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Communication skills for health care professionals

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					Title page : Communication skills for health care providers

Communication skills for health care provide rs
Abstract : Communication is a basic human skill and has been one since man has been a social animal. Communication skills have assumed gr eat importance as a core clinical skill in the recent years in the health care sector. The fast pace of modern life has affected the medical field too, with caregivers spending much less time with patients. They are unable to communicate as well as they c ould or should have in the past. A large number of medical errors and sentinel events have been reported in hospitals worldwide in the last 30 years. There has been a spate of litigations against medical practitioners too . Root cause analyses of all these issues have found one common factor – that is the inadequate communication skills of the health care providers and its consequent effects. No amount of talks or literature can make a person a better communicator unless the message comes from the heart of t he sender , is put across to the receiver in a manner in which he/she can comprehend its meaning and can respond adequately to the sent message. The authors hope that with this review they might reemphasize the importance of communication skills for the health care providers and may make them think about polishing their existing communication skills.

Introduction

Many of us have read the much publicized article on the death of a journalist in 1994 who w as wrongly given four times the dose of Cyclophosphamide during chemoth erapy for breast cancer, using an experimental treatment protocol , which was assessing if Cimetidine could augment the tumor killing effects of Cyclophoshamide. 1 What was the reason for this costly mistake ? Misreading by a research fellow o f the protocol and wrong prescription of the required dosage of Cyclophosphamide, which resulted in serious adverse effects in two breast cancer patients , one of whom the health journalist, died. Since these mu ch publicized cases of medical errors, the role of effective communication has been appreciated by health care providers world wide. It has subsequently been found that patients’ who are well informed about treatment , course of the disease, preventive a spects of health care, expected outcomes and possible complications are generally the ones w ho do better and are more satisfied with the health care provided to them.

Communication

Communication is the process of exchange of information, messages o r thoughts by or to people or groups by speech, signals, writing or behaviour. It does not just include the written or the spoken word but

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also the process of communication, the spoken or written message, the unspoken message etc..,

Medical communication

Communication that is used to convey medical information is called medical communication. It could include the written notes of a health care practitioner, , the telephonic call made by a nurse to a doctor, or the documentation of the examination findings of a patient by a physician or even t he conversation a doctor has with his patient. Goals of medical Communication ( figure 1)

The purpose of medical communication

To ensure a safe and sound patient after the medical care is the goal of an accurate and efficient medical communication .

Medical communication has certain important objectives. It should not be done if there is nothing to communicate . The purposes of medical communication could include exchanging information within the team and with patients, making treatment related decisions through the process of communication and creating a good interpersonal relationship with patients, with colleagues and the whole medical team . Effective medical communication makes caregivers work better in a interdisciplinary health care team and to understand the needs of the patients. One day Samuel Butler visited his wife on what he believed to be her deathbed. "Promise me solemnly”, he said, " I f you find in the world beyond the grave that you ca n communicate with me – that there is some way in which you can make me aw are of your continued existence - promise me solemnly that you will ne ver, never avail yourself of it”. She recovered from the illness but never quite forgave him. This anecdote show us how important good communication is in a husband wife relationship of many years. Think about how much more significance it would assume in a caregiver patient relationship that lasts a few encounters only . Communication can mend or break relationships; it can forge a caregiver patient communication pathway that could melt the iciest of hearts and make the physician the best friend of the patient. Outcomes of bad communication Communication breakdowns in the health care syst em can lead to that bane of the medical profession – medical errors. An error is

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defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. 3 Breakdowns in the medical communication network The process of communication is like a network of different components and the intercommunications between them. To understand the network of communication better, one must understand its component parts and what could go wrong with the different entities. When one thinks of communicating something, he needs to have a clear message.

