Communication Skills - Keys To Understanding by DR Fayza 2016

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PREPARED BY
Dr. Fayza Rayes

Consultant Family Physician
Joint Program of Family & Community Medicine
Jeddah, Saudi Arabia
EDITED & FORMATTED BY
Mrs. Vittoriana Crisera

Journal Manager, Journal of Health Specialties
Saudi Commission for Health Specialties
Riyadh, Saudi Arabia
© Saudi Commission for Health Specialties, 2016

King Fahd National Library Cataloging-in-Publication Data
Rayes, Fayza – Riyadh, 2016

Communication Skills: Key to Understanding
105p; 14.8cm x 21cm
ISBN: 978-603-90608-4-0
1- Communication I-Title
650.13 dc 147/4816
L.D. no. 1437/4816

ISBN: 978-603-90608-4-0
© 2016 by the Saudi Commission for Health Specialties
All rights are reserved. You must have prior written permission for any reproduction,
storage in a retrieval system, or transmission, in any form or by any means. Requests for
permission should be directed to
The Saudi Commission for Health Specialties (SCHS), PO Box 94656, Riyadh 11614, Saudi
Arabia.
It is also possible to contact SCHS through the Consolidated Communication Centre (from
within KSA): 920019393, and through International Contact Call +966114179900.
This Manual is a publication of the Department of Medical Education and Postgraduate

Studies, The Saudi Commission for Health Specialties (SCHS). It was written and edited by
a group of experts in the field of medical education and medical ethics. Its contents do not
necessarily reflect the policies of the SCHS, except where this is clearly and explicitly
indicated.
Production and Concept

The Saudi Commission for Health Specialties, KSA.
For further information and suggestions, please contact Mrs. Vittoriana Crisera,
[email protected]
Disclaimer: Every effort has been made in preparing this Handbook to provide accurate
and up-to-date information that is in accord with accepted standards and practice.
Nevertheless, the editors and authors can make no warranties that the information
contained herein is totally free from error, not least because clinical standards are
constantly changing through research and regulation. The editors and authors therefore
disclaim all liability for direct or consequential damages resulting from the use of material
contained in this book.
Although many of the case studies contained in this Handbook are drawn from actual
events, every effort has been made to mask the identities and the organizations involved.
Citation:
Rayes F. Communication Skills: Key to Understanding. Ware J, (ed). 1st Edition. Riyadh,
Saudi Arabia: Saudi Commission for Health Specialties, 2016.
COMMUNICATION SKILLS
Key to Understanding
Table of contents
PREFACE XIII
ACKNOWLEDGMENT XIV
INTRODUCTION 1
Training objectives 1
Discussion 2
Are there problems in doctor-patient communication? 2
Is there evidence that training can overcome these problems? 3
Further reading 3
ILLNESS BEHAVIOUR 4
Patient reasoning and feelings 4
Case scenarios 4
Case 1 4
Case 2 4
Case 3 5
Factors affecting illness behaviour 5
Discussion 7
Recommendation 7
Self-assessment exercises 8
Exercise 1 8
Exercise 2 9
Exercise 3 9
Further reading 9
COMMUNICATION 10
Introduction 10
Communication cycle 10
1. Develop idea 10
2. Encode (compose) message 10
3. Transmit (deliver) message 10
4. Receive message 11
5. Decode (analyse) message 11
6. Feedback 11
How to improve communication 11
Common barriers to effective communication 11
Recommendation 12
Self-assessment exercise 13
Exercise 1 13
VERBAL COMMUNICATION 14
Introduction 14
Verbal communication process 14
How to convey illness diagnosis and health education to a patient 15
Benefits of patient health education 16
ix
Table of contents
Recommendation 16
Exercise 1 16
NONVERBAL COMMUNICATION 18
Introduction 18
Aspects of Nonverbal communications 18
Body language or body movements 18
Appearance 20
Closeness and personal space 20
Paralanguage 20
Environment 21
Role of nonverbal cues 22
How smart physicians communicate 22
Tips for reading nonverbal communication 22
Discussion 23
Recommendation 23
Exercise 1 23
Exercise 2 23
Further reading 24
DOCTOR-PATIENT RELATIONSHIP 25
Introduction 25
Why is doctor-patient relationship important? 25
Types of doctor-patient relationships 25
1. Default - Patient and doctor have low control 25
2. Paternalism - Doctor has high control (Disease Model) 26
3. Consumerism - Patient has high control 26
4. Mutuality (Partnership) - Patient and doctor
have high control (Illness Model) 26
8 Steps to develop good doctor-patient relationship 27
Step 1. Establishing the relationship 27
Step 2. Facilitation 28
Step 3. Building rapport 29
Step 4. Empathy 31
Step 5. Physical examination 33
Step 6. Doctor-patient partnership 35
Step 7. Closing 36
Step 8. Preparation 36
Discussion 37
Recommendation 38
Exercise 1 39
Exercise 2 39
Exercise 3 40
Exercise 4 40
x
Table of contents
Exercise 5 42
Exercise 6 42
Exercise 7 43
Exercise 8 43
Exercise 9 44
Further reading 44
BREAKING BAD NEWS 45

Introduction 45
Breaking bad news 45
6-step protocol - SPIKES 46
1. Getting started 47
2. What does the patient know? 48
3. How much does the patient want to know? 48
4. Sharing information 49
5. Responding to feelings 49
6. Planning and follow-up 50
How to deal with family that say “don‟t tell” 51
Summary 52
Reassurance skills 52
Doctor as a drug 52
Art of reassurance 53
Exercise 1 54
Exercise 2 57
Further reading 58
CONSULTATION MODELS 59
Introduction 59
Consultation models 59
Traditional Medical Consultation Model 59
Byrne & Long Model, 1976 60
Expanded Model (Stott & Davis, 1979) 61
Disease-Illness Model (McWhinney, 1984) 62
7-Task Model (Pendleton, 1984) 63
Inner Consultation (Neighbour, 1987) 64
Three-Function Model (Cole & Bird, 1990) 65
Calgary-Cambridge Model (Kurtz & Silverman, 1996) 66
Patient-Centred Interviewing (Smith et al., 2001) 69
The New Comprehensive Clinical Consultation Model 71
Exercise 1 73
Exercise 2 73
Exercise 3 74
Exercise 4 75
Further reading 76
xi
Table of contents
REINFORCEMENT & SELF-ASSESSMENT 77

Tips for learning new skills (Pendleton 2003 with modifications) 77
Tips to manage time effectively during consultation 77
Tools for training 78
How to perform self-assessment 79
Audio taping and/or videotaping 79
Patient feedback 79
Peer review 80
Exercise 1 80
REFERENCES 82
ANSWER KEYS 85
Illness Behaviour 85
Exercise 1 85
Exercise 2 86
Exercise 3 86
Communication 86
Exercise 1 86
Verbal Communication 87
Exercise 1 87
Nonverbal Communication 88
Exercise 1 88
Exercise 2 88
Doctor-Patient Relationship 88
Exercise 1 88
Exercise 2 89
Exercise 3 90
Exercise 4 90
Exercise 5 92
Exercise 6 92
Exercise 7 93
Exercise 8 94
Exercise 9 94
Breaking Bad News 95
Exercise 1 95
Exercise 2 99
Consultation Models 100
Exercise 1 100
Exercise 2 101
Exercise 3 102
Exercise 4 104
Reinforcement & Self-Assessment 104
Exercise 1 104
xii
PREFACE
The Saudi Commission for Health Specialties (SCFHS) yet again adds a feather
to its cap by proudly presenting the ―Communication Skills: Key to
Understanding‖ book, which we believe would be revolutionary in nurturing a
more ethical and meaningful doctor-patient relationship.
Communication is an important skill we all need to acquire early in life to

converse with the world around us. Evidently, as adults and healthcare
practitioners, we continue to refine this skill further. Communication skills open
the gates of understanding, and the better we understand our patients the
more efficiently we can diagnose and treat them.
In brief, this book covers the different aspects of communication and explains
how to communicate better with patients. At the end of each chapter, you will
also find a few self-assessment exercises designed to help you scale your level
of understanding. The focus here is mainly on the practical aspects of doctor-
patient communication and every doctor has his/her own unique method
tailored to their needs. Step by step you will learn how to approach your
patients and ease their concerns as well as.
The video version of this book is also available online through the SCFHS
website:
http://www.scfhs.org.sa/en/MESPS/TrainingProgs/EduMatActiv/Pages/display.a
spx?category=5
This book is designed to take your communication skills to a higher level and I
believe it will meet the needs of our healthcare practitioners.
Lack of communication has been the root cause of unsafe, tragic and
unsatisfactory healthcare practice; so let‘s communicate better to avoid the
easily avoidable matters.
Professor Abdulaziz Al Saigh

Secretary General
Saudi Commission for Health Specialties
xiii
ACKNOWLEDGMENT
I would like to acknowledge the valuable contribution and feedback received

from Prof. Adnan Albar, Prof. Sulaiman Al-Emran, and Dr. Mohammad Al-Onazi
in the development of this book.
I would also like to extend my sincere appreciation and gratitude to the

Consultation Skills Development Committee (CSDC), namely: Dr. Maha Alatta,
Dr. Zulfa Al Rayes, Dr. Sameer Saban, Dr. Bakr Kalo, Dr. Widad Bardesi, and
Dr. Zenab Ezzaldeen for their support.
I appreciate the efforts of all the postgraduate residents who participated in the
role-play of the DVD version of this book, namely: Dr. Faisal Algaows, Dr. Hani
Alghamdi, Dr. Haitham Abadel, Dr. Hattan Mominkhan, and Dr. Sami Alhawassi.
A very special thanks to Mrs. Vittoriana Crisera for her editing and formatting
skills that made this book presentable.
This work could not have been accomplished without the support of the above-
mentioned individuals and organizations.
Dr. Fayza Rayes

Consultant Family Physician
Joint Program of Family & Community Medicine
Jeddah, Saudi Arabia
xiv
Introduction
INTRODUCTION
TRAINING OBJECTIVES
The aim of this book is to educate physicians how to practice a more
comprehensive consultation model with effective doctor-patient relationship,
using appropriate communication skills.
We shall enhance the traditional doctor-centred consultation model (grey

column) with more patient-centred consultation contents (blue column) as well
as how to adopt and maintain a good doctor-patient relationship (green
column).
Doctor-Centred
Patient-Centred
 Chief complaint
+ Patient‘s ideas, Doctor-Patient
 History of
concerns, expectation Relationship
present illness
 Past medical and effects of the Establish the
history problem relationship
 Systems review Facilitation
 Family history + Psycho-social
Building rapport
 Social history diagnosis
 Drug & allergy Empathy
+ Patient
history management Making use of
Physical examination physical examination
 Explanation and
Biological diagnosis health education Partnership
 Reassurance
Disease management Closing and
 Health
 Investigation maintaining the
promotion
 Prescribing relationship
Management of
 Follow-up Preparation
Doctor feelings
appointment
By the end of this book, one will be able to:

1. Understand patient‘s illness behaviour
2. Understand patient‘s verbal and nonverbal communication
3. Use verbal and nonverbal communication more effectively
4. Apply more effective skills in establishing and maintaining doctor-patient
relationship
5. Apply a comprehensive consultation model with every patient in daily
clinical practice
Benefits of this book

 Identify patients' problems more accurately.
 Patients adjust better psychologically and are more satisfied with their
care.
 Greater job satisfaction and less work stress.
1
Introduction
 Most of the theories and skills in this book can be applied in personal life,
social life and at work in general. It will make life run more easily,
successfully and happily.
DISCUSSION
Are there problems in doctor-patient communication?
Do doctors know the real reasons for patients‟ attendance?
Research shows that:
 Patients bring 1.2 - 3.9 problems at each visit
 Doctors discover only 50% of the patients‘ problems.
 Doctors interrupt their patients after 18 seconds (Beckman & Frankel,
1984).
 Doctors very often assume that the first complaint mentioned is the only
one that the patient has brought.
How do doctors give patients information?

 Waitzkin in 1984, demonstrated that American internists devoted little
more than one minute on average to the task of giving information in
interviews lasting 20 minutes and overestimated the amount of time that
is spent on this task by a factor of nine.
 When doctors provide information, they do so in an inflexible way and
tend to ignore what individual patients wish to know. They pay little
attention to checking how well patients have understood what they have
been told (Silverman et al., 1998).
 There are significant problems with patients‘ recall and understanding of
the information that doctors impart (Tuckett et al., 1985).
 Many studies have shown that doctors not only use language that patients
do not understand but also appear to use it to control their patients‘
involvement in the interview.
Compliance
 On average, 50% of the patients do not take their medicine at all or take
it incorrectly (Meichenbaum & Turk, 1987; Butler et al., 1996).
 Non-compliance is enormously expensive. Estimates of the overall costs of
non-compliance (including extra visits to physicians, laboratory tests,
additional medications, hospital and nursing home admissions, lost
productivity and premature death) is 7-9 billion CAN$ in Canada (Coambs
et al., 1995) and 100 billion plus US$ in the US (Berg et al., 1993).
Medico-legal complaints related to communication

 Patient dissatisfaction and the perceived absence of caring on the part of
physician led to letters of complaint (Beckman, 1995).
 There is a relationship between physician empathy and malpractice sues.
 In USA, 98,000 deaths occur each year because of medical errors. Poor
doctor-patient communication was identified as one of the root causes.
Patient and doctor‟s satisfaction

 30 - 40% of the patients express their lack of satisfaction from their
physician (Schwent & Romana, 1992).
2
Introduction
 60% of the doctors feel unsatisfied and under great job stress (Appleton
et al., 1998).
 A review of 25 surveys on doctor-patient relationships concluded that
doctors with good bedside manners had a better impact on patients than
physicians who were less personal (Ho & Longnecker, 2010).
Do doctors in Saudi Arabia receive appropriate training in this field?

 In the Kingdom of Saudi Arabia, until recently, communication and
consultation skills were neither in the curriculum of undergraduate medical
colleges nor in postgraduate medical training of most of the medical
specialties. In 2015, Saudi Commission for Health Specialties (SCFHS) has
revised all the Training Programme Curriculums to adopt the CanMED
Model which includes communication skills.
 Some specialties like Family Medicine consider communication and
consultation skills part of the training programme, but the training
methods in most of these programmes are mainly theoretical.
Is there evidence that training can overcome these problems?

 Many studies over the last 25 years have demonstrated that consultation
skills training can make a difference in all of the objective measurements
of medical care - it is not just subjective.
 In several states of the USA, malpractice insurance companies award
premium discounts of 3 - 10% annually to their insured physicians who
attend a communication skills workshop (Carroll, 1996).
FURTHER READING
Kurtz S, Silverman J (1996). The Calgary-Cambridge Referenced Observation
Guides: an aid to defining the curriculum and organizing the teaching in
Communication Training Programmes. Med Education 30, 83-9
3
Illness behaviour
ILLNESS BEHAVIOUR
PATIENT REASONING AND FEELINGS

Illness behaviour can be defined as: How a person feels, thinks and reacts to
his/her illness. A patient‘s health understanding influences the way a symptom
is perceived, and what prompts a person to consider him/herself in need of
medical advice is a complex decision. It does not correlate with the true
seriousness of the illness or the doctor‘s perception of a need to consult. In
other words, patients are poor judges of illness and take decisions often at
variance with what doctors believe to be the correct use of the services. The
likelihood of deciding to visit the physician depends on many factors which will
be discussed in this chapter.
TRAINING OBJECTIVES
 Increase doctors‘ understanding of patients‘ suffering.
 Increase doctors‘ understanding of human behaviour.
 Help doctors‘ see the full picture of patient's problems (bio-psychosocial
dimensions).
 Identify the factors which affect patients‘ health beliefs and illness
behaviour.
CASE SCENARIOS
Case 1
A young healthy man has a low-grade fever. He
may react to it by:
 Neglect
 Taking time off work
 Self-medication
 Visiting his Family Physician
Answer: 20% of the patients neglect their

illness (Hannay, 1988).
Reasons for illness denial

 It is not easy for a patient to show his/her weakness.
 Doctors are authority figures, and speaking to someone who is supposed
to be an authority is often hard for people.
 Cost of consultation.
Case 2
A young healthy lady has a high fever. She may react to it by:
 Neglect
 Self-medication
 Visiting her Family Physician
Answer: 75% of the patients may try to help themselves by rest and self-
medication (Hannay, 1988).
4
Illness behaviour
Reasons for the recent increase in self-care

 Shift from acute to chronic diseases.
 Public dissatisfaction with medical care.
 Recognition of modern medicine limitations.
 Increased visibility of alternative medicine.
 Increased awareness about the lifestyle effects on health.
 Desire to exercise personal control.
As health is the most precious thing anyone can have, anyone who comes to a
doctor with a problem is in a disadvantageous position, worried, vulnerable,
weak, forced to acknowledge that a problem exists which cannot be coped
unaided. The state of illness is also a threat to self-esteem (Balint, 1957).
Case 3
A young healthy lady has a high fever for two weeks. She may react to it by:
 Neglect
 Self-medication
 Visiting her family physician
Answer: 5% of the patients visit their Family Physician and only 1% of them
need a referral to hospital outpatient. 5 in 1,000 need hospital admission
(Hannay, 1988).
Many minor conditions are extremely common and it is normal for people to
feel ill a lot of the time, but only small proportions (about 20%) consult their
physician while the majority neglect their symptoms/illness. These 20% of the
patients are called the clinical tip of the iceberg.
Reasons patients seek medical help

Cecil Helman (1981), an anthropologist, suggested that a patient with a
problem comes to the physician seeking answers to six questions:
1. What has happened?
2. Why has it happened?
3. Why me?
4. Why now?
5. What would happen if nothing was done about it?
6. What should I do about it and whom should I consult for further help?
Symptoms (presenting complaint) are not the only reason a patient is seeking
medical help for, the real reasons are:
 Patient‘s beliefs and worries
 Factors affecting patient‘s beliefs and worries
FACTORS AFFECTING ILLNESS BEHAVIOUR

1. Gender
In general, females use healthcare services more than males as they are more
sensitive to their body. The growing body of gender-specific studies highlights a
5
Illness behaviour
trend of delayed help seeking when they become ill. A prominent theme among
white middle class men implicates ‗traditional masculine behaviour‘ as an
explanation for delays in seeking help among men who experience illness
(Galdas et al., 2005).
2. Age
Children and elderly are more fragile, this makes them use healthcare services
more often than adults.
3. Race
Some races have lower threshold for pain, e.g. Egyptians compared to the
British can tolerate pain more.
4. Learned behaviour
Prescribing placebo and referring a patient for unnecessarily investigations will
lead to somatic fixation; the patient will assume that his/her complaint is
serious, while the truth is the contrary.
5. Accessibility to health services
People living close to healthcare services will be encouraged to seek medical
help more often than those who have limited or no access.
6. Previous experience
If an individual‘s previous experience with health service is positive this will
improve his/her compliance, however, if the experience was negative then
he/she is less likely to return
7. Lay beliefs
The general population‘s perception of symptom as being serious or not will
affect an individual‘s decision to whether or not to seek medical help.
8. Social class
Health practices and beliefs are affected greatly by an individual‘s economic
level, way of life, family and culture. In general, low-income people with little or
no education prefer alternative medicine more while the high-income educated
people use preventive services more.
9. Symptom presentation
Some symptoms are perceived by patients as serious or annoying that need
medical attention, e.g. fever or joint pain; however, the psychological
symptoms are usually ignored.
10. Trigger factors
Sometimes a patient may feel unable to deal with mild symptoms by self-care,
not because of the severity of symptoms, but just because the patient may be
feeling weak and exhausted at that particular time due to other psycho-social
stressors.
11. Locus of control
Some people have independent personality and they believe everything is
under their control, these types of people have ―internal locus of control‖; such
patients try more self-help before seeking medical help. Other people feel they
have no control over their life, these types of people have ―external locus of
control‖ and they tend to seek more medical help but are frequently less
compliant.
6
Illness behaviour
DISCUSSION
 It has been shown that 40 - 80% of patients do not follow the given
recommendation by the physician. In many cases, because the
recommendation did not fit the question, need or priority that the patients
brought to the encounter (Meichenbaum & Turk, 1987; Butler et al.,
1996).
 Kindelan and Kent (1987) showed that most patients wanted to know
about the prognosis, causation and diagnosis of their condition, whereas
doctors underestimated the patients‘ need for this sort of information, and
overestimated the need for information about treatment and drug therapy.
 Discovering patients‘ expectations leads to greater patient adherence to
plans whether or not these expectations are met (Eisenthal & Lazare,
1976).
RECOMMENDATION
When a physician combines the disease framework (physical symptoms) with
the illness framework (patient‘s reaction), he/she will recognize the real reason
for the patient‘s attendance.
 Try to see the full picture of your patient (disease and illness).
 Try to see the unseen feelings and hear the unspoken suffering of your
patient.
 What is happening to me?
Ideas
 Is it serious and/or infectious?
 Am I going to die?
Concerns  What will happen to my loved
ones if I do?
 Will I be able to lead a regular life?

