Doctor Patient

Consultation
MODELS FOR COMMUNICATION, COMMUNICATIONS SKILLS PART 1
Doctor Patient Relationship

▶ Models of the doctor–patient consultation that have

been developed from ancient times until today have
aimed to provide teachers and students with examples of
philosophies, skills, processes and behaviours,
▶ With the ultimate goal of improving outcomes and
satisfaction.
▶ They give a framework for learning, teaching and
assessing the medical consultation
Types of Doctor-Patient Relationships

▶ Parsons
▶ Paternalistic
▶ Patient Centered
▶ Consumerist
Models for communication 1850-1950

▶ demographics;
▶ presenting problem(s);
▶ history of presenting problem(s);
▶ past medical history;
▶ systems enquiry;
▶ family history;
▶ medication history and
▶ social history
The Development of Psychoanalysis

Balint and his contemporaries

▶ Psychotherapeutic medical consultation
▶ Holistical View(physicall,psychlogical,social)
▶ The first one who used term “patient-centred”
Development of Technologies

Byrne and Long(1976)

▶ the doctor’s task to establish a relationship with the patient;
▶ his/her attempt to discover the reasons the patient consulted the doctor;
▶ the physical examination or the verbal exploration of the problem;
▶ consideration of the condition by the doctor or the patient or both;
▶ further treatment or investigations usually suggested by the doctor and
▶ termination of the consultation, usually by the doctor.
Patient Centered Model
▶ New consultation models that operationalised the research findings and the
concept of patient‐centredness. Pendleton et al.’s model of good practice
(1984) assigned seven tasks to the medical consultation:
▶ finding the reasons the patient visits the doctor;
▶ exploring problems other than the presenting complaint;
▶ sharing understanding and decision making;
▶ involving the patient in the consultation;
▶ empowering him/her to accept responsibility of his/her part in the process
of diagnosis, prognosis and treatment;
▶ efficient and effective management of time and resources and
▶ building and maintaining a therapeutic relationship.
Disease-Ilness Model(McWhinney 1989)

Doctor Agenda or Patient Agenda or

Disease Framework Illness Framework

• attentive listening;
• use of open and closed questions;
• clarification;
• summarizing and
• use of verbal and nonverbal behaviours
to build and maintain a therapeutic relationship.
Cohen‐Cole (1991) developed the Three‐
Function Approach
▶ Building an effective doctor–patient relationship;
▶ Assessing the patient’s problems
▶ Managing the patient’s problems.
Calgary-Cambridge Guide to Medical
Interview
▶ information gathering,
▶ physical examination,
▶ explanation and planning
▶ closing the consultation
E4 Model - US

The E4 Model (Keller & Carroll 1994), which suggests that the doctor has two
biomedical tasks:

find what the problem is and fix it.

In order to do that he/she needs to employ the following communication tasks:
▶ engage;
▶ empathise;
▶ educate and
▶ enlist.
Four Habits(Frankel & Stein 1996)

▶ invest in the beginning;

▶ elicit the patient’s perspective;
▶ demonstrate empathy
▶ invest in the end.
Shared Decision Making (Elwyn 2012)

▶ Introducing choice;
▶ Describing options, often by integrating the use of patient decision support
▶ Helping patients explore preferences and make decisions.
Essential Elements for Communication
Feedback
▶ Greeted me in a way that makes me feel comfortable.
▶ Treated me with respect.
▶ Showed interest in my ideas about my health.
▶ Understood my main health concerns.
▶ Paid attention to me (looked at me, listened carefully).
▶ Let me talk without interruptions.
▶ Gave me as much information as I want.
▶ Talked in terms I can understand.
▶ Checked to be sure I understand everything.
▶ Encouraged me to ask questions.
▶ Involved me in decisions as much as I want.
▶ Discussed next steps, including any follow‐up plans.
▶ Showed care and concern.
▶ Spent the right amount of time with me.
How communication heals

▶ Increased access to care;

