Eliciting Patients' Problems and Concerns

Establish eye contact at the beginning of the consultation and maintain it at reasonable intervals to show interest. Encourage patients to be exact about the sequence in which their problems occurred; ask for dates of key events and about patients' perceptions and feelings. This helps patients to recall their experiences, feel understood, and cope with their problem.

Use "active listening" to clarify what patients are concerned about that is, respond to cues about problems and distress by clarifying and exploring them. But avoid interrupting before patients have completed important statements.

Summarize information to show patients they have been heard, and give them an opportunity to correct any misunderstandings. Inquire about the social and psychological impact of important illnesses or problems on the patient and family; this shows the patient that you are interested in his or her psychosocial well-being, and that of the family.

Giving Information

Check what patients consider might be wrong and how those beliefs have affected them. Ask patients what information they would like, and prioritize their information needs so that important needs can be dealt with first if time is short. Present information by category for example, "you said you would like to know the nature of your illness." Check that the patient has understood before moving on.

With complex illnesses or treatments, check if the patient would like additional information written or on audiotape. However, if you have to give the patient a poor prognosis, providing an audiotape may hinder psychological adjustment.

Discussing Treatment Options

Properly inform patients of treatment options, and check if they want to be involved in decisions. Patients who take part in decision making are more likely to adhere to treatment plans. Determine the patient's perspective before discussing lifestyle changes.

Being Supportive

Use empathy to show that you have some sense of how the patient is feeling ("the experiences you describe during your mother's illness sound devastating"). Use educated guesses too. Feed back to patients your intuitions about how they are feeling ("you say you are coping well, but I get the impression you are struggling with this treatment"). Even if the guess is incorrect it shows patients that you are trying to further your understanding of their problem.

Effective Training Methods

A "good" doctor, wanting to audit and improve his or her skills, should ensure that any course or workshop they attend includes three components of learning: cognitive input, modeling, and practice of key skills.

Cognitive input

Courses should provide detailed handouts or short lectures, or both, that provide evidence of current deficiencies in communication with patients, reasons for these deficiencies, and the adverse consequences for patients and clinicians. Participants should be told about the communication skills and changes in attitude that remedy deficiencies and be given evidence of their usefulness in clinical practice.

Modeling

Trainers should demonstrate key skills in action with audiotapes or videotapes of real consultations. The participants should discuss the impact of these skills on the patient and doctor.

Alternatively, an "interactive demonstration" can be used. A facilitator conducts a consultation as he or she does in real life but using a simulated patient. The interviewer asks the group to suggest strategies that he or she should use to begin the consultation.

Competing strategies are tried out for a few minutes then the interviewer asks for people's views and feelings about the strategies used. They are asked to predict the impact on the patient. Unlike audiotaped or videotaped feedback of real consultations, the "patient" can also give feedback. This confirms or refutes the group's suggestions. This process is repeated to work through a consultation so that the group learns about the utility of key skills.

Practicing key skills

If doctors are to acquire skills and relinquish blocking behavior, they must have an opportunity to practice and to receive feedback about performance. However, the risk of distressing and deskilling the doctor must be minimised.

Practicing with simulated patients or actors has the advantage that the nature and complexity of the task can be controlled. "Time out" can be called when the interviewer gets stuck. The group can then suggest how the interviewer might best proceed. This helps to minimize deskilling. In contrast, asking the doctor to perform a complete interview may cause the doctor to lose confidence because "errors" are repeated.

Asking doctors to simulate patients they have known well and portray their predicament makes the simulation realistic. It gives doctors insights into how patients are affected by different communication strategies.

For a simulation exercise to be effective, doctors must be given feedback objectively by audiotape or videotape. To minimize deskilling, clear ground rules should be followed:

• Positive comments should be offered about what strategies (oral and non-oral) were liked and why
• Constructive criticism should be allowed only after all positive comments have been exhausted
• Participants offering constructive criticisms should be asked to suggest alternative strategies and give reasons for their suggestions
• Any blocking behavior should be highlighted and the interviewer asked to consider why it was used (including underlying attitudes and fears)
• The group should be asked to acknowledge if they have used similar blocking behavior and why
• To reinforce learning, the doctor should be asked to reflect on what he has learned, what went well, and what might have been done differently.

Context Of Learning

Some doctors feel safer learning within their own discipline. Others welcome the challenge of learning with those from other disciplines, such as nursing; multidisciplinary groups enable doctors to understand and improve communication between disciplines. The relative merits of these two different environments has still to be determined.

Doctors are more likely to attend workshops or courses in communication skills if they know that substantial time will be devoted to their own agenda. Thus, they should be asked to identify the communication tasks they want help with. These will commonly include the tasks discussed already plus more difficult situations, such as breaking bad news, handling anger, and responding to difficult questions.

Limiting the size of the group to four to six participants creates the sense of personal safety required for participants to disclose and explore relevant attitudes and feelings. It also allows more opportunity to practice key communication tasks.

Facilitators who have had similar feedback training are more effective in promoting learning than those who have not. Residential workshops lasting three days are as effective as day workshops lasting five days. Whether longer courses are more effective than workshops plus follow up workshops needs to be determined.

Practicing communication skills with simulated patients leads to the acquisition of skills and the relinquishing of blocking behavior. However, doctors do not transfer these learned skills to clinical practice as comprehensively as they should. Offering doctors feedback on real consultations should ensure more effective transfer of skills.

Current evidence suggests that the good doctor who attends short residential workshops or courses to improve his or her skills and then has an opportunity to receive feedback about how he or she communicates in real consultations will learn most.

Doctors will find that both they and their patients benefit. Patients will disclose more concerns, perceptions, and feelings about their predicament, will feel less distressed, and be more satisfied. Doctors will feel more confident about how they are communicating and obtain more validation from patients.

Good doctors will wish to continue their learning over time by self assessment (recording their own interviews and reflecting on them) or attending further courses or workshops.

British Medical Journal September 28, 2002;325:697-700 Full Text Article