Effects of the
problem  Do I still have time to make a
Illness framework change/adjustment in my life?
Expectations
 Is it treatable?
 How can I understand my illness?
Feelings and  I am worried and anxious

thoughts of the  I feel vulnerable
patient
Investigations
Symptoms Underlying
pathology
Signs Differential
diagnosis
Disease framework
7
Illness behaviour
SELF-ASSESSMENT EXERCISES
Exercise 1
Read the following patient scenarios and speculate the possible perspective of
the patient's illness.
Case scenario 1
1. Mrs. Salma is a 28-year-old divorcee, living with her 5 children, working as
a teacher. Over the last 12 months, Salma has had intermittent episodes
of soreness and stiffness in her knees.
 Possible ideas
___________________________________________________________
___________________________________________________________
___________________________________________________________
 Possible concern
___________________________________________________________
___________________________________________________________
___________________________________________________________
 Possible expectation
___________________________________________________________
___________________________________________________________
___________________________________________________________
 Possible effect of the problem
___________________________________________________________
___________________________________________________________
___________________________________________________________
Case scenario 2
2. Mr. Naser is a 42-year-old teacher. He has chest pain
 Possible ideas
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
8
Illness behaviour
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Exercise 2
Think of how you might phrase questions to ask patients directly about their
Ideas
Concerns
Expectations
Feelings
Effect
Exercise 3
Speculate possible causes of illness denial.
1.___________________________________
2.___________________________________
3.___________________________________
FURTHER READING
Vallis TM, McHugh S (1987). Illness behaviour: Challenging the medical model.
Humane Medicine Health care 3(2)
)‫التفاعل مع المرض (من كتاب األسس العلميح لالستشارج الطثيح‬
9
Communication
COMMUNICATION
INTRODUCTION
Communication involves the sending and receiving of messages, it is a two-way
process. The cycle of communication proceeds through a number of stages and
there are different categories of communication: verbal, nonverbal, visual, and
written communications. In this book, we shall discuss and focus on two
communication categories: verbal (message relayed through the use of sounds
and language) and nonverbal (message relayed through gestures, facial
expressions, and postures).
TRAINING OBJECTIVES
 Increase awareness of individual communication style.
 Increase awareness of patient‘s communication style.
6. Feedback 1. Develop idea
Communication
5. Decode (analyse) Cycle 2. Encode (compose)
message message
4. Receive message 3. Transmit (deliever)

message
COMMUNICATION CYCLE
As mentioned above, in communication, there is a sender and a receiver. In
this section, we shall briefly describe the 6 stages of communication
individually.
1. Develop idea
To start any communication, an idea (thought) must be developed that the
sender wishes to convey to the receiver.
2. Encode (compose) message

In order to express the idea developed, one should structure and choose the
appropriate channel and language of communication, bearing in mind the
person receiving the message as well as the idea to be delivered.
3. Transmit (deliver) message

In this stage, the message encoded is sent to the receiver through a selected
medium of communication (verbal or nonverbal).
10
Communication
4. Receive message
Once the message is transmitted, it is sent by the sender and is received by the
receiver.
5. Decode (analyse) message

During this phase, the receiver must analyse the message transmitted by the
sender and interpret it in order to comprehend the message.
6. Feedback
Finally, feedback is provided by the receiver to assess whether he/she has
received, comprehended, and correctly interpreted the message delivered to
him/her. Accordingly, the sender will either proceed with communication or
provide clarification if needed.
HOW TO IMPROVE COMMUNICATION

 Learn to listen. Hearing does not mean listening, hence, pay attention to
what your patients say, verbally or nonverbally (these categories of
communication will be discussed further in the coming chapters).
 Select words appropriately. Always be careful of the words you select
to communicate with others. The wrong choice of words could lead to
unwanted misunderstanding between doctor and patient.
 Relax. The more nervous you are the more you tend to speak quickly and
less clearly. Remember your patient is coming to you for help and not to
be confused or undermined.
 Be optimistic. Most people appreciate and prefer positive individuals.
This could be done by letting your patients know that you will continue to
help them and hopefully find a solution to their health issue. However,
remember not to give your patients false hopes that you cannot achieve
as this will just damage your credibility.
 Empathise. Try to see and understand other people‘s perspective or
concerns; this way you can learn new things while gaining the respect and
trust of others. For example, if a patient is terminally ill or is worried about
a treatment method due to any personal values/reason, try to associate
yourself to their situation and give him/her words of kindness and support
by letting him/her know that he/she is not alone.
 Learn to be assertive. Avoid being aggressive, stubborn and a know-it-
all. Try to express your opinion in a way that others can understand and
respect. As we all know, patients can sometimes be difficult to manage
due to their social status, education level, religious beliefs, etc. However, a
successful doctor can guide his/her patient more easily by gentle
persuasion and flattery than by hostile confrontation.
 Reflect and improve. Learn from your past mistakes and successes. The
only source of knowledge is experience (Albert Einstein).
COMMON BARRIERS TO EFFECTIVE COMMUNICATION

 Use of jargon. Physicians sometimes fail to remember that the everyday
medical terminology they use are confusing to a layperson, e.g. using the
word epistaxis instead of nosebleed.
11
Communication
 Lecturing without feedback. This occurs when a physician delivers a

large chunk of information without giving the patient a chance to respond
or ask questions. While it may seem efficient to the physician, patients are
often unable to follow the pace of the physician‘s information delivery
(Back et al., 2005).
 Emotional barriers, cultural differences and taboos. Some patients
find it difficult to express their concerns due to self-conscious emotions,
e.g. shame, guilt or embarrassment because they consider them to be
'off-limits' or taboo. Help your patients open up to you by making him/her
feel comfortable and safe to share his/her concern.
 Lack of attention, interest, distractions, or irrelevance. This occurs
when the receiver is not interested about the sender‘s message and there
is no shared understanding between the patient and his/her physician.
 Passive listening. Physician listens to the patient without giving any
feedback, verbal or nonverbal, that would encourage the patient to
continue/elaborate further.
 Blocking. This happens when the physician neglects the patient‘s
concerns by either failing to respond to his/her query or redirecting the
conversation.
 Collision. Patients hesitate to bring up difficult topics and physicians do
not ask them specifically - a "don‘t ask, don‘t tell" situation. Patients often
assume that if something is important then the physician will mention it,
whereas physicians assume that if patients want to know anything, they
will ask.
 Physical barriers to nonverbal communication. Physicians fail to
interpret their patient‘s nonverbal cues (signals), gestures, posture and
general body language, making doctor-patient communication less
effective. Nonverbal cues are as important as verbal communication since
it conveys more emotional and affective meaning than does verbal
communication.
 Language differences and the difficulty in understanding
unfamiliar accents.
 Premature reassurance. This occurs when a physician responds to a
patient‘s concern with reassurance before exploring and understanding
his/her concern.
RECOMMENDATION
Confusion can occur during any stage of the communication process. Reducing
possible misunderstandings and overcoming any barriers to communication at
each stage in the communication process contribute to effective
communication.
To effectively communicate with your patients you need to understand your

patients, choose your language/terminology appropriately and improve your
message in order to reduce misunderstanding. Always ensure that your patient
understands your message by asking if they need further clarification or if they
have any questions and/or concerns regarding the information provided to
them. Correct any misunderstanding or confusion as soon as possible.
12
Communication
SELF-ASSESSMENT EXERCISE
Exercise 1
List what are the effective doctor-patient communication skills and what make
doctor-patient communication ineffective
Effective Ineffective
Doctor-Patient Communication Doctor-Patient Communication
13
Verbal Communication
VERBAL COMMUNICATION
INTRODUCTION
Effective communication skills are the key features needed to exchange
information and feelings between physicians and patients. Having good
communication skills is very essential to build-up effective physician-patient
relationship.
TRAINING OBJECTIVES
 Increase learner‘s self-awareness about their own communication method.
 Increase learner‘s accuracy, efficiency, supportiveness and effectiveness in
dealing with patients.
VERBAL COMMUNICATION PROCESS

 Preliminary communication. Appropriate greeting with a smiling face
along with a handshake and introducing yourself while maintaining eye
contact are important. Remember, first impressions have a lingering
effect.
 Reinforcement. Encourage the patient to discuss their concern and
illness. Boost the patient to elaborate further, maintain eye contact, nod
your head as he/she speaks with warm facial expressions and show
interest in his/her concern. This will encourage your patient to openly
express him/herself.
 Effective listening. Avoid distractions, always pay close attention to the
patient, maintain an open mind, and concentrate on what he/she is
saying. Avoid interrupting the patient and hold back your conclusions
and/or questions until he/she finishes speaking. Remember to always
remain objective.
 Questioning. Through questioning you can obtain further relevant
information which will assist you to achieve diagnosis. By questioning you
can assess whether you have understood what the patient is trying to say.
Ask your patient only one question at a time and wait for his/her reply
before asking the next question. The main types of questioning are:
 Open-ended questions. Open questions give more room for
response since they call for further discussion and explanation. Open
questions take longer to answer; however, they do give far more
opportunity for self-expression and encourage participation in the
discussion.
 Leading or „loaded‟ questions. A leading question, usually
delicately, points the respondent‘s answer in a certain direction.
This gives away or suggests to the patient what answer you
expect. For example, ―You said you were feeling miserable,
could you tell me more?‖
 Recall and process questions. Queries can also be
characterized as ‗recall‘ - requiring something to be remembered
or recalled, or ‗process‘ - requiring some deeper thought and/or
analysis. ‗Recall‘ example, ―When did you first start to
14
experience these symptoms?. ‗Process‘ example, ―What do you

think may have been the triggering factor of these symptoms?
 Closed-ended questions. Closed questions are aimed to seek only
a one or two word answer (usually simply 'yes' or 'no'). However, by
doing so, one limits the range of the response. These types of
questions control the communication and limit verbal communication.
All the same, closed questions can be beneficial for directing
discussion and attaining clear, concise answers when needed.
 Funnelling. Funnelling uses perceptive questioning to basically
funnel the patient‘s answers, i.e. to ask a series of questions that
become more (or less) restrictive at each step, starting with open
questions and ending with closed questions or vice-versa. This
approach often confuses the patient as he/she may feel rushed or
put down. If any of these feelings are present, the patient is not
likely to give meaningful information. The one specific use of
funnelling is to encourage a quiet patient to take responsibility and
talk more freely.
 Reflecting and clarifying. Reflecting is the practice of clarifying your
understanding of what the patient has said to you. In other words, you
summarize your patient‘s message in your own words, outlining the core
facts and feelings expressed, in order to communicate your understanding
back to the patient. This process will show the patient that you were
attentive to what he/she has said while assessing your understanding of
their concern.
 Closing communication. At this stage of the communication you should
be able to provide your diagnosis based on the information the patient has
provided you. Remember you have to ensure the patient has understood
the condition and is satisfied with the information provided before closing
the communication.
How to convey illness diagnosis and health education to a patient

To explain to your patient your diagnosis and provide him/her with the proper
health education, you have to:
 Briefly introduce what you are going to explain
 Ask the patient about his/her knowledge of the illness or condition
 Listen to the patient with empathy
 Start conveying the education message with:
a. Positive attitude towards the diagnosis.
b. Simple language, avoiding jargon.
c. Appropriate patient education.
d. Convincing scientific evidence.
e. Prioritize and categorize information.
f. Organized and limited (5-7 message role or less)
 Watch the pace, check repeatedly for the patient‘s understanding and
feelings as you proceed and take feedback. Basically, avoid lecturing.
 Give the patient opportunity to ask questions.
 Respond immediately and appropriately to patient‘s cues (signals).
 Summarize to the patient what you have explained to him/her
15
 Use demonstration as much as you can

 Give hope and support
BENEFITS OF PATIENT HEALTH EDUCATION

Patient health education is any set of strategic educational information or
activities aimed to improve patients‘ health manners and health status. Its main
purpose is to conserve or improve patient health and sometimes decrease
deterioration. By avoiding lecturing and providing patients with the required
information and education, a patient can enthusiastically partake in his/her own
treatment, improve results, aid recognize mistakes before they happen, in
addition to reducing his/her period of illness or just simply controlling it. Listed
below is a list of the benefits of patient health education:
 Simplify understandings of health statuses, diagnosis and treatment
options, and concerns of care for patients and their families.
 Increase a patient's capacity to handle and manage his/her health.
 Promote rehabilitation to improve function
 Support patients to learn better health behaviours
 Increase patient‘s ability to adhere to a healthcare plan
 Allow a patient to partake in the decisions related to their care
 Decrease treatment complexities
 Increase patient self-confidence in his/her self-sufficiency
RECOMMENDATION
In the previous chapters, we discussed how illness can make patients feel weak
and vulnerable. By now, you should be equipped with the necessary skills
needed to break any barrier in order to establish a good connection with your
patient. Keep in mind, that the more comfortable a patient feels with his/her
physician, the more he/she will give important and relevant information about
their symptoms without hesitation. Once this connection is established,
diagnosing and treating your patient will become more relaxed and efficient.
Exercise 1
Explanation and health education: Self-evaluation form
Patient Data:______________________ Age:__________ Gender:_________
Reason for attendance:____________________________________________
Skills 0 1 2
1. Give introduction about the importance of the topic
2. Explore patient knowledge and feelings
3. Empathic listening
4. Deliver message in a positive way (reassurance)
 Make your message simple & clear
 Make it appropriate to the patient‘s education level
 Make it a convincing message (logical explanation)
 Make it organized & limited
16
5. Frequently take feedback

6. Invite patients to ask questions
7. Response to patient's cues
8. Repeat if necessarily (T3)
 T1: Tell him what you will tell him (Introduction)
 T2: Tell it
 T3: Tell him what you have told them (Summary)
9. Use demonstration if appropriate
10. Always give hope and support
0 = not done; 1 = done but not good enough; 2 = perfectly done
1. Write your feelings about your performance:
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
2. Important areas of strength and areas that need improvement:
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
3. Your specific learning needs and your action plan:
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
17
Nonverbal communication
NONVERBAL COMMUNICATION
INTRODUCTION
Within any interaction between two people, over 90% of the communication
that occurs is channelled through the nonverbal band. Nonverbal behaviours
allow the observers to discern people‘s emotional state, e.g. happiness, anger,
surprise, fear, disgust, sadness, etc. Nonverbal communication is a universal
language, with some nonverbal cues (signals) having different meanings in
different cultures. Nonverbal communications include: facial expressions, tone
of the voice and gestures displayed through body language. These non-verbal
signals can give clues and additional information and meaning in addition to the
spoken (verbal) communication. Verbal communication alone would not have
significant effects on a patient‘s satisfaction and health outcomes.
Non-verbal communication is an extremely confusing yet integral part of our

daily overall communication. People are often unaware of the non-verbal
behaviour they use. A basic understanding of non-verbal communication
strategies, in addition to what is actually said, will help improve your interaction
with others. Knowledge of these signs can be used by physicians to encourage
their patients to talk about their concerns; consequently, leading to a greater
shared doctor-patient understanding.
Moreover, in order to communicate effectively, avoid misunderstandings, and

enjoy solid, trusting relationships both socially and professionally, it‘s important
to understand how to use and interpret nonverbal signals.
TRAINING OBJECTIVES
 Increase understanding of nonverbal cues.
 Learn how to recognize patients‘ nonverbal cues.
ASPECTS OF NONVERBAL COMMUNICATIONS

Body language or body movements
Gestures or body movements are an important form of communication.
Patient‘s attempts to mask feelings can be detected readily by observing their
body behaviour. Conversely, by using appropriate body language, the physician
can convey his/her attention and concern in the most effective manner
possible.
Body language includes gestures, facial expressions, body postures, and eye
contact.
Facial expression: The face is perhaps the most important conveyor of

emotional information; it can express enthusiasm, energy, approval, confusion
or boredom and scowl with displeasure. The eyes are particularly expressive in
telegraphing joy, sadness, anger, or confusion.
Body postures: Our body postures can create a feeling of warm openness or
cold rejection. For example, when someone faces us, sitting quietly with hands
loosely folded in the lap, a feeling of anticipation and interest is created. A
18
posture of arms crossed on the chest portrays a feeling of inflexibility. The

action of gathering up one's materials and reaching for a purse signals a desire
to end the conversation.
Gestures: Gestures are woven into the fabric of our daily lives. We wave,
point, beckon, and use our hands when we‘re arguing or speaking animatedly -
expressing ourselves with gestures often without thinking. However, gestures
can be different in various cultures and regions, so be careful to avoid
misinterpretation.
Eye contact
 Giving and receiving feedback: Appropriate eye contact is an
expression of respect and interest on the content of the speech.
Communication may not be a smooth process if a listener averts their eyes
repeatedly, however, bear in mind that prolonged eye contact or staring
can be an expression of aggression. Lack of eye contact gives clues to
presence of anxiety, depression, masked emotions, lack of security and
confidence as well as negligence and disrespect.
 Signalling 'turn' to speak: Changing eye contact with verbal
communication can be considered a meaningful cue. When someone is
listening, eye contact is more likely to be continuous rather than when
he/she is speaking. When a person has finished speaking, he/she will look
directly at the other person giving him/her the signal that it‘s his/her turn
to speak. If someone wishes not to be interrupted while speaking, eye
contact may be avoided.
 Communicate something about a relationship between people:
The size of the pupil changes with the mood of the person, e.g. if you
despise someone, you tend to avoid eye contact and your pupil size is
often reduced. Alternatively, maintaining positive eye contact signals
interest or fascination. There are racial variations in the explanation of eye
contact.
Positive and negative body language

Positive Negative
 Maintaining eye contact with the  Not looking at a person when speaking.
person to whom you are speaking.  Tapping a foot, fingers etc.
 Smiling (if appropriate) but especially  Rocking backwards and forwards.
as a greeting and when parting.  Scratching.
 Sitting squarely on a chair, leaning  Continually clearing your throat.
slightly forward (this indicates you  Fiddling with hair, ear lobes, jewellery,
are paying attention). jacket, glasses, etc.
 Nodding in agreement.  Picking at fingers or finger nails.
 A firm handshake.  Yawning.
 Presenting a calm exterior.  Repeatedly looking at your watch or a
 Looking interested. clock in the room.
 Standing too close to others.
 Inattention to a person who is speaking.
19
Appearance
How the patient dresses, says a lot about him/her, such as: social class, mood,
beliefs, attitude, etc.
How the physician dresses is also important. Clothing has been found to affect
perceptions of credibility, likeability, attractiveness, and dominance.
Researchers agree that clothing has the most potent effect on credibility.
Closeness and personal space

In every culture and society there are different levels of physical closeness
appropriate to different types of relationship. People learn these different
distances from the society they grew up. As a physician, you encounter patients
from multicultural society, as a result you must know the importance of
considering the range of non-verbal codes as expressed in different ethnic
groups. When someone disregards an 'appropriate' distance, people may feel
uncomfortable or defensive. Their actions may well be open to
misinterpretation.
A close personal interest in the patient can be communicated by the

appropriate use of touch. The most socially acceptable method is a handshake,
which enables a physician to establish early contact with his/her patient.
Physical examination is another opportunity to use touch to communicate
reassurance and support. For example, when performing a physical
examination, make sure you explain to the patient that you may do something
that might be painful. This would prepare the patient for any pain that might
arise.
Listed below are the four main categories of proxemics, these zones are
affected by factors such as culture, status, role, etc.
 Intimate Distance (touching to 45 cm): This is the zone we classify as
our own property. Only those who are emotionally close to us are
permitted to cross the threshold. This includes close family and friends.
 Personal Distance (45 cm to 1.2 m): It is the distance over which we
interact at social events with our friends.
 Social Distance (1.2 m to 3.6 m): It is the distance at which we stand
when meeting new people and interacting with groups of people.
 Public Distance (3.7 m to 4.5 m): It is a comfortable distance to
maintain between strangers in public.
Paralanguage
Paralanguage relates to all aspects of the voice which are not strictly part of the
verbal message, including the tone and pitch of the voice, the speed and
volume at which a message is delivered, and pauses and hesitations between
words. These signals can serve to indicate feelings about what is being said.
Emphasising particular words can imply whether or not feedback is required.
 Volume: Without enough volume you cannot be heard. However,
shouting or a harsh sounding voice may be perceived as disruptive or
20
insulting. Many a times, lowering your voice almost to a whisper will help
you make a point better than shouting.
 Pitch: Most factual communication includes moderate changes in the
pitch of your voice. A monotone involves little or no change and may be
perceived as apathy or boredom. Try to make the conversation engaging
and bear in mind that when you are agitated or even enthusiastic, vocal
chords tense and shorten causing the voice to get higher. Emphasise
certain words and remarks within the conversation to convey their
importance and help add variety.
 Pace: This is the speed at which you talk. A slow pace of speech may
frustrate the patient. An increasing pace may be perceived as increasing
intensity. A fast pace may be perceived as nervousness and it may also be
difficult to understand. Try to vary your pace, this would help maintain
interest.
 Rhythm: The regular or rhythmic voice pattern will normally make you
sound more confident or authoritative. Irregular speech rhythm might be
perceived as thoughtful or uncertain, depending on your words and other
nonverbal messages used.
 Articulation/Pronunciation: Some people speak through clenched
teeth with little lip movement, causing the sound to be trapped in the
mouth and not out. To have good articulation one must unclench the jaw,
open the mouth and properly enunciate each sound, paying particular
attention to the ends of words. This would help the listener as a certain
amount of lip-reading will be possible. To be understood, you must also
use the correct sounds and emphasis on pronouncing each word.
Mispronouncing a word might be perceived as indicator of ignorance or
incompetence. When words are spoken clearly, it makes it easier for the
listener to understand what is being said.
Environment
Clinic setting can convey a positive nonverbal message about the physician to a
patient if arranged in the correct manner. A clinic should be coloured in relaxing
colours, welcoming, clean, well-organized and containing basic professional
equipment. The correct placement of the furniture in the clinic could put the
patient at ease and feel less terrified.
For example, some physicians place their tables and patient‘s chair 45 cm - 1.2
m apart (personal distance zone); as
shown in the figure below.
The advantages of this type of setting

for doctor-patient communication are:
 The patient is in the personal zone
and treated as a friend.
 It is a good balance between
professional and intimate
relationship.
21
 The computer and desk are not barriers.

