32 CHAPTER

Foundation of Communication-1
Contributors: Dinesh Kumar V, Yogesh Sontakke

COMPETENCY
nonjudgmental and empathetic manner.
.Demonstrate ability to communicate to patients in apatient, respectful, nonthreatening,

S PECIFIC LEARNING OBJECTIVES

At the end of the chapter, the student should be able to:
To contextualize the importance of communication in the healthcare profession
To define the role of the Indian medical graduate in terms of being a good communicator
To explain the principles of communication in the physician-patient relationship.

Poor communication skills often lead the physician to

COMMUNICATION SKILL be perceived as arrogant, non-empathetic, and non
" Communication refers to effective exchange of
information compassionate.
with others through various means, such as speaking, o On the other hand, good communication skills might
listening, and non-verbal communication. help showcase the doctor as supportive, open-minded,
expression and caring.
" Basic communication skill involves effective received
understanding of the > Decision upon optimal management plans requires shared
as well as an effective
information. decision-making along with patients and their caregivers.
For this, a doctor needs to listen actively, ask clarifying
Importance of Good Communication Skills in Healthcare questions, discuss feasibility and affordability, ascertain
the consensus, and ensure compliance.
Delivery skills? * Unless a doctor has good communication skills, achieving
Q Why do physicians require good communication
relationship, good communication allthese in a brief encounter is impossible.
" In aphysician-patient outcomes and patient Apart from verbal communication, the phvsician needs
skills are pivotal in enabling better toharbor effective non-verbal communication skills in
satisfaction.
medico-legal drifts, effective terms of bodygestures, expressive face, good eve contaCt,
" In the eraof increasing in decreasing the number of maintaining optimal distance, and taking measures to
communication would help
build rapport with patients.
litigations.
requires the usage of medical A patient, being in a vulnerable state, expects his/her
" Interaction with patients
jargon, and this mightlead to inadequate understanding doctor to reduce his ailment. For this, eftective non-verbal
Hence forth, aphysician must simplify communication is required.
among patients. the stipulated
and explain the concepts to the patient in In conditions that are either sensitive or devastating to the
period. patients (commonly referred to as 'breaking bad new's'], it
140 Section I: Attitudes, Ethics, and Communication

Sourco of
Information with center
information:

Mode of transfer

Information received by recipient

Understanding/decoding information

Act based on Feedback to

interpretation sender
Fig. 32.1:Effetive doctor patient communication. Fig. 32.2: Basic flow of communication.

is always better to do counseling and prime the patient to Decode: The process of deliberating the message along
receive the information. In such conditions, a physician with the associated non-verbal signs of communication
should be careful about the wording used and explain the and emotional expressions. The decoded message
further development of the disease without suffocating the would differ from the encoded one in communication
patient's mental well-being. This requires experience and failure or gaps.Also, negative emotional expressions can
anextremely good communication skill set. be perceived by the receiver in a hard manne, which
* Thus, the importance of good communication skills for might lead to further development of communication.
healthcare worker includes the followings (Fig, 32.1): Receiver: One at the other end of the conversation and
To demonstrate goodclinical skill the message's target.
For diagnostic accuracy Communication channel: The medium through which
To maintain patient adherence totreatment the exchange of information happens. It can be a direct
To explain the need for follow-up face-to-face conversation, telecommunication in long
Patient satisfaction distance consultation, chat in the digital medium, and
Patient and healthcare delivery system safety so on. Each communication channel has its etiquette
Team satisfaction and techniques for effective outcomes.
To reduce malpractice Feedback: The process of communication is
Quality healthcare delivery incomplete without effective feedback. Feedback
Quality outcome and improving health status of is the acknowledgment or appraisal of the message
individuals and society transmitted to the receiver. It is important in healthcare
Message to students practice as it helps in ascertaining the degree of
understanding of the message by the receiver. If not
Do introspect upon the doctors whom you have encountered in your understood or misunderstood, feedback helps in
lite. Based on that, reflect on the merits of having good communication rectifying the message.
skills from the patient's side. For example, if a patient could not understand the
prescribed medicine dosage in the first instance, they
Communication Process could get it clarified by raising afeedback question to
the doctor. If not, he/she would land up in the
The process of communicationinvolves the following practice. wrong
components (Fig. 32.2): An effective
Senderor source: One who initiates the communication conversation involves two-"ay
by sending amessage or information. communication,
side to the other.
so the message keeps passing
tron o
Encode: The tact of choosing a specific way of
communicating an intended message to the receiver.
Message; Thecore information that needs to be
Message to students
" Learn
conveyed to the receiver effectively. The message communication skills at the earliest.
to the collective process of Communication rete
should be crisp, understandable, not filled with medical transmitting information and common
jargon,and be titrated according to the leaned levelof understanding
" The from one person to another.
components of communication include sender/souree
the listerner. encoding, message, decoding, receiver, channel, and feedback.
 Chapter 32: Foundation of Communication-1 141

