Medical communication skills

The Communication and Cultural Competence program is based on case studies that give examples of everyday medical practice in Canada. These modules do not focus on diagnosis and treatment. Instead, they focus on communication between health professionals and patients. Please note that the modules are not intended to show the only way to deal with a situation. Instead, they are intended to provide guidance on how to approach and reflect on these different scenarios.

• Introduction

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• Welcome. This part of the Communication and Cultural Competence program is designed to help you understand medical communication in the Canadian context. In this section, you will find a detailed discussion of communication styles and techniques and the standards expected of physicians in their daily practice. Used with the case-based modules, it may help you recognize and understand the difference between effective and less effective communication. Please keep in mind, however, that this is not intended to be a preparation for any examination, neither is it a course on communication skills. As physicians, we use communication skills in many different ways. A physician does the following during a typical day of practice:

  • Makes rounds on hospitalized patients with the house staff
  • Calls colleagues about patient referrals
  • Emails notes about referrals
  • Sees new patients
  • Writes up charts, letters and reports (dictation, e-files, etc.)
  • Takes calls from a ward nurse or other health professionals about an inpatient
  • Consults guidelines relevant to a patient
  • Attends committee meetings
  • Sees follow-up patients
  • Returns patient phone calls
  • Reads the latest journal issue

  You can see that a physician’s day involves four kinds of communication:

  • Listening
  • Speaking
  • Reading
  • Writing

  These components are the essential parts of communication. They are contextual and the type and level of skill required depends on the setting, for example speaking to a patient as opposed to speaking to a colleague or communicating with a friend. We adjust our behaviour depending on the situation.

CONTEXT IN MEDICAL COMMUNICATION

Selection of a communication technique and our expectations of a conversation depend on our cultural background. There are two major cultural systems at work in medical communication: the medical culture in which we trained and/or practice and the non-medical society in which we were raised and/or now live. The requirements of a physician with regard to medical communication differ from those needed in other parts of life, such as socializing with friends, shopping, etc. Physicians must consider and process a large amount of information while selecting and interpreting input from patients and colleagues through active listening and observation. This information must then be integrated and summarized in the physician’s mind and in oral and written formats.

Understanding physician-patient communication

The part of medical communication that many physicians, especially international medical graduates (IMGs), tend to find most different from their previous experience is usually the physician-patient encounter. All physicians have learned certain professional behaviours regarding the physician-patient relationship. These behaviours are culturally and historically determined, depending upon where and how the physician was trained.

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• There are now many different models for physician-patient communication in the literature. These range from checklists of skills and techniques, to books on the functions of interviewing or the strategies to be employed. Most of them emphasize an understanding that the patient’s context — his or her social, physical and psychological environment — is equally as important as the biomedical information the physician requires to diagnose disease.

  Why are communication skills felt to be so important? It is now recognized that better communication leads to being more patient-centred. While continuing to exercise medical reasoning, the physician gathers specific information not only about the patient’s symptoms, but also the meaning of those symptoms to the patient. The closer a physician can come to an understanding of the patient’s illness experience, the better he can fulfill his professional obligation to care for the patient. That obligation is to exercise medical expertise in a specific and unique patient context. For many physicians accustomed primarily to the biomedical model, this means that the kind of information considered clinically relevant must change. This important concept is illustrated in the following brief encounter between a physician and a patient in the emergency room. Watch both versions before continuing.

• The medical experience

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• Dr. Smith: Hi, I’m Dr. Smith. What can I do for you?

  Patient: Hi, doctor. Well you see I hurt my finger the other day. I did something really stupid. I was vacuuming and it got clogged so I put my hand inside to see what it was and my finger got stuck and I don’t think it’s broken but maybe I sprained it or something.

  Dr. Smith: Okay, well let’s have a look. Well, there’s no cuts or bruises or anything and it doesn’t look swollen. Does it hurt when I press here?

  Patient: Yeah it does.

  Dr. Smith: And here?

  Patient: Yes.

  Dr. Smith: And how about if I squeeze here?

  Patient: That hurts.

  Dr. Smith: Just a little bit, okay. Can you extend your fingers like that and now make a fist?

  Patient: Yes, I can do all of that it’s just that it really hurts.

  Dr. Smith: Well, you have all your range of motion so that’s good. Oh, can you grab my finger like this and I’ll bend it, now pull, pull, pull.

  Patient: That really hurts.