 Physician can distance him/herself if needed, e.g. to grab an anatomical
model to explain further to the patient, or grab the sphygmomanometer to
check his/her patient‘s blood pressure, etc.
 The physician can also view the patient‘s nonverbal communication.
 Touch the patient in order to console/reassure him/her and/or express
empathy.
ROLE OF NONVERBAL CUES

Most of the time, we attribute the meaning of words, not from the words
themselves but from the nonverbal communication. Nonverbal cues can play
five roles:
1. Repetition: They can repeat the message the person is making verbally.
2. Contradiction: They can contradict a message the individual is trying to
convey.
3. Substitution: They can substitute verbal message. For example, a
person's eyes can often convey a far more vivid message than words do.
4. Complementing: They may add to or complement a verbal message. For
example, a physician who pats a patient on the back in addition to giving
supportive comments can increase the impact of the message.
5. Accenting: Non-verbal communication may accent or underline a verbal
message.
HOW SMART PHYSICIANS COMMUNICATE

 Smart physicians understand the importance of nonverbal communication.
They use it to increase their effectiveness, and understand more clearly
what their patients are really saying.
 Smart physicians ensure consistency between their verbal and nonverbal
messages. When messages are inconsistent, the patient may become
confused. Inconsistency can also create a lack of trust and weaken the
chance to build a good doctor-patient relationship.
 When a patient sends a message with conflicting verbal and nonverbal
information, a smart physician believes the nonverbal information.
 Smart physicians can pick up non-verbal cues and use them to facilitate
communication. For example, ―You sound sad when you talk about your
father. I sense that you‘re not quite happy with the explanations you‘ve
been given in the past. Is that right?‖
Tips for reading nonverbal communication

 Pay attention to inconsistencies. Nonverbal communication should
support what is being said. Ask yourself, ―If the person is saying one
thing, and their body language something else?.‖ For example, are they
telling you ―yes‖ while shaking their head no?
 Look at nonverbal communication signals as a group. Don‘t read
too much into a single gesture or nonverbal cue. Consider all of the
nonverbal signals you are receiving, from eye contact to tone of voice and
body language. Taken together, are their nonverbal cues consistent - or
inconsistent - with what their words are saying?
22
 Trust your instincts. Don‘t dismiss your gut feelings. If you get the
sense that someone isn‘t being honest or that something isn‘t adding up,
you may be picking up on a mismatch between verbal and nonverbal cues.
DISCUSSION
 Only 7% of doctors actively encouraged their patients to elaborate.
 13% listen passively
 81% make no effort to listen or deliberately interrupt their patients.
The conclusion here is that patients are keen to disclose their own thoughts
and feelings which doctors unfortunately ignore! (Tuckett et al., 1985)
RECOMMENDATION
As a smart, professional and caring doctor, you should effectively use your
nonverbal communication skills to convey positive messages about yourself.
When your nonverbal signals match up with the words you‘re saying, they
increase trust, clarity, and rapport. When they don‘t, they generate tension,
mistrust, and confusion.
Moreover, if you want to become a better communicator as a physician, it‘s

important to become more sensitive, not only to the body language and
nonverbal cues of your patients, but also to your own. Pay attention to your
patients‘ nonverbal cues and respond immediately and appropriately to their
cues.
As you continue to pay attention to the nonverbal cues and signals you send
and receive, your ability to communicate will improve.
Exercise 1
1. State the different aspects of nonverbal communications:
a)___________________________________
b)___________________________________
c)___________________________________
d)___________________________________
e)___________________________________
f)___________________________________
Exercise 2
1. Write down three words that best describe the way you want to be
perceived by your patients:
a)……………………………… b)…………………………..…… c)……………………..………
23
2. Write down how can you use your communication skills to convey these
positive messages about yourself?
a. …………………………………………………………………………………………….….….......
b. …………………………………………………………………………………………….……........
c. …………………………………………………………………………………………….……........
FURTHER READING
)‫مهاراخ االتصال (من كتاب األسس العلميح لالستشارج الطثيح‬
24
Doctor-Patient Relationship
DOCTOR-PATIENT RELATIONSHIP
INTRODUCTION
Effective doctor-patient communication is the fundamental skill of medical
practice which consists of both verbal and nonverbal processes. Even the most
knowledgeable and skilled physician will have limited effectiveness if he/she
was unable to develop effective relationship with his/her patient. Failure to
develop good doctor-patient relationship will make working with the patient a
very stressful job.
Medical consultation is not only for gathering information in order to reach

diagnosis; it is also the foundation on which the doctor-patient relationship is
established. During consultation, patients share information and physicians get
a chance to know their patients more as a people rather than only patients
coming in for treatment.
In this chapter, we shall discuss the different types of doctor-patient

relationship as well as the 8 steps for establishing and maintaining effective
doctor-patient relationship.
TRAINING OBJECTIVES
 Explain the basic communication skills needed during consultation.
 To increase learners‘ knowledge and skills in establishing and maintaining
effective doctor-patient relationship.
WHY IS DOCTOR-PATIENT RELATIONSHIP IMPORTANT?

 Increases patient care and satisfaction
 Better patient compliance
 Increases physician satisfaction
 Improves quality of healthcare
 Effective use of resources
TYPES OF DOCTOR-PATIENT RELATIONSHIPS

Here, we will briefly discuss four types of doctor-patient relationships.
1. Default - Patient and doctor I‘m sorry; there is nothing

have low control I can do for you.
This type of relationship lacks
sufficient direction because the patient
adopts a passive role even when the
doctor reduces some of his/her
control. Some patients are nervous or
DEFAULT
shy to adopt a more participative

relationship. This type of relationship
is neither professional nor effective.
25
2. Paternalism - Doctor has high

control (Disease Model) These are doctor‘s orders
In this type of relationship, the physician and you must follow my
is dominant and acts as a ‗parent‘ figure orders.
that chooses what he/she believes to be
in the patient‘s best interest. This form of
PATERNALISM
relationship traditionally branded medical
consultations and, some patients even
found it comforting to be able to rely on
the doctor and be relieved of burdens of
worry and decision making. Nowadays,
medical consultations have become
increasingly characterized by higher patient control and relationships based on
mutuality. The negative aspects of this type of relationship are:
 It follows the traditional medical consultation
 Nobody accepts paternal authority these days
 Poor compliance
 Low patient satisfaction
 It is very exhausting for the physician because he/she takes full
responsibility instead of the patient
3. Consumerism - Patient has high You are working for me! You
control have to do what I want you
A consumerist relationship describes a to do.
situation in which the patient takes the
active role and the doctor adopts a fairly
CONSUMERISM
passive role, agreeing to the patient‘s

requests for a second opinion, referral to
hospital, a sick note, etc. This is typical
in private practice. The negative aspects
of this type of relationship are:
 High-risk for the patient
 Exhausting for the physician
 Waste of resources
Let us discuss together…..
4. Mutuality (Partnership) -  What do you think?
Patient and doctor have high  What do you prefer?
control (Illness Model)
A relationship of mutuality is
characterized by the active
involvement of patients as more equal
MATURITY
partners, where both patient and

physician participate in the exchange
of ideas and sharing of belief systems.
The physician brings his/her clinical
skills and knowledge to the
consultation in terms of diagnostic techniques, knowledge of the causes of
disease, prognosis, treatment options and preventive strategies, and patients
26
bring their own expertise in terms of their experiences and explanations of their
illness, and knowledge of their particular social circumstances, attitudes to risk,
values and preferences. The highlights of this type of relationship are:
 Respect for patient‘s mind and feelings
 Better compliance and patient satisfaction
 Sharing responsibility with the patient
 Sharing uncertainty with the patient
 Challenging and stimulating for the doctor
 Too much empathy and negotiation sometimes exhausting for the doctor
8 STEPS TO DEVELOP GOOD DOCTOR-PATIENT

RELATIONSHIP
The patient‘s first visit is vital; as it can either lead to a good therapeutic
doctor-patient relationship or it may end in dissatisfaction, leaving the patient
in search for another care provider. In the first few minutes of the encounter,
the patient will decide whether or not he/she will feel comfortable with his/her
selected physician. Keep in mind that most of this first impression is not made
on what the physician says, rather on how he/she says it and how he/she
interacts with the patient. Patients must feel that they are treated with respect,
at all times. Once physicians understand their patients‘ background, they can
effectively communicate with patients to best help them.
Below are 8 steps, discussed individually, that could help you develop a good
doctor-patient relationship.
Step 1. Establishing the relationship

Greet the patient
 Call the patient by his/her surname. Never call a patient over the
paediatric age group by their first name without permission, it is
disrespectful.
 Stand, smile and shake (SSS) the patient‘s hand.
 Introduce yourself and indicate your role to the patient.
 Use appropriate welcoming phrase.
 Show the patient where to be seated but never stand over the patient; the
patient should not have to look up to you to make eye contact.
Remember, first impression is the last impression; you will never get a second
chance to make a first impression.
Socialize with the patient

Patients are normally nervous meeting the doctor for the first time. Put the
patient at ease and build rapport by inquiring about non-medical areas of
his/her life in the first few minutes to assist in developing a relationship with
them as a person. Below are a few types of questions you may ask before
asking the patient to tell his/her story and explain why he/she is there:
 Ask male patients about his work
 Ask female patients about her family
 Ask children about their school activities
 Talk to elderly patients about the nice good old days
27
Advantages of establishing consultation by greeting and socialization

 It creates a positive first impression
 It conveys respect
 It builds trust
 It breaks the ice and puts patient at ease
 It encourages openness
 It improves our own satisfaction
Step 2. Facilitation
Facilitation is the technique used to encourage the speaker to elaborate more,
overcome his/her anxiety or hesitancy and express his/her story in addition to
his/her emotions.
We need to balance carefully, facilitation and active listening on one hand and
on the other hand, focus on guiding the patient to the right direction in order to
use time effectively.
Nonverbal facilitation
 Minimize distractions. Close the door, put your beeper and mobile on silent
mode during consultation.
 Maintain eye contact. Maintaining eye contact will show the patient that
the physician is paying attention to what is being said.
 Active listening. Concentrate of what the patient is communicating verbally
and nonverbally taking into account both facts and emotions.
 Nod appropriately. By mirroring the patient‘s tone, the physician would let
the patient know that he/she is on the same page with him/her.
 Touch. When appropriate, you could hold the patient‘s hand to console
him/her or you could give a gentle pat on the back, etc.
 Posture. Lean forward and do not cross your arms.
Verbal facilitation
 Questioning and listening. Using of open-ended questions gives the
patient a chance to be in control and direct the attention to the most
important points from his/her perspective and this will facilitate
communication for more details. Patients can offer great insight into their
conditions from what they say, therefore, it is necessary to limit the
number of times questions. Moreover, avoid interrupting the patient when
he/she presenting his/her chief complaints.
 Probing. A response that may restate a question in a different way using
different words or may even ask the same question. In telling about their
symptoms, patients do not give you all the details you need. Once they
have told you about a phase of the illness, it may be necessary to probe
for more specific information. Ask the patient about any alternative
treatment that he/she may be using or used recently.
 Confrontation. A response that points out to the patient's feeling,
behaviour or previous statement. Confrontations are most effective in
focusing the patient‘s attention upon his/her feeling, behaviour, or
statement. They may also let the patient know that you understand what
he/she said and this may encourage the patient to explore his/her feelings
28
further. Seek to identify or clarify the patient‘s feelings by saying ―Tell me

how you‘re feeling about this….‖ or ―I have the sense that…‖
 Paraphrasing. This is a concise statement of the patient's message
content. A paraphrase should be brief and focus on the facts or ideas of
the message rather than feeling. The paraphrase should be in the
physician's own words rather than "parroting back", using the patient's
words. Ask the patient to correct or add to your responses until he/she
confirms your understanding, e.g. ―Did I miss anything?‖.
 Verbal mirroring. Verbal mirroring is another form of mirroring; it occurs
when the physician approximates the patient's voice tone and repeats the
patient's last few words and occasionally uses a slight questioning
inflection. This mirroring process avoids distorting the patient's words and
encourages the patient to say more, e.g. ―Do your headaches get worse
when under stress?‖. This would encourage the patient to explore more
into this point and also show your attention.
 Reflection. It is a response that repeats, or echoes a portion of what the
patient has just said. Although it focuses on a particular point, a reflection
helps the patient to continue in his/her own style. For example, when a
patient comes in and asks you ―Doctor, do you think it‘s cancer?‖, try to
reflect the patient‘s comment back at him/her, ―Do you really think it‘s
cancer?‖. By using reflection, you encourage the patient to think out loud
about his/her deep thoughts and fears.
 Interpretation. This is the discussion between you and patient based
upon two or more events presented in a manner to tie the events together
to reach a conclusion. Try not to jump around from one topic to another.
At this stage, you can ask any forgotten question(s) you needed to ask as
long as you use transition statements so the patient knows where you are
going. Transition statements summarize and enable you to process. The
patient should be able to understand what the purpose of any question
would be.
 Summarising. Here, the physician pulls together the main ideas and
feelings of the patient to show understanding. This skill is used after a
considerable amount of information has been shared. It will reveal
whether or not the physician grasps the total meaning of the message. It
also helps the physician gain an integrated picture of what he has been
saying.
Step 3. Building rapport

Rapport is a state of balanced understanding with another individual or group
that enables greater and easier communication. In other words, rapport is
getting on well with another person, or group of people, by having things in
common; this makes the communication process easier and usually more
effective. Rapport can also be built and developed by finding common ground,
developing a bond and being empathic. Creating rapport at the beginning of a
conversation with somebody new will often make the outcome of the
conversation more positive. However stressful and/or nervous you may feel,
the first thing you need to do is to try to relax and remain calm, by decreasing
the tension in the situation, communication becomes easier and rapport grows.
29
Although initial conversations can help us to relax, most rapport-building

happens without words and through non-verbal communication channels. We
create and maintain rapport subconsciously through matching non-verbal
signals, including body positioning, body movements, eye contact, facial
expressions and tone of voice with the other person.
As a physician, you must put away your own opinions and principles and
abstain from projecting them onto your patient. The medical problem or issue
is not about the physician, but about the patient and his/her belief system and
the physician needs to comprehend it from their viewpoint. Understand the
patient‘s weakness, mistake or abnormal behaviour, without reprimanding
him/her. Moreover, respect the patient‘s right to choose for him/herself and be
responsible of his/her choice. This usually comes after negotiating all the
options and giving the patient enough information to make his/her own
treatment choice or decision. If patient attends with his/her family: watch
family dynamics, and build rapport with the family as well.
Points to remember when building rapport with a patient

 Show interest and respect.
 Show support and care.
 Recognize and respond immediately to verbal and non-verbal cues.
 Balance intimate and professional relationship.
 Be flexible and respect patient autonomy.
 Demonstrate appropriate confidence.
 Do not be judgemental.
 Respect patient confidentiality.
Helpful tips to build effective doctor-patient relationship with children:

 Direct the conversation to the child, if possible.
 For very young children, providing them with a distraction or mutual task while
talking can be helpful. For example, a toy or the stethoscope.
 Stay at the same level as the child, verbally and physically.
 Let the child touch the examination instrument before using it; e.g., the tongue
depressor or ear scope or stethoscope.
 Be honest and tell the child how painful the examination or the treatment is going to
be but reassure them that you will stop when you want them to.
Helpful tips to build effective doctor-patient relationship with adolescent:

 Treat him/her with respect.
 Appreciate their independency and let him/her feel that he/she is in charge of
his/her problem(s).
 Understand their feelings and needs.
 Offer your support and that of other healthcare professionals when appropriate.
 Maintain a good balance between your professional image and your friendly attitude.
 Anticipate possible common problems, but avoid judgmental attitude and comments.
 Understand their family dynamics.
30
Helpful tips to build effective doctor-patient relationship with elderly:

 Show respect by standing up for him/her.
 Help him/her to be seated.
 If necessary, ensure hearing aid or spectacles are available.
 Talk more slowly and wait for replies.
 Allow more time; sit face to face with the patient.
 Do not talk loudly.
 Do not patronize the patient.
 Talk about the beautiful ‗good old days‘ and give the patient a chance to talk about
them.
 Show interest and respect to his/her beliefs.
 Help him/her while undressing and dressing during physical examination.
 Touch can be reassuring.
Step 4. Empathy
Empathy is a religious and humane value; it is not just a package of skills.
Empathy is a response that recognizes or names the patient‘s feeling and does
not in any way criticize it. A physician should accept the patient‘s feeling even
though he/she believes the feeling to be wrong or uncalled for. It is the most
effective way a physician can use to show how much he/she cares.
Empathic responses
Approach a patient with the aim of understanding his/her personal experience
of the disease or health problem. Respond to a patient‘s emotion with the
acronym NURSE (Back et al., 2001).
 N= Name the emotion
―I can see that you are anxious and worried‖
―You seem sad today‖
―You seem stressed today‖
 U= Understand and acknowledge the patient‘s suffering
―I can understand why you feel confused and worried‖
―That must be very difficult for you to cope with.‖
 R= Respect the patient without criticism
―You're doing great.‖
 S= Support the patient
Silence can be supportive and touch can be reassuring
―God help you‖
―We will work together to get through this‖
 E= Explore and facilitate
―Tell me about your feeling‖
―How do you fell about …?‖
Nonverbal expression of empathy

Simply saying ‗sorry‘ to a terminally ill patient will neither help nor comfort
him/her. Nonverbal communication plays an essential role in expressing how
dedicated and concerned a physician is about his/her patient‘s well-being.
Below are a few examples.
 Use a sad or sympathetic tone when speaking to a worried/troubled
patient dealing with or expressing a health problem.
31
 Express concern through facial expressions.

 Hold the patient‘s hand to show compassion.
Non-empathic or distracting comments physicians should avoid

 Interrupting patient‘s description and changing the topic, e.g. telling the
patient, ―let us concentrate on your back pain first‖, while he/she was
explaining his/her other associated symptoms, will give the patient the
impression that the physician is not listening to his/her main concern.
 Disregarding and underestimating a patient‘s concern, e.g. when a patient
is explaining his/her high level of pain and the physician precipitously says
"I know better than you, there's nothing wrong with you and you'll feel
better tomorrow‖ or ―The real problem is that your mother spoiled you‖,
are statements that can forever destroy any chance of an efficient doctor-
patient relationship.
 Judgmental responses are very wrong, e.g. ―You are very obsessional and
overreacting to a common and simple problem‖. Such statements could
offend the patient and make him/her feel meaningless.
 Counselling the patient before he/she has finished explaining their
problem, e.g. interrupting a patient complaining of backache and telling
he/she what needs to do next time to alleviate this kind pain in the future.
This could be misinterpreted by the patient as a signal to stop sharing
their concern or that the physician wishes to get this visit over and done
with quickly.
 Premature reassurance, e.g. a patient tells you that her husband didn't
come home last night and you comment, ―Don't worry about it, he'll be
home tonight." This is interpreted by the patient as the physician is
saying, "Don't talk to me about it anymore." A good physician should allow
the patient to share some information with him/her, this only strengthens
the rapport.
 Asking a series of questions without giving the patient time to answer, e.g.
a patient has problems in his/her marriage and the physician starts
interrogating, "Do you two talk?", "Do you go out?", "How about his/her
mother?". Questions control and guide such conversations without helping
the patient appropriately. A good physician should give the patient
adequate time to answer questions individually.
 Physicians getting carried away with their own similar experience and
explain the story based on a problem being described by the patient. This
may make the patient feel that the physician has forgotten to focus on the
patient‘s concern.
Useful tips to help physicians improve empathic responses

With time, a physician will learn to better guess his/her patient's feelings. This
insight comes from two major sources:
a. Listening to your own gut feelings and reactions. Place yourself
mentally in the patient's situation; then imagine what you would do and
notice how the situation would make you feel. This is one of the most
powerful techniques for generating "intuition" about the patient's
32
emotions. Alternatively, if you had experienced situations similar to that of

the patient, then you can recall and mentally re-create the feelings you
had. It is reasonable to assume that the patient may be feeling the same
way you did in the same or similar situation.
b. Listening to and watching the patient. Hear the patient's words and
tone of voice, but, also, observe his/her facial expression and other non-
verbal messages. Read "between the lines" and pickup verbal and
nonverbal cues.
Common barriers to empathic listening:

 Physician trying to mind read what the patient really thinks. ―He probably
thinks I'm not a good doctor for saying that‖.
 Planning what argument or story to give next.
 Physician filters what is being said by the patient to hear only certain
topics or fails to hear the patient‘s critical remarks.
 Judging a statement before it is completed, e.g. "crazy," "boring,"
"stupid," "immature," "hostile," etc.
 Physician going off on one's own daydreams.
 Physician remembering his/her own personal experiences instead of
listening to the patient.
 Drafting your prescription or advice long before the patient has finished
telling his/her woes.
 Quickly changing the topic or laughing it off if the topic was not a physical
problem.
 Placating the other person by automatically agreeing with everything, e.g.
"you're right...of course...I agree...really!".
Truths and myths about physician empathy

Myth Truth
Patients know that physicians care about Patients do not experience the physicians‘
them by default. care and compassion until the physician gives
voice to it.
Physician‘s empathy will not change Acknowledgement of patient‘s suffering and
patients suffering. allowing him/her to vent, is reassuring, and it
improves doctor-patient relationship.
Step 5. Physical examination

Physical exam is gradually being overlooked, and replaced by diagnostic tests,
which are easier, and take less time to order. Physical exam, when done well,
―earns the trust of the patient, and it also lays the foundation for strong doctor-
patient relationship.‖ However, when done poorly, ―it does the opposite, it
creates mistrust, or even a sense of being disrespected.‖
In today‘s medical practice, the cause of the problem is time, or the lack
thereof; so, it‘s no revelation that physical exam falls by the wayside. However,
this is to the patient‘s detriment. Just think about how much an exam costs
patients in terms of missed diagnoses, unnecessary tests and complications
33
from tests (such as reactions to contrast for a CAT scan) that were never
indicated.
Physical examination could help a physician detect asymptomatic condition.