▶ Greater patient knowledge and shared understanding;
▶ Higher quality medical decisions;
▶ Enhanced therapeutic alliances;
▶ Increased social support;
▶ Patient agency and empowerment
▶ Better management of emotions.
Patient Centered-what is it anyway?
RCC can be defined as care in which all participants appreciate the
importance of their relationships with one another.
▶ According to Beach et al. (2006), relationship‐centered care is
founded upon four principles:
▶ 1 that relationships in health care ought to include the
personhood of the participants;
▶ 2 that affect and emotion are important components of these
relationships;
▶ 3 that all healthcare relationships occur in the context of
reciprocal influence and
▶ 4 that the formation and maintenance of genuine relationships
in healthcare is morally valuable.
Empathy- again?

▶ Making a personal connection can be done by expressing genuine interest in a

patient’s life world; it does not require reciprocal self ‐disclosure on the part of
the doctor (Beach et al. 2004).
▶ Others too found that making a personal connection by expressing only
seconds of compassion and attention can make a huge difference to patients;
▶ Study participants reported better information recall, less anxiety and fewer
concerns after having seen an empathic doctor (Fogarty et al. 1999; Van Vliet
et al. 2013; Sep et al. 2014; Van Osch et al. 2014).
Relationship-Centered
Communication (RCC)
▶ Communication with the goal of establishing an
authentic relationship

- Relationships are therapeutic

- Patient perspective & psychosocial context is vital

- Partnership and shared decision making

CEHC Foundations of Healthcare I

The Healthcare Relationship
Does not require Does require
▶ Friendship ▶ Personal connection
▶ Agreeing on everything ▶ Mutual respect
▶ Unlimited time ▶ Genuine interest in the
▶ Acceptance of patient
boundary violations ▶ Shared understanding of
▶ Practicing outside your pt. illness
scope of practice ▶ Shared commitment to
patient health & wellbeing
Evidence-Based Patient Outcomes
of RCC
▶ Symptom improvement ▶ Comprehension & recall (20, 38)
or resolution (2, 16, 23, 54) ▶ Trust & loyalty (20, 46, 50)
▶ Sense of self-efficacy &
▶ Functional support (16, 20, 56)
improvement (2, 54)
▶ Satisfaction with care (16, 42, 44,
46)
▶ Health status & quality
of life (38, 44, 55) ▶ Treatment adherence (38, 55)
▶ Self management of chronic
▶ Safety (38, 42) disease (20)
Evidence-Based Physician Outcomes
of RCC (continued)
▶ Diagnostic accuracy (40)
▶ Efficiency (32, 33, 58)
▶ Self confidence (37)
▶ Job satisfaction & engagement (45)
▶ Reduces professional burnout (60)
▶ Fewer malpractice claims
(2, 10, 25, 31)

▶ Lower cost of providing care (40)

Communication is the most common
medical procedure
▶ Over 200,000 times in an
average practice lifetime

▶ Minimal physician education

in communication skills

▶ Communication skills decline

throughout residency
Communication Skills Can Be Taught

▶ Like medical procedures, skills

can be learned

▶ Must be practiced

▶ Mastery requires deliberate

practice
and feedback

Ericsson,
2008
 Listening for emotion
25

Communicating skillfully with a patient

requires tuning to the patient's emotions.

Halpern, J. What is Clinical Empathy? J Gen Intern Med. 2003 August; 18(8): 670–674.
 26

Skill 1
“Listening with both ears”

Other ear:
One ear: emotion in
medical patient’s words,
information tone, expression,
posture
Skill 2 27

Reflect and listen, Repeat

1.
3.
Hypothe
Feedback
size

2. Test
Communication Skill Sets 28

▶ content skills – what you say

▶ process skills – how you say it

▶ Self-perception skills – awareness of your own feelings and biases

Collaboratively Set the Agenda

▶ Orient patient to elicit a list of presenting

concerns (9)
“I’d like to get a list of all the things you’d like to
address today…”

▶ Use an open-ended question to initiate survey

“What concerns brought you in today? Before I
ask you some questions that I have, what
questions do you have for me?

▶ Ask “What else?” until all concerns are

identified (5, 21)
Metacommunication 30

▶ communicating about communicating

▶ “Do you follow me?”

