Communication Skills in Clinical Practice, Part 1 – The Basics By Dr. Robert Buckman



in section 1 we'll focus on the two main guides to the medical interview the main objectives or tasks the four ease or the e4 approach plus that additional e then the five main steps or stages the clas s-class approach so let's start with the four es the e for the first e stands for engaging the patient and engaging really means making contact between you the clinician and the patient in the paper referenced here this task is considered under three headings join the patient licit the agenda in the story and then setting the agenda joining the patient has to do with warmth and welcome introductions adapting your language to meet the patient's we'll talk about some of the practical guidelines and steps in a few moments in eliciting the agenda and the story one of the most important features is allowing the patient to talk uninterrupted the classic paper that you see referenced here shows that doctors tend to interrupt patients after an average of 18 seconds 18 seconds whereas if you leave the patient to talk they will only talk for a maximum of about two minutes hence the first two minutes really are crucial and not interrupting is a key technique in facilitating the interview we'll be demonstrating that later on good to see you again mr. Thompson so how are things going along so mrs. Parker um tell me how things have been through just lately Steve how things been over the last couple of weeks since we saw you last well not a big change things have been getting a little worse over the last few months now on to the most important part of being an effective communicator and the most important part of being an effective listener empathy that you'd almost say that this entire cd-rom set is centered around responding empathically showing empathy and the relatively straightforward techniques that you need to do that most of us in our professional training have not had any formal education in the handling of patients emotions whereas by contrast we had lots of training in diagnostic tests yet although most of us are unfamiliar with dealing with emotions it is actually a matter simply of learning some techniques in other words emotion handling is not an intuitive god-given gift it is a learned skill that consists of techniques we'll be showing you the details of those techniques later on in the clas s system I do appreciate that not knowing exactly what the future holds is extremely unpleasant for ya it's kind of tough it is kind of tough and many people find that the toughest bit actually is not knowing you know do I prepare myself for being seriously disabled or do I say always will be over in a month that's never happened before doctor that must have been very upsetting I I had no idea where I was where I was going oh yeah yeah that's a big part of it it's kind of been snowballing lately uh you know that was breaking down along with me getting fed up with school and not doing that well and I was just is one thing led to the other I was considering dropping out of school and my girlfriend was she couldn't handle it anymore the way I've become and it kind of all came together at once this sounds very tough I'm just gonna ask you some quick the third e is for educating the patient we all know then as many as 50% of cases the patient will not follow medical recommendations or treatments and part of the reason for that is that the patient may have a particular view of his or her situation including the possibility that they may not recognize the fact that anything is wrong hence educating the patient is very important and in order to do that you have to get a feeling of the patient's expectations and to use several techniques which you'll see an action later on in order to form an agreed plan of action stratton so those are the main tasks the four ease the e4 approach and that additional II the patient's expectations now let's talk about the techniques that you need to perform those tasks and for that the acronym that is easiest to remember particularly when an interview is tense or emotionally charged or awkward is the CLA SS the class approach you might say that what you need in a difficult medical interview is a touch of class or even a class act the see of class stands for context meaning the physical context or the setting of the interview they're really three major components to getting the setting right the first is arranging the space around you optimally second is to make sure the patient is seated nearest to you and any friend or relative is close to them and the third component is to get your own body language and your own eye contact right so the first component of context is the way you arrange the physical space around you and between you and the patient and any family members or friends present actually what a lot of work has been done on the influence of space on communication it's sometimes called proxemics so let's start with a few practical pointers to creating an optimal context good proxemics in your office here's how you can send messages in in an ordinary office setting without fully realizing it here's an ordinary desk is actually quite a nice desk from my point of view it's lovely I've got the computer the keyboard my books blotter telephone pens and stuff like that I feel rather nicely protected and it feels very comfortable from my point of view but it's entirely different when I'm trying to talk to a patient from the point of view of the patient what is nice and protective from my point of view is actually a wall to her it's a barrier to act active interactive communication between the two of us and here is how you can change the atmosphere so that it's much more easy and welcoming very simply not only Val dates or legitimizes the emotion as a response that the patient has it also validates a legit amazes the emotion as an item on the agenda between the two of you it actually says to the patient we can talk about your feelings normally about the medical situation not merely about the prognosis or the treatment if the patient has a strong emotional reaction then that form of validating with an empathic response is very important now in addition to the empathic response there's another communication skill which is most often used as an acknowledgement technique or as a facilitation technique but which actually can be used at almost any significant point during the interview and that is touch touch is of course a primary person-to-person contact as such can be very valuable in reducing feelings of isolation and in helping the patient feels supported however not all clinicians are comfortable doing it also not all patients appreciate being touched or liked it in general terms touch can be a very valuable communication skill providing two simple rules are followed first if you touch the patient touch the patient briefly on a neutral area of the body that really means the hand or the forearm secondly touch the patient briefly and see if they appreciate it or if they withdraw if they withdraw then don't try it again many patients however do appreciate being touched and if they do then in those cases touch is a very useful part of your communication skills so touch can be a very useful part of acknowledging and empathizing as well as being useful in other parts of the interview now there are a few other general points we need to make about the empathic response first of all about a technique called normalizing which often works very well after acknowledging second that acknowledgement doesn't mean you agree with what the patient says and finally that you can use an empathic response on your own emotions and it may be helpful in de-escalating potential conflict so let's deal with all of those three points now first you may well find after acknowledging the emotion that you can normalize meaning that you can tell the patient that their reaction or response is appropriate and normal or whether other people would feel the same after acknowledgement normalizing is often helpful you

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