Clinical skills viewed as worthless without communication

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THE FOLLOWING LECTURE HAS BEEN
APPROVED FOR
ALL STUDENTS
This lecture may contain information,
ideas, concepts and discursive
anecdotes that may be thought
provoking and challenging
Any issues raised in the lecture may
require the viewer to engage in further
thought, insight, reflection or critical
evaluation
Clinical
Communication
Professor Craig Jackson
Prof. Occupational Health Psychology
Head of Psychology
BCU
Clinical Communications Outline
Benefits for clients
Benefits for clinicians
Demerits
Skills
Shut up and listen
Clinical Communications Outline
“The good clinician treats the
disease, but the great clinician
treats the patient”
William Osler
Relatively new area
Communication was a “wet skill”
Now part of curriculum
Seen as important ( not more important than clinical skill) . . .
. . . Clinical skills viewed as worthless without communication
Communication skills not universal
Different types of communication
Depends on therapists’
Training
Philosophy
inclination
Theoretical position
Psychodrama
Holotropic breathwork
CBT
RET
“Hello Chris”
Covert naturalistic experiment
8 sessions with psychotherapist
Was NOT psychotherapy
Pseudo hypnotherapy
Distractions
. . . . . iPad
Not the “breathy voice” again
Sounds too “American”
. . . Too controlled
. . . Too therapeutic
. . . Too effortful
. . . Not naturalistic
Benefits for Clinicians & Clients
Time saving
Effective & efficient
Reduces Stress & Burnout
Reduces litigation
Clients more satisfied
Best predictor of resolution
(e.g. Chronic headache; Headache study group Ontario (1986)
Shorter care needed
(coronary care patients with emotional support - 2 days less bed time)
Mumford et al 1982
Benefits for Clients
Positive evaluations
Both Clinician and Client agree on reason for consultation
Clinician asks client about ideas, concerns or health beliefs
Clinician takes time to achieve a shared understanding with client
Positive consultations take no longer than negative ones
(Arborelius & Bremberg 1992)
Improved outcomes
A Meeting of Experts
Any clinical consultation is a meeting of two experts
Clinician
- Skills & Knowledge
Client
- Their body & Experience
But sometimes, people just want to be told what to do . . .
It’s all subjective of course
Clients rating their clinicians
Not knowledge based
Not skills based
Based on communication and subtle cues
They might be wrong . . . but their perception is everything
Medspeak
Jargon
Sets boundaries - reminds of power relationships
“Sick”
“Nerves”
“Chronic”
“Acute”
“Diet”
“Drugs”
“Stomach”
“History“
Lay person
Clinician
Illness
Anxiety
Severe
Severe
Calorie restriction
Narcotics
Abdomen
The past
Vomit
Neurology
Long duration
Sudden onset
Intake
Medication
Organ
Previous disease
Interruptions & Redirections
Consultations start with client
Appearing rushed
Checking watch
Fidgeting
Monitoring email
28% of clinicians interrupt client in first opening
Mean of 23 seconds (Marvel et al 1999)
Average of 2 interruptions per consultation
Mean of 12 seconds in home consultations (Rhoades et al 2001)
Valerie: HIV patient in 1985
Useful sources
90% of info comes from taking a history
10% (or less) from case files and records
Visual metaphor
Might come in bits and pieces
Communication Skills: General Manner
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Responds to cues
Active Listening
Use Empathy
Offer Support
Non-judgemental
Avoid personal beliefs
Simple language
Use appropriate body language
Questioning style
Information giving
Information gathering
Information Gathering
Appropriate language
Ordered and Methodological
Comprehensive / Succinct
Coaxing
Use triangulation . . . “So you said that . . . Therefore . . .”
Offer partners or collaborators to input
Props e.g. clipboard, notes, questionnaire
Information Gathering . . . Don’t rely on symptoms
“Doorknob concerns”
“By the Way” syndrome (Robinson 2001)
Clients often reveal real reason only when comfy
Real reason is not the first reason hey give
Psychosocial issues
Worries about future
Their own ideas
Social context of their problem
Barry et al 2000
Information Giving
Convey info
Check understanding
Control of consultation (allows it to vary)
Signpost change of direction
Summarises / indicates next steps
Recognise and respond to client’s concerns and anxieties
Consultation General Skills
1.
2.
3.
4.
5.
Gives name and explains role; checks patient’s name
Gives greeting appropriate to culture (handshake not always needed)
Non-verbal behaviour appropriate to culture (eyes not always needed)
Establishes purpose of interview
Clarifies why interview is taking place:
- from client’s perspective
- from clinician’s perspective
6. Checks that patient is happy to proceed
7. Establishes desired outcome of interview
8. Establishes baseline knowledge/understanding
9. Uses open questions
10.Listens
11.Confirms what s/he has learned
12.Signals move to information-giving at end
Some natural cynicism from medical circles
Case Summary of a counselling client
Date
Symptoms
Referral
Investigation
Outcome
1980 (18)
Abdominal pain
GP --> surgical OP
Appendictomy
Normal
1983 (21)
Pregnancy
(boyfriend in prison)
GP --> obs and gynae
OP
1985-7
(23-25)
Bloating, abdominal
blackouts (divorce)
GP --> Gastro and
neurology OP
1989 (27)
Pelvic pain
(wants sterilisation)
GP --> obs and gynae Sterilised
OP
Pain persists for 2 years
1991 (29)
Fatigue
GP --> infectious
diseases unit
Diagnosis of ME by patient
and self help group
1993 (31)
Aching muscles
GP --> rheumatology Mild cervical
clinic
spondylosis
1995 (34)
Chest pain, breathless A&E --> chest clinic
(child truanting)
Termination
All tests normal
Nothing abnormal
IBS diagnosis
unexplained syncope
Pain clinic - Tryptizol
Nothing abnormal
Refer to psychiatric services
poss hyperventilation
Summary
Clinicians expected to be good communicators
Clinical skill does not make up for communication lacking
Communication does not replace clinical skills
Getting it right worthwhile
Rewards
Getting it right takes time and experience
Clinical supervision essential
Case reviews essential
Communication without Knowledge
Communication without Knowledge
Some References
Makoul, G. (2001). Essential elements of communication in medical encounters:
the Kalamazoo consensus statement. Academic Medicine, 76(4): 390-393.
RSM forum on Communication in Healthcare (2004). Core curriculum for
communication skills in medical schools. In E. McDonald (ed). Difficult
Conversations in Medicine. Oxford: Oxford University Press. pp 209-211.
Simpson, M et al. (1991). Doctor-patient communication: the Toronto consensus
statement. British Medical Journal. 303(6814): 1385-1387.
Von Fragstein, M. et al. (2008) UK consensus statement on the content of
communication curricula in undergraduate medicine education. Medical Education
42(11): 1100-1107.

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