|Basic Counselling Skills for Medical Practice|
A good doctor-patient relationship is the cornerstone of good medical practice. Such relationships, epitomized by physicians with 'good bedside manners', contribute to the process of healing. However, training programmes rarely address such issues and many studies suggest that serious communication problems are common in clinical practice. Though the principles of counselling skills are based on psychological theory, it is not necessary to understand the theory to learn the skill.
While there is no correct or single way to conduct interviews, the steps mentioned may provide some useful pointers. They maximize the chances of patients expressing their concerns.
ADVANTAGES OF GOOD COMMUNICATION SKILLS
A significant proportion of medical diagnoses and treatment decisions are made on the basis of information obtained from the medical interview. Doctor-patient communication is an integral part of quality medical care and has an important influence on clinical outcome (Table I).
REASONS FOR LACK OF ADEQUATE COMMUNICATION
Doctors with poor communication skills often cite lack of time and the belief that such issues detract from the task of diagnosis and treatment as reasons for not talking to patients about their emotional state. Personal fears also contribute to poor communication. The fear of causing pain (as breaking bad news causes distress) and the fear of being blamed (as the bearer of such news is often held responsible for the news) add to the reluctance to discuss emotional problems. Other fears which inhibit good communication include: fear of treading into areas not taught during training, precipitating a reaction from patients, expressing their own emotions, upsetting the medical hierarchy and of not knowing all the answers. However, these fears can be mastered and investing in communication skills is rewarding for both patients and doctors.
DOCTOR'S RESPONSES WHICH INHIBIT GOOD COMMUNICATION
Doctors with poor communication skills use a number of 'distancing tactics' that inhibit good communication (Table II).These responses are usually reflex and inhibit the smooth progression of the interview.A combination of these tactics in a single session can prove disastrous. However, the use of such manoeuvres can be avoided with appropriate training.
CORE COMMUNICATION SKILLS
The basic requirements which facilitate communication can be divided into four broad areas: approach, environment, verbal and non-verbal skills (Table III).
The ability to establish a good relationship with patients is an important quality of a good physician which can be mastered with practice. Communication techniques do not work unless the user is convinced of their efficacy. Empathy, warmth, respect for and interest in the patient's welfare form the core of interpersonal skills. The need to be professional in one's approach in order to be able to establish relationships with different kinds of patients should be emphasized during training.
Ensuring privacy encourages disclosure. While it may be practically difficult to ensure absolute privacy in many medical settings, it may be possible to use curtains/screens to create an illusion of privacy. Providing comfortable seating, with the doctor and patient at the same level, aids communication.
TABLE III. Basic requirements for good communication
The use of a brief, socially and culturally appropriate greeting at the beginning of the interview is useful. A personal query, directed at patients on their second visit adds warmth. Asking open-ended questions (Example: How are you feeling?) is a useful strategy which allows patients to present their difficulties instead of closed questions (Example: Isn't the pain better today?) which tend to bias replies towards favourable answers. Allowing time after an open-ended question is another useful method, and provides an opportunity for subjects to mention their difficulties.
Repeating the last three words of the patient's sentence usually results in the subject elaborating his/her point of view. Picking up cues from the patient's responses is useful in identifying the subject's main worries and fears. Technical phrases and jargon should be avoided. Simple language is much less intimidating and aids in the patient's understanding of his/her illness.
Sitting forward, maintaining eye contact, and nodding at appropriate moments are powerful signals of interest. Showing personal interest is a potent factor in doctor-patient relationships.
ESSENTIAL FACTORS IN PSYCHOLOGICAL INTERVENTION
Different schools of psychotherapy claim superiority of their specific techniques. However, there is a growing realization that good psychotherapists, irrespective of their philosophical and psychological orientation, use certain common techniques, which are crucial for psychological improvement. The essential techniques are listed in Table IV. Attempts to use these when interacting with patients may require a conscious effort at first. However, with practice, these techniques will become second nature and improve the physician's therapeutic armamentarium.
The ability to establish a warm confiding relationship is vital for good patient care. Unconditional positive regard for the patient is mandatory for psychological interventions to succeed. Negative feelings about the patient results in impaired communication.
Patients benefit from talking about their difficulties to their physicians. Allowing time for such a process to occur is useful. This also allows the physician to judge the magnitude of the problem. Providing the patient with an orderly account of his/her problems is another useful technique, which clarifies the situation. Re-framing issues and providing new perspectives on them is helpful. Identifying dysfunctional patterns helps patients think about confronting their problems differently. Mobilizing disaffection for the subject's present state is necessary for them to change. The arousal of hope and the expectancy that the distress will reduce is an essential part of the process of therapy.
Patients with stress-related problems often shop for miracles from doctors. The responsibility for improvement, when the distress is stress-related, should be gently yet firmly transferred from physician to patient. The realization that the subject should manage stress differently is necessary for improvement.
