HUMAN COMMUNICATION SKILLS LECTURE NOTES

LECTURE 1

INTRODUCTION

What is communication?

This may seem a question with an obvious answer. But is it? What does the word communication
mean to you? do some brainstorming, either by yourself or in a group. Write down all the words
or phrase which comes to mind. Think about:

 A definition of communication
 The method of communication.
 The purpose of communication.

The oxford English dictionary tells us that the word “communication” comes from the Latin to
impart to share. Communication is imparting conveying or exchanging ideas and knowledge.

What is good communication?

A study carried out some years ago by Dr. Peter Maguire and colleagues in Manchester where
patients who had been interviewed by medical students were asked for their opinion of the
students interviewing abilities. Patients preferred interviewers who:

 Were warm and sympathetic

 Were easy to talk to
 Introduced themselves.
 Appeared self confident.
 Listened to the patients and responded to their verbal cues.
 Asked questions that were easily understood and were precise.
 Did not repeat themselves.

Why is good communication important?

The short answer is ‘better care of our patients’. There is considerable evidence to show that
doctors who communicate well with patients are more likely to:

1. Make an accurate, comprehensive diagnosis. Good communication skills enable one to

collect information about a patient’s problem that is comprehensive, relevant and
accurate. It has been shown that doctors who have received training in communication
skills are more likely to diagnose psychiatric morbidity in their patients than those who
have not been trained.
2. Detect emotional distress in patients and respond appropriately.
 3. Have patients who are satisfied with the care they have received and who are less anxious
about their problems.
4. Have patients who agree with and follow the advice given

There is also evidence that good communication can have a positive effect on the patient’s
physical condition. One study showed that patients with hypertension who had been allowed to
express their concern about their problem had a significantly greater reduction in their blood
pressure than those who had not been given this opportunity but had been treated similarly in
other respects.

A study carried out in general practice showed that patients presenting with sore throat were
more likely to get better sooner if they felt were able to discuss their concerns with the doctor.

Unfortunately, it is not difficult to find examples of the consequences of poor doctor- patient
communication. A study in Florida compared patients’ opinions of obstetricians who had
malpractice claims made against them with those who had not been sued. It was found that
patients were most likely to complain about aspects of patient- doctor communication rather than
the technical aspects of care. The most frequent complaints about the doctors were that they:

 Would not listen

 Would not give information.
 Showed lack of concern or lack of respect for the patient.

In countries where patients are less likely to sue their doctors, patients also express
dissatisfaction about how doctors communicate and relate to them. A report of a survey carried
out in the UK included a quote from a patient with breast cancer.

“They just told me I was going to have a mastectomy. No choice, no explanation. They don’t
discuss much with patients. I would have preferred that they had explained more”.

This survey was reported in 1993 and, although there is now greater emphasis on providing
patients with information and explanation, it is important to remember that most complaints are
still related to a breakdown in communication.

Can communication skills be learned?

Training to be a doctor involves the acquisition of knowledge, skills and appropriate attitudes.
Like many aspects of medical education, it was assumed until fairly recently that students
acquired good communication skills and appropriate attitudes by a sort of osmosis- by observing
and modeling their behavior on that of their teacher.

As we have already seen, however, this may not produce doctors who are good communicators.
It is now recognized that the apprenticeship method is not sufficient and that formal training in
communication skills is necessary and effective. Medical schools have responded by introducing
communication skills as a formal and important part of the curriculum and assessments.

What is the evidence for the effectiveness of communication skills training?

In the 1970s a series of studies was carried out on medical students during their fourth year
clerkship in psychiatry. The study found that, before training, students experienced difficulties in
obtaining histories from patients. The difficulties which were highlighted included:

 Not obtaining all the necessary information from the patient.

 Forgetting to ask about the influence of the patients problems on him or herself and
family.
 Failing to notice and respond to verbal and non verbal cues from the patient.
 Looking bored during the interview.