▶ “You seem worried; is that right?”
▶ “I’m not sure I get what you’re saying.”
▶ “You sound really mad at me!”
▶ “Is it ok if I ask you some questions about that?”
Metacommunication - your life ring 31

▶ When content and process don’t match up

▶ When a patient is very upset with you or

something about his or her medical care
Why invite complaints? 32

As the patient, a metacomment inviting feedback tells you:

▶ that the doctor is really listening;

▶ that the doctor cares enough to take the time to pursue your concerns;
▶ that the doctor is not afraid of potentially unpleasant emotion and so you can be
honest, and
▶ that the doctor really cares how you feel.
“Listening” includes attending to non- 33

verbal communication
Nonverbal attunement led physicians to pause at
moments of heightened anxiety, at which times
patients disclosed information. If physicians did not
do this, patients did not share vulnerable
information, despite the physicians asking the
patients appropriate and accurate questions.

Suchman A, Markakis K, Beckman H, Frankel R. A model of empathic

communication in the medical interview. JAMA. 1997;277:678–82.
The power of your positive attention 34

A physician simply making

contact by observing to the
baby’s mother: “I can see
she has your eyes,” or “He’s
snuggled right into you,
isn’t he?” engaged the
mothers more than other
far more complicated
interventions.

Brazelton et al.
Are We Opening Pandora’s Box?

▶ How soon do physicians interrupt patients after asking a question?

18-23 seconds (9, 32)

▶ How long will a patient talk if uninterrupted?

90 seconds (28)

▶ What are the risks of not allowing patients to tell their story?
▶ Most important concern won’t come out! (11)
▶ 75% never finish what they were saying (28, 32)
▶ Difficulty diagnosing 50+% of these cases (61)

Beckman & Frankel, 1984; Marvel et al, 1999; Weston, Brown & Stewart, 1989; Langewitz et al, 2002
Relationship Establishment
▶ Review chart in advance
▶ Knock & inquire before entering room, if possible
▶ Greet patient formally with smile & handshake (4, 13)
▶ No pressure. First impression forms
at 39 milliseconds
▶ Introduce self & team
▶ Position self at patient’s eye level
▶ Recognize & respond to immediate signs of physical or
emotional distress
▶ Make a brief patient-focused social comment,
if appropriate (41)
We call it communication, 37

but it’s really about relationship

The mechanics of good
communication are valuable as tools
to help you create a trusting doctor-
patient relationship.
Seminar
round of rhythm and movement
Form a circle. One of them goes into the middle and makes any kind of
movement, as strange or unusual as she likes, accompanied by a sound and in
a rhythm of her own invention.
All the others imitate her, trying to reproduce exactly her movements and
sounds, in time with her. Then, still making her movement and sound, this
leader approaches and stands opposite someone in the circle, challenging
them to take her place; this person goes into the middle and slowly changes
the movement, the rhythm and the sound in any way she likes.
There must be no fear of the ridiculous, or the strange. If everybody is
ridiculous, no one is! Everyone else must try to reproduce everything they
see and hear, as precisely as they can – the same movements, the same voice,
the same rhythm. . . .
If it is a woman who is in the middle, the men in the circle must try not to
produce a ‘masculine’ version of the movement, but to reproduce exactly
what they have perceived; and vice versa..
What is happening here? What
mechanism?
Simple – in the act of trying to reproduce someone else’s way of moving, singing,
etc., we begin to undo our own mechanisations.
By our reproduction, we are usefully relaying to that person our vision of her, but
more importantly we are working to restructure our own way of being, in many
different fashions (since many actors will go into the middle).
We do not do a caricature, because though that would lead us to do different
things, we would be doing them in the same way (our own). We try to
understand and make an exact copy of the exterior of the person in the middle, in
order to gain a better sense of their interior
Small Group Work

In small groups use the printout to develop a dialogue between a doctor and
patient.
Half of the group will be pretend to be in the patient role, half in the doctors
role.

What was the most surprising about this activity?

What was the hardest part to fill in? Why?