noticing that the occupation of the patient is something he or she is interested in asking about. It comes down to patients feeling that the doctor is actually interested in them. When such connections are made, any tension in the consultation room can be seen to evaporate.

Other rapport-building techniques

A person can develop a rapport with another by mimicking his or her body language, speech, posture, pace and other characteristics. Such techniques can be used to help the doctor communicate better with a patient and also to improve the patient’s attitude by changing the patient’s body language position.

Mirroring

Mirroring is a useful technique whereby the limb positions and body angles of the person you are talking to can be copied. A mirror image is formed of their position so that when they look at you they see themselves as in a mirror. It is not necessary to copy uncomfortable gestures or unusual limb positions, such as hands behind the head. A partial mirror is often sufficient.

Pacing

People exhibit a certain rhythm or pace that can be revealed through their breathing, talking, and movements of the head, hands or feet. If you can copy the pace of another person, it will establish a sense of oneness or rapport with them. Once this pace is established, you can change their pace by changing yours. This is called leading.

Vocal copying

Vocal copying is another way to develop rapport with people. It involves copying intonation, pitch, volume, pace, rhythm, breathing and length of the sentence before pausing.

Manage flow

At the end of the day, the doctor has a professional responsibility to appropriately meet the needs of the patient but also to keep control of a consultation so that it does not affect other consultations which follow. In most consultations, this is not difficult, but with a small proportion of patients, particularly those who have mental health and/or psychosocial issues to deal with, maintaining control and managing time can be challenging.¹⁹

A balance must be struck between maintaining control and not undermining the doctor–patient relationship.

The doctor having a ‘wide-angle lens’ on the consultation, so that he or she is mindful of where they are up to in the consultation and how much time has been taken up already, as well as the actual medical issues being discussed, will help anticipate a problem. Doing so subtly (e.g. not looking at a watch!) will help. It can be useful to have a wall clock situated behind the patient’s chair or to be aware of where the consultation timer is on the computer screen. Being time aware can be particularly difficult for inexperienced doctors, who will be more focused on not making a mistake with the medical issues at hand. Naturally, even if the time is way over, it may be entirely appropriate to carry on if it is an important issue, such as with a suicidal or distressed patient.

If a consultation’s flow is becoming problematic, the doctor should employ appropriate use of power.¹⁸ This can be done with techniques such as setting rules in advance for patients where this is a problem (e.g. time limits for the consultation or limits on the number of concerns to be addressed). We can also use, if required, blocking behaviours, which can be verbal or non-verbal. These are behaviours that consciously block the flow of a consultation that is not being appropriately controlled. Examples include the doctor using body language that suggests he or she has something to say, or purposefully focusing on the (sometimes very short) space between a hyper-verbal patient’s sentences to enable him or her to ‘jump in’ and take control of the consultation.