As part of these studies a group of students were divided into a control group and a feedback
group. In order to assess their baseline interviewing skills, students in both groups were asked to
interview a patient and obtain a history of the patient’s main problems within 15 minutes. The
interviews were videotaped and the students were asked to write up the patient’s history. The
feedback groups then interviewed two more patients and were also videotaped. However, on
these occasions the students watched and discussed their interviews with a tutor during a
feedback session, comparing it with an instructional handout. Finally both the control group
(who had no training) and the feedback group made a final videotaped interview with a patient.
These interviews and the pre training interviews were then rated and given a score by a
psychologist who was blind to whether a student had received training or was a control.

How to develop good communication skills

The most important point to realize is that you have the ability to communicate and that you use
this ability continually when relating to other people. Learning communication skills is ,
therefore, different from learning for example, to take someone’s blood pressure, which you are
unlikely to have done before coming to medical school. The communication skills courses that
are now part of the curriculum in all medical schools aim to help you to hone your innate skills
and develop specific skills that enable you to communicate effectively with patients.
Communication skills training will enable you to identify these skills and practice them with
your fellow students or simulated patients (often actors role playing patients). This is important
for learning how to take a history from a patient, but even more important for situations when
communication may be particularly difficult for both of you and the patient, for example when
you have to tell a patient that he or she has cancer, or when you need to take a sexual history.

These situations are never easy to cope with, but it does help if you have been able to practice the
necessary skills and explore your own feelings about these isses with other students and a tutor in
a supportive setting.
So, what is the best ay to learn skills of effective communication? Clearly, this will depend on
your teacher’s experiences and opinions. However, there is evidence from Maguire’s work that
students learn communication skills most effectively if the following conditions are fulfilled.

 Students are given written instruction about the information to be obtained from training
and the skills to be used.
 The skills are demonstrated by the teacher.
 Students are given opportunities to practice these skills with real or simulated patients
under controlled conditions.
 Students are given feedback on their performance by audio- or videotaped replay.
Students are able to discuss their performance and related issues with a tutor.

Finally, here is a cautionary note. You may think that you have execellent communication skills
and will have no problems in dealing with patients. You may be tempted to say: ‘communication
skills seminars are not for me. I don’t need them. However, one study of medical students has
shown that students who are the most confident tend to be least competent in communicating
with patients.

LECTURE 2

BASIC COMMUNICATION SKILLS

Factors that influence communication and in particular, doctor patient communication.

First of all, the setting is clearly important- you are unlikely to discuss how you feel if the

conversation takes place on the top of a bus or in a crowded room. Secondly, how you feel at the

time will influence what you say, and so will the attitude if the other person - both at the start of

the conversation and during it. You are more likely to be able to share information and to find

the process helpful if the other person is friendly and attentive. Similarly, the sharing of

information between patient and doctor can be influenced by factors that relate to the setting of

the interview and to each of the participants.

Patient-related factors influencing communication.

People cope with illness in different ways depending on their personality, upbringing, social

class, ethnic and cultural background and their life experiences. These factors will influence how

they communicate. Reactions to illness include denial, anger, anxiety and depression. These

responses will determine if and when a person seeks medical attention and will also influence a

patient’s behavior when receiving care.

Most people experience a degree of anxiety and apprehension when consulting a doctor. In

particular, admission to hospital is a disturbing experience for most of us. Factors that contribute

to our anxiety include an unfamiliar environment, loss of personal space, separation from family

and friends, loss of independence, and uncertainty about diagnosis and management. Thus

individual’s physical condition and their psychological state related to both their illness and their

medical care they will receive will influence the communication process. As we shall see later, it

is important to identify and seek to overcome patient-related factors (E.g. anxiety) that may

impair communication.

Other factors that must be taken into account are:

 The patient’s beliefs about health and illness.

 The problems the patient wishes to discuss.

 The patients expectations of what the doctor will do( often based on previous experience)

 How the patients perceives the role of the doctor.

Doctor-related factors
Some medical students and doctors find it easier than others to empathize and communicate with

patients, although, as we have already noted, these attributes and the acquired by training. Other

factors influence our behavior during a consultation (Table 2.1). As a medical student you may

initially find it difficult when interviewing patients who are much older than yourself,

particularly when sensitive issues such as sexual behavior are involved. It is not difficult to

understand why medical students just before finals, a junior doctor at the end of a long shift or a

GP who has already seen two dozen patients earlier in the morning may have less to give a

particular patient. Tiredness, anxiety and preoccupation with other concerns are also unlikely to

impair communication, and we need to be aware of these limitations. We also need to be aware

of our prejudices and together they do not interfere with our communication with patients. For

example, a patient who persistently present with symptoms that do not appear to have a physical

basis must be taken seriously, and not be dismissed as hypochondriac.