Components of Communication Types of Communication

The two fundamental components of effective communication The communications are of different types as follows:
should be used judiciously. They are as follows: * One-way comnunication, e.g., showing awareness video
Verbal components to the patient
Nonverbal components * Two-way communication, e.g., delivering a talk to patients
where they can ask about doubts
Verbal Components of Communication Verbal communication, e.g., talking with patient or
Always use the proper language for communication. communicating with the help of written document/email
* Non-verbal communication, e.g., empathetic touch, and
Qualities of verbal components include:
Politeness facial expression
Clarity of message <* Formal communications, e.g., physician explains details
Active listening about the dosage of medicine to patient
Proper tone, pitch, and volume * Informal communication,e.g., physician is asking personal
Assuring voice details such as about the weather to gain trust of the
Confidence patient.
Empathetic terms Ways for Effective Communication
Simple language Q. How can effective communication be developed?
Non-verbal Components of Communication A few ways for active listening and thereby enabling
effective communication are as follows (Reference: Kneen,
The body language and gestures should be proper while J. Essential skills: Essential speaking and listening skills.
communication to support its aim. New York, NY: Oxford University Press. 2011):
The non-verbal components include (Fig. 32.3): Reducing one-way talking and keeping listening
Body position: Sitting, standing as per the need Keeping the receiver at ease and permissive
(preferred at the level of a patient) Demonstrating signs that you are listening to others
Proper facial expression without disinterest
Eye contact Removing distractions in the physical environment and
Gestures using hand, eyes reducing noise
Personal appearance Empathizing with receivers
Proximity and distance
Active listening
Being patient and holding the temper
Not entering into an argument or turning down the
Pause in communication
receiver
Empathetic touch Encouraging questions from the receiver
Message to students Listening and responding to the feelings expressed by
the receiver
Many conflicts and disputes can be avoided with proper Rephrasing the message and ensuring its correctness.
communication. You can earn the trust of your patient and team
members with polite and empathetic communication.
Message to students
In communication, use simple language so that your patient should
Active Clarity in understand it easily. Most of the patients do not understand the
listening expression medical terminologies. Work on the communication barriers to get
good communication skill.
Tone and body
Adaptability language Flow of an Effective Physician-Patient Encounter
The following is an example of effective physician-patient
Elements of communication (Reference: Makoul G. Essential elements
communication Empathy of communication in medical encounters: the Kalamazo0
Confidence
skills consensus statement. Acad Med. 2001;76:390.):
<o Setting the stage
Opening the discussion
Allow the patient to complete his/her opening
Open-mindedness statement
Patience
Elicit the patient's full set of concerns
qualities of communication skils Establish/maintain apersonal connection.
Fig. 32.3: Components and their
142 Section I: Atitudes, Ethics, and Communication

* Eliciting information the receiver could not understand should be avoided by

Gather information the sender.
Use open-ended and closed-ended questions Brief and to the point: The message should be concise
appropriately The sender should avoid including extraneous material
Structure, clarify, and summarize information and be considerate of the recipient's attention and tine
Listen actively using verbal and non-verbal techniques * Complete: The communication should have all
Understand the patient's perspective details therecipient needs tofully understand itand act
Explore contextual factors: Family, culture, gender, accordingly. Any queriesor worries the receiver could haxe
and so on. should be anticipated by the sender and addressed in the
Explore beliefs communication.