History and physical examination are the basis of clinical medicine.
Below are a few tips on how to best use physical examination to build a good
doctor-patient relationship:
 Perform physical examination gently, in a humane manner.
 Take the patient‘s permission to examine him/her.
 Inform the patient what is going to be examined and why.
 Break the ice and put the patient at ease.
 Explore minimal body parts as needed (nothing more).
 Prepare the patient for possible pain or embarrassment.
 Apologise for any discomfort which may be caused and any potentially
painful or embarrassing examinations.
 Inform patient when the physical examination has finished and thank
him/her for his/her cooperation.
 Never ask the patient about any history of physical symptoms while
examining him/her.
Practice physical examination to explore how the patient feels

 Exposing the body for physical examination can make the patient more
ready to explore his/her emotion.
 Never miss the opportunity of listening to the patient during and after
examination.
 Physicians need to pay attention to their verbal and nonverbal
communication during physical examination and convey reassuring
messages as much as possible. For example, a nonverbal look of concern
while listening to the patient‘s heart beat could scare and lead the patient
to assume the physician has heard something wrong.
 Keep eye contact while examining the patient as much as you can.
Practice physical examination to reassure the patient
 If appropriate, smile when you are examining the patient. It is very
reassuring.
 If there is no need for examination, at least touch the diseased part of
his/her body or take his/her pulse just to make the patient feel that
he/she has been examined and cared for.
Practice physical examination to enhance positive messages

 Patients on the examination table feel weak and may be helpless; this
makes them more suggestible.
 Remember – the power of consultation and the healing effect of touch.
 A smart physician can take the advantage of this psychological situation
for the best benefit of his/her patient and give positive suggestions, e.g.
reassuring suggestions or counselling to quit smoking.
34
Truths and myths about physical examination

Myth Truth
Physicians believe that physical Physical examination is an opportunity to
examination is just for detecting signs and reassure a patient
making diagnosis
Physicians believe that painful or Smart doctors can make it less painful by
humiliating physical examination is not simply letting the patient know that the
his/her fault examination might be painful and asking the
patient to bear with him/her for a while.
Step 6. Doctor-patient partnership

There is a misassumption that most patients do not want to be involved in the
treatment process/options and that clinicians are good judges of their
preferences (Elwyn et al., 2003). The days of patients accepting prescriptive
and paternalistic advice from their physician are nearing their end. Leave the
didactic monologues behind. Partnership with the patient, in their treatment
decisions or care, is increasingly advocated because:
 It improves patient compliance.
 It improves patient safety.
 Allows physician to share the load and responsibility with the patient.
 Makes the patient feel that he/she is in control of his/her problem/health.
 Reduces the need for unnecessary interventions, e.g. postoperative
analgesia and anxiolytic medications.
How to establish doctor-patient partnership
 Define the problem that requires shared decision.
 Legitimize patient involvement and encourage his/her positive role.
 Discuss management options with the patient.
 Explore patient's ideas and encourage him/her to ask questions.
 Negotiate a mutually acceptable plan with the patient.
 Recognize patient's verbal and nonverbal cues and immediately respond
appropriately.
 Frequently take feedback from the patient.
 Give the patient enough time to make his/her own decision.
Partnership barriers
 Lack of information and a reluctance to share data: Physicians
cannot lay out options and their pros and cons if they do not know them
(Elwyn et al., 1999).
 Time and timing: It is unusual to take big decisions within one
consultation, so the task could be staged. Further discussions are often
necessary and the agreed view is that "...sharing a decision is a process
not an event."
 Contextual modifiers: You need to be sensitive to "contextual"
modifiers such as age and educational achievement.
 Types of decisions: In instances such as urgent or dangerous medical
problems or situations of conflict where patient "demand" is contrary to
empirical evidence, different decision-making approaches are needed.
35
Step 7. Closing
In order to create a lasting impression, at the end of the consultation, a
physician must be able to:
1. Summarize
 Briefly explain and clarify plan of action.
 Safety nets, explain possible unexpected outcomes, such as: what to do if
plan does not work, when and how to seek help.
 Make a contract with the patient, explaining what is expected from
him/her and what is expected from the physician in the next visit.
2. Answer the patient‟s questions and take feedback

 The patient should leave knowing that all of their concerns have been
addressed. Ask the patient if he/she requires any further clarification,
questions answered or other items he/she wishes to be discussed.
3. Confirm partnership
 The patient needs to be able to depend on the fact that the physician will
be there in the future for them. Therefore, a physician should let the
patient know that he/she is there for the patient if he/she needed
him/her.
4. Ensure patient satisfaction

 Final check that the patient agrees and is comfortable with the set plan.
Step 8. Preparation
As a physician, you must be prepared to treat all your patients. Below are a few
tips that can help you:
 Prepare yourself (Housekeeping). Some consultations may result in
some negative feelings on the physician. A physician should acknowledge
all these feelings and deal with them before seeing the next patient. This
means making sure that you do not carry forward remaining feelings from
one consultation to the other. Ensuring that you‘re in the right frame of
mind to keep yourself mentally, physically, and psychologically in good
nick from one patient to the other, or from one surgery to the next or
from one week to the next (Neighbour, 1987).
 Prepare the environment (the clinic). This means ensuring the clinic
is clean and orderly, ready to receive the next patient.
 Prepare patient‟s data. Before a patient enters the clinic all the data
pertaining to him/her should be available, i.e. patient history, test results,
etc. If there is any data missing you could ensure it is sorted before the
patient enters the clinic. This would save a lot of your time as well as the
patient‘s time.
How to deal with job stress

 Stress during a consultation with a patient
 Think positive, get rid of projection
 Avoid stereotyping
 Tensing and stretching muscles
36
 Unwind between patients

 Cup of coffee
 Short walking
 Making a phone call
 Reading a book
 Checking for mail
 Talking to someone
 Breathing exercise
 Stretching
 Long-term stress relief recommendations
 Positive thinking
 Leisure and social activities
 Group discussion - meetings
 Continuing Medical Education (CME)
 Effective time management
 Physical exercise
 Stress control techniques: yoga or relaxation
Positive effects of doctor-patient relationship on a patient‟s care

1. Reassurance
2. Compliance
3. Less doctor shopping
4. Decreased errors and medical litigation
5. Improved quality of healthcare
DISCUSSION
 Patients of physicians who encourage them to participate more actively in
the medical encounter and in treatment decisions enjoy more favourable
outcomes both physiologically and functionally (Tuckett et al., 1985).
 When the patient and physician agree on the nature of the problem and
the proposed solution, (i.e. diagnosis and treatment), the outcome is
enhanced.
 Women with breast cancer who were seen by surgeons offering patients a
choice between mastectomy and lumpectomy suffered less anxiety and
depression than patients seen by surgeons favouring either one or the
other (Lee et al., 2002).
Medical decision making preferences of 999 women with breast

cancer (Lee et al., 2002)
Theoretical model Decision making process %
Paternalistic Physician makes decisions 18
Physician as agent Physician makes decisions after considering patient‘s 17
input
Shared decision making Physician and patient make decision together 44
Informed decision making Patient makes decisions after considering physician‘s 14
input
Consumerism Patient makes decisions 9
37
Doctor-patient partnership agreement

To apply doctor-patient partnership more formally in patients with chronic
diseases, you may sign a contract or an agreement with the patient, example
below:
Doctor-Patient Partnership Agreement
OBJECTIVE
To better manage your hypertension through a doctor-patient partnership and goal setting.
REASON
Medical research and clinical experience have shown that optimal management of hypertension
significantly reduces the known complications of this disease, including heart attack, kidney
failure and stroke.
EXPECTATIONS
You can expect your physician to provide the following services, which are an essential part of
hypertension management.
Office visits - ………………..
Monitoring - …………………. Annual screening - …………………..
PERSONAL GOALS
Weight/Body Mass Index: Current: / Ideal: /
Blood pressure (< 140/90 mm/Hg): Current: Goal:
Total cholesterol (< 200 mg/dl): Current: _____ Goal: LDL (< 100 mg/dl):
Current: _____ Goal:___________
YOUR RESPONSIBILITIES
 Schedule follow-up appointments every three months or as indicated by your doctor.
 Monitor blood pressure at home at the agreed testing frequency.
 Work towards attaining the personal goals noted above.
Patient signature: ___________________ Date: _
Physician signature: Date: ________
RECOMMENDATION
Demonstrate to your patients you understand their situations and feelings by
showing empathy during consultation. Empathetic communication is one of the
most valued modalities of physician which help to ensure a trusting relationship
between a physician and his/her patients.
Physician counselling and listening skills could be enhanced by using a simple

five step process to gather information about the context of the patient‘s visit
by asking the patient: 1) What is happening in your life? 2) What are you
feelings about that (or how does it distress you)? 3) What is it about the
situation you find upsetting you most? And 4) How are you managing that?
Then, show understanding by observing: 5) ―I can perceive that must be very
challenging for you.‖ This method is identified by the abbreviation BATHE
(which stands for background, affect, trouble, handling, and empathy).
Attentive physicians, who maintain eye contact and provide positive cues,
encourage patients to open up to them easily.
38
Exercise 1
Role-play: With two colleagues, take turns being: (1) the doctor giving
nonverbal facilitation responses, (2) the patient pretending to have problems
and (3) the observer giving feedback using a 5-point scale. The observer must
rate every response given by the doctor. Stop the interaction after 4 or 5
responses have been rated. All three can discuss the good responses and how
a certain response could have been more effective.
Nonverbal Facilitation 1 2 3 4 5
1 Eye contact
2 Silence
3 Paralanguage
4 Facial expression
5 Touch
6 Posture & Gestures
Exercise 2
Role-play: With two colleagues, take turns being: (1) the doctor giving verbal
& nonverbal facilitation responses, (2) the patient pretending to have
problems and (3) the observer giving feedback using a 5-point scale. The
observer must rate every response given by the doctor. Stop the interaction
after 4 or 5 responses have been rated. All three can discuss the good
responses and a how certain response could have been more effective.
Verbal & Nonverbal Facilitation 1 2 3 4 5
1 Questioning
2 Probing
3 Confrontation
4 Paraphrasing
5 Verbal mirroring
6 Interpretation
7 Reflecting
8 Summarizing
9 Eye contact
10 Silence
11 Paralanguage
12 Facial expression
13 Touch
39
Exercise 3
Skills How
Show interest & respect
Recognize verbal and
non-verbal cues
Immediately respond to
patient‘s cues
Show support and care
Balance between
intimate & professional
relationship
Be flexible & respect
patient autonomy
Demonstrate
appropriate confidence
Control your judgmental
attitude
Respect patient
confidentiality
If patient attends with
his/her family: watch
family dynamic, and
build rapport with the
family
(Lang & Tennessee, 2002)
Exercise 4
Discuss the skills needed by physicians to maintain effective doctor-patient
relationship while conducting physical examination
Case 1
Examination of a child
 …………………………………………………………………………….
 …….………………………………………………………………………
 …………………………………………………………………………….
 …………………………………………………………………………….
 …………………………………………………………………………….
Case 2
Examination of an elderly patient
 …………………………………………………………………………….
40
 …….………………………………………………………………………
 …………………………………………………………………………….
 …………………………………………………………………………….
 …………………………………………………………………………….
Case 3
Examination of a patient of different gender than the doctor
 …………………………………………………………………………….
 …….………………………………………………………………………
 …………………………………………………………………………….
 …………………………………………………………………………….
 …………………………………………………………………………….
Case 4
Examination of an anxious patient
 …………………………………………………………………………….
 …….………………………………………………………………………
 …………………………………………………………………………….
 …………………………………………………………………………….
 …………………………………………………………………………….
Case 5
Examination of a patient in pain
 …………………………………………………………………………….
 …….………………………………………………………………………
 …………………………………………………………………………….
 …………………………………………………………………………….
 …………………………………………………………………………….
41
Exercise 5
From what we have discussed in the previous chapters, write 30 strategies,
verbal statements or nonverbal cues, which you may use during a consultation
that would positively affect your relationship with your patient.
1 16
2 17
3 18
4 19
5 20
6 21
7 22
8 23
9 24
10 25
11 26
12 27
13 28
14 29
15 30
NB: Remember to add feelings to your words
Exercise 6
empathic responses, (2) the patient pretending to have a variety of
problems and (3) the observer giving feedback to the empathizer using a 5-
point empathy scale. The observer must rate every response given by the
doctor. Stop the interaction after 4 or 5 empathic responses have been rated.
All three can discuss the good responses and how a certain response could
have been more effective.
Empathic Responses 1 2 3 4 5
N Naming the emotion
U Understanding & acknowledgement of suffering
R Respect and no criticism
S Support & silence
E Exploring and facilitating
42
Exercise 7
How to share decision-making with patients
Steps How
1. Define the problem that requires shared
decision
2. Legitimize patient involvement and
encourage his positive role
3. Outline the options: Describe one or
more treatment options and, if relevant, the
consequences of no treatment
4. Explore patient's ideas and encourage
questions
5. Negotiate mutually acceptable plan
6. Recognize patient's verbal and non-
verbal cues & respond to his cues
7. Frequently take feed back
8. Give patient enough time to make his
decision
Exercise 8
Discuss the below rapport building skills and their barriers
Skills Barriers
1. Establish the relationship
2. Facilitation
3. Building rapport
4. Empathy
5. Making use of physical examination
6. Partnership
7. Closing & maintaining the relationship
8. Preparation
Discuss possible strategies that would help you to overcome these barriers
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
43
Exercise 9
Concentrate entirely on the decision-making aspect of the below consultations:
Case scenario 1
1. Atrial fibrillation
Patient wants to know about the pros and cons of warfarin and aspirin for
prevention of stroke
Comments:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Case scenario 2
2. Benign prostatic hypertrophy
Patient wants to know more about the typical options that face a man who is
told that he has "prostatism," with no other risk factors
Comments:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Case scenario 3
3. Menopausal symptoms
Patient undecided about hormone replacement therapy and anxious about the
risk of breast cancer
Comments:
________________________________________________________________
________________________________________________________________
________________________________________________________________
FURTHER READING
Morgan M (2003). The Doctor-Patient relationship. In: Scambler G, editor,
Sociology as applied to Medicine. 5th ed. Saunders (W.B.) Co Ltd (Elsevier
Health Sciences). pp 55-70
http://faculty.ksu.edu.sa/nadalyousefi/communication%20skills/The%20Doctor
%E2%80%93Patient.pdf
)‫العالقح تين الطثية و المريط (من كتاب األسس العلميح لالستشارج الطثيح‬
44
BREAKING BAD NEWS
BREAKING BAD NEWS
INTRODUCTION
Bad news is defined as any information which adversely and seriously affects
an individual‘s view of their future; whether news is bad or not can only be in
the eye of the beholder (Buckman, 1992). Physicians need to develop the skill
of breaking bad news, as they will do it time and time again during their career.
During the past medical training, breaking bad news was not considered an
essential skill a physician needed to acquire and consequently, little attention
was focused on the topic during training period. However, this has of course
changed over the recent years and it has now become a primary part of
medical school curriculum. This is because studies have now shown that poor
communication, especially with patients diagnosed with life alerting diseases
such as cancer, was associated with worse clinical and psychosocial outcomes,
including worse pain control, worse adherence to treatment, confusion over
prognosis and dissatisfaction at not being involved in decision making (Hanratty
et al., 2012).
The information provided in this chapter can be used not only as a model for
communicating bad news to patients but it should also be implemented as a
model for communicating information to all patients.
TRAINING OBJECTIVES
 Improve physicians skills in communicating bad news
 Understand the importance of communicating bad news efficiently
 Understand how to relate the protocol to communicate any news
BREAKING BAD NEWS

Physicians need to individualize their manner of breaking bad news centred on
how serious the diagnosis is as well as the patient's desires and needs. To
break bad news, the physician must understand and master the skills and
ability required to recognise and respond to patient‘s emotions, support them
deal with the stress that the bad news creates while still being able to involve
the patient in any decisions while maintaining hope, where there may be little.
Many physicians find it difficult to convey bad news to their patients, especially
when it involves a life-threatening illness. Besides the verbal element of actually
conveying bad news, breaking bad news also requires a set of other skills; such
as: acknowledging and responding to the emotional reactions of patients,
getting the patient involved in the decision-making process, handling the stress
generated by patients' expectations for treatment/cure, participation of multiple
family members, and the perplexity of how to give hope when the
circumstances are desolate. However, delivering bad news in a direct and
caring way may improve the patient‘s as well as family‘s ability to plan and
cope, encourage realist goals and self-reliance, support the patient emotionally,
strengthen doctor-patient relationship and stimulate collaboration among the
45
BREAKING BAD NEWS
patient, family, physicians, and other professionals which would be involved in

the treatment or management process.
Described below is the recommended six-step protocol ―SPIKES‖ which has

been shown to improve clinicians‘ confidence when used to break bad news to
their patients. It is a gradual and soft method of breaking bad news to seriously
ill patients.
It is important that a physician asks, early in clinical relation, about his/her

patent‘s general preference(s) for the handling of medical information and
decision making before significant information needs to be shared.
6-STEP PROTOCOL - SPIKES

SPIKES 6-step protocol to clarify diagnosis and prognosis
Getting started
 Prepare yourself, the environment and patient‘s data readily
available.
 Arrange for some privacy, in an environment that is favourable
for effective communication.
Setting
 Involve significant others by inviting spouse, relative, friend, etc.
appropriately.
 Sit down.
 Make connection and establish rapport with the patient.
 Manage time constraints and avoid interruptions.
What does the patient know?
 Introduce yourself properly.
 Spend a few minutes establishing rapport.
Perception  Determine what the patient knows about his/her medical history
and assess what he/she suspects.
 Carefully listen to the patient‘s level of comprehension.
 Accept denial but do not confront at this stage because denial is
a healthy defence mechanism.
How much does the patient want to know?
 Await invitation from the patient to give information.
 Ask patient if he/she wishes to know the details of the medical
Invitation condition and/or treatment as well as how much he/she wishes
to know.
 Accept patient‘s right not to know.
 Offer to answer questions later if he/she wishes.
Sharing the information
 Give medical facts.
 Use language that is understandable by the patient.
Knowledge  Take into account the patient‘s educational level, socio-cultural
background, current emotional state.
 Share the information gradually, in small chunks and check
understanding.
46
BREAKING BAD NEWS
 Check whether the patient understood what you said

 Respond to the patient‘s reactions as they occur
 Give any positive aspects first e.g.: Cancer has not spread to
lymph nodes, highly responsive to therapy, treatment available
locally etc.
 Give facts accurately about treatment options, prognosis, costs
etc.
 Warning shots (Say it, and then stop speaking)
 Deliver the information in a sensitive but straightforward manner
Responding to feelings
 Explore emotions and sympathize
 Prepare to give an empathetic response:
1. Identify emotion expressed by the patient (sadness,
silence, shock etc.)
2. Identify cause/source of emotion
3. Give the patient time to express his/her feelings, then
respond in a way that demonstrates you have recognized
connection between 1 and 2.
Emotion  "I imagine this is difficult news..."
 "You appear to be angry. Can you tell me what you are feeling?"
 "Does this news frighten you?"
 "Tell me more about how you are feeling about what I just
said."
 "What worries you most?" "What does this news mean to you?"
 "I wish the news were different."
 "I'll try to help you."
 "Is there anyone you would like me to call? - Remind them that
their responses are normal
Planning and follow-up
 Close the interview
 Ask whether they want something else clarified.
 Establish a plan for the next steps.
Strategy 1. Gathering additional information
2. Performing further tests.
3. Treat current symptoms.
 Reassure the patient and family that you will be actively
engaged in an ongoing plan to help.
 Ensure that the patient will be safe when he/she leaves.
(Baile et al., 2000)
1. Getting started
Setting
To get started, as physician, you must first know and understand what you will
be discussing with the patient. Ensure that your medical facts about the illness
are up-to-date. Avoid interruptions and allocate adequate time for discussion,
arrange to hold telephone calls and pages. Ask your patient who else would
he/she like to have present for the discussion, such as: family, spouse, friend,
etc.
47
BREAKING BAD NEWS
2. What does the patient know?