1. The message( Figure 2)

A message is often defined as the information which the communicator transmits to his listeners, which may be in the form of words, pictures or signs. 4 It originates within the brain of the sender and is something that provides information. It is sent from a source to the receiver. It goes without saying that if there is no sender there is no message.( figure 3)

A good message must have an objective wh ich is in line with what the communicator wants to transmit; it must be meaningful, clear, understandable, specific , accurate and culturally and socially acceptable. In the field of medicine , if the physician or the nurse o r the pharmacist does not have a clear message, then what is intended to be communicated will be something entirely different from what the caregiver intended. This would then lead to a breakdown in the communication network . Barriers in the message that lead to ineffectual communication

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Sometimes, words used by the sender may have different meanings when understood by the recipient. This happens if the sender does not know the understanding of the language by the listener. There can be different dialects of the same language being used by different message senders. In the medical field , it could lead to costly errors or misunderstanding the caregiver orders and following them differently from what the caregiver intended. It could also happen that some illustrations or examples used by the caregiver are not clear to the patient. In certain situations, caregivers may not present clear messages, they may beat around the bush -this often happens when he/she wants to break bad news to the patient. These sender and message problems cou ld lead to communication breakdowns. 2. The process of communication : After the information to be sent is decided upon , the next important thing is the process of communication . This involves a few sub steps ,which is modeled on the Shannon Weaver’s commu nication theory. The essential requirements for any good communication, whether medical or not, are : 1. The sender 2. An encoding apparatus 3. The route of communication 4. A decoding apparatus 5. The receiver 6. The feedback Source of the message : The sender- Who or what is a sender ? A sender is some one who has something to communicate, share or is the source of the communication. In fact all communication begins with the sender. When a source has some thing to communicate, he tries to make sure that his message has the desired effect on the right person or the right situation . Any sender will try to present the following features while communicating:  That he is friendly  That he wants to transmit some information  That he wants the receiver to do something fo r him  That He wants to persuade the receiver to come around to his point of view.(figure 4)

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SENDER
Stage of encoding : Any message that is transmitted does not go across to the receiver in the exact same format as it is thought out of in the sender’s brain . It undergoes a stage of encoding. This is similar to the situation of a telephone , when after we speak into the receiver of the phone, the sound energy from our oral muscles is converted into electromagnetic energy and sent to the receiver by means of the telephone wires. A process of encoding takes place within the mouth piece of the telephone . Similarly in a person to person vocal communication, the encoding takes place by means of the vocal muscles and the facial muscles of the sender and sometimes even the muscles of the hand. For successful encoding to occur, there must be a source(who also acts as the encoder) of the message and a n encoding apparatus which maybe his vocal muscles or his mental faculties which help him to encode the message approp riately . What are the problems that could occur with the sender and the encoding process?(figure 5)

THE ENCODER

It is obvious from the above discuss ion, that if there is a physical problem in the vocalizing apparatus of a speaker or he is unable to write or type because of physical disability , it could lead to a problem with encoding , which might lead to a communication failure. The means of communication: We can think of many means by which one could communicate as shown below:  Talking is one of the common est means of communication used by man  Mails : To send messages to someone who is far away from you, people used the means of the written letter or the electronic media through emails. 5

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Television is used to communicate to large numbers of people at the same time.  The telephone is another means of verbal communication  Print media: the newspapers are a c heap means of mass communication. For medical communication , the discharge summary, or the doctor’s notes or the nurses ’ records’ are all the means of communication . All these documents pertain to important medical information whi ch could affect the delivery of safe medical care to patients’. (figure 6)

Step 3 : Stage of decoding Just like an encoder, a decoder is an essential part of the receiver .The decoder of the communication , should have all the fac ulties needed to decode and convert the message into a form which the receiver's brain can understand, assimilate and sometimes even provide a feedback for. So often this is the stage at whic h a communication breakdown can occur . The decoder has problems with decoding or deciphering the message sent by the source of the information. The message and the process may be okay, but the comprehending capacity of the patient if not there, he is unable to understand what the physician wants to commun icate. (figure7 )

A blind person may not ha ve the faculties to see what has been demonstrated by the sender of the information. Sometimes a message may be re ceived in a language or text incomprehensible by the receiver, in which case again he is handicapped in understanding