Acknowledge and respond to the patient's ideas,

feelings, and values. LISTENING SKILLS
* Give information * Listening is a basic element of communication skills (Fi.
Use language that the patient can understand 32.5).
Check for understanding & In the medical field, good listening skill helps to acquire
Encourage questions. information that can be utilized for learning. patient
* Understand the patient's perspective treatment, and so on.
Reach an agreement on problems and plans Basic listening skills need the following elements (tig.
Encourage the patient toparticipate in decisions 32.6):
Check the patient's willingness and ability to follow Focus on speaker: Pay attention to the speaker using
the plan eye-to-eye contact and nodding the head.
Identify and enlist resources and support. Attention: Respond to the speaker by nodding thehead
* Ending the encounter or following the commands.
Provide closure Active listening: Try to understand the received
Ask whether the patient has any other issues or informationand ask questions for clarification or
Concerns
provide feedback if asked.
Summarize and affirm agreement with the plan of
action
Suggest a new or modified treatment/ prevention plan
if required. Listening skill

Baker's Principle Focus on speaker

According to the Baker principle, conveying a message that Eye-to-eye contact
is thorough, succinct, and clear is necessary for effective Sit at the level
communication (Fig. 32.4). of patient
to
* Clear: The message must be unambiguous and simple
understand. Use of jargon or technical terminology that Attention

Active listening

Avoid interruptions
Listen
actively Fig. 32.5: Listening skill.

Focus on speaker

Learn more languages Attention

Baker's
principle Elements of
Improve vocabulary baslc listening Active listen1ng

Show skills
Open understanding
mindedness
Avoid interruption Reflection

Baker's principle of
communication. Fig. 32.6: Elements of basic
Fig. 32.4: listening skills.
 Chapter 32: Foundation of Communication-1 143

. Reflection: Repeat the received information by

rephrasing and confirming it from the speaker to clarify Listen
understanding.
actively
Avoid interruptions: Avoid interrupting communication
unless and otherwise needed. Let the speaker complete
their speech and then ask the queries.
Improve vocabulary: To understand the communicated Open Show
information, improve your vocabulary. mindedness understanding
Ways of
empathetic
. Learn more languages: You may need to learn the local communication
language of the patient to understand the nature of the
complaints.
Message to students
Avoid Respond
Effective communication is required to avoid conflicts that healthcare criticism with respect
workers face nowadays. and judging and care

Empathy in Communication Skill Fig. 32.7: Ways of empathetic communication.

