communication skills for medical students, staff

1. Establishing rapport
Dr / Khalid D. Al-Harby
MBBS,SBFM,ABFM
Family medicine trainer

2. Establishing rapport
• The physician ,in order to be effective, should
speak softly, be well-dressed, have quiet ways
and have eyes that do not wander
• Personal appearance is an important non-verbal
communication
DR/KHALID ALHARBY 2

3. Cont…
• Lack of eye contact may be interpreted as a lack
of concern
• A genuine smile can be helpful in quickly
establishing a friendly atmosphere and
developing a warm interpersonal relationships
DR/KHALID ALHARBY 3

4. Cont…
• Posture:- standing erect, moving briskly with
head up and stomach in is better than slouching
• Listless or lethargic appearance can be
interpreted as lack of concern.
DR/KHALID ALHARBY 4

5. Cont…
• Review the chart:-
patients believe that well informed physician is
truly interested in them
DR/KHALID ALHARBY 5

6. Respect
• Pt.must believe that the • Give +ve statements about
physician values their others:- pts. do not respect
comments and opinions a physician who is
before trusting him or her building himself up by
with information of a tearing someone else
more personal nature down.
• Mutual respect is • Know your feeling and
important. do not act on them “
• Problems of the clenching of the
physician’s side: physician’s fist is a
lack of security and of self- clinical sign of the
confidence. hysterical patients.
DR/KHALID ALHARBY 6

7. Cont. Respect
The more patients that physicians see,
and the more overloaded their
practices, the more likely they are to
describe pt. Complaints as trivial,
inappropriate, or bothersome.

8. Measures of rapport
patient’s satisfaction
• Most studies indicate that • Factors which interfere
pt. Satisfaction depends on with the patient
information, and the satisfaction :-
degree to which the pt. 1. Poor communication
Understands the illness 2. Perception of physician
(more than doing full insensitivity
examination and
investigation . 3. Office foul-up e.g
appointment delay,
• Even pt.with chronic billing mistake, and
disease has Qs to be frustration with the
answered. telephone system
• Increase satisfaction leads
to increase compliance
DR/KHALID ALHARBY 8

9. Communication and rapport
• The majority of complaints against physicians are
simply the results of a lack of communication between
Dr. and pt.
• Failure of communication can also affect the outcome
of treatment, often as seriously as can an error in
treatment.
• Easy accessibility enhance better communication
DR/KHALID ALHARBY 9

10. cont
• Establishing an open • Face-to-face
channel is the first element communication may be
of the communication intended or unintended.
process and influence all • Intended messages:
that follows. Verbal and non-verbal cues
(as face-to-face to transmit a message
conversation in clinical (strong,unafraid, and
setting). willing to face reality)
• The recognition of pt’s • Unintended
true thoughts and feeling message(unaware):- e.g
is a central skill in tremor of the hand (in fact
establishing and he is afraid)
maintaining rapport
DR/KHALID ALHARBY 10

11. Verbal communication
• Refer to the wards 4. Reason for attendance:
literally transmitted and • Oh; by the way doc.
account for around 10% • Child as a ticket
of the communication • Known pt (OPD) vs.
only new ( as in ER where Dr
• C/O,PMH,FH,DH…. talk more than the pt.)
• Explore :- • The pt. cultural
background and
1. Slips of the tongue educational level should
2. Major areas of omission be considered
3. Why he is telling me that • Avoid medical
terminology
DR/KHALID ALHARBY 11

12. Non – verbal communication
• One third of the
communication
• It conducts the personal
attitude and emotions
• Elements:-
1. Paralanguage (voice
effects)
2. Kinesics (body
language)
3. Touch
4. Proxemics (spatial
factors
DR/KHALID ALHARBY 12

13. cont
5. Physical
characteristics (e.g
age)
6. Artifacts (clothes and
accessories)
7. Environmental factors
(furniture, décor,…)
DR/KHALID ALHARBY 13

14. Paralanguage
• Rather than concentrating
on what the pt. is saying
but on how he is saying it
• Velocity, tone, volume,
sighs, grunts, pauses, and
inflections
• Sarcasm is a common
example of a contradiction
between vocal and verbal
messages.
DR/KHALID ALHARBY 14

