While a combination of safety-aware systems and good clinical skills will go a long way towards creating a safe service for your patients, there is a third, crucial, component that glues it all together. This sphere of practice is commonly referred to as non-technical skills and is defined as “The cognitive, social and personal resource skills that complement technical skills and contribute to safe and efficient task performance”.9
While much of the research carried out to date on non-technical skills for clinicians has focused on high-risk specialties, generic attributes such as good communication skills and the ability to reflect and learn are applicable in any healthcare setting.
Generic attributes such as good communication skills and the ability to reflect and learn are applicable in any healthcare setting
The patient’s agenda
- Ideas, concerns, expectations (ICE)
- Feelings, thoughts, effects
- Understanding of his/her feelings
The doctor’s agenda
- Signs and symptoms
- Differential diagnosis
As the above lists illustrate, patients and doctors tend to approach the consultation with markedly different agendas – a situation that can easily lead to misunderstandings, frustration and disappointment unless the needs of each party are met.
Most experts in the art of communication with patients agree that it’s important to find out what the patient’s ideas, concerns and expectations are (ICE). Patients hold all sorts of beliefs – about the nature of illness, about their bodies and about treatments – about which their doctors are often blithely unaware.
These hidden attitudes and beliefs may determine the degree to which they comply with treatment. In the UK, for example, it has been estimated that between 30% and 50% of patients do not take their prescribed medicine as recommended and, very often, the prescribing doctor is completely unaware of the fact.10
Preparing patients for less than optimal outcomes is not only humane but also an effective risk-management measure
Patients may also harbour unrealistic expectations about the outcome of treatment. If there’s little chance of returning a patient to full health without any residual problems, you should discuss these limitations openly so that the patient is spared the experience of unfulfilled hopes (or at least experiences them early enough to come to terms with the news while treatment is still ongoing).
Quite apart from your professional obligation to obtain informed consent to treatment, preparing patients for less than optimal outcomes is not only humane but also an effective risk-management measure. Angry, disappointed patients are far more likely to sue when the outcome of clinical care fails to meet their expectations.
Taking time to listen
An often-quoted study from the 1980s11 in which researchers observed GP consultations, found that doctors were interrupting patients an average of 18 seconds into a consultation. A second, and larger, study carried out 12 years later by Marvel et al12 found that the mean time before the patient was ‘redirected’ by the doctor was 23.1 seconds. Most of the redirections occurred after the patients had expressed their first concern, and this then became the focus of the ensuing consultation regardless of whether the patient considered it the most important of the concerns he/she wished to raise.
Most of the redirections occurred after the patients had expressed their first concern, and this then became the focus of the ensuing consultation
“Once the discussion became focused on a specific concern, the likelihood of returning to complete the agenda was very low (8%).”13 Apart from the obvious risk of missing important and relevant information, consultations conducted along these lines often take longer than they need to. Assume that each patient attends the consultation armed with at least three concerns that they want to address (research indicates that this is about right).
Most people will rehearse in their heads what they want to tell you, and the order in which they want to tell it – ie, they have an agenda. If you interrupt that agenda, or divert them from it, the likelihood is that the patient will, in attempting to deliver the pre-rehearsed story, start repeating him/herself, forcing you back over ground already covered.
It is also likely that the first concern mentioned is inconsequential compared to others, and if you seize on it as the reason for the consultation you will be using up valuable time that could be better employed exploring the real problem. It may seem risky just to let the patient talk until he/she runs out of steam, but in fact Marvel et al found that when patients with one or more concern were given the opportunity to give a full account at the outset of the consultation, the time taken averaged only 32 seconds.
Most people will rehearse in their heads what they want to tell you, and the order in which they want to tell it – ie, they have an agenda
Marvel et al concluded that: “Given the relatively small proportion of the interview needed to clarify the patient’s concerns, the related decreased likelihood of late-arising concerns and the difficulty of exploring new concerns late in the visit, our data support complete agenda setting as an efficient manner to open the medical encounter.
“Despite concern that a patient-centered approach will take more time, our study further reinforces that soliciting all of the patient’s concerns does not decrease efficiency. Using a simple opening solicitation, such as ‘What concerns do you have?’ then asking ‘Anything else?’ repeatedly until a complete agenda has been identified appears to take six seconds longer than interviews in which the patient’s agenda is interrupted.
“One style that seemed useful was to follow each open-ended solicitation with a focused open-ended question (eg, ‘Tell me more about the leg pain’), then revert back to another open-ended solicitation (eg, ‘Anything else?’) before moving into closed-ended questioning and the examination.”14
Box 14: Active listening skills
Open ended questions – Questions that cannot be answered in one word require patient to expand.
Open-to-closed cones – Move towards closed questions at the end of a section of the consultation.
Checking – Repeat back to patient to ensure that you have understood.
Facilitation – Encourage patient both verbally (“Go on”) and non-verbally (nodding).
Legitimising patient’s feelings – “This is clearly worrying you a great deal,” followed by, “You have an awful lot to cope with,” or, “I think most people would feel the same way.”
Surveying the field – Repeated signals that further details are wanted: “Is there anything else?”
Empathic comments – “This is clearly worrying you a great deal.”
Offering support – “I am worried about you, and I want to know how I can help you best with this problem.”
Negotiating priorities – If there are several problems draw up a list and negotiate which to deal with first.
Summarising – Check what was reported and use as a link to next part of interview. This helps to develop a shared understanding of the problems and to control flow of interview if there is too much information.
- Gask and Usherwood, ABC of Psychological Pedicine: The Consultation, BMJ 324 1567—8 (2002)
Update your skills
If you think your communication skills could do with some work, you may be interested in attending one of the following MPS workshops.
Mastering Your Risk – A highly interactive and internationally renowned workshop attended to date by 10,000 doctors in eight countries. International research shows doctors can reduce the risk of litigation by improving communication skills and better managing patient expectations.
Mastering Adverse Outcomes – This workshop highlights the importance of recognising patient expectations when an adverse outcome occurs, and how failing to address them can increase the risk of the patient turning to legal and disciplinary processes for answers and accountability.
You can earn yourself six CEU (CPD) points by attending the course
All of the above workshops are free for MPS members in South Africa. They were developed specially for doctors by the Cognitive Institute in Australia and are an effective and engaging way of improving your communication skills. And, as an added bonus, you can earn yourself six CEU (CPD) points by attending the course.
You can find out more about the workshops either by going to the MPS website or by emailing Enid Dettmer at firstname.lastname@example.org.