3. Concepts
■ What is communication?
The process in which feelings or ideas are
expressed as messages sent , received and
comprehended .
It should be dynamic , continuous
and reciprocal .
❑ Once you send it, it is
irreversible (non erasable).
8. Listening
➢ Focus your attention: Avoid barriers
➢ Show that you are listening
➢
➢
➢
Understand ideas and pick words
Retain information (memory, notes)
Give your feedback
9. Probing
➢ What clients think
➢ Encourage clients to talk: tell them that
you are really listening and want to hear
more
➢ Ask open questions
➢ Keep privacy
11. Informing
➢ In a clear, correct, concise and complete
➢ the needs, language and
way
Consider
obstacles
➢ summing
➢ Check back with the speaker to ensure
that the statement is accurate
12. Means of communication
❑
❑
❑
❑
❑
❑
❑
1. Verbal: written or spoken
2. Non verbal: any thing except words:
Body movement
Posture: way of setting, standing
Gesture: movement of hands, legs, arms
Facial expression, eye contact
Space
Touch
Paralanguage: mmm
20. ■ How do you know that your
communication was effective?
➢ Feedback
➢ Your message affect other people:
➢
start to change behavior
Had effect on the whole community
22. Consultation Models
Bad consultations result from
❑ having insufficient clinical knowledge,
❑ failing to relate to patients or
❑ failing to understand the patient's
behaviour, his perception of his illness
or its context
23. Consultation
■
■
A process in which the counselor works
with (parent, teacher, administrator) with
the goal of positive change in the child
Voluntary problem-solving process with
goals of enhanced services and improved
functioning
28. Consultation
After each consultation session five things
must be established:
1. Discover the reasons of patient attendance
2. Define clinical problem (HPT, DM)
3. Address the patient’s problem (details)
4. Explain the problem to the patient
5. Make effective use of the consultation
29. The Consulting Process
1. Pre-entry
Look at oneself to see if you are right for the
task and services to be provided
2. Entry, problem exploration and contracting
learn about needs, presenting problem, people
involved, previous interventions, and
expectations of seeker
30. .)The Consulting Process (Cont
3. Diagnosis stage
Information gathering, problem confirmation,
goal setting, and potential interventions
4. Solution searching and intervention selection
avoid favorite paradigm
consider human and structural factors
31. .)The Consulting Process (Cont
5. Evaluation
■
■
■
Ensures professional effectiveness
Were goals achieved?
Did interventions work?
6. Termination
■
■
Describe what was and was not successful
Look for areas of improvement
32. Initiating the Session
Gathering Information
Explanation and Planning
Closing the Session
Building
the
Relationship
Attending
to
Task
Expanded Framework
33. Providing
Structure
InitiatingtheSession
Closingthe Session
• preparation
• establishinginitial rapport
• identifying thereason(s) for the consultation
• providingthecorrectamountandtype of information
• aidingaccurate recallandunderstanding
• achievinga shared understanding: incorporatingthe patient’s
illness framework
• planning: shared decisionmaking
•
•
Gathering information
Physical examination
Explanation and planning
• exploration of the patient’s problems to discover the:
biomedical perspective the patient’s perspective
background information - context
• ensuring appropriate pointof closure
• forward planning
Buildingthe
relationship
• using
appropriate
non-verbal
behaviour
developing
rapport
involving
the patient
• making
organisation
overt
• attending to
flow
34.
35. Consultation Styles
■ doctor-centred
■
■
■
■
dominates the consultation
asks direct, closed questions
rejects the patient's ideas
evades the patient's questions
■ patient-centred
■
■
■
asks open questions
actively listens
challenges and reflects the patients' words and
behaviour to allow them to express themselves in
their own way
40. Initiating the session
a) Establishing Initial Rapportةةةةة:
-Greets the patient and obtains name.
-Introduce self, role and nature of interview.
-Demonstrate respect and interest.
b) Identifying reasons for the consultation:
-Identifies patient’s problems using opening question.