Perception
Introduce yourself and spend a few minutes building rapport with the patient
and any other person present with him/her. Then once you feel the patient is
at ease, initiate the discussion by asking the patient what he/she knows about
his/her medical history to assess the patient‘s previous knowledge about
information given and/or recent investigations. This could be done through a
series of questions, such as:
 What do you know about your medical history, condition or any
procedures that you have had?
 Do you know the cause of your medical symptoms?
 What are your worries about your illness or symptoms?
 Do you think these symptoms are a result of something serious?
 What did the other physicians inform you about your health?
This would allow you to determine the patient‘s level of understanding, discover
what has happened since his/her last visit and how to proceed. Sometimes a
patient (or a guardian – mother, father, aunt, grandmother, etc.- if the patient
is a child) will fall silent and seem completely unprepared or unable to respond.
You can try to encourage discussion by clarifying the patient‘s understanding
about his/her health using the results of recent investigations/studies
conducted. However, if all your attempts to stimulate discussion are
unsuccessful and the patient remains silent, or if it appears that the patient
requires more support, such as the presence of a family member or others on
whom he/she relies on; it may be better to reschedule the meeting for another
time. Denial is a healthy defence mechanism, therefore, do not confront denial
at this stage.
3. How much does the patient want to know?

Invitation
Everyone handles information differently, depending on their race, society and
culture, level of education, religion and socioeconomic class. Ask your patient
how he/she would prefer to receive information about their health condition.
This could be either shared directly to the patient alone, in the presence of
someone else (family member, friend, etc.), or through a person who he/she
has designated to receive the information on his/her behalf. You can determine
this by using questions such as:
 In the event that these symptoms turn into something serious, would you
like to know?
 Do you want to know the full details of your condition? If not, can you
elect somebody else you would prefer I talk to?
 Are you ready to go over the results of the recent investigations now and
listen to what is exactly wrong?
It is important that the physician maintains eye contact with the patient to
explore the patients concerns and expectations as well as interpret the patient‘s
nonverbal signals (face/body language).
48
BREAKING BAD NEWS
4. Sharing information
Knowledge
When conveying your message, first try to see the world through the patient‘s
eyes; how would you feel if you were the patient? Convey the information in a
sensitive yet straightforward manner. Start communicating the bad news using
a warning shot, start with an opening sentence and then stop, this will prepare
the patient for what is to come. Avoid delivering all of the information in one
chunk, instead use staging to categorise the information to be given and
gradual delivery of the message in small chunks. Watch the pace, pause
frequently and check repeatedly for patient‘s understanding and feelings as you
proceed; do this in subsequent visits as well. Give the patient time to process it
all and ask questions about points he/she needs clarified. Give basic
information, simply and honestly; repeat important points if needed. Do not use
technical jargon or euphemisms; ensure you use simple language that is easy
to understand. Below is an example of how to use warning shots, staging and
finally break bad news.
 Doctor: (Warning shot) I'm afraid the news isn't very good.
 Patient: What do you mean?
 Doctor: (Staging) The bone marrow is not making the right type of blood
cells.
 Patient remains silent but looks at doctor enquiringly.
 Doctor: (Staging) There are underlying problems with the bone marrow
Patient: So what is it?
 Doctor: (Breaking the bad news) it‘s a type of leukaemia.
Use silence and body language as tools to facilitate the discussion. Try
recognising the feelings that lie behind the stunned silence. Avoid minimizing
the severity of the situation; a good-hearted attempt to ―mitigate the blow‖
may lead to ambiguity and misunderstanding. You might choose to break bad
news by using comments such as:
 Unfortunately, I‘m afraid the news is not good. The test results indicate
you have leukaemia.
 The test results are in and it‘s not what we had expected: it‘s pneumonia.
 I‘m afraid I have bad news for you. The results show that you have HIV.
Use safety netting (checking you have not missed anything and preparing a
contingency plan) to judge how much further information the patient wants and
in what way it can be usefully communicated. Try not to use the phrase ―I‘m
sorry‖ because this may be interpreted to imply that you as a physician is
responsible for the situation at hand. Furthermore, this may also be
misunderstood as pity or coldness, therefore, if you use the phrase modify it to
show empathy.
5. Responding to feelings
Emotions
Different people deal or respond to bad news differently; some cry, get angry,
feel sad or anxious, etc. Parents may become very emotional when thinking
about actually telling their child the diagnosis. Outbursts of strong emotion
49
BREAKING BAD NEWS
make many physicians uncomfortable. The physician must acknowledge,

recognise and be empathic about the patient‘s pain, grief or bewilderment, for
example by saying,
 ―You seem to be angry. Can you tell me what you are feeling?‖
 ―This must come as an awful shock to you."
 ―Are you frightened by this news?‖
 ―Is there anyone you would like for me to call?‖
 ―I‘ll help you tell your daughter.‖
Let the patient know it is alright to cry and express their feelings, if he/she
needs too. Try to break down devastating feelings into manageable concerns,
prioritising and distinguishing the fixable from the unfixable. Be aware of
unshared meanings, for example, what cancer means to a patient could be
different from what it actually means medically to a physician. Hold the
patient‘s hand, if appropriate. Offer a drink of water, cup of tea or anything
else that might be soothing. Assess and respond to the patient‘s as well as the
family's emotional reaction. Give realistic hope including both worst and best
scenarios (preparing for the worst and hoping for the best). Highlight any
positives help e.g. pain relief. Offer continuing support/ practical advice.
When sharing bad news to a patient, a physician must remember that he/she is
also human with emotions and feelings who is probably experiencing/
experienced a similar situation him/herself. Therefore, a physician must
remember to do ―housekeeping‖. Housekeeping is when a physician reviews
his/her own feelings, such as dealing with death or dying of a loved one or
patient, which is a major cause of stress for medical staff. It is acceptable for a
physician to shed a tear with his/her patients: it seems that patients gain
support in dealing with bad news when they perceive their informant is also
distressed and concerned. The professional statement of "not to get involved"
has encouraged emotional suppression within the profession that prevents the
doctor showing distress which could be harmful for the physician in the long
run.
6. Planning and follow-up

Strategy
At this stage of this 6-step protocol, the physician must be able to summarise
all that‘s been said and plan for the next steps such as: gathering additional
information or performing further tests, etc. The physician here could also:
 Help parents tell their child about their illness and what treatment would
be right for them.
 Arrange for appropriate referrals.
 Explain plans for additional treatment.
 Setup follow-up visit.
 Discuss potential sources of emotional and practical support, e.g. family,
significant others, friends, etc.
 Discuss sources of support for an ill child‘s siblings.
It is supportive to reassure the patient and family members that the physician
will not abandon them and that he/she will be there, actively engaged in the
50
BREAKING BAD NEWS
ongoing plan to help. Provide a telephone number that the patient and family
members can use to reach the physician in order to have answers to any
additional question.
Last but not least, the physician must ensure that the patient will be safe when
he/she leaves the clinic/hospital. Ensure the patient will be able to drive home
alone, whether the patient is distraught, feeling desperate or suicidal?
HOW TO DEAL WITH FAMILY THAT SAY “DON’T TELL”

Family members, at times, ask the physician not to tell the patient the
diagnosis or other critical information. However, even though it is the
physician‘s legal obligation to obtain informed consent from the patient stating
his/her decision to not know and have someone else receive any bad news, an
effective beneficial relationship requires a friendly alliance with the family.
Instead of opposing their request with ―I must tell the patient,‖ request them to
explain why they do not want to tell the patient, what it is they are afraid will
be said to the patient and what was their experience in regards to bad news in
the past. A physician must also inquire whether there is a personal, cultural, or
religious context to family members‘ concern. Recommend to the family
members that everyone (including the physician) all go to the patient together
to ask how much he/she wants to know about his/her health and what
questions there might be. Such situations may require significant negotiation.
In particularly difficult cases, support from the institution ethics committee may
be very helpful. Eventually, it could be decided, after discussion with the
patient, which specifics of diagnosis and prognosis and treatment decision will
be discussed only to the family. However, unless the patient has previously
indicated that he/she wants no information, concealing diagnosis or important
information about prognosis or treatment from the patient is neither ethical nor
legally acceptable. Physicians do not need to feel forced to practice in a manner
that compromises care or feels unethical. If the physician and the family cannot
come to agreement, the physician may choose to withdraw from the case and
transfer care to another physician.
When dealing with a pediatric patient, the parents may not wish to inform the
child about the illness. This caring instinct is comprehensible, but it may
ultimately be problematic because, as the child undergoes treatment and
procedures, he/she will perceive there is a problem. When this happens, it
could make the child feel distrustful and misled. To avoid such situations, a
better approach would be to help the parents understand this possibilty is likely
to occur. To help the parents in break bad news to a child, get a child
psychology staff member available along with the medical team to
communicate important medical information to the child at an age-appropriate
level.
There are several ethnic and cultural differences in the preferred handling of
information. While knowledge of such differences is useful as background,
international conclusions about them rarely help with decision making for an
individual. A patient should be asked about his/her general preferences for the
handling of medical information and decision making early in the clinical
51
BREAKING BAD NEWS
relationship before important information needs to be conveyed. This will help

the physician avoid making a mistake in this regard.
SUMMARY
When breaking bad news is challenging with or without training, however,
physicians can improve patient satisfaction as well as their own satisfaction by
using the following simple memory aid, ABCDE, to provide courage and healing
to patients receiving bad news:
 Advance preparation: Adequate time and privacy must be arranged,
medical facts ought to be confirmed, relevant clinical data should be
reviewed, and the physician must emotionally prepare him/herself for the
encounter.
 Build a therapeutic relationship: Patient preferences regarding the
disclosure of bad news must be established early on in clinical relationship.
 Communicate well: Determine the patient's knowledge and
understanding of the situation, proceed at the patient's pace, avoid
medical jargon or euphemisms, allow for silence and tears, and answer
questions.
 Deal with patient and family reactions: Assess and respond to
emotional reactions and empathise with the patient.
 Encourage/validate emotions: Offer realistic hope based on the
patient's goals and deal with your own needs.
Don‟ts
 Do not make assumptions about:
 The impact of the news on the patient
 The patient‘s readiness to hear the news
 Who else should be present when breaking bad news
 Patient‘s understanding
 Do not give the patient too much information at one time.
 Do not give inappropriate reassurances/false hope.
 Do not hurry or rush the patient.
 Do not use medical jargon, e.g. ulcer, etc.
 Do not break the bad news to relatives before telling the patient unless
this has already been agreed upon in early clinical relationship or when
there is a justifiable reason.
 Do not collude with the family.
REASSURANCE SKILLS
Supportive comments are not enough for effective reassurance. Credibility is
not just a package of skills. Credibility is the reflection of our beliefs and values.
Here are a few points we shall discuss to enhance reassurance skills
Doctor as a drug
The pharmacology of doctor-patient relationship can be therapeutic if the
physician uses his/her authority for reassurance, and it can be toxic if it is used
in high-doses and it can also cause patient dependency (Balint, 1957).
52
BREAKING BAD NEWS
Art of reassurance
1. Effective doctor-patient relationship
a. Credibility and trust: Doctor needs to gain the trust of his/her
patient in order to be effective in his/her reassurance. And the
patient needs to look up to his/her credible physician in order to
believe him/her.
b. Caring support: This can be done verbally by using positive
comments, e.g. ―it is your right to feel this way‖, ―I will do my best to
deal with this problem‖, ―I am your doctor and helping you is my
duty‖. This can also be done nonverbally through touch (if
appropriate), e.g. holding the patient‘s hand, helping the patient
before and after physical examination.
c. Accessibility: It is very important, for effective reassurance, to have
reasonable access to the doctor if a patient need‘s him/her;
otherwise the patient may feel neglected and face his/her problem(s)
alone. This accessibility can be through telephone consultation, if
needed, or in a following appointment.
2. Exploration and good listening tips
a. Fears: Encourage the patient to talk about his/her fears without
interruption or judgment.
b. Hidden agenda: Try to be sensitive to any verbal or nonverbal cues
in order to ask for any possible hidden agenda.
3. Physical examination
a. There is no effective reassurance without physical examination.
Doctor will lose credibility if he/she tells the patient ―you are ok‖
―there is nothing to worry about‖ without doing a physical
examination.
b. Remember the magical effect of touch and exhibition of concern.
4. Explaining and giving reassuring information.
a. Avoid jargon, when naming the diagnosis.
b. Explain how common it is.
c. Answering patient's questions and uncertainty.
d. Discuss prognosis in a positive objective approach.
e. Discuss the available treatment options.
f. Empowering patients through positive thinking and faith.
5. Offer appropriate management option (care if you cannot cure).
a. Treat the disease.
b. Control the symptoms.
c. Support psychotherapy or counselling if needed and use referral
when appropriate.
53
BREAKING BAD NEWS
Exercise 1
Case scenario 1
Mrs. Badria aged 39 years, pregnant for the first time. At 30 weeks‘ gestation,
you diagnosed IUFD.
Q1. Speculate how this patient may feel.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Q2. Discuss possible strategies in dealing with this patient.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Q3. Suggest some specific verbal and nonverbal skills.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Case scenario 2
Mr. Badr aged 39 years; investigations confirmed that he has AIDS
Q1. Speculate possible problems this consultation may raise.
________________________________________________________________
________________________________________________________________
________________________________________________________________
54
BREAKING BAD NEWS
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Case scenario 3
Mohammed is an 8-year-old lovely boy, he needs heart transplantation
Q1. Speculate possible problems in communicating with his parents.
________________________________________________________________
________________________________________________________________
________________________________________________________________
Q2. Discuss possible strategies in dealing these problems.
________________________________________________________________
________________________________________________________________
________________________________________________________________
55
BREAKING BAD NEWS
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Case scenario 4
Mrs. Badria, a 32-year-old lady with frequent somatic symptoms attends with a
history of headache for the past 5 years. It appears to be tension headaches.
She asks for a CT scan.
Q1. Discuss the patient‘s feelings.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Q2. How would you proceed?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Case scenario 5
Mrs. Salma is a 40-year old lady. She has a large uterine fibroid, attending
today to discuss with you the hysterectomy operation.
Q1. Discuss the patient‘s feelings.
________________________________________________________________
________________________________________________________________
56
BREAKING BAD NEWS
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Exercise 2
Write 30 strategies that may help physicians to increase their credibility and
be more effective in reassurance:
Verbal communication skills
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Nonverbal communication skills
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
57
BREAKING BAD NEWS
Clinical competence
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Professionalism
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Dynamism
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
FURTHER READING
)‫مهاراخ تثليغ الخثر السيء (من كتاب األسس العلميح لالستشارج الطثيح‬
58
Consultation models
CONSULTATION MODELS
INTRODUCTION
Consultation models help add structure to a consultation, averting it from going
everywhere and deteriorating into a chaotic mess. Consultation models allow us
to understand the patient‘s perspective which consequently leads to better
doctor-patient understanding that ultimately results in better harmony and less
patient complaints.
During the last 30 years, many consultation models have been developed.
These models vary in their content, psychometric properties and usability but
they all have three points in common: information input, information processor,
and output of results. There is little agreement on the ideal model, as no single
model covers all consultation tasks and skills. Listed below are different
consultation models generated through the past decades:
1. Balint (pronounced Bay-lint) (1957)
2. Transactional Analysis (TA) (1964)
3. The Triaxial Model (1972)
4. Health Belief Model (1975)
5. Six Category Intervention Analysis (1976)
6. Byrne and Long (1976)
7. Stott and Davis (1979)
8. Helman‘s ‗Folk-Model‘ (1981)
9. Pendleton, Schofield, Tate and Havelock (1984)
10. McWhinney‘s Disease-Illness model (1984)
11. Problem Based Interviewing (1985)
12. Neighbour (1987)
13. The Three Function Model (1990)
14. Tate‘s Model (1994)
15. The Calgary Cambridge Model (1996)
16. Neurolinguistic Programming (NLP), (2002)
17. Narrative Medicine (2002)
18. BARD Model (2002)
In this chapter, we present only a few of the most commonly used models with
brief comments and discussion.
TRAINING OBJECTIVES
 Familiarise you with the different consultation models (past and present).
 Help you build consultation model that best fits your professional needs.
CONSULTATION MODELS
Traditional Medical Consultation Model
This type of model is purely basic approach to managing patients, where the
disease and diagnostic process are of principal importance. It does not consider
the patient‘s thoughts or feelings, neither does it consider what is happening in
their lives. It‘s purely a functional model to do the main job of sorting out the
59
Consultation models
problem, not necessarily the patient. Basically this model is not interested in
the patient‘s illness; it‘s only interested in sorting out the problem.
Disease Management Chief

complaint
• Investigation(s) History of
• Prescription(s) the present
• Follow-up appointment complaint
Biological Family
diagnosis Traditional history
Medical
Consultation
Personal and
Systems
social
review
history
Cons
Drug and
allergy
history
Past medical
history Pros
Pyscho-social perspective of
presenting complaint ignored.
Could fail to discover diagnosis

It sort the main
problem out
Fails to regards the doctor as a person
who has feelings. Medically all-inclusive
Fails to regard the patient as a human being It is structured

with feelings, concerns and a schedule too.
It is not an effective time saving approach,
as it covers areas which may have little
relevance.
Byrne & Long Model, 1976

Byrne and Long analysed 2,500 audio-tape consultations from over 100 GPs in
New Zealand and the UK. They identified styles of consultations:
 Doctor-centred consultation: The doctor was more likely to make the
decision for the patient and instruct him to seek some service.
 Patient-centred consultation: The doctor was more likely to seek the
patient‘s views and permit him/her to make his/her own decision
concerning the outcome.
 Negative behaviour: Failure to explore the real reason of the patient‘s
problem by not listening, evading patient‘s questions, etc.
Their model was the first consultation to consider specifically the task of
introducing and concluding the consultation. They formulated a framework of
six tasks or ‗fields to be covered‘ for any consultation.
60
Consultation models
Phase I: The doctor

establishes a relationship
with the patient.
Phase VI: The Phase II: The doctor
consultation is either attempts or
terminated usually by actually discovers the
the doctor. reason for the patient’s
attendance.
6 phases of
the
consultation
Phase V: The doctor, and Phase III: The doctor
occasionally the patient, conducts a verbal or
detail further treatment or physical examination or
further investigation. both.
Phase IV: The doctor,
doctor and patient, or
the patient (in that
Cons Pros
order) consider the
condition.
Attempts to include patient's thoughts

Tasks still predominatly doctor-centered
Focus of consultation turned towards illness
Expanded Model (Stott & Davis, 1979)

The exceptional potential in each consultation suggests that four areas can be
systematically explored each time a patient consults. (Stott & Davis, 1979)
Managment of
presenting e.g. BP checking,
e.g. vaccinations, problems alcohol history,
smears, smoking
smoking history, state
advice, etc.
of marital relations
Oppurtunistic Expanded Management

health of continuing
promotion model probems
Educating the patient about

the natural history of the Modification of
illness, self-medication of help seeking
minor illnesses, better use of behaviour
the practice appointment
system
61
Consultation models
Example: Mrs. Salma is a 70-year-old lady with DM. She sends her daughter,
who requests a repeat prescription of glibenclamide and paracetamol for her
arthritis. You noticed that Mrs. Salma did not come to the clinic since last year,
what do you do?
1. What are the presenting problems? 2. What are the continuous problems?
 Repeat prescription  DM
 Possible elderly neglect  Arthritis
3. Is there any help seeking behaviour 4. What is the appropriate screening
that needs modification? and health promotion?
 No compliance with appointment  Hearing and vision, renal disease.
 Cognitive impairment.
 Pneumococcal vaccine, influenza
vaccine, etc.
Examples of help seeking behaviour that need modifications:

 Denial: Some patients unconsciously forget about their health problems
and act as if they did not exist. This psychological defence mechanism
leads to poor compliance with management plan.
 Displacement: Some patients use another psychological defence
mechanism called displacement, instead of complaining directly of the real
reason for their problem, e.g. embarrassing physical, psychological or
social problems, they bring a ticket to their physician like: backache or
headache, or they may bring their children, complaining of a variety of
illogical problems (Balint, 1957).
Disease-Illness Model (McWhinney, 1984)

The Disease-illness Model attempts to provide a practical way of transforming
clinical method to a more ‗patient-centred clinical interviewing‘ by putting
together two approaches: the patient‘s experience of the illness and the
traditional biomedical history consultation. This model helps you realise that
disease is the cause of sickness whereas illness is the unique experience of the
sickness.
Disease
framework
Patient presents (Doctor's agenda)
problem Symptoms Differential
Signs diagnosis
Investigations
Underlying
Gathering pathology
information
Integration of the two frameworks
Collaborative explanation and planning
Shared understanding and decision-making
Parallel search of
two frameworks Illness framework
(Patient‘s agenda)
Ideas
Concerns
Expectations Explanation and
Investigations planning in terms that
Feelings the patient can
Thoughts understand and accept
Effect
62
Consultation models
 This model is patient-centred.