Table 2.1: Factors which influence doctor-patient

communication.

Patient-related factors:

 Physical symptoms.

 Psychological factors related to illness and /or medical

care (e.g.: anxiety, depression, anger, denial)

 Previous experience of medical care.

 Current experience of medical care.

Doctor-related factors:

 Training in communication skills.

 Self confidence in ability to communicate.

 Personality.
  Physical factors( e.g. tiredness)

 Psychological factors (e.g. anxiety)

The interview setting:

 Privacy

 Comfortable surroundings.

 An appropriate sitting arrangement.

The setting of the interview.

Most consultations take place in a hospital ward, outpatient clinic or the GP’s surgery. In each

case every effort should be made to provide a setting that facilitates communication (Table 2.1)

Privacy is essential. A patient in a hospital bed is unlikely to divulge personal sensitive

information if she knows that Mrs Smith in the bed next door can hear every word through the

curtains. If you do not feel that the setting is right, try to find an alternative (the majority of

words of interviewing rooms which ensure privacy), providing of course, that the patient can be

moved. Try to avoid interruptions and make sure that the lighting and temperature are as

comfortable as possible. It is important to consider the arrangement of seats; they can influence

how people communicate with each other and may give clues to how they perceive their own and

each other’s roles in the encounter. In the outpatient clinic or GP’s consulting room, where there

are usually chairs and a desk or a table; there are two possible ways of arranging the seating.

Arrangement (a), with the patient and doctor facing each other across a desk, is unlikely to make

the patient feel at ease or facilitate discussion. Although, the doctor me feel in control of the

interview. Another point to consider the distance between the interviewer and the patient.
Placing seats too close together may make the patient feel threatened, while too far apart making

their feelings at the interview is not interested in what the patient is saying. Most consultations

take place at a distance of 1.25-2.75 metres (4-9 feet), although the distance may change during

the course of the interview, e.g. as as the doctor, you might draw your chair close to the patient

when offering reassurance.

Interviewing a patient who is in a hospital bed deserves special consideration. Standing over a

patient is likely to increase a patient’s feeling of vulnerability and should be avoided. It should

always be possible to draw the chair so that you are on the same level as a patient.

Beginning an interview.

The setting and the way in which will we begin a conversation can have a profound effect on

what follows. The aim in a formal setting should be to make the interviewee feel at ease. How

can this be done?

In describing what made you feel at ease, you might have included:

 A comfortable setting.

 Being greeted by name and a handshake.

 Being shown where to sit.

 The interview introducing themselves and explaining the procedure.

 An easy first question.

 The interviewer appearing interested in your remarks.

Unfortunately, we may neglect some or all of these strategies, and doctors are no exception. An

unsatisfactory beginning is likely to lead to an unsatisfactory consultation, as a following case

illustrates.

Case sample 2.1: How not to begin an interview.

Mrs Francis, a shop assistant aged 31 attended medical outpatients at a local hospital. Here is her

story:

“When I went into the room which Is big and bare, I was lost he didn’t know where to sit

the doctor had his head down and was writing and on the telephone ,there were medical

students talking to each other. I waited around and wanted to run up to outside. After

what seems like ages the doctor told me to sit down and asked what was wrong.I didn’t

know his name and I’m not sure that in your mind I’ve been thinking about my problems

and what I wanted to tell the doctor but I forgot it all he didn’t seem very interested

anyway hope I don’t have to go again.”

It is not difficult to spot what is wrong with the way this interview was conducted. By following

simple rules, you can help patients feel at ease, you can begin to build a relationship and that

enables your patience to share the story of the illness with you. Beginning the interview involves

greeting the patient, introducing yourself and orienting the patient (Table 2.2)

Much of the doctor’s behavior is simply common sense and courtesy, but this may be easy to
forget or ignore, particularly when time is short