15. Touch
• Should be appropriate and • The limp or “wet dishrag”
socially acceptable handshake indicates lack
• Touching can an effective of interest or insincerity,
method for especially if it is rapidly
communicating or withdrawn
compassion and can break • A moist palm is a sign of
down some of the nervousness or
defensive barriers to apprehension
communication. • The “half way there”
• It can be done by fingers – only handshake
handshaking or indicate reluctance or
application of the Lt.hand indecision.
to the upper or lower arm • Pt.
DR/KHALID ALHARBY Often feel better after 15
a

16. cont
routine physical examination.
• The magic of touch can be good medicine,
especially when combined with concern,
support, and reassurance.
• Infants deprived of touch and stroking
suffer mental and physical deterioration
(adults also require stroking to maintain a
healthy emotional state)
DR/KHALID ALHARBY 16

17. Kinesics
• The study of non-verbal • If they are different: non-
gestures, or body verbal message message is
movements, and their more accurate than verbal
meaning as a form message
communication • Positive verbal
• Body language alone does communication as “you
not reveal the entire are looking better today”
behavioral image any when accompanied by –ve
more than does verbal non-verbal cues will be
language alone (they are interpreted by the pt. As
meaningful only when insincere.
considered in the context • Premature reassurance
of a person’s total may be interpreted as
DR/KHALID ALHARBY 17
behavioral pattern rejection

18. Cont…
Reassurance should be:-
genuine,realistic, and
given only after a
thorough evaluation of the
problem.
The physician will see the
fear and uncertainty in the
pt’s face only if he or she
is looking at the pt. Rather
than the medical record.
DR/KHALID ALHARBY 18

19. Body position
• Tense persons sets erect
with a fairly rigid posture.
• Moderately relaxed lean
forward 20 degrees& side
lean 10
• Higher pt. Satisfaction is
ass. with physician’s
forward body lean,
rotation of the torso
toward the pt., relaxation
of the chin in his hands,
and gaze directly at the pt.
• Pt.
DR/KHALID ALHARBY Feel more comfort and 19

20. Mirroring
• When good rapport exists
between two persons, each
will mirror the other’s
movements.
• If the physician notices
sudden disruption of
mirroring activity by the
patient, more attention
should be focused on the
comment that led to the
change of position *
DR/KHALID ALHARBY 20

21. Head position
• Head is held forward in
anger, backward in
defiance, anxiety, or fear,
and downward in sadness,
shame, or guilt.
• Tilting the head to one
side indicates interest, and
attention.
• The physician should sit
forward in the chair with
an interested, attentive
facial expression and the
head slightly tilted.*
DR/KHALID ALHARBY 21

22. Face
• The facial expression
of emotions, when
undisguised, is
independent of culture
and is identical
throughout the world.
(especially the
eyebrows, eyes, and
the forehead)**
DR/KHALID ALHARBY 22

23. Micro-expressions
• Most facial expressions
last more than one second,
but micro-expressions last
only one fifth of a second
(the time to blink the eye)
• Easily missed if the
physician is not carefully
observing pt.
• It occurs when the pt.
Begins to show a true
facial expression, senses
this and immediately
neutralizes or masks the
DR/KHALID ALHARBY 23
expression

24. Eyes
• The principle organ of • They constrict if
expression. unpleasant
• When anonymity is • Dilated pupil indicate
desired, only the eyes interest and vice versa
need to be covered. • The best method for
• Eyebrows have 40 conveying sincerity is
different positions of frequent eye contact
expression and eyelids 23 • A listener who doesn’t
• Even the lower eyelids maintain eye contact, but
alone can convey continue to look down, or
considerable information* away from the speaker
• Pupils dilate when seeing may be shy, depressed, or
rejecting (speaker or his 24
something pleasant DR/KHALID ALHARBY