TECHNIQUES FOR SPECIFIC SITUATIONS
Common situations requiring specific skills include (i) breaking bad news, (ii) talking to an angry patient, and (iii) talking to a tearful patient.
Breaking bad news
Bad news can be defined as any news that drastically alters the patient's view of his/her future. The greater the gap between the patient's expectation and reality, the worse the news. The key to breaking bad news is to establish the magnitude of the gap.
The three general models for breaking bad news are: nondisclosure, full disclosure and individualized disclosure models.
The non-disclosure model is untenable because it provides false hope, denies the patient an opportunity to come to terms with hislher situation, undermines the doctor-patient relationship, precludes the patient's participation in hislher own treatment (with the therapeutic advantage that it is known to confer), creates barriers within the family unit and obstructs vital mutual support. It also leads to information gathering from uninformed sources.
Full disclosure is paternalistic and does not take into account the amount of information and the timing of the disclosure and hence may not be appropriate for all patients. The individualized disclosure model takes into consideration the varying needs of patients in terms of their coping and the amount of information they want. It allows for time to absorb and adjust to the bad news. It builds confidence in the doctor-patient relationship and forms the basis of mutual decision-making. The process for individualized disclosure is listed in Table V.
Often, the task of breaking bad news is much easier than expected, as many patients with serious medical conditions suspect the possible diagnosis. In such subjects, the doctor needs to confirm views which the patient may already hold. The task is more difficult when the patient has not considered the possibility of bad news. However, these situations can be managed with a little practice.
The technique requires a graded step-wise approach to providing information to the patient after obtaining a clear signal to proceed with the details. The opportunity to discuss the implications in greater depth should always be provided. It is important to discuss the patient's feelings in addition to the implications of the bad news. The information should be provided in a language that is understandable to the subject. It is more important to communicate the seriousness of the condition and its treatment than mention technical terms. Pausing after providing information is necessary so that the subject has time to absorb the significance of the communication. Drawing simple diagrams to explain medical or surgical procedures is helpful. The individual should also be given the option of bringing confidants to discuss issues. Giving specific appointments for reviewing the situation is mandatory.
Patients often like to know the chances of success of various therapies. Such questions are difficult to answer using figures. For example, it may be difficult to explain to an individual patient his chances of remission for a treatment, which has a 90% chance of success. Although the general perspectives on recovery should be mentioned, the central attitude should be one of 'prepare for the worst and hope for the best' . It may be better to acknowledge the state of uncertainty, which though unpleasant, does not offer false hope. Similarly, patients may seek advice on making personal decisions. It is better not to make decisions for patieqts. Such decisions are best postponed until the choices become clear to the patient. The task of those counselling patients is to present the facts and let patients and their families make their own decisions.
Sometimes the patient's relatives feel that the patient should not be told about the diagnosis (e.g. cancer). It is useful to mention that many patients with cancer and other grave illnesses usually guess the seriousness of the condition but feel isolated as everybody around them avoids the issue. The strain of deceiving the patient is also enormous. Relatives should be advised that if the patient gives a clear signal that he/she wants to know about his/her illness, they should talk about it rather than worsen the distress by avoiding the subject.
The technique of breaking bad news is crucial for those directly involved in the clinical decision-making process. It is not so essential for second-line workers.
Managing an angry subject
Occasionally, patients and their relatives are upset by hospital procedures, policy or by the way they have been treated. The management of angry and irritable subjects requires tact. The steps in managing such situations are mentioned in Table VI.
Acknowledging anger and giving permission to express it are important first steps. Avoiding the emotion or being defensive about the situation exacerbates the problem as the subject's reaction may be justified. Criticizing the subject or defending colleagues, hospital policy or procedures without finding out the subject's point of view is usually disastrous. Showing concern is cardinal to resolving the situation.
Talking to a tearful patient
The steps in managing a tearful patient are similar to those used to defuse anger. These include: (i) acknowledging distress, (ii) giving permission to express the suffering, (Hi) finding out the extent of the anguish, (iv) shifting the focus onto the person, and (v) showing concern. The final step should include an agreed plan to review progress at a future appointment.
Counselling skills are essential for good medical practice. Simple details lie between success and failure. The issues discussed are guidelines, not rules. These are possible choices and alternatives, which can be used in real-life situations in busy medical and surgical wards and in general practice. Even long interviews do not usually last more than 10-15 minutes. All persons involved in patient care can use them: doctors, nurses, social workers, counsellors, etc.
Breaking bad news is difficult. However, it is part of the job of people involved in clinical care. It is important to realize that all of us make mistakes. We can become flustered, angry and be caught on the wrong foot. However, if we recognize the problem we can often retrieve the situation. The skills required can be mastered with practice and will improve the quality of patient care.
The author would like to thank Dr D. Braganza for her comments on the draft.