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the intent of the sender. When informed consent is taken from a patient or his legally authorized representative, it is mandatory that the decoding faculties of t he recipient are intact for complete comprehension. Stage 4 : The final link of the chain of communication : Feedback is an essential part of the communication network. When we talk to someone we expect that person to respond to our conversation, rather than be a silent listener. Teachers like to have students who ask questions , rather than have a quiet class. Modern models of communication give a lot of importance to this part of the chain of communication. A nod from the patient , doubts asked by the patient etc.., can all be considered to be feedback from the patient to the caregivers. When Shannon Weaver proposed their model of communication in the 1940s , they were not bothered about the psyche of the sender or the effect the messag e would have on t he receiver. But the modern theory of communication assigns an important role to the feedback provided by the recipient to the sender. It is an understood fact that with each step in the model of communication , the meaning of the message origin ally intended by the sender comes down qualitatively. If we compare the message originally intended to be communicated by the sender with the message understood by the receiver , we will find that some part of the meaning of the message has invariably been lost. 3. External elements which affect communication : In addition to the network of communication, a n atmosphere, conducive to good communication would include on e which is free of interference, where the communicators could focus on each other and be able to communicate freely .Use of mobile phones during a conversation with a patient wo uld be an important deterrent for effective communication with a caregiver . Adequate t ime would be another external element requirement for good communication. The modern day physician orders sophisticated tests for diagnosing patients’ ailments. He would be much better placed if he could put his hand on the patient and perform the traditional methods of examining patients - the inspection , palpation , percu ssion & auscultation . Patients would appreciate his services more than the care provided by unemotional machines. So the more sophisticated the test ordered , the lesser is the quality and quantity of time spent by the physician with the patient. These external factors could again lead to communication failures. At the end of a communicative chain, one’s receiver (patient ) gets only 40% of t he original intended message one had for him. (Figure 8)

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SOURCE

ENCODER

CHANNEL OF COMMUNICATIO N
FEEDBACK

MESSA GE

Figure 8

DECODER

RECEIVER

Diagrammatic representati on of the MODEL OF COMMUNICATION, original ly proposed by Shannon Weaver. All these aspects were about communication in general. Now let us focus on medical communication. The levels at which medical communication takes place Medical communication could take place between caregivers and patients. (Figure 9)

As there are different caregivers of a patient, there can be different types of caregiver patient communications. These could be 1. Between formal caregivers : Formal caregivers are those who are responsible for the health care of the patients. They h ave been formally trained and are qualified to provide medical care. (Figure 10)

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2. Between formal caregivers and informal caregivers ( Figure 11) Medical communication could take place between formal caregiv ers and informal caregivers like the patient’s relatives who would be responsible for the continuous health care of the patient.

3. Between formal caregivers and patients ( Figure 12)

Very often the formal caregivers communicate with the patients themselves. This is the third type of medical communication that could occur. Caregivers adopt specific communicative behavio r to communicate their message to their recipients. All caregivers do not follow a set behavior pattern for all their communications. The b ehavior adopted could include:  Instrumental or affective ( cure oriented or care oriented )behavior: Here the health care practitioner practices medicine with the aim of providing only the cure of the patient’s suffering ( cure oriented behavior) or the co mplete mental ,

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physical and social wellbeing of the patient ,which is the care oriented behavior. Verbal or non verbal behavior: Health care practitioners use verbal or non verbal cues to communicate health information to their patients. Some practitioners only rely on the spoken word for their communications but some use their hands, eyes, faculty of touch etc.., for communicating. Such health care providers will be the better communicators in the long run. High controlling or low controlling behavior : The traditional relationship between the caregiver and the patient has been one of dependence, with the caregiver giving orders and the patient following them. These would come under the purview of high controlling behavior. On the other hand, the modern viewpoint is that medical practitioners should include patients as participants in their own health care, taking their own decisions and deciding what is best for them. Formal or informal behavior : An extension of the traditional relationship between the care giver and the patient would be the language used by the caregiver during communication. This could be formal , medical jargon containing or it could be the use of everyday language, which is understandable by the participant. It goes without saying that pr actitioners who employ informal language and behavior with their patients are more likely to have a better rapport with their patients.