 It emphasizes the importance of exploring the patient‘s perspective of
his/her illness (ideas, concerns, feelings, thoughts and the effect of the
problem).
 Diagnosis depends on objective and subjective data gathering (doctor
impression and patient feelings) as well as psychosocial data.
Discussion
 Organic disease fails to explain many patients' problems: About a third of
the patients who present to the Emergency Department with chest pain
have a current psychiatric disorder and that psychiatric disorders among
chest pain patients are associated with a high rate of Emergency
Department utilization for chest pain evaluations (Wulsin & Yingling,
1991).
 Eliciting patient beliefs about their illness is the key to enabling the patient
to understand and recall information.
 Undiscovered discordance between the health beliefs of patients and
physicians can lead to a problem in patient's satisfaction as well as
patient‘s compliance and outcome (Wulsin & Yingling, 1991).
Cons Pros
Nice simple practical framework
Takes a little extra time and commitment
Provides a balance between satisfying
both doctor‘s and patient‘s agendas
Both patient and doctor happy
7-Task Model (Pendleton, 1984)

In Pendleton‘s model, the personal and psychological aspects of the illness are
further developed. The model describes 7 tasks: the first 5 tasks are concerned
with what the doctor needs to achieve and the final two deal with the use of
time/resources and creating an effective relationship.
Tasks Details
The First Task  The patient's problem:
To understand the reasons for patient  It's nature & history
attendance  It's aetiology
 It's effects
 The patient perspective:
 Personal and social circumstances
 Ideas and values about health
 Ideas about the problem
 Concerns about the problem
 Expectations
63
Consultation models
The Second Task  Continuing problems

To achieve a shared understanding  At-risk factors
The Third Task  Options and implications
To choose an appropriate action for each
problem
The Fourth Task  Discuss the patient ability
To enable the patient to manage the  Agree about responsibilities
problem  Agree about targets
The Fifth Task  Not yet presented
To consider other problems  Continuing problems
 At-risk factors
The Sixth Task  In the consultation
To use time appropriately  In the long term
The Seventh Task  Welcoming (positive first impression)
To establish or maintain the relationship  Closing (positive last impression)
Cons Pros
Patient‘s thoughts assume an
Although set out in logical sequence, not all important role in this model.
consultations will follow this order.
Not particularly appropriate for acute settings It encourages patient responsibility

like emergencies.
Both patient and doctor happy
Inner Consultation (Neighbour, 1987)
1. Connecting -
Rapport Building
Skills
5. Housekeeping -
Stress 2. Summarising -
Management Skills Eliciting Skills
3. Handing-over -
4. Safety-netting -
Communication
Predicting Skills
Skills
Neighbour's 5-stage consultation model
64
Consultation models
 Connecting: Establishing relationship with the patient by viewing the

world from his/her perspective.
 Summarizing: Determining why the patient has come using eliciting
skills to discover their ideas, concerns, expectations and summarising back
to the patient.
 Handing-over: Sharing vital and important information, in addition to,
returning control and responsibility to the patient by involving him/her in
management/decision-making process.
 Safety-netting: Anticipatory care, by checking you have not missed
anything and making a contingency plan. Consider ‗What if?‘ scenarios.
 Housekeeping: Checking and dealing with your own emotions and
stress.
The Doctor‟s Two Heads

Neighbour describes the two different heads of a doctor during consultation.
Physicians need to find a way to balance the two heads together for a smooth
and fruitful consultation.
1. One is entitled the Organiser which is the doctor-centred head busy trying
to:
 manage the organisation of the consultation,
 asking questions and deciding to examine
 planning and negotiating clinical management
 time keeping – i.e. slowing down and speeding up consultations
 and making records.
2. The other head is called the Responder which is the patient-centred head
trying to make sure he/she is:
 Being attentive by listening to the patient properly
 Taking time to think and process information
 Creating and testing ideas
 Being empathic towards the patient.
Cons Pros
Empowers the patient by ensuring
Is a bit doctor-centred at times the doctor hands back responsibility
The 5 checklists are easy to remember.
A good starter for new trainees.
The first model to recognise the importance of
safe doctoring (safety-netting) and being a
healthy doctor (housekeeping).
Three-Function Model (Cole & Bird, 1990)

Cohen-Cole and Bird developed a consultation model that has been adopted by
The American Academy of Physicians for teaching the Medical Interview. Each
of the below functions is served by a set of skills as listed in the table below.
1. Gathering data to understand the patient‘s problems.
2. Developing rapport and responding to patient‘s emotions.
3. Patient education and motivation.
65
Consultation models
Function Skills
Gathering data  Open-ended questions
Here is where the physician understands the  Open to closed one
patient‘s problems, by conducting an accurate  Facilitation
interview. Understanding the patient‘s  Checking
personal and social context would not only be  Survey of problems
useful for diagnosis but also to establish a  Negotiate priorities
suitable treatment plan.  Clarification and direction
 Summarizing
 Elicit patient‘s expectations
 Elicit patient‘s ideas about aetiology
 Elicit impact of illness on patient‘s quality
of life
Developing rapport  Reflection
This is a crucial part in this model, where the  Legitimating
physician carefully handles the relationship  Support
component of communication and the  Partnership
patient‘s emotion to promote a positive  Respect
doctor-patient relationship using five types of
empathic responses (expressed verbally or
nonverbally).
Education and motivation  Eliciting patient‘s existing views and
In this last function, the physician stimulates knowledge
and educates the patient to develop a clear  Education about illness
and shared understanding about the nature  Negotiation and maintenance of a
of the problems, what must be done about treatment plan
them and a shared commitment to carry this  Motivation of non-adherent patients
out with better patient agreement and
cooperation.
Calgary-Cambridge Model (Kurtz & Silverman, 1996)

Suzanne Kurtz & Jonathan Silverman developed a model of the consultation,
encapsulated within a practical teaching tool, the Calgary Cambridge
Observation Guides. The guide is continuing to evolve and now includes
structuring the consultation. The guides define the content of a communication
skills curriculum by describing and structuring the skills that have been shown
by research and theory to aid doctor-patient communication. The guides also
make available a concise and accessible summary for facilitators and learners
alike which can be used as an aide-memoire during teaching session.
Framework of the Calgary-Cambridge Guide

(Kurtz & Silverman, 1996)
This model identifies five steps in a consultation. These steps are needed to
provide structure to an interview and build a relationship with a patient. It
identifies a number of specific skills (behaviours) a doctor should practice.
1. Initiating the Session
 Establishing initial rapport
 Identifying the real reason(s) for consultation
2. Gathering Information
 Exploration of problems
66
Consultation models
 Understanding the patient's perspective

 Providing structure of the consultation
3. Building the Relationship
 Developing rapport
 Involving the patient
4. Explanation and Planning
 Providing the correct amount and type of information
 Aiding accurate recall and understanding
 Achieving a shared understanding: incorporating the patient's
perspective (illness framework)
 Shared decision-making
5. Closing the Session
 Summary
 Contract
 Safety-netting
 Final check
Revised Content Guide to the Medical Interview (Calgary-Cambridge)
(Kurtz et al., 2003)
In 2003, this model was revised to highlight both process and content
components of the three-function model by combining the ‗old‘ content with the
‗new‘ content of the patient‘s perspective. It also includes a place for physical
examination; eliciting both biomedical disease process and the patient‘s
perspective, emphasising them as essential components of medical history.
1. Patient‟s problem list
2. Exploration of patient‟s problems
 Medical perspective - disease
 Sequence of events
 Symptom analysis
 Relevant systems review
 Patient‘s perspective - illness
 Ideas and beliefs
 Concerns
 Expectations
 Effects on life
 Feelings
3. Background information - context
 Past medical history
 Drug and allergy history
 Family history
 Personal and social history
 Review of systems
5. Differential diagnosis - hypotheses (including both disease and
illness issues)
6. Physician‟s plan of management
 Investigations
 Treatment alternatives
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Consultation models
7. Explanation and planning with patient

 What the patient has been told
 Plan of action negotiated
This model is patient-centred where doctor-patient relationship is essential

through the entire consultation. It emphasizes the importance of negotiating
management options, explanation and planning. It also highlights the
importance of providing structure to a consultation, the importance of skilful
initiation as well as closure of a consultation. The complete checklist contains
71 skills which are highly recommended for physicians to read as well as use
accordingly within their interview.
Summary of Calgary-Cambridge Observation Guide

The summary is concise, clear, simple and practical for teaching, assessment
and evaluation. The summary can also be used in several clinical contexts and
at several educational levels.
TOPIC COMMENTS COMPETENCY

PREPARING FOR THE SESSION
Housekeeping etc. 1 2 3 | 4 5 6 | 7 8 9
INITIATING THE SESSION

Greets patient 1 2 3 | 4 5 6 | 7 8 9
Introduces self, role 1 2 3 | 4 5 6 | 7 8 9
Demonstrates respect 1 2 3 | 4 5 6 | 7 8 9
IDENTIFYING REASON (S) FOR THE CONSULTATION

Identifies problems with appropriate 1 2 3 | 4 5 6 | 7 8 9
opening question
Listens, no interruption 1 2 3 | 4 5 6 | 7 8 9
Confirms list and screens for other 1 2 3 | 4 5 6 | 7 8 9

problems early
Negotiates agenda 1 2 3 | 4 5 6 | 7 8 9
GATHERING INFORMATION
Encourages patient to tell story, in own 1 2 3 | 4 5 6 | 7 8 9
words, clarifying reason for attending
now
Uses open and closed question 1 2 3 | 4 5 6 | 7 8 9
technique
Listens 1 2 3 | 4 5 6 | 7 8 9
Facilitates – verbal and non-verbal 1 2 3 | 4 5 6 | 7 8 9

responses, use of silence, repetition
etc.
Picks up verbal and non-verbal cues 1 2 3 | 4 5 6 | 7 8 9
Clarifies patient understanding 1 2 3 | 4 5 6 | 7 8 9
68
Consultation models
Periodically summarizes 1 2 3 | 4 5 6 | 7 8 9
Uses concise, easily understood, jargon 1 2 3 | 4 5 6 | 7 8 9

free
Establishes dates and sequence of 1 2 3 | 4 5 6 | 7 8 9
events
Ideas, concerns, expectations 1 2 3 | 4 5 6 | 7 8 9
Encourages patient to express feelings 1 2 3 | 4 5 6 | 7 8 9
PROVIDING STRUCTURE
Summarizes to confirm understanding 1 2 3 | 4 5 6 | 7 8 9
Progresses from one section to another 1 2 3 | 4 5 6 | 7 8 9

using sign posting, transitional
statements
Structures interview in logical sequence 1 2 3 | 4 5 6 | 7 8 9
Attends to time keeping, and keeping 1 2 3 | 4 5 6 | 7 8 9

interview on task
BUILDING RELATIONSHIP
Uses appropriate non-verbal behaviour 1 2 3 | 4 5 6 | 7 8 9
Develop Rapport – Accepts beliefs, 1 2 3 | 4 5 6 | 7 8 9

empathy, provide support, deals
sensitively.
Involves the patient – shares thinking, 1 2 3 | 4 5 6 | 7 8 9
explains rationale, explains process
during physical exam
EXPLANATION AND PLANNING
Provides correct amount and type of 1 2 3 | 4 5 6 | 7 8 9
information
Aids accurate recall and understanding 1 2 3 | 4 5 6 | 7 8 9
Achieves a shared understanding – 1 2 3 | 4 5 6 | 7 8 9

involving patient perspective
Shared decision making in planning 1 2 3 | 4 5 6 | 7 8 9
CLOSING THE SESSION

Forward planning, safety netting 1 2 3 | 4 5 6 | 7 8 9
Ensuring appropriate point of closure – 1 2 3 | 4 5 6 | 7 8 9

summarizing, final check
Patient-Centred Interviewing (Smith et al., 2001)

In 2000, Smith et al., established an evidence-based method for conducting a
patient-centred interview with the following benefits:
1. Effective patient-centred interviewing improves health outcomes (Kaplan
et al., 1989).
69
Consultation models
2. It improves patients‘ quality-of-life and satisfaction as well as increases

physicians‘ professional and personal satisfaction (Suchman et al., 1988;
Hall et al., 1988).
3. Decreases medical liability claims (Valent et al., 1988).
Comprehensive Clinical Method
Integrated Patient-Centred and Doctor-Centred Interviewing

Basic Patient-Centred Interviewing Basic Skills for Patient-Centred
Method Interviewing
1. Setting the stage for the interview Nonfocusing open-ended skills
a. Welcome the patient  Silence
b. Use the patient‘s name  Nonverbal encouragement (head
c. Self-introduction and speciﬁc role nodding, leaning forward)
d. Ensure patient readiness and privacy  Neutral utterances, continuers (―um-
e. Remove barriers to communication hmm‖)
f. Ensure comfort and put patient at
ease
2. Chief complaint/Agenda-setting Focusing open-ended skills
a. Indicate time available  Reflection, echoing (e.g., patient
b. Indicate own needs; obtain a list of says: ―I‘m worried;‖ physician echoes,
all the issues the patient wants to ―Worried?‖)
discuss  Open-ended requests (―Can you say
c. Summarize agenda more about that?‖)
d. Negotiate agenda items to be  Summary, paraphrasing
covered in future visits if list is too
long
3. Opening the history of present Emotion-seeking skills
illness (HPI)  Direct (―How did that make you
a. Open-ended beginning question/ feel?‖)
statement  Indirect: self-disclosure, impact on
b. Use open-ended skills to encourage life, impact on others, and belief
story about problem
4. Continuing the HPI Emotion-handling skills (NURS)
a. Develop physical symptom story  Naming, labelling (e.g., ―You sound
b. Focus on impact of symptom on sad.‖)
patient‘s life  Understanding, legitimation (e.g., ‖I
c. Determine emotion caused by this can sure understand why . . .‖)
impact  Respecting, praising (e.g., ―You have
d. Address emotion been through a lot.‖)
i. Name  Supporting, partnership (e.g., ―I am
ii. Understand here to help you any way I can.‖)
iii. Respect
iv. Support
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Consultation models
5. Transition to clinician-centred
interview
a. Brief summary
b. Check accuracy
c. Indicate that style and content of
interview will change
d. Begin doctor-centred interview
(Smith, 1996)
The New Comprehensive Clinical Consultation Model

This model integrates the traditional clinical method with effective
communication skills, making good use of all the previous models, to help
physicians create a model that best matches their needs. The aim of this model
is to complement and not to destruct your traditional model of consultation.
TRADITIONAL COMPLEMENTARY
MEDICAL MODEL CONTENTS
Chief complaint Real reason for patient attendance

Patient‘s ideas
Concerns
+ Expectations
+
History of the present complaint Effect & feelings
Past medical history

Family history
+ Continuous problem
Establishing and maintaining effective

Personal & Social history
Risk Assessment
Drug and allergy history
Systems review
Physical Examination +
Biological diagnosis + Psycho-social diagnosis +
Patient Management
+ Explanation—Health education
Reassurance—Health promotion
+
Modification of help seeking behaviours
Disease Management
Investigation
Prescribing
Follow-up
+ Management of time and Resources +
Housekeeping
+ Management of physician's feelings +
DOCTOR-CENTRED PATIENT-CENTRED
The criteria of the new comprehensive consultation model

1. It is comprehensive and it integrates traditional clinical method with
effective communication skills (patient-centred + doctor-centred)
2. It makes good use of all existing models. So the new comprehensive
consultation model incorporates some important contents and skills not
considered in the previous consultation models:
71
Consultation models
 Establishing and maintaining effective doctor-patient relationship is

considered as an important task (Pandleton Model)
 Opportunistic health promotion. It should be every physician‘s
business in all specialties (Stott & Davis Model)
 Managing continuous problem (Stott & Davis Model)
 Modification of help-seeking behaviour (Stott & Davis Model)
 Management of time and resources (Pandleton Model)
 Management of physician‘s feeling (housekeeping) (Neighbour‘s
Model)
3. It adds important contents and skills not covered enough in the previous
consultation models:
 Making use of physical examination as part of doctor-patient
relationship.
 Preparation before seeing the patient (preparing yourself, place,
patient‘s data)
 Consider reassurance as an essential part of patient management is
as important as prescribing medication and ordering investigation(s)
(Balint, 1957).
4. It complements and it does not destruct or neglect the traditional
biological model of most practicing physicians
5. As this model is built on what the learners already know, this will make
the process of training more enjoyable and the behaviour change more
attainable
6. It is simple and practical
This model is a summary of my Arabic book entitled:

‫كتاب األسس العلميح لالستشارج الطثيح‬
The New Comprehensive Consultation Model

Integration of communication skills with medical records
1. Chief complaint
2. History of the present complaint
3. Patient‘s ideas, concerns, expectations and feelings
4. Risk assessment and continuous problems
5. Past medical history
6. Family history
7. Social history
8. Systems review
9. Drug and allergy
11. Bio-psycho-social diagnosis
12. Disease and patient management
Tasks done but not written in medical records

1. Doctor-patient relationship
2. Management of time and resources
3. Management of doctor feelings (Housekeeping)
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Consultation models
Exercise 1
Q1. What are the missing skills in the traditional medical model?
________________________________________________________________
________________________________________________________________
________________________________________________________________
Q2. Why is it that 50% of the patients do not take their medicine?
________________________________________________________________
Q3. Why is it that 40% of the patients express their lack of satisfaction?
________________________________________________________________
Q4. How can you reassure your patients more effectively?
________________________________________________________________
Q54. Does the patient's complaint always have a biological explanation?
________________________________________________________________
Q6. If you are in doubt about diagnosis, what is the role of the patient?
________________________________________________________________
Q7. How can you manage if you have only 5-10 minutes for each patient?
________________________________________________________________
Q8. How can an unsatisfied physician satisfy his/her patients?
________________________________________________________________
Exercise 2
Read the following case scenarios, and discuss how you can apply the
expanded model of consultation for each patient?
Case scenario 1
1. A 65-year-old retired military officer rarely visits the practice, he came
today with back pain, headache and generalized weakness.
3. Is there any help seeking behaviour 4. What is the appropriate screening and
requiring modification? health promotion?
1._______________________________________________________________
2._______________________________________________________________
73
Consultation models
3. ______________________________________________________________
4. ______________________________________________________________
Case scenario 2
2. Sameera is a 14-month-old girl, her mother is very anxious because
Sameera cannot walk independently till now. She demands that something
be done about this. Sameera is the youngest of five children. Her father is
unemployed.
1._______________________________________________________________
2._______________________________________________________________
3. ______________________________________________________________
4. ______________________________________________________________
Case scenario 3
3. Mrs. Hala is a 28-year-old lady, recently married, presents with vaginal
discharge.
1._______________________________________________________________
2._______________________________________________________________
3. ______________________________________________________________
4. ______________________________________________________________
Exercise 3
The Comprehensive Consultation Model: Self-evaluation form

Tasks 0 1 2
2. Facilitation
3. Building rapport
4. Empathy
74
Consultation models
6. Partnership
8. Preparation
Comprehensive Bio-psycho-social Diagnosis
9. Gathering information about disease & illness
10. Broad thinking and exclusion of important differential diagnosis
11. Exclusion of possible serious complications
12. Identification of at risk factors & continuous problems
Comprehensive Management
Patient Management:
13. Explanation and Health Education
14. Reassurance: (remember: you are the most effective drug)
15. Health Promotion
16. Modification of help-seeking behaviour (denial, displacement)
Disease Management
17. Intervention by investigations or treatment
18. Management of time & management of resources
19. Management of doctor‘s feelings (house-keeping)
0= not done 1= done but not good enough 2= perfectly done
Write your feelings about your performance:
________________________________________________________________
________________________________________________________________
Important areas of strength and areas that need improvement:
________________________________________________________________
________________________________________________________________
Your specific learning needs and your action plan:
________________________________________________________________
________________________________________________________________
Exercise 4
Match the left list (Consultation Models) with the appropriate part of the right
list (Characteristics):
Consultation Models Characteristics
A. Traditional Medical Model 1. Doctor as a drug
B. Disease-Illness Model 2. Doctor as an educator
C. Calgary-Cambridge Guide 3. Patient as a partner
D. Inner Consultation 4. Doctor has feelings
E. Stott & Davis 5. Patient as a case
F. Pendleton 6. Consultation has two sets of content‖
G. Balint 7. Consultation has structure
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Consultation models
FURTHER READING
1. Putting Communication Skills to Work
2. The Medical Interview - Evidence-Based Interviewing Method - A practical
guide to teaching and assessing the ACGME Core Competency
3. ‫مناهج االستشارج الطثيح و نهج الطثية الحاذق (من كتاب األسس العلميح‬
)‫لالستشارج الطثيح‬
76
Reinforcement & Self-Assessment
REINFORCEMENT & SELF-ASSESSMENT
Practicing consultation skills with simulated patients leads to the acquisition of

skills. However, physicians do not transfer these learned skills to clinical
practice as comprehensively as they should.
Current evidence suggests that a good physician who attends short workshops
or courses to improve his/her skills and then has an opportunity to receive
feedback about how he/she communicates in real consultations will learn most.
Tips for learning new skills (Pendleton 2003 with modifications)

