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A parting well made?
Communication skills in practice
A parting well made?
 And whether we shall meet again I know not.
Therefore our everlasting farewell take:
For ever, and for ever, farewell, Cassius!
If we do meet again ,why, we shall smile;
If not, why, then, this parting was well made.
William Shakespeare
Julius Caesar Act V Scene I
Does Communication Matter?
Does Communication Matter?
Patients give priority to:
• being treated with humanity, dignity
and respect
• having good communication with health
professionals
• being given clear information about their condition
• receiving the best possible symptom control
• receiving psychological support when they need it
The NHS Cancer Plan, September 2000
Patients ask for Clinicians
To be:honest giving straightforward and clear
information
sensitive to their emotions
involve them in decisions
Darzi 2008
National reports
 Department of Health Cancer Plan (2000)
 NICE Supportive and Palliative Care Cancer Service
Guidance (2004)
 Health Service Ombudsman Report (2006)
 Cancer Reform Strategy (2007)
 High Quality Care for All – NHS Next Stage Review,
Lord Darzi (2008)
 End of Life Care Strategy (2008)
 Equality and Excellence: Liberating the NHS (2010)
 Improving Outcomes Guidance (2011)
 National Cancer Survey (2012)
 NICE Patient Standard (2012)
Patient’s Association
September 2012
40% GPs poor communication skills
80% patients want to be more involved in
decisions
6/10 GPs have no compassion
Rebecca Smith. Medical Editor
November 9th 2012
GMC report the state of medical education and
practice 2011
Key findings.
 Complaints up 23% in last year
 Complaints re poor communication up 69%
Over representation
 More than 20 yrs since qualifying
 Male, surgeons, psychiatrists and GP
Consequences of poor
communication
Psychological distress and morbidity (Massie et al., 1994)
Reduced quality of life (Kerr et al., 2003)
Poor adherence to treatment (Kim et al., 2004)
Dissatisfaction with care (Zachariae et al., 2003; Kim et al., 2004)
Complaints and litigation (Lenckus, 2005)
Potential burnout in healthcare professionals (Ramirez et al., 1995, 1996;
Berman et al., 2007)
What will help us communicate
effectively?
Minimise Barriers
Reduce Blocking Behaviours
Pick up Cues
Gather patient information
Acknowledge patients agenda/concerns
Give tailored information effectively
Negotiate decision making
Barriers to effective communication
 Fears
 Beliefs/attitudes
 Skills / abilities
 Environment
Blocking behaviours
Blocking behaviours:
 Inhibit patient disclosure of feelings and
concerns
Maguire et al 1996; Wilkinson et al 2008
Del Piccolo et al 2006
Cues
Something that the patient says or does that is a hint to
you that there is something more to be explored.
Butow et al 2002
A verbal or non verbal hint which suggests an underlying
unpleasant emotion and would need clarification from
the health provider.
Del Piccolo et al 2006
Importance of cues
 Facilitative questions linked to cues increase the
probability of further cues and are key to a patientcentred consultation
Zimmerman et al 2003
 Open questions linked to a cue are 4.5 times more
likely to lead to further significant disclosure than
unlinked open Questions
 Facilitating the first patient cue appears to be important
20% drop in cues during consultation if first cue is not
facilitated
Fletcher PhD thesis 2006
Cues - will it take more time ?
 Consultations which were cue based were shorter
that those in which cues were missed
 GP consultations 12.5%
 Surgical consultation were 10.7% shorter
Levinson et al 2000
 In oncology consultations, addressing cues, reduced
consultation times by 10-12%
Butow et al 2002
Facilitative behaviours
Goldberg et al 1993; Wilkinson 1991; Maguire et al 1996: Zimmerman et al 2003; Del Piccolo et al 2011;
Gathering information
 Open questions
 Open directive questions
 Screening questions
 Clarification
 Exploration
 Pauses
 Pauses/silence
 Minimal prompts
Picking up cues
Active listening skills
• Reflection
(acknowledgment)
• Paraphrasing
(acknowledgement and
checking)
• Summary
• Empathy
• Educated guesses
Supporting Evidence
 Silence or minimal prompts most likely to precede
disclosure
Eide H et al 2004
 Giving information reduces likelihood of further
disclosure
Zimmerman et al 2003
 Polarity of words important:
Screening questions: “something else” elicited
significantly more concerns than “anything else”
Heritage J et al 2006
DVD
DVD
A parting well made?
 And whether we shall meet again I know not.
Therefore our everlasting farewell take:
For ever, and for ever, farewell, Cassius!
If we do meet again ,why, we shall smile;
If not, why, then, this parting was well made.
William Shakespeare
Julius Caesar Act V Scene I