-Listens attentively to patient’s opening statement without
interrupting.
-Confirms lists and screens for further problems.
-Negotiates agenda taking and doctor’s needs into
account.
41. Gathering Information
: Exploration of patient’s problem
-Encourages patient to tell the story.
-Uses open and closed questioning technique.
-Listen attentively.
-Facilitates patient’s responses.
-Clarifies patient’s statements.
-Periodically summarizes.
-Uses concise, easily understood questions.
-Establishes dates and sequence of events.
42. Building Relationship
a) Using appropriate non-verbal behavior:
-Demonstrate appropriate non-verbal behavior (eye contact,
posture, vocal cues).
-Demonstrate confidence.
b) Developing rapport:
-Accepts patient’s views and feelings.
-Provides support.
-Deals sensitively with embarrassing and disturbing topics.
c) Involving the patient:
-Shares thinking.
-Explains rationale.
-Asks permission and Explains process during physical examination.
43. Explanation and Planning
a) Providing the correct amount and type of information:
-Assesses patient’s starting point (prior knowledge).
-Asks patients what other information does he needs and would be helpful.
-Give explanation at appropriate time.
b) Aiding recall and understanding:
-Organizes explanation.
-Uses explicit categorization.
-Uses easily understood language.
-Uses visual methods of conveying information.
-Checks patient’s understanding.
c) Achieving a shared understanding: incorporating the
patient’s perspective:
-Relates explanations to patient’s illness framework.
-Provides opportunities and encourages patients to contribute.
-Picks up verbal and non-verbal cues.
-Elicits patient’s beliefs, reactions and feelings.
44. : d) Planning: shared decision making
. Shares thinking-
. Involves patient-
Encourage patient to contribute his-
. thoughts
. Negotiate acceptable plan-
. Offers choices-
Checks with patients if he accepts plans-
.and if his concerns have been addressed
45. Closing the sessions
a) Forward planning:
-Contracts with patients next steps.
-Explain possible unexpected outcomes.
b) Ensuring appropriate point of closure:
-Summarizes session briefly and clarifies plan of
care.
-Final check that patient is satisfied, comfortable
with plan.
46. Breaking Bad News
■ A difficult but fundamentally important
task for all health care professionals
■ Physicians feel uncertain & uncomfortable
while breaking bad news, leading to being
distant & disengaged from their patients.
47. Delivering Bad News
Rabow & Mcphee (West J. Med 1999) synthesized a
simple model of ABCDE:
■
■
■
■
■
Advance Preparation
Build a therapeutic environment/relationship
Communicate well
Deal with patient & family reactions
Encourage and validate emotions
48. Advance Preparation
■ Familiarize yourself with the relevant clinical
information (investigations, hospital report)
■ Arrange for adequate time in private, comfortable
environment
■ Instruct staff not to interrupt
■ Be prepared to provide at least basic information
about prognosis and treatment options (so do read it
49. Advance Preparation
■ Mentally rehearse how you will deliver the news.