  Dr. Smith: Do you have any numbness or tingling?

  Patient: No, nothing like that. It’s just that I can’t really use it to…

  Dr. Smith: Okay, yes I understand, I understand. Well, there is no significant tendon or muscle damage probably just a minor soft tissue injury, be stiff for a few days but, well… you know, maybe put some ice on it or something.

  Patient: Yeah, I’ve been doing that already.

  Dr. Smith: And next time your vacuum cleaner’s clogged, call a technician.

  Patient: Well, okay but it’s just that I can’t really use it to…

• The illness experience

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• Dr. Smith: Hi.

  Patient: Hi.

  Dr. Smith: Hi, I’m Dr. Smith. What can I do for you?

  Patient: Well, I hurt my finger the other day. I did something really stupid. I was vacuuming and it got clogged so I put my hand inside to fix it and my finger got stuck and I don’t think it’s fractured but maybe I sprained it or something.

  Dr. Smith: Okay, all right. Well let’s have a look. Well it doesn’t appear to be any cuts or bruising or swelling or anything like that. Does it hurt when I press here?

  Patient: Yes a little.

  Dr. Smith: And how about like that?

  Patient: It’s tender.

  Dr. Smith: It’s tender yeah… Can you open your hand like that and now make a fist?

  Patient: Yes, I can do all of this it’s just that it really hurts.

  Dr. Smith: It hurts, okay. How about if you bend your index finger and don’t let me straighten it, how’s that?

  Patient: It really hurts.

  Dr. Smith: It hurts, okay… Well, I don’t think it’s serious. There’s no tendon or muscle damage, so it should be better in a few days. Is there anything else you’re worried about?

  Patient: Yes, well you see I play the violin and I haven’t been able to practice for a few days and I’m starting to get worried.

  Dr. Smith: Okay, yes I understand. Well, why don’t you show me how you hold the violin.

  Patient: Well, I hold it like this and what hurts the most is when I try to press like this.

  Dr. Smith: Okay, I see because when you press like that it would hurt more. I suggest putting some ice on it and I will refer you to a physiotherapist for musicians and that should take care of it.

A brief history of physician-patient communication

Changes in the approach to physician-patient communication in North American medicine over the past 100 years are presented below.

PHYSICIAN-CENTRED APPROACH PRE-WORLD WAR II

The following is a short listing of some major trends. There have been and continue to be physicians who practice a variety of models of communication.

Pre-World War II

• Physicians were highly regarded, paternalistic and patients trusted them to behave in their best interests
• Physicians were disease oriented (physician-centred)
• There were few effective treatments to offer patients
• Most physicians were generalists and knew their patients well

• Interview: Physician-centred approach

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• Physician: There is no doubt. Your symptoms are due to gallstones, Cynthia. Now we’ll get an ultrasound and I’ll arrange a consult with one of our surgeons, okay?

  Cynthia: Surgery? But are you sure doctor? I thought it was just indigestion. You see we’re planning this family trip and I’d hate to ruin it for them.

  Physician: Yes, Cynthia, I am quite sure now. This is your health we’re talking about. And you can take a holiday anytime. So we’ll just arrange that, okay?

PHYSICIAN-CENTRED APPROACH POST-WORLD WAR II (~ 1950-1975)

Physicians became even more overtly disease oriented as:

• More effective therapy became available (e.g., antibiotics)
• There was an explosion of diagnostic and therapeutic technology
• Specialization and research increased, which tended to distance the physician from their patient

The physician-patient relationship was still strongly paternalistic, not because the physician knew the patient well enough to know what was best, but because the physician now had a much larger store of effective knowledge and treatments, resulting in:

• An even greater separation of the physician and patient, in terms of communication
• Increasing dissatisfaction with visits to physicians
• Patients felt they were neither heard nor understood
• Increasing distrust of physicians, who were thought to be more interested in money, and fame in the case of researchers and specialists
• In some societies, a contractual, consumer model of the physician-patient relationship emerged. Physicians would show their wares and patients, with access to more knowledge, could shop around

Medical training reflected the advances in biomedical knowledge, focusing on disease and the increasingly complex technology of medical practice. The dissatisfaction of patients was largely ignored as being irrelevant to patient care. History-taking was the type of patient communication that was taught. In other words, physicians were taught to have a dialogue that was focused on asking questions to find out the reason for their visit and potentially what disease or abnormality the patient may have.

