General Description:
Communication is an essential component of medical education. Good communication enables one to collect information about a patient’s problems that is comprehensive, relevant and accurate. It helps to make an accurate, comprehensive diagnosis. In the clinical and community practice, the graduates will be able to communicate clearly, sensitively and effectively with patients and their relatives and also with colleagues from a variety of health and social care professions. Behavioural sciences, ethical issues, information technology and communication skills knowledge have become an essential part of medical practice. There are Guidelines for minimal essential requirements for medical education by various agencies and Communication Skills Program (CSP) is an important component of these requirements.
This course provides a range of basic communication skills and skills required in special circumstances relevant to working with patients, peers and other health team workers so as to increase accuracy, efficiency and supportiveness while providing healthcare, enhance patient and physician satisfaction, improve health outcomes and promote collaboration and partnership with peers, professionals and the community.
General Objectives:
By the end of the communication skills course, the students will be able to communicate effectively and efficiently with patients, peers and other health care professionals.
Specific Objectives
- By the end of the sessions on core communication skills, the students will be able to:
- Initiate the session: Establish initial rapport
- Greet patient and obtain patient’s name
- Introduce self, role and nature of interview; obtain consent if necessary
- Demonstrate respect and interest, attend to patient’s physical comfort
- Identify the reason(s) for the consultation
- Identify the patient’s problems or the issues that the patient wishes to address with appropriate opening question
- Listen attentively to the patient’s opening statement, without interrupting or directing patient’s response.
- Confirm list and screens for further problems
- Negotiate agenda taking both patient’s and physician’s needs into account.
- Gather information: Exploration of patient’s problems
- Encourage patient to tell the story of the problem(s) from when first started to the present in own words (clarifying reason for presenting now).
- Use open and closed questioning technique, appropriately moving from open to closed
- Listen attentively, allowing patient to complete statements without interruption and leaving space for patient to think before answering or go on after pausing.
- Facilitate patient’s responses verbally and non-verbally e.g. use of encouragement, silence, repetition, paraphrasing, interpretation.
- Pick up verbal and non-verbal cues (body language, speech, facial expression, affect); check out and acknowledge as appropriate.
- Clarify patient’s statements that are unclear or need amplification
- Periodically summarise to verify own understanding of what the patient has said; invite patient to correct interpretation or provide further information.
- Use concise, easily understood questions and comments, avoid or adequately explain jargon.
- Establish dates and sequence of events.
Additional skills for understanding the patient’s perspective
- Actively determine and appropriately explore:
- patient’s ideas- (i.e. beliefs regarding cause).
- patient’s concerns- (i.e. worries) regarding each problem.
- patient’s expectations- (i.e., goals, what help the patient had expected for each problem).
- effects- how each problem affects the patient’s life.
- Encourage patient to express feelings
- Provide structure to the consultation:
Making organization overt
- Summarize at the end of a specific line of inquiry to confirm understanding before moving on to the next section
- Progress from one section to another using signposting, transitional statements; include rationale for next section
Attending to flow
- Structure interview in logical sequence
- Attend to timing and keep interview on task
- Build relationship: Use appropriate non-verbal behaviour
- Demonstrate appropriate non-verbal behaviour
- eye contact, facial expression
- posture, position & movement
- vocal cues e.g. rate, volume, tone
- Read, write notes or use computer, in a manner that does not interfere with dialogue or rapport
- Demonstrate appropriate confidence
Develop rapport
- Accept legitimacy of patient’s views and feelings; be non-judgmental
- Use empathy to communicate understanding and appreciation of the patient’s feelings or predicament; overtly acknowledge patient’s views and feelings
- Provide support: express concern, understanding, willingness to help; acknowledge coping efforts and appropriate self care; offer partnership
- Deal sensitively with embarrassing and disturbing topics and physical pain, including when associated with physical examination
Involve the patient
- Share thinking with patient to encourage patient’s involvement
- Explain rationale for questions or parts of physical examination that could appear to be non-sequiturs
- During physical examination, explain process and ask permission
- Explain and plan
Provide the correct amount and type of information
- Chunk and check: give information in manageable chunks, check for understanding, use patient’s response as a guide to how to proceed.
- Assess patient’s starting point: ask for patient’s prior knowledge early on when giving information, discover extent of patient’s wish for information.