You may wish to practice out loud
■ Script specific words & phrases to use or to
avoid
■ Be prepared emotionally
50. Build a therapeutic
environment/relationship
■ Introduce yourself to everyone present
■ Summarise where things have got to date, check with
patient/relative
Discover what has happened since last seen
Judge how the patient is feeling/thinking
Determine the patient’s preferences for what and how
much he/she wants to know
51. Build a therapeutic environment/relationship
■
■
■
■
(contd)
Warning shot “I’m afraid it looks more serious
than we had hoped”
Use touch where appropriate
Pay attention to verbal & non verbal cues
Avoid inappropriate humour
Assure patient that you will be available
52. Communicate well
■
■
■
■
■
■
Speak frankly but compassionately
Avoid medical jargon
Allow silence & tears; proceed at patient’s pace
Have the patient describe his/her understanding of the
information given
Encourage questions
Write things down & provide written information
■ Conclude each visit with a summary & follow up plan
53. Deal with patient and family reactions
■
■
■
■
■
Assess & respond to emotional reactions
Be aware of cognitive coping (denial, blame, guilt,
disbelief, acceptance, intellectualization)
Allow for “shut down”, when patient turns off & stops
listening
Be empathetic; it is appropriate to say “I’m sorry or I
don’t know. Crying may be appropriate
Don’t argue or criticize colleagues
54. Encourage and validate emotions
■ Offer realistic hope
■ Give adequate information to facilitate decision
making
■ Explore what the news means to the patient &
inquire about spiritual needs
■ Inquire about the support systems in place
55. Encourage and validate emotions
■ Attend to your own needs during and following the
delivery of bad news (counter-transference can be
harmful)
■
■
Use multidisciplinary services to enhance patient care
( hospice)
Formal or informal debriefing session with concerned
team members may be appropriate
56. ?What to do
■
■
■
■
■
■
■
■
■
Introduce yourself
Look to comfort and privacy
Determine what the patient already knows
Warn the patient that bad news is coming
Break the Bad News
Identify the patient’s main concern
Summarize and check understanding
Offer realistic hope
Arrange follow up and make sure that some one
57. ?How to do it
■
■
■
■
■
■
■
■
■
Be sensitive
Be empathic and consider appropriate touching
Maintain eye contact
Give information in small chunks
Repeat and clarify
Regularly check understanding
Do not be afraid of silence or tears
Explore patient’s emotions and give him time
to respond
Be honest if you are unsure about something
58. ?What not to do
Hurry
■
■
■
■
■
■
■
Give all the information in one go
Give too much information
Use medical jargon or unclear language/words
Lie or be economical with the truth
Be blunt. Words can be like loaded pistols/guns
Guess the prognosis (She has got 6 months, may
be 7)
59. Quotation
■ The greatest revolution of our generation is the discovery
that human beings, by changing the inner attitudes of
their minds , can change the outer aspects of their lives.
William James
American Psychologist & Philosopher
60. Angry Patient
WHAT TO DO?
■
■
■
■
■
■
Introduce yourself
Acknowledge the person’s anger
Try to find out the reason for his anger, e.g.
frustration, fear or guilt
Validate his feelings
Let him ventilate his anger or any feelings that
led to his anger
Offer to do something or for him to do something
61. Angry Patient
HOW TO DO IT?
■
■
■
■
■
■ Sit at the same level as the patient, not too close
and not too far, with eye contact
Speak calmly without raising your voice
Avoid dismissive or threatening body language
Encourage the person to speak with open ended
questions
Empathize as much as you can with verbal and
non verbal cues
Be aware of your own safety
62. Angry patient
WHAT NOT TO DO?
■
■
■
■
■
■
■
Glare at the person
Confront him or interrupt him
Patronize him or touch him
Put the blame on others/seek to exonerate
yourself
Make unreasonable promises
Block his exit
If the person is a patient’s relative, be mindful
about confidentiality
63. Quizzes
■
■
■ Explain two other models of breaking bad
news? With illustration by examples?
How to use communication skills in taking
history from anxious patient?
Differentiate between counselling &
consultation?
64. SCENARIO 1
Sameh, a 55-year-old chain smoker taxi driver with
persistent cough for 3 months, attends your clinic to find out
the biopsy report of a lesion shown on a chest x-ray and CT
scan. He is rather anxious, that he has a serious condition.
His biopsy report confirms that he has a Bronchogenic
Carcinoma of right lung.
You are required to proceed with this consultation.
65. Scenario2
■
■
A 44-year-old woman attends your clinic to find
out the result of an MRI of her spine. She has
had constant pain all over her spine for the last 2
months. She also has a history of Breast cancer,
which was treated 5 years ago.
Her report shows that she has secondaries all
over her spine
Proceed with this consultation.
(Examination not required)