 Divide the change planned into small manageable amounts, and make one
change at a time.
 Start asking the patients their ideas and concerns about their symptoms
and what they would like you to do for them.
 Be comfortable with one new skill before starting another.
 When that feels comfortable you can encourage joint decision-making.
 Make a written plan for yourself at the beginning and the end of each
clinic. Mentally review each consultation to see what was achieved.
 Plan: This clinic, I will check each patient‘s understanding of the
medicines prescribe.
 Practice a new consultation skill when you do not have too much
pressure. It would be wise to try out a new skill early morning when
there are only few patients.
 Continue to practice a skill until it no longer feels awkward. Change
the words you use until they feel natural.
 Do not be put off by the patient‘s initial reaction. It is probably new
for them too, you need more explanation or you may need to try a
variety of new phrases until you find the suitable words for you and
your patients.
 If you do not like ―What do you think is wrong with you?‖ then try
―Have you any idea what might be causing this?‖ or ―What might
have started this off?‖, ―I was asking because some people might be
worried about symptoms like this and I wondered if you were‖.
Tips to manage time effectively during consultation

 Start early or on-time: Arriving to the clinic/hospital early will allow you
time to get comfortable, have a drink, check your emails, start the
computer and arrange for the first patient.
 Improve your IT skills: Struggling with your computer is definitely
going to slow you down. Ensure that you familiarize yourself with the
system along with any shortcuts that can be used. If you cannot touch
type, learning to do so can also save a lot of time
 Gather information in optimal time: Using open-ended questions and
empathic listening will allow you to gather information in a relatively
shorter time compared to using close-ended and direct questions with
interruption.
77
 Organize the clinic: Good organization saves time, e.g. instead of

waiting for the patient to get ready for a physical examination, sending
the patient to a separate examination room, will allow the doctor to start
with a second patient.
 Keep patients informed: Many patients do not know the length of the
appointment they have booked. Letting patients know when they book or
through a poster in the reception/waiting areas will help them understand
their expectations of the consultation.
 Book appropriately: If a patient has a number of things to go through,
the patient should be informed that he/she has the option of booking a
longer or double appointment in the next visit to spend time dealing with
the problems effectively. Likewise when a patient, who you know always
makes you run late, tries to book a follow-up appointment; encourage
him/her to book double appointments so it does not affect your
appointments.
 Delegate: Make use of the healthcare team whenever possible, e.g. the
nurse in chronic diseases clinic can give health education to the patient
and/or provide printed materials to reinforce important messages.
 Ending the consultation: When a patient continues to chat or prolong
the consultation, despite the consultation clearly being over and the
patient‘s needs have been met within the consultation; breaking rapport at
this point is acceptable and necessary. Ways to do this include:
 breaking eye contact
 altering your body position away from the patient
 speaking faster and louder than the patient
 sitting up straighter
 handing over a prescription or patient information leaflet
 starting to stand up
 In some cases, it may even be necessary to stand up and open the
door for the patient.
Tools for training

Use reminder cards to help you master the new skills, place it on your desk in a
position where you catch sight of it. In the card, include some examples of
phrases which can help you practice the skills.
Partnership
‫قح ٗاحذج ٍحذدج‬ٝ‫ طش‬ٚ‫س ْٕاك إجَاع عي‬ٞ‫ ى‬
.‫ىيعالج‬ Reassurance
.‫ ْٕاك طشق ٍخريفح ىيعالج‬ 1. Exploration & empathy
.....‫٘تٖا‬ٞ‫إا ٗ ع‬ٝ‫قح ىٖا ٍزا‬ٝ‫ ىنو طش‬ 2. Physical examination (use of touch)
‫ ٍارا ذفضو أّد؟‬ 3. Explanation in a positive manner
Dialogue no monologue ―No lecturing‖
78
Welcoming (4S) Take Feedback

 Stand up to greet the patient ‫ ششحد‬ّٜ‫ ٍا قيرٔ ىل ألذأمذ أ‬ٜ‫ذ ى‬ٞ‫رل ذع‬ٞ‫ى‬ 
 Smile . ‫ىل اىْقاط اىٖاٍح‬
 Shake hand ٛ‫؟ ٕو ْٕاك أ‬... ‫َنْل عَو‬ٝ ‫ل ٕو‬ٝ‫ٍا سأ‬ 
 Socialise ‫ صَد ٗ إّصاخ‬.... ‫أي صع٘تاخ؟‬ 
Effective closure Respond immediately

... ٚ‫ً٘ ذ٘صيْا إى‬ٞ‫اى‬ 
&
‫ صَد ٗ إّصاخ‬....‫ إضافح ؟‬ٛ‫ل أ‬ٝ‫ٕو ىذ‬  appropriately to
‫) تئرُ هللا‬...‫؟‬ٚ‫اسج اىقادٍح سرنُ٘ (ٍر‬ٝ‫اىز‬  patients‟ cues
‫؟‬ٍْٜ ٓ‫ذ‬ٝ‫ء آخش ذش‬ٜ‫ ش‬ٛ‫ٕو ْٕاك أ‬ 
There are a variety of assessment strategies available - choose the one that is
right for you. Whatever method you use, you may want to keep a workbook to
monitor your progress. As you do your assessment, jot down skills that you feel
you are doing well, some that you are improving on, and others that still need
work.
HOW TO PERFORM SELF-ASSESSMENT

 After finishing your consultation, take a few minutes to reflect on your
performance and make some mental or written notes about your own
strengths and weaknesses (Gibbs, 1989).
 Try doing the self-reflection exercise as close as possible to the time of the
consultation; otherwise, you are likely to forget the ‗fine points‘ of the
interaction.
 Use the evaluation forms and the checklists of this book to make the
learning process more systematic.
 Try to concentrate on the new skills, for example, exploring ideas,
concerns and expectations or encouraging doctor-patient partnership.
Audio taping and/or videotaping

It must be noted, however, that our perceptions of our own behaviour through
reflection are not always accurate. It is often more useful to observe or listen to
a recording of your interaction.
 Get the patient‘s permission before going ahead.
 Audio taping is cheap, more acceptable and easy; the only drawback being
that it does not permit you to analyse your body language.
 Videotaping allows you to capture your expressions and other non-verbal
behaviour; these days with new technology, it has become more available
and handy. However, videotaping can be more threatening to patients.
 Use evaluation checklist to evaluate your recorded performance.
Patient feedback
 Patient feedback can be obtained through a questionnaire, issued after the
interview session.
 In order to get feedback that is as honest as possible, take appropriate
steps to ensure that the patient is offered the opportunity to respond
anonymously.
79
 Example of patient feedback form:

4 3 2 1
...................... : ‫تاريخ التقىيم‬
‫ذ جذا‬ٞ‫ج‬ ‫ذ‬ٞ‫ج‬ ‫ٍقث٘ه‬ ‫ء‬ٜ‫س‬ ٌٝ٘‫اىَؤششاخ اىَخراسج ىيرق‬
‫ل تاحرشاً ٗ ذشحاب‬ٞ‫ْظش إى‬ٝ ٕ٘ ٗ ‫ة‬ٞ‫اك اىطث‬ٞ‫ٕو ح‬ .1
‫ثل‬ٝ‫جعيل ذنَو حذ‬ٝ ‫قاطعل ٗ ال‬ٝ ‫ة‬ٞ‫ٕو شعشخ أُ اىطث‬ .2
ٔٞ‫ثل إى‬ٝ‫ة ىحذ‬ٞ‫ سضاك عِ دسجح إّصاخ اىطث‬ٙ‫ٍا ٍذ‬ .3
‫ة‬ٞ‫ٕو اسرطعد أُ ذق٘ه مو ٍا أسدخ أُ ذث٘ح تٔ ىيطث‬ .4
ً‫ة تشنو عا‬ٞ‫ٍا دسجح سضاك عِ اسرشاسذل ىٖزا اىطث‬ .5
% % = 5 ×22 ٍِ ‫اىَجَ٘ع‬
 Learners can use this form periodically to evaluate their progress. They
can also change the questions according to the specific skills they want to
evaluate.
Peer review
 You may ask a colleague to be present during your consultations (with the
patient‘s permission, of course) to evaluate your performance or you may
ask a fellow physician to review your session video or audio recordings.
 Set some ground rules for the peer review - for example, that discussions
of weaknesses include a strong focus on suggestions for alternative
approaches.
Exercise 1
Look in the mirror and answer the following:
1. What are the 3 things you do very well in your consultation?
 ……………………………
 ……………………………
 ……………………………
2. List the most important three areas in your consultation that need some
modification.
 ……………………………
 ……………………………
 ……………………………
3. What is your action plan?
 …………………………………………………………………………..
 …………………………………………………………………………..
80
 …………………………………………………………………………..
 …………………………………………………………………………..
 …………………………………………………………………………..
 …………………………………………………………………………..
 …………………………………………………………………………..
 …………………………………………………………………………..
81
References
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interviewing. Boston: Little, Brown.
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Press, London.
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Experts: An Approach to Sharing Ideas in Medical Consultations. London:
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physician-patient communication in reducing medical liability. Md Med
J37:75–8.
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54. .‫ الطثعح الثانيح‬.‫) كتاب األسس العلميح لالستشارج الطثيح‬2005( ‫فايزج محمد ريس‬
www.fayzarayes.com ‫ مطثعح السرواخ‬:‫جدج‬
84
Answer Keys
ANSWER KEYS
ILLNESS BEHAVIOUR
Exercise 1
Read the following patient scenarios and speculate the possible perspective of
the patient's illness.
Case scenario 1
1. Mrs Salma is a 28-year-old divorcee, living with her 5 children, working as
a teacher. Over the last 12 months, Salma has had intermittent episodes
of soreness and stiffness in her knees.
 Possible ideas
 She may think it could be rheumatoid arthritis
 It could be osteoarthritis
 It could be (bad eye) or (black magic)
 It could be infection or exhaustion
 Her main concern could be her children, or her work
 She might be worried of losing the custody of her children or losing her
work
 She might be worried of losing her chance of having another husband
 Her main concern could be her image as a distinguished teacher
 She may expect effective medications
 She may just want reassurance and explanation
 She may expect referral for investigations or possible surgery
 She may expect medical report or sick leave
 The problem may affect her performance at work or at home
 It might affect her social activity
 It might affect her self-confidence
 It might disturb her sleep and affect her general well-being
 It might affect her future plans
Case scenario 2
2. Mr. Naser is a 42-year-old teacher. He has chest pain
 Possible ideas
 He may think it is from his heart
 He may think it could be a result of heavy meal
 He may think it could be (bad eye) or (black magic)
 He may think it could be trauma
 His main concern could be his work
 His main concern could be his image as a distinguished teacher
 He might be worried his fitness
 He might be worried about his family, what will happen to them if he died
85
Answer Keys
 His main expectation could be just explanation and reassurance
 He may expect ECG or X-Ray or cardiac catheterization
 He may expect referral for more reassurance
 He may expect medical report or just a sick leave

 This problem may affect him physically and prevent him from doing his
daily work or daily exercise
 It may affect him socially and make him isolated
 It may affect him psychologically and make him anxious and depressed
Exercise 2
Think of how you might phrase questions to ask patients directly about their
Ideas What do you think it could be?

What is in your mind?
Do you think of any particular cause for this problem?
Concerns What concern you most about this problem?
Expectations What is your expectation?

Is there anything in particular you need from me?
Feelings Tell me about your feelings about this problem?
Effect How are you doing at work?

How are you doing at home? Does this affect your family?
How are you doing at school?
Exercise 3
Speculate possible causes of illness denial.
1. Illness is a situation of weakens and no body like to be in a weak situation
2. Stigma of being ill
3. Lack of trust
4. Shame of possible ugly diagnosis
5. Seeking medical help cost effort , time and money …
6. Afraid from medication side effect or any possible aggressive medical
intervention
COMMUNICATION
Exercise 1
List what are the effective doctor-patient communication skills and what makes
doctor-patient communication ineffective.
Effective Ineffective
Doctor-Patient Communication Doctor-Patient Communication
Welcoming Lack of welcoming
Smiling Very serious attitude
86
Answer Keys
Showing interest and respect Lack of respect

Listening carefully Interruption
Friendly attitude Unfriendly attitude
Eye contact Lack of eye contact
Talking nicely Aggressive manner
Showing care and professionalism Lack of empathy and unprofessional attitude
VERBAL COMMUNICATION
Exercise 1
Explanation and health education: Self-evaluation form
When you go to your clinic try to apply the skills of explanation and health
education with every patient, and whenever you have time use this checklist to
evaluate your performance. You can also use role-play to train and evaluate
your performance using this checklist.

Skills 0 1 2
1. Give introduction about the importance of the topic
2. Explore patient knowledge and feelings
3. Empathic listening
4. Deliver message in a positive way (reassurance)
 Make your message simple & clear
 Make it appropriate to the patient‘s education level
 Make it a convincing message (logical explanation)
 Make it organized & limited
5. Frequently take feedback
6. Invite patients to ask questions
7. Response to patient's cues
8. Repeat if necessarily (T3)
 T1: Tell him what you will tell him (Introduction)
 T2: Tell it
 T3: Tell him what you have told them (Summary)
9. Use demonstration if appropriate
10. Always give hope and support
0 = not done; 1 = done but not good enough; 2 = perfectly done
1. Write your feelings about your performance:

 Satisfied and content
 Dissatisfied or partially satisfied
 Anxious or under pressure
NB: Whatever your feelings may be, you need to write down why you felt that
way, as this will help you to monitor your progress.
2. Important areas of strength and areas that need improvement:

The items in the checklist that you performed perfectly are your areas of
strength.
87
Answer Keys
3. Your specific learning needs and your action plan:

The items in the checklist that you failed to do or performed but not good
enough are your areas of weakness. You need to list them so that you can
focus on them in your future self-evaluations.
NONVERBAL COMMUNICATION
Exercise 1
1. State the different aspects of nonverbal communications:
a. Body language & Facial expression
b. Appearance
c. Touch
d. Paralanguage
e. Body bubble
f. Environment
Exercise 2
1. Write down three words that best describe the way you want to be
perceived by your patients:
Most doctors like to be perceived by their patients as:
a. A caring and nice person
b. Skilful and updated
c. Friendly but professional
2. Write down how you can use your communication skills to convey these
positive messages about yourself?
a. To let the patient know that you are a caring and nice person stand up
and welcome him/her to your clinic, smile, shake his/her hand, put
him/her at ease and break the ice through small talk about his/her life.
b. To show that you are a skilful and updated doctor you need to listen
carefully to the patient‘s complaints, explore his/her ideas, concerns and
expectations, perform a proper physical examination and convey
appropriate explanation with reassurance.
c. To show that you are a friendly but professional doctor, you need to speak
using simple terminology that the patient understands (no jargon),
continuously take feedback from the patient and show empathy.
NB: All these are a few examples of proper communication skills. Every
physician has his/her own communication approach that works best for
him/her. Your communication skills affect how your patients perceive you; as a
good or a bad physician.
DOCTOR-PATIENT RELATIONSHIP
Exercise 1
nonverbal facilitation responses, (2) the patient pretending to have
88
Answer Keys
responses and how a certain response could have been more effective.
Nonverbal Facilitation 1 2 3 4 5
1 Eye contact
2 Silence
3 Paralanguage
4 Facial expression
5 Touch
NB: This is a reflection exercise designed to help every physician discover

his/her own personal communication strengths as well as barriers and to
consequently deal with them appropriately. Therefore, results will vary from
person to person; keep repeating this exercise until you master all the skills.
Exercise 2
Role-play: With two colleagues, take turns being: (1) the doctor giving verbal
& nonverbal facilitation responses, (2) the patient pretending to have
responses and a how certain response could have been more effective.
Verbal & Nonverbal Facilitation 1 2 3 4 5
1 Questioning
2 Probing
3 Confrontation
4 Paraphrasing
5 Verbal mirroring
6 Interpretation
7 Reflecting
8 Summarizing
9 Eye contact
10 Silence
11 Paralanguage
12 Facial expression
13 Touch

89
Answer Keys
Exercise 3
Skills How
Show interest & respect  Standing up for the patient
 Using Nice welcoming phrases
 Keeping appropriate eye contact
Recognize verbal and Reflect your observations by telling the patient: ―you look
non-verbal cues anxious….‖ or ―you look sad…..‖
Immediately respond to Ask the patient to speak more about his/her feelings, e.g. ―tell
patient‘s cues me what‘s making you feel this way?‖, with appropriate eye
contact and enough silence to give the patient time to respond.
Show support and care  Verbally, e.g. by telling the patient ―you have the right to
feel this way‖ or ―I will do my best to help you‖
 Nonverbally, e.g. by appropriate use of touch.
Balance between  Try to direct the patient to talk about his/her feelings
intimate & professional without going in the details of long stories.
relationship  If the patient needs to contact you by telephone, give
him/her your office number but not your personal mobile
Be flexible & respect If the patient demands a specific intervention and you fail to
patient autonomy convince him/her not to have it, if it is not iatrogenic and not
very costly , you need to agree with him/her for the sake of
maintaining the relationship
Demonstrate  Through positive gestures and appropriate eye contact
appropriate confidence  Through appropriate paralanguage (tone and
pronunciation)
Control your judgmental When any patient makes you feel uncomfortable, try to
attitude recognise your feelings and stop judging the patient. Act
according to ―here and now‖
Respect patient During consultation and after consultation
confidentiality
If patient attends with  Appropriately welcome all the family members
his/her family: watch  Give the family members a chance to explore the
family dynamic, and patient‘s complain
build rapport with the  Direct your explanation to the patient and his/her family
family
(Lang & Tennessee, 2002)
Exercise 4
Discuss the skills needed by physicians to maintain effective doctor-patient
relationship while conducting physical examination
Case 1
Examination of a child
 Lay out the consulting room with toys and drawing materials
 Make the childe feel comfortable
90
Answer Keys
 Put aside time at the beginning of the consultation to build rapport

 Find out where the child is most comfortable - on the parent‘s knee or on
the floor playing with toys, particularly during the examination
 Pay attention to proximity between you and the child - many children like
you to be at their level
Case 2
Examination of an elderly patient
 Elderly patients may require additional time to undress and transfer to the
examining table; they should not be rushed.
 Help the patient to undress before examination and dress after
examination
 Maintain eye contact as much as possible while examining the patient.
 The examining table should be adjusted to a height that patients can
easily access; a footstool facilitates mounting.
 Frail patients must not be left alone on the table.
 Portions of the examination may be more comfortable if patients sit in a
chair.
 If patients become fatigued, the physical examination may need to be
stopped and continued at another visit.
Case 3
Examination of a patient of different gender than the doctor
 You need chaperon, a nurse and/or patient‘s guardian/relative
 Ask patient‘s permission
 Talking while examining will decrease tension and break the ice
 You need to be very professional if there is risk of misunderstanding
 Avoid emotional issues while examining the patient
 Expose the necessary body part and then cover it as soon as possible
Case 4
Examination of an anxious patient
 Physical examination is very important for reassurance
 Keep appropriate eye contact and relaxed facial expression while
examining the patient
 Recognize patient‘s cues and react accordingly
 Explain to the patient what you are examining
 Keep saying positive comments whole examining the patient
Case 5
Examination of a patient in pain
 Ask for patient‘s permission
 Start with less painful examination
 Try to be very gentle
 Keep eye contact to modify your examination according to your patient‘s
pain-threshold
 Apologise to the patient for the pain and discomfort you caused during
your examination
91
Answer Keys
Exercise 5
From what we have discussed in the previous chapters, write 30 strategies,
verbal statements or nonverbal cues, which you may use during a consultation
that would positively affect your relationship with your patient.
1. Prepare yourself before seeing the 16 Summarise
patient, e.g. get rid of any negative feelings
caused by a previous consultation that made
you feel uncomfortable
2. Prepare the clinic before seeing the 17. Take feedback
patient
3. Prepare patient file before seeing the 18. Physical examination is very important
patient to show your professionalism and for
effective reassurance
4. Stand up and shake the patient‘s hand 19. Use gentle and non-threatening physical
examination
5. Welcome the patient using nice phrases 20. Keep a relaxed facial expression while
and call your patient by name examining the patient
6. Smile and introduce yourself 21. Say positive comments while examining
and immediately after finishing the physical
examination
7. Socialize with the patient to break the ice 22. Explain the diagnosis in a positive way
8. Start with open-ended question 23. While explaining the diagnosis,

recognise and immediately respond to the
patient‘s cues
9. Give enough silence for patients to share 24. Ask the patient for his/her feedback
their concerns
10. Do not interrupt the patient 25. Negotiate the management plan and
respect patients point-of-view
11. Facilitation, encourage the patient to 26. Explain clearly in simple language avoid
speak more about his/her concern using jargon
12. Maintain appropriate eye contact 27. Ensure patient‘s satisfaction, e.g.
―Anything else you need from me?‖
13. Respect his/her thoughts and feelings 28. Make yourself accessible e.g. ―you can
come back anytime if you need to see me‖
14. Give him/her enough chance to talk 29. Stand up to say ―see you next
about his/her feelings appointment‖
15. Showing empathy 30. Give positive last impression
NB: Remember to add feelings to your words
Exercise 6
empathic responses, (2) the patient pretending to have a variety of
problems and (3) the observer giving feedback to the empathizer using a 5-
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Answer Keys
point empathy scale. The observer must rate every response given by the
doctor. Stop the interaction after 4 or 5 empathic responses have been rated.
All three can discuss the good responses and how a certain response could
have been more effective.
Empathic Responses 1 2 3 4 5
N Naming the emotion
U Understanding & acknowledgement of suffering
R Respect and no criticism
S Support & silence
E Exploring and facilitating