25. Eyes cont
• Prolonged eye contact or • The frequency of eye
staring can be offensive. contact also can provide
• The acceptability of eye clues to whether pt. Is
contact varies significantly anxious or depressed
among different cultures • Anxious pts: their eyes
• Patients are most blink frequently or darted
comfortable when the back and forth, they can’t
physician looks at them maintain eye contact,
approximately 50% of the stroke them selves more
time and are (hand on hand, hand on
uncomfortable when eye face), smile less, have
contact is avoided rigid torsos, afraid to
move, and have rapid R.R.
DR/KHALID ALHARBY 25

26. Eyes cont.
• Depressed pts: • In case of abdominal
1. Maintain eye contact pain : pt. with organic
only 1/4th as normal disease keep more eye
2. Have downward contact during
contraction of the abdominal
mouth and a examination than
downward angling of those with non-
the head specific pain
DR/KHALID ALHARBY 26

27. Hands
• Sadness: flaccid, and the index finger, pulling
droopy hands. at the ear lobe, or raising
• Anxiety: fidgety or to the lips ( NB/ it may
grasping hands, shake also indicate hidden
when holding a pen information : attempt to
• Anger: clenched hands suppress a comment)
• Confidence & assurance The “THINKING position” :
in the comments being 1. Index finger across the
made(steepling)* lips
• Palms outward: a warm & 2. Index finger extended
friendly greeting along the cheek
• Urge to interrupt : slight
raising of the hands orDR/KHALID ALHARBY 27

28. Cont.
3. One sitting with
elbows on the table
and hands clenched in
front of the mouth.
DR/KHALID ALHARBY 28

29. Arms
• Crossed arms :
1. Defensive posture, or
disagreement *
2. sign of insecurity
3. Position of comfort
• The resistant position (in
anger):
Clenched fists held tightly
against the body in a
holding-back manner
(preventing them from
hitting) *
DR/KHALID ALHARBY 29

30. Legs
• Crossed legs :
1. Common position of
comfort
2. Protection (shutting out)
against the outside world
(will not give diagnostic
information, will not
follow instructions)*
• Anxious or scared
person :
1. Sit forward in the chair
2. Feet in the ready-to-run
position
DR/KHALID ALHARBY 30

31. Cont
• Angry person:
place the feet widely
apart in a position of
instability
Sad person :
Move in a slow circular
pattern
DR/KHALID ALHARBY 31

32. Preening gesture
• Be carefull of the
seductive patients
(more than expected of
peering gestures)
DR/KHALID ALHARBY 32

33. Respiratory avoidance response
• Frequent clearing of the describes a split between
throat when no phlegm or inner thoughts and
mucous is present.(it can outward action
be a non-verbal indication Associated with :
of disgust or rejection) 1. Lying
• NOSE-RUB: * 2. The struggle to appear
(not vigorous & repeated as calm while suppressing
that used normally to anger or discomfort
relieve itch)
Soft, one or two tight strokes
DR/KHALID ALHARBY 33

34. Verbal – non verbal mismatch
• Clues that pt. Is not
telling the truth:-
1. “how is the relation
between you and your
wife?” “fine” while
looking sad and avoiding
eye contact
2. Asymmetrical facial
expression
3. Prolonged smile
4. Expression of a
amazement
DR/KHALID ALHARBY 34

35. Proxemics “(spatial factors)”
• The study of how people distance for most people
unconsciously structure • The space can be divided
the space around them. into:
• It varies with culture: 1. Intimate space :range
1. In north American (body from close physical
bubble or distance contact to 18 inches
gaze)* 2. Personal space :18 in to
2. In middle east (no body 4 feet
bubbles (proper to 3. Social space : 4F – 12F
invade this area) 4. Public space : >12F
• The arm’s length is a • Placing a desk between 2
good measure of persons shifts personal to
appropriate personalDR/KHALID ALHARBY
social space 35

36. Hidden or masked
communication(concern)
• The average person • If the physician deals only
has a symptom about with the symptom (e.g
headache), the real
every 6 days, he visits concern (e.g. meningitis)
a physician only once / may go undetected, and
4months the result will be a
• Those who visit more dissatisfied & a non-
frequently tends to compliant patient
have a higher level of • Investigate the pt’s current
life stresses when visits
anxiety, fear, grief, or are made if there is no
frustrations change in clinical status
DR/KHALID ALHARBY 36