It has often been observed that our health care practitioners are poor communicators . There are many fact ors responsible for this . a. Time factor : Modern medicine is hard pressed for time just like modern life. Inadequate time spent with patients make our caregivers poor communicators. b. Cure oriented health care systems : . Our medical system trains physicians in cure oriented medical care (instrumental) and not affective (care oriented medical care). Medical education systems provide training to students to look at the patient’s ill system part and try to effect a cure rather than looking at the whole patient, who is in need of care. A patient who only wants the physical touch of the physician is often subjected to the cold, icy touch of the X- ray machine or steely feel of an instrument. c. Inadequate training in interpersonal skills and communication : Most of our caregivers are not trained in the humane aspects of health care which includes good communication skills. The medical curriculum does not focus on these subtle skills ,which if developed adequately would lead to more effective health care communicat ion. d. Language problems: The caregivers and the patients’ may speak or communicate in different languages. After all one’s native tongue is the best means of communication that one has. Even the same language spoken by two communicators can have different

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dialects ,in which the same words may mean different things, again leading to miscommunication. e. Large volume of data discussed: The health care provider may discuss more than what the patient can assimilate, as compared to his knowledge or skill level . This could lead to a breakdown in the communication network. f. Use of technical terms: Health care providers might use medical jargon, incomprehensible to the patient, with deleterious consequences at times. The patient might look on the doctor as the decision maker and might not want to ask for clarifications for terms not understood by them. g. Breakdowns in the channels of communication : There could be breakdowns in the routes of communication , comprehension problems , communication errors as mentioned abo ve. Are our patients ’ poor communicators? Health care providers are not always to blame in the issues of poor communication. Remember it takes two hands to clap ; t here is always the other side to the coin. The patient factors responsible for poor communication could be :  The time factor again: Patients may find it difficult to get to appointments on time, so that by the time they reach the hospitals, they may not always give the correct descriptions of their ailments to the caregivers, which could lea d to problems in communication.  Health issues: The patients may have medical problem s which could lead to confusion or memory losses and inability to communicate their problems to the caregivers. Patients may have emotional problems too which may prevent them from concentrating adequately on physicians’ instructions’.  Belief in the superiority of physicians: The old dictum was that physicians commanded as much respect as the Gods , for one’s health was dependent on them. So patients have often been loathe to communicate their personal health details or doubts to their caregivers thinking of what would the ir physicians think about them. They may not clear their doubts with their caregivers, making them make their own conclusions with harmful consequences.  The need of patients being different from the care provided by the health care practitioners: Often patients come to the health care system not for the physical care they would receive from the health care facility, but more to talk with some one, to have some one hold their hands, or spend time with them. The time that the health care provider spends with the patient is quality time for the patient . Patients’ rate physicians higher if they have good communication skills, up to date knowledge, involve them in decision making or whether they show respect and dignity to them. A delicate balance of technical competence wrapped up in a personalized mode of approach would be called for. 2

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Physical barriers to good communication : External noise and Cold or hot temperatures can act as physical distractions for good caregiver patient communications. What do these communication problems lead to ?  Decreased patient adheren ce to physicians’ plans: Often caregivers complain that patients do not follow their plans for them, and so do not get the desired effect from the treatment . Patients want to ask questions to the caregivers but the caregivers may be hard pressed for time to answer their questions, which could lead to improperly followed treatment protocols.   Poor patient numbers at clinics : It is often found that caregivers who are poor communicators have fewer patients attending their clinics. Difficulty gathering information : Another important effect of communication breakdowns is difficulty in building rapport with patients and getting information from them, which is vital in the patient care process. Lack of empathy and understanding with patients: The modern man is often found to be self centered, focusing on his own problems rather than on issues that would be of benefit to others. The same attitude is reflected by our health caregivers Medical errors : Poor communication skills, oral or written could lead to medical errors on prescriptions or on caregiver notes like the case of Betsy Lehman in the overdose of Cyclophosphamide case. Medico legal problems - These days there are a large number of litigations against health care systems and providers. Root cause analysis of such issues often show an important aspect that is communication issues. Many of these iss ues might not have risen or might have ended differently if there had been better communication between caregivers and patients’. Cure oriented behaviour : Behavior that is cure oriented, is what our modern medical training trains residents and students to have. More laboratory tests are asked for rather than the tender loving care that patients often want . Use of medical vocabulary, un-understandable by the patient is another side effect of this behaviour. The only contact that occurs between the patient an d the physician is verbal. All these result in poor patient outcomes. Lack of coordinated patient care which can lead to duplicated medical care and wastage of scant resources.