By the mid-1980s, the call for change in physicians’ behaviours was insistent, driven in part by the right’s movement, the consumer movement and the appearance of the field of bioethics, which emphasized patient autonomy as a goal of care. In the last 30 years, many medical schools recognized the need to revise their curriculum to include communication skills. They began to look to those whose approach to the physician-patient relationship recognized the importance of the patient’s role in the dialogue. Among them were:

• Balint, who started discussion groups to talk about “difficult” patients
• Engel, whose biopsychosocial model was one of the first models of holistic medicine
• Cassell, who described the difference between disease and illness and language as a critical tool of medicine
• Kleinman, who expanded patient-centred attitudes to all cultures
• Stewart, Levenstein and McWhinney, developers of the Patient-Centred Clinical Method

Full references to these authors can be found in the Bibliography.

• Interview: Physician-centred approach

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• Physician: I’m sure your symptoms are due to gallstones, Cynthia. Now, there are several ways in which to handle this. First of all, you can do nothing and you may not have another attack. Secondly, you can try dieting, cut down the fat in your diet to see how that works for you, and otherwise, well you can try surgery.

  Cynthia: Oh…

  Physician: Now there are two ways. There’s laparoscopic surgery and if you have trouble with that, they may just have to open you up.

  Cynthia: Yes but…

  Physician: But it’s your choice which surgery you’d like to try. Have you thought about a surgeon, you have any in mind?

  Cynthia: No.

  Physician: Well, there’s a few that I can recommend or you can try the internet. Good.

The patient-centred model of physician-patient communication

• Interview: Patient-centred approach

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• Physician: Well from what you’ve told me, Cynthia, I think the problem might be gallstones now. Did you have any worries or concerns about what it might be?

  Cynthia: Well not really worries, I mean I hoped it was just indigestion but gallstones, doesn’t that mean surgery?

  Physician: It could be, yeah. It’s likely.

  Cynthia: You see we’re planning this big family trip soon and I’d hate to ruin it for them. Is there anything I could do like a diet?

  Physician: Sure, you can cut down on your fat intake since fat can provoke the attacks. At some point, they may have to be removed though and we don’t want it to go over too long before it becomes serious but listen, it’s not an emergency now. Maybe we can work around that family vacation. So tell me, where do you plan on going and for how long?

  Cynthia: We’ll be going for two weeks we’re heading down to Mexico with the whole family on a resort on the Pacific coast.

  Physician: Wonderful, good.

What does the physician do to elicit the patient’s illness experience?

• Physician-patient communication: Patient-centred, model 1

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• While the patient-centred clinical method described in the literature does have implementation strategies, no written material can ever show the true uniqueness and variability of physician-patient dialogue. It is difficult to capture on paper the many ways in which real interviews are developed. The use of video scenarios makes this more possible. Also, the focus here is on communication itself: the verbal and non-verbal language of both physician and patient, and how that shapes the encounter. The principles are those of any patient-centred model, but the level of attention is more detailed. The following definitions are important. By physician-centred, we mean that the physician’s mind is focused on disease, the categories and locations of pathology. Communication with the patient is intended to provide information to assist the physician in locating and naming the disease, so that appropriate therapy can be provided. In this situation, it is the physician’s experience and interpretation of the patient’s distress that is important, e.g., does she have pain here, does she have weakness there? Because the physician is thinking in terms of categories of biomedical pathology, the individual patient context may not be heard. An individual patient’s experience of and interaction with a disease process is not considered helpful to the physician hence the frequent use of the term “subjective” for the patient’s illness experience.

• Physician-patient communication: Patient-centred, model 2

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• By patient-centred, we mean that the physician values the individual patient’s understanding and meaning of illness as well as the biomedical information needed to manage the disease. Both are required. Further, it means that such information is valued because it contributes to the ability of the physician to provide high quality care for the patient. Patient-centred care has been shown to lead to better outcomes. It is important to note what these definitions do not include. Being physician-centred does not mean being a bad physician. Application of biomedical expertise is necessary, but not sufficient in clinical care. Being patient-centred does not mean complying and giving a patient everything they request. This approach means being respectful of the patient’s point of view and arriving at a management plan that is acceptable to both the patient and physician. Now, patient-centred interviewing requires some special skills of the physician. They include the following:

  • Understanding the importance of context, of both the physician and patient
  • Self-awareness in the interviewer
  • Flexibility