Exercise 7
How to share decision-making with patients
Steps How
1. Define the problem that requires For example, tell the patient: ―Let‘s decide
shared decision together whether antibiotic will be of benefit
for your throat infection or not‖
2. Legitimize patient involvement and The decision depends on your personal needs
encourage his positive role and preference
3. Outline the options: Describe one or The advantage of taking antibiotic: it will
more treatment options and, if relevant, shorten your illness by 24 hours. The
the consequences of no treatment disadvantage is the side-effect of the
antibiotics
4. Explore patient's ideas and encourage What do you think? What do you prefer? Do
questions you have any question?
5. Negotiate mutually acceptable plan Ok if you prefer to take antibiotic , it is going
to be (….) you need to take it (…) you may
develop (…) as side-effect of this antibiotic
6. Recognize patient's verbal and non- You look uncomfortable with this side-effect?!
verbal cues & respond to his cues Did you change your mind?
7. Frequently take feed back Do you like to say anything?
8. Give patient enough time to make his If the patient cannot make his final decision
decision quickly , give him time to think and replay,
especially for big decision like surgery or life-
long medication
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Answer Keys
Exercise 8
Discuss the below rapport building skills and their barriers
Skills Barriers
2. Facilitation
3. Building rapport
4. Empathy
6. Partnership
8. Preparation
Discuss possible strategies that would help you to overcome these barriers
________________________________________________________________
________________________________________________________________
________________________________________________________________
consequently deal with them appropriately. Therefore, answers will vary from
Exercise 9
Concentrate entirely on the decision-making aspect of the below consultations:
Case scenario 1
1. Atrial fibrillation
Patient wants to know about the pros and cons of warfarin and aspirin for
prevention of stroke.
Case scenario 2
2. Benign prostatic hypertrophy
Patient wants to know more about the typical options that face a man who is
told that he has "prostatism," with no other risk factors.
Case scenario 3
3. Menopausal symptoms
Patient undecided about hormone replacement therapy and anxious about the
risk of breast cancer.
The objectives from these 3 scenarios:

1. To review all the different updated options of management.
2. To evaluate the advantages and disadvantages of each option.
3. To practice how to present these information to the patient in simple
understandable language.
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Answer Keys
4. To use the skills of shared decision-making checklist to evaluate your

communication skills.
NB: The above 3 scenarios are examples of clinical issues which require shared
decision making. To benefit from this exercise, you must start the workshop by
discussing management options, then applying the information in role-play with
a friend/colleague, followed by performance evaluation using the shared
decision-making checklist detailed in Exercise 7.
BREAKING BAD NEWS

Exercise 1
Case scenario 1
Mrs. Badria aged 39 years, pregnant for the first time. At 30 weeks‘ gestation,
you diagnosed IUFD.
Q1. Speculate how this patient may feel.

 Badria may feel very depressed for losing her baby
 She may inter into the cycle of bereavement and feel some time
numbness of emotion and sometime disbelieve, anger and argument then
she go to depression till she accept this bad news
 She may feel anxious about her health and the consequences of IUFD on
her future chance to have another baby
 She may feel insecure about her relationship with her husband

Go through the steps of breaking bad news, the 6-step protocol – SPIKES

Examples of verbal skills:
 "I imagine this is difficult news..."
 "You appear to be angry. Can you tell me what you are feeling?"
 "Tell me more about how you feel about what I just said."
 "What worries you most?" "What does this news mean to you?"
 "I wish the news was different."
 "I'll try to help you."
 Remind her that her responses are normal
 Remind her about religious principles e.g. the benefit of being patient
(‫)وبشر الصابرين_المؤمن مُبتلى_عسى ان تكرهو شيئا وهو خير لكم‬
Examples of nonverbal skills:

 Mirroring patient‘s gesture, facial expression
 Speak slowly in low tone
 Use touch whenever appropriate
 Give the patient her space to express her negative feelings by using
silence and by avoiding eye contact at some stage of the consultation.
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Answer Keys
Case scenario 2
Mr. Badr aged 39 years; investigations confirmed that he has AIDS
Q1. Speculate possible problems this consultation may raise

 Badr may feel very depressed
 He may enter into the cycle of bereavement for losing his future and may
become emotionally numb. He may also refuse to accept his diagnosis
(denial), he might become angry and argumentative, and finally go into
depression until he accepts the bad news
 He may feel ashamed due to the stigma of this diagnosis
 He may feel insecure about his relationship with his wife and children
Q2. Discuss possible strategies in dealing with this patient

Go through the steps of breaking bad news, the 6-step protocol - SPIKES
Q3. Suggest some specific verbal and nonverbal skills

See Question 3, Exercise 1, Case Scenario 1
Case scenario 3
Mohammed is an 8-year-old lovely boy, he needs heart transplantation
Q1. Speculate possible problems in communicating with his parents

 Here the doctor is dealing with 3 patients (the parents and the child)
 Parents might be very anxious and emotional
 The doctor may feel very sad for them and became emotional too
Q2. Discuss possible strategies in dealing these problems

 Direct the explanation to the parents and the child equally
 Speak with simple and clear language suitable for the child
 The doctor needs to balance between showing his/her empathy and being
very objective while being scientific in his/her explanation of the situation
and the prognosis of surgery
 The seating of the clinic should be children friendly to help the child to
relax
Q3. Suggest some specific verbal and nonverbal skills

Use reassurance
a. Credibility and trust: e.g. telling the patient that you are an expert
in this type of surgery and sharing your high success rate is definitely
reassuring
b. Caring support: e.g. attempt to help the patient and his family to
overcome the administration obstacles as much as possible
c. Accessibility: Patients with such life-threatening conditions need
free access to their physician. Caring physicians usually have special
mobile numbers that their critical patients can use to reach him/her
at any time.
a. Fears: Encourage the patient and his family to explore their fears
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Answer Keys
b. Hidden agenda: Try to be sensitive to any verbal or nonverbal cues

in order to ask for any possible hidden agenda
a. Because this patient was already diagnosed, physical examination
would not be needed here.
4. Explanation and giving reassuring information.
a. Avoid jargon, when naming the diagnosis
b. Explain that it is not uncommon
c. Answer the patient's questions and uncertainties.
f. Empower the patient through positive thinking and faith.
5. Offer appropriate management option (care if you cannot cure).
a. Support psychotherapy or counselling if needed and use referral
when appropriate.
Case scenario 4
Mrs. Badria, a 32-year-old lady with frequent somatic symptoms attends with a
history of headache for the past 5 years. It appears to be tension headaches.
She asks for a CT scan.
1. Discuss the patient‘s feelings

a. Headache can be a devastating symptom.
b. She may feel anxious about a serious diagnosis e.g. cancer, meningitis,
epilepsy…
c. She may feel very anxious about possible complications, e.g. paralysis,
blindness, death …
d. She may feel depressed and rejected by her family or friends or at work as
a result of being ill most of the time
2. How would you proceed?

Use reassurance
a. Credibility and trust: e.g. through a warm welcome and
professional appearance
b. Caring support: e.g. by respecting her suffering without any
judgmental attitude towards her demand for CT scanning
c. Accessibility: e.g. an easy appointment system and the option of
using telephone consultation in an emergency situation will definitely
reassure the patient
a. Fears: encourage the patient to explore all her feelings about this
headache
b. Hidden agenda: be alert to any possible hidden agenda, e.g.
marital conflict or financial problem …
a. There is no effective reassurance without physical examination: A
doctor needs to do an appropriate physical examination to rule out all
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Answer Keys
the patient‘s fear and ideas about a possible serious diagnosis or

serious complications. After each part of examination, keep saying
reassuring comments, e.g. ―your neurological system is fine, your
fundoscopy examination is very reassuring…‖
b. Remember the magical effect of touch: e.g. while touching the
patient‘s head, the physician can say this is what we call ‗tension
headache‘, it is benign and common
a. Avoid jargon, when naming the diagnosis, you can tell the patient
―you have tension headache, which means because you are a
sensitive stressor you feel this pain‖
b. Explain how common it is, e.g. ―tension headache is very common
these days as most people have lots of pressure at work and at
home.‖
c. Answer patient's questions and uncertainties.
f. Empowering patients through positive thinking
5. Offer appropriate management option
Case scenario 5
Mrs. Salma is a 40-year old lady. She has a large uterine fibroid, attending
today to discuss with you the hysterectomy operation.
Q1. Discuss the patient‘s feelings

a. She may feel very anxious about possible serious diagnosis. e.g. cancer
b. She may feel very anxious about the surgery and possible complications
c. She may feel very anxious about anaesthesia and possible complications
d. She may feel depressed for losing her uterus and her ability to be a
mother again
e. She may think hysterectomy will affect her sexual relationship with her
husband.

Use reassurance
a. Credibility and trust: it is very reassuring to know that the
attending surgeon is expert in this operation
b. Caring support: warm welcoming , appropriate use of touch, and
offering all possible help
c. Accessibility: by giving follow up appointment after surgery, and if
the patient still wary and need more information she may call you
through the clinic telephone
a. Fears: you need to encourage her to explore all her idea , concerns
and feelings . listen with empathy, without interruption and without
judgment
b. Hidden agenda: Doctor need to be alert to any verbal or nonverbal
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Answer Keys
cues and try to encourage her to explore her hidden agenda, e.g.
fear of sexual dysfunction
a. Avoid jargon, when explaining the surgery details
b. Explain how common this surgery is.
c. Answering patient's questions and uncertainty.
e. Empowering patients through positive thinking and faith.
Exercise 2
Write 30 strategies that may help physicians to increase their credibility and
be more effective in reassurance:
Verbal communication skills

1. Say warm welcoming phrases to show your care and interest
2. Speak clearly
3. Speak with reasonable tone
4. Use simple understandable language
5. Use professional language
6. Use open ended question to make patient feel free to explore all his ideas,
concerns and feeling
7. Repeat important massages to insure compliance
8. Take feedback frequently
Nonverbal communication skills

9. Keep eye contact with the patient
10. Use silence to encourage patient to talk
11. Use touch when appropriate
12. Work in reasonably organized clinic
13. Dress reasonably (not very casual, not very formal)
14. Mirror his patient facial expression
Clinical competence
15. Take appropriate history
16. Perform appropriate physical examination
17. Discuss the diagnosis
18. Share the uncertainty with the patient with confidence
19. Ask for reasonable investigation
20. Prescribe appropriate medication
21. Explain the diagnosis and management options clearly
Professionalism
22. Respect patient appointment and see the patient on time
23. Treat patient with respect e.g. stand up for welcoming
24. Respect patient autonomy (the right to decide for himself)
25. Respect patient confidentiality
26. Use step care approach in investigation and in management to reduce
harm
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Answer Keys
Dynamism
27. Use time during consultation appropriately
28. Move fast if needed
29. Speak with good energy in his paralanguage
30. Appreciate patient suffering and offer the most effective management
option
CONSULTATION MODELS
Exercise 1
NB: With effective doctor-patient communication all the following barriers could
be overcome easily.
Q1. What are the missing skills in the traditional medical model?
 No exploration of patient ideas, concerns, expectation, effect of the
problem and patient‘s feelings
 The psycho-social component of the patient‘s problem
 No illness management (Explanation, reassurance, health education and
health promotion)
 No management of doctor feelings
Q2. Why is it that 50% of the patients do not take their medicine?
There are many reasons for example:
 Lack of trust
 Lack of appropriate explanation
 Lack of recognition of patient‘s point-of-view regarding medication, e.g.
patient may have false belief about side-effect of the medication, or the
patient may cannot afford buying expensive medications.
Q3. Why is it that 40% of the patients express their lack of satisfaction?
Many reasons for example:
 Unfriendly doctor attitude
 Failure to explore patient‘s idea, concerns, feeling and expectations
 Lack of empathy
 No explanation or inappropriate explanation
 Paternalism in doctor-patient relationship
Q4. How can you reassure your patients more effectively?

 First you need to listen carefully to patients‘ ideas, concerns, feelings and
expectations
 Respect patients‘ ideas and deal with it appropriately
 No reassurance without appropriate physical examination
 Explain diagnosis to the patient in a positive way
 Ensure your accessibility and show your care
Q5. Does the patient's complaint always have a biological explanation?

 The answer is no
 Sometimes the problem is psycho-social only
 Psycho-social diagnosis need effective doctor-patient communication
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Answer Keys
Q6. If you are in doubt about diagnosis, what is the role of the patient?
The patient is a partner and should be involved in every step of the
consultation, starting from shared understanding of the problem and ending
with shared decision-making about the problem
Q7. How can you manage if you have only 5-10 minutes for each patient?
Effective communication and continuity of care can make short consultation
period very effective. Below are a few examples of some strategies that can be
used:
 Use open-ended questions to get more relevant information in a relatively
short time
 A relationship of trust and respect between doctor and patient make
patients more open and to the point
 Exploring the psychosocial component of a patient‘s problem will lead to
correct diagnosis and reduce unnecessar future consultation.
Q8. How can an unsatisfied physician satisfy his/her patients?

Physicians need to develop strategies to improve their personal satisfaction.
They need to develop skills that will help them deal with negative emotions
caused during consultations, immediately after consultations and continuously
in the long run, (Neighbour, 2005). This technique is called ‗housekeeping‘ and
it is considered as the fifth task of any consultation, i.e. after every patient
interview, a doctor needs to check him/herself for any negative emotion(s) and
deal with it immediately to be able to serve the next patient efficiently.
Exercise 2
Read the following case scenarios, and discuss how you can apply the
expanded model of consultation for each patient?
Case scenario 1
1. A 65-year-old retired military officer rarely visits the practice, he came
today with back pain, headache and generalized weakness.
1. The presenting problems are back pain, headache and generalized

weakness.
2. The continuous problem is retirement and the health consequences of
retirement
3. Help seeking behaviour that requires modification is his infrequent visit
practice, he needs to know the importance of periodic health checkup;
especially for his age
4. Appropriate screening and health promotion at this age according to the
policy in your practice
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Answer Keys
Case scenario 2
2. Sameera is a 14-month-old girl, her mother is very anxious because
Sameera cannot walk independently till now. She demands that something
be done about this. Sameera is the youngest of five children. Her father is
unemployed.
1. The presenting problem is Samara cannot walk independently.

2. The continuous problem is poor family, unemployed father, big family.
3. Help seeking behaviour that needs modification could be the mother is
using the child as presenting complain while the real reason is psych-social
stresses
Case scenario 3
3. Mrs. Hala is a 28-year-old lady, recently married, presents with vaginal
discharge.
1. The presenting problem is vaginal discharge.

2. The continuous problem is recently married, she may need counselling
and support.
3. There is no help seeking behaviour in this consultation that needs
modification.
Exercise 3
The Comprehensive Consultation Model: Self-evaluation form

Tasks 0 1 2
2. Facilitation
3. Building rapport
4. Empathy
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Answer Keys
6. Partnership
8. Preparation
Comprehensive Bio-psycho-social Diagnosis
9. Gathering information about disease & illness
10. Broad thinking and exclusion of important differential diagnosis
11. Exclusion of possible serious complications
12. Identification of at risk factors & continuous problems
Comprehensive Management
Patient Management:
13. Explanation and Health Education
14. Reassurance: (remember: you are the most effective drug)
15. Health Promotion
16. Modification of help-seeking behaviour (denial, displacement)
Disease Management
17. Intervention by investigations or treatment
18. Management of time & management of resources
19. Management of doctor‘s feelings (house-keeping)
0= not done 1= done but not good enough 2= perfectly done

consequently deal with them appropriately. Therefore, answers will vary from
Write your feelings about your performance:
________________________________________________________________
________________________________________________________________
Important areas of strength and areas that need improvement:
________________________________________________________________
________________________________________________________________
Your specific learning needs and your action plan:
________________________________________________________________
________________________________________________________________
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Answer Keys
Exercise 4
Match the left list (Consultation Models) with the appropriate part of the right
list (Characteristics):
Consultation Models Characteristics
A. Traditional Medical Model 1. Doctor as a drug
B. Disease-Illness Model 2. Doctor as an educator
C. Calgary-Cambridge Guide 3. Patient as a partner
D. Inner Consultation 4. Doctor has feelings
E. Stott & Davis 5. Patient as a case
F. Pendleton 6. Consultation has two sets of content‖
G. Balint 7. Consultation has structure
Answer:
Traditional Medical Model Match with 5
Disease-Illness Model Match with 6
Calgary-Cambridge Guide Match with 7
The Inner Consultation Match with 4
Stott & Davis Match with 2
Pendleton Match with 3
Balint Match with 1
NB: The Comprehensive Consultation Model has all these characteristics
REINFORCEMENT & SELF-ASSESSMENT

These are reflection exercises designed to help every physician discover his/her
areas of strength and areas that need further practice and improvement.
Therefore, answers will vary from person to person; keep repeating this
exercise until you master all the skills.
Exercise 1
1. What are the 3 things you do very well in your consultation?
 ……………………………
 ……………………………
 ……………………………
2. List the most important three areas in your consultation that need some
modification.
 ……………………………
 ……………………………
 ……………………………
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Answer Keys
3. What is your action plan?
 …………………………………………………………………………..
 …………………………………………………………………………..
 …………………………………………………………………………..
 …………………………………………………………………………..
 …………………………………………………………………………..
 …………………………………………………………………………..
 …………………………………………………………………………..
 …………………………………………………………………………..
105
©2016 BY THE SAUDI COMMISSION FOR HEALTH SPECIALTIES
ISBN: 978-603-90608-4-0

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

Dr. Fayza Rayes

EDITED & FORMATTED BY

Mrs. Vittoriana Crisera

© Saudi Commission for Health Specialties, 2016

Rayes, Fayza – Riyadh, 2016

L.D. no. 1437/4816

This Manual is a publication of the Department of Medical Education and Postgraduate

Production and Concept

BREAKING BAD NEWS 45

REINFORCEMENT & SELF-ASSESSMENT 77

Communication is an important skill we all need to acquire early in life to

Professor Abdulaziz Al Saigh

I would like to acknowledge the valuable contribution and feedback received

I would also like to extend my sincere appreciation and gratitude to the

Dr. Fayza Rayes

We shall enhance the traditional doctor-centred consultation model (grey

By the end of this book, one will be able to:

Benefits of this book

How do doctors give patients information?

Medico-legal complaints related to communication

Patient and doctor‟s satisfaction

Do doctors in Saudi Arabia receive appropriate training in this field?

Is there evidence that training can overcome these problems?

PATIENT REASONING AND FEELINGS

Answer: 20% of the patients neglect their

Reasons for illness denial

Reasons for the recent increase in self-care

Reasons patients seek medical help

FACTORS AFFECTING ILLNESS BEHAVIOUR

 Will I be able to lead a regular life?

Feelings and  I am worried and anxious

6. Feedback 1. Develop idea

4. Receive message 3. Transmit (deliever)

2. Encode (compose) message

3. Transmit (deliver) message

5. Decode (analyse) message

HOW TO IMPROVE COMMUNICATION

COMMON BARRIERS TO EFFECTIVE COMMUNICATION

 Lecturing without feedback. This occurs when a physician delivers a

To effectively communicate with your patients you need to understand your

VERBAL COMMUNICATION PROCESS

experience these symptoms?. ‗Process‘ example, ―What do you

How to convey illness diagnosis and health education to a patient

 Use demonstration as much as you can

BENEFITS OF PATIENT HEALTH EDUCATION

Patient Data:______________________ Age:__________ Gender:_________

Reason for attendance:____________________________________________

5. Frequently take feedback

1. Write your feelings about your performance:

Non-verbal communication is an extremely confusing yet integral part of our

Moreover, in order to communicate effectively, avoid misunderstandings, and

ASPECTS OF NONVERBAL COMMUNICATIONS

Facial expression: The face is perhaps the most important conveyor of

posture of arms crossed on the chest portrays a feeling of inflexibility. The

Positive and negative body language

Closeness and personal space

A close personal interest in the patient can be communicated by the

The advantages of this type of setting

Patient Data:____________ Age: Gender:_