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Most of you would agree that communication is a core clinical skill, by now . The old adage is : It is not what you say but how you say it that is important. Most health professionals want to show patients that they care.. According to Howard and Strauss, there were

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eight identified conditions for a humanized type of health care. They were :  Patients treated as inherently worthy of the health care professional’s concern  Each patient treated uniquely  Patient treated a s an irreplaceable human being  Patients encouraged to exercise control over medical events of their lives  Patients share in decision making that affec ts t= their care  The relationship between patient and caregiver must be reciprocal and not patronizing  Health care providers must exhibit empathy and warmth to the patients 3 It is just not th e practical knowledge that is one gains from medical schools that important – it is how that is put across to others – patients’ and our colleagues’, that is important. Communication skills turn what we have learnt in medical school (theory) into practice. Research shows that better the use of communication skills can lead to :  Better interview process with patients  Better patient satisfaction  Better patient recall and understanding  Better patient adherence to doctor’s instructions ’  Improved patient outco mes  Decreased medical errors and consequent medico legal problems  Better psychiatric health  Improvement of health status of the patients What communicative behavior could be adopted by health care practitioners?  Care oriented behaviour is appreciated by all patients, with more time spent with patients.  Low controlling behaviour: putting patients in charge of their own treatments  Using everyday use language , the vernacular, local dialects etc.,  Use of good verbal and non verbal communication – eye contact/touch etc. How can health care providers be good communicators ? For a start they could spend more time with their patients , using humor and social talk in their conversations with them. These could help in establishing a rapport wi th their patients and would also demonstrate an empathy. Most patients require empathy rather than sympathy from their health care providers. These rapport building sessions could help build up trust between them. Another essential need is to ensure con tinuity of care when health care practitioners follow up their patients’. Patients’ trust care givers

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who are always available for them. In case there is a need for the transfer of patient care from one practitioner to another, patients are more likely to trust the new physician if the primary physician has handed over his/her care personally to the new physician. Many of our health care practitioners neglect to use non verbal behavior like warm friendly facial expressions, direct eye contact, appropriate use of touch, demonstration of empathy by using even silences in conversations, which could go a long way in establishing a rapport with their patients. Physicians’ must position their body in such a way as to not demonstrate superiority over their patient s’ but to facilitate eye contact with them. Being a good listener and looking for non verbal cues from the patient is another method which could help the caregiver in building up trust from the patients’. Practitioners must also provide patients with an op portunity to provide responses to any message they have communicated to them, thus ensuring adequate use of the feedback part of the communication network. While communicating with colleagues, caregivers must follow the code of medical ethics and treat all human beings as they would want to be treated themselves under similar situations. It would never be appropriate to criticize a colleague’s actions to patients. In case of conflict, it is better to go for open dialogue with one’s colleagues. This would lead to a quicker solution to problems. In situations where patient care has to be transferred to another physician, the primary care giver must behave with dignity and refrain from concealing vital information in the transfer process . Above all , it is essential to keep good healthy professional relationships with colleagues. Thus patients and their health providers should form partnerships for better patient outcomes and thus improve the overall health of the patients and make better health c are systems. Communication skills are the essential foundation skills on which clinical care of patients depend. It is imperative to understand and utilize these skills for better patient health care provider relationships. References 1. David M Benjamin. Reducing medication errors and increasing patient safety: Case studies in clinical pharmacology David M Benjamin, Journal of clinical pharmacology,2003, 43: 773 2. Mark Crane. Who caused this tragic m edication mistake? Medical Economics, 2001 3. Ruth Purtilo. Ethical dimensions in the he alth professions, 2 n d edition 4.Linda T Kohn, Janet M Corrigan, Molla S Donaldson .To err is human: Building a safer health system, Committee on quality of health care in America 5. J.B. Park.Park’s textbook of Community Me dicine, 18 t h edition by Dr. Anjum Susan John, 2008 from Communication skills lectures for health care professionals

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