37. Patient expectations
• Rapport and
satisfaction will be
enhanced if the
physician identifies
and satisfies the
patient’s expectations
for the visit
DR/KHALID ALHARBY 37

38. Hand –on- the –doorknob
syndrome
• The patient’s parting Mentioning the real reason
phrase is sometimes a clue for the visit
to the primary reason for • Ask your pt. Routinely at
the visit the end of a visit “is there
• With the hand on the door, any thing we have not
escape is readily covered or any thing else
accessible if the you would like to ask me”
physician’s reaction is • Apprehension regarding
unfavorable cancer is widespread, and
• Because of the fear of often the only cure for this
rejection or humiliation, fear is a therapeutic
the pt. May test the conversation with the
physician with minor physician
DR/KHALID ALHARBY 38
complaints before

39. cont
• “Oh, by the way
doctor” is a variation
of the hand – on –
doorknob syndrome
• About 20% of the
patients raise their new
problems at the end of
the visit
DR/KHALID ALHARBY 39

40. Listening well
• A good family physician
must be a good listener
• It is the most important
communication skill
essential to rapport
• The physician, to be a
good listener should bend
forward, maintain eye
contact, appear relaxed yet
attentive, and be non-
judgmental
• The less physician will say
DR/KHALID ALHARBY more the pt. Will say 40
the

41. Silence
• Silence can be as effective
mean of eliciting
information as direct
questions
• It should be used only
when the physician is
relatively certain that there
is more information to
follow the last statement
• A shift of position, or a
nod and a smile, properly
timed and coupled with
silence, can be more
DR/KHALID ALHARBY 41
effective than a comment

42. Interruption
• Physicians usually use
closed- ended questions to
interrupt the pt. and
thereby inappropriately
control the interview
• This prematurely
terminates opportunities
for pts. to present their
primary concern
• Male physicians tend to
interrupt more often than
female physicians
DR/KHALID ALHARBY 42

43. Interviewing effectively
• The skilled family that we have not
physician can spend 10 discussed?
minute with a pt. & the pt. • Rather than assuming that
Feels it was 20 minutes the pt. Have understood
• Even the busiest physician the instructions, ask them
can accomplish wonders to repeat as they
in a few minutes by understood
indicating that their full • use the pt’s name or ask
attention is on the patient him what he prefer to be
• Please conclude every called as
interview with the • Use “how can I help you?
statement “ is their any Rather than “what brings
thing else bothering you
DR/KHALID ALHARBY here today?”
you 43

44. Cont
• Facilitating techniques communicating very well.
- and then? Can you tell me what is
- Repeating a portion of the wrong?
statement just made. • Summarizing
• Humor (paraphrasing)
two-edged sward - brief restatement of what
the patient has said can
Can be used to break the ice give both the interviewer
and to show “We are and the pt. a chance to
together” correct errors or
• Confrontation misunderstanding.
-you look unhappy - A summary gives the pt.
-We do not seem to be DR/KHALID ALHARBYopportunity to add
an 44

45. cont
more details but also let if the physician “at the
him know that you are same time” :
listening 1. Put away the pen and
- “let me see if I have pad
understood you correctly” 2. Closes the chart
- It can be used to change 3. Start edging toward the
the subject by the door
physician • Open ended question
• Concluding a history -the single most valuable
-to avoid leaving gaps in H/O rapport-promoting
“is there any thing else you element of the verbal
would like to mention ?” communication
DR/KHALID ALHARBY
- It can be of little value To be effective, physician 45

46. cont
should appear relaxed and • Signals that discourage
ready to listen regardless communication:
of the amount of pressure -people can turn off the
from waiting patients speaker if they frequently
comment “yes” in a
-once it becomes apparent manner that conveys
that more time is necessary disinterest or impatience
than is available, a new • Confidentiality:
appointment should be
-is a cardinal principle of
made so that adequate time professionalism
is assured
-pt. Should feel secure that
their information is kept
secret (esp.adolescents) 46
DR/KHALID ALHARBY