$ Empathy is a keystone of communication skills.
" It helps connect with patients at a deeper level and helps Sender barrier
to gain faith and trust.
o It helps to understand the feelings and perspectives of Attitude barrier Encoding barrier
others.
* Ways of empathetic communication are as follows
Barriers to
(Fig. 32.7): Physical barrier effective Medium barrier
Listen actively: Always pay attention to the person communication
speaking. Let him/her complete it. Avoid interrupting
and ask for clarifications for better understanding. Feedback barrier Decoding barrier
Show understanding: Try to express your understanding
of the speaker's situation. Receiver barrier
Respond with respect and care: Try to offer support
respectfully and counsel the person. Fig. 32.8: Barriers to effective communication.
Avoid criticism andjudging: Do not argue with patients
or criticize.
Open-mindedness: Be ready to accept others' views * Receiver barrier: Some patients might fail to grasp the
and opinions. message due to hastiness or pre-occupied nature or
condescension.
Barriers to Effective Communication * Feedback barrier: Lack of feedback questions would
Effective communication can be hampered by the barriers at ignore the chance of rectifying the message and enable
various levels (Fig. 32.8): the faulty message to stay with the patient.
" Sender barrier: The physician fails to communicate
with o Physical barrier: Physical distractions in the
the patient due to lack of time, tiredness, or a negative communication environment tend to distract the attention
attitude. of both the sender/receivers. For example, constantly
" Encoding barrier: Due to variations in
culture or language ringing the telephone could easily break communication
negative non-verbal gestures, the and reduce effectiveness.
or sometimes due to manner.
message could get communicated in a faulty * Attitude barrier: Each individual has a set of beliefs,
communication happens over the thoughts, and feelings toward people. In addition to the
" Medium barrier: When message would verbal communication channel, attitude tends to get
telephone ordigital platforms, part of the
leading to acommunication communicated to others.
not be transmitted properly, This can be either:
gap. emotional vulnerability or Positive such as caring, warmth, respect, acceptance,
" Decoding barrier: Due to patient might fail to decode and so on
ineffective understanding, the informauion
tofaulty or incomplete
the message, leading himn/her.
Negative such as demonstrating eg0, superiority over
others, disinterest, coldness, arrogance, and so on.
being transmitted to
144 Sectin kAate, Etties, ed(euica
Communication Skilh for Undergraduate Students
) tow tn deveap ammunitatian skilles in underyaduate
medial eduatint
Message to students
The triirriny ase the ways tr, dresptheutsinisatn
skill frt undiery atuate medt al stiens (heferene (te
M, Parttt T, Crik (, Impting yif umunitati
skills #MÊ 2012, 44 57 dah 1011H/tnije1y
Tarn usir cieat latiyuay with patients, fsideriny Breaking Bod Mews or Death Didrure
cultural tItitzts arid taking intt, #11nat the emutatal
qutient f the resie
. Be cotistinus f tbody gestures and non verhal
ommunication es Actiny dilizently ard matisrety rsharig ensitive intornatitmat a iniapp z
in front of patients is quintesseritial. (Untortunately, this task, wtich tequites tiz,er
Practice establishing a dialogue with others and
try tohave an ayenda for the dialngue The tactof fmedical educatíon for rmary yeats, wtiictn has 125. kw
building a dialge neessitates years of poraticE and as ernotinaldiscanfort to the patierts
introspection. Recentty, frcused traininz conterning nut la a
Be awate of the nmunication styes of the patients skills has been inculcated ín many medic2. k2
and pace your interaction acandingy. If a patient is onsidering its salience in dinical practice
olid in terme of his/her thouyht procese, a doctor ABCDE mnemonle forbreaking bad news
Can he more directive, and if a patient is erotionally 4 Rabow and McPhee evisaged a rnsdel fror treassyd
secking, the doctor needs to be supportive. Analyziny, news and developed an ABDE mnernonic t: e e
the onmunication style of your friends and relatíves (Heference: Rabw MW, McPhee SJ. Beyond hreer,2 d
and practicing would he of inmense help. news: hrw to heip patients whr suffer. West j Meri
" Be careful in holding your emnotions while 1712)-3). (Fig 32.9):
communicating, avoiding aryuments, solding, or A: Advanne preparation: Fromthe side of the pry1
threatening patients is irrnperative. ín terms of arrangýng aconducive ervironrnern z
Practice reflective writing on the outeomes of your adequate tíme, rehearsing hat to he said, ard Keepng
interaction with others and patiernts in wards/OPD. emotionally charged.
Solicit feedhack from peers, seniors, and faculty and B. Building therapeutic relationship: Estahlishing tazpot
try to mndify the ommunication proess hased on with the receiver and priming up for the infortnat.
that. Working on the criticisn would be of yreat help C: Communicating well: Elicitíng the priof KwA
in the future. Also, try to observe the conmunication informatíon from the patient, being cornpassionate and
style of faculty, who are admired try others, and try to frank, allowing enotional outbursts of the patient and
inorporate their positive aspects. checking for understanding of the inforrnation
Apologize when you commit a communication error, D: Dealing with patient and family reactions: (apabie d
as this would help maintain the rapport with the handlingtheernotional reaction of the patient and farnily
receiver. and being ernpathetic with therm.
. Nurture empathy and compassion in yourself as they E: Encouraging and validating emotions: Being cvgnizant
form the cruz of hurmanism, which would indeed of the impact of the news on the patient and offering
reflea in communication. A
patient could observe the realistic solutions to the ailing farnily
empathy demonstrated at tines of his/her eriticality, Message to students
and the recoynition of a doctor is vatly deternined
by it. Good cornmunication skills are one of the inportant traits of a
. Keep onpracticing communication related exercises hurmanistic physician. It needs to be conciously prormoted by the
with complete mindfulness. Over the years, you could faculty arndreinstated to the students. Without
howsoever talented he/she might be, a physician cornnunication skll
witness maturity in the process and non verbal body would not delvef
satisfactory outcornes arnong patients.
languag.
 T
Chapter 32: Foundation of Communication-1 145

A
Advance
C
Communícating Encouraging
preparation well and validating
emotions

B
Building
D
Dealing with
therapeutic patient and
relationship family reactions
Fig. 32.9: ABCDE protocol for breaking bad news.

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