- Ask patients what other information would be helpful e.g. aetiology, prognosis
- Give explanation at appropriate times: avoid giving advice, information or reassurance prematurely
Aid accurate recall and understanding
- Organize explanation: divide into discrete sections, develop a logical sequence
- Use explicit categorization or signposting
- Use repetition and summarizing to reinforce information
- Use concise, easily understood language, avoid or explain jargon
- Use visual methods of conveying information: diagrams, models, written information and instructions
- Check patient’s understanding of information given (or plans made): e.g. by asking patient to restate in own words; clarifies as necessary
Achieve a shared understanding: incorporate the patient’s perspective
- Relate explanations to patient’s illness framework: to previously elicited ideas, concerns and expectations
- Provide opportunities and encourage patient to contribute: to ask questions, seek clarification or express doubts; respond appropriately
- Pick up verbal and non-verbal cues e.g. patient’s need to contribute information or ask questions, information overload, distress
- Elicit patient’s beliefs, reactions and feelings regarding information given, terms used; acknowledge and address where necessary
Plan: shared decision making
- Share own thinking as appropriate: ideas, thought processes, dilemmas
- Involve patient:
- offer suggestions and choices rather than directives
- encourage patient to contribute their own ideas, suggestions
- Encourage management options.
- Ascertain level of involvement patient wishes in making the decision at hand.
- Negotiate a mutually acceptable plan:
- Signpost own position of equipoise or preference regarding available options.
- determine patient’s preferences
- Check with patient:
- if accepts plans.
- if concerns have been addressed
- Close the session
Forward planning
- Contract with patient regarding next steps for patient and physician.
- Safety net, explaining possible unexpected outcomes, what to do if plan is not working, when and how to seek help.
Ensure appropriate point of closure
- Summarize session briefly and clarify plan of care
- Finally, check that patient agrees and is comfortable with plan and ask if there are any corrections, questions or other issues.
Options in explanation and planning (includes content and process skills)
If discussing opinion and significance of problem
- Offer opinion of what is going on and name if possible.
- Reveal rationale for opinion.
- Explain causation, seriousness, expected outcome, short-and long-term consequences.
- Elicit patient’s beliefs, reactions, concerns re-opinion.
If negotiating mutual plan of action
- Discuss options e.g. no action, investigation, medication or surgery, non- drug treatments (Physiotherapy, walking aids, fluids, counseling), preventive measures.
- Provide information on action or treatment offered: names steps involved, how it works, benefits and advantages, possible side-effects.
- Obtain patient’s view of need for action, perceived benefits, barriers, motivation.
- Accept patient’s views; advocate alternative viewpoint as necessary.
- Elicit patient’s reactions and concerns about plans and treatments, including acceptability.
- Take patient’s lifestyle, beliefs, cultural background and abilities into consideration.
- Encourage patient to be involved in implementing plans to take responsibility and be self-reliant.
- Ask about patient support systems; discuss other support available.
- Provide clear information on procedures e.g. what patient might experience, how patient will be informed of results.
- Relate procedures to treatment plan: value, purpose
- Encourage questions about and discussion of potential anxieties or negative outcomes.
B. By the end of the sessions on communication skills required in special circumstances, the students will be able to:
- Deal with people from different social backgrounds
- Communicate with children
- Take sexual history
- Deal with physically and mentally impaired person
- Deal with violent and aggressive patients
- Communicate during procedures
- Break bad news
- Deal with other health professionals
C. By the end of the sessions on the following specific skills, the students will be able to:
- Make effective presentations
- Write clear and legible clinical notes
- Write effective consultation/referral letters
- Write concise and comprehensive reports
4. Teaching Methods:
- Interactive Lecture
- Mini Lecture
- Role-play
- Interaction with simulated patients
- Demonstration with return demonstration
- Video show and discussion
5. Evaluation:
- Formative Assessment at the end of first and second year: Assessment will be carried out by the communication skills unit using 5 OSCE stations with simulated patients and check lists. The marks will be added in the internal assessment of Medicine in the third year. Twenty percent of the total marks i.e. 8 out of 40 will be allocated.
- Summative Assessment on Communication Skills will be taken at the final exam of all the clinical subjects by at least one OSCE station.
