bmj key communication skills and how to acquire them

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2002;325;697-700BMJPeter Maguire and Carolyn PitceathlythemKey communication skills and how to acquire

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Clinical review

Key communication skills and how to acquire themPeter Maguire, Carolyn Pitceathly

Good doctors communicate effectively with patientsthey identify patients problems moreaccurately, and patients are more satisfied with the care they receive. But what are the necessarycommunication skills and how can doctors acquire them?

When doctors use communication skills effectively,both they and their patients benefit. Firstly, doctorsidentify their patients problems more accurately.1 Sec-ondly, their patients are more satisfied with their care

and can better understand their problems, investiga-tions, and treatment options. Thirdly, patients are morelikely to adhere to treatment and to follow advice onbehaviour change.2 Fourthly, patients distress and theirvulnerability to anxiety and depression are lessened.Finally, doctors own wellbeing is improved.35 Wepresent evidence that doctors do not communicatewith their patients as well as they should, and weconsider possible reasons for this. We also describe theskills essential for effective communication and discusshow doctors can acquire these skills.

Sources and selection criteria

We used original research studies into doctor-patient

communication, particularly those examining the rela-tion between key consultation skills and how wellcertain tasks (such as explaining treatment options)were achieved. We used key words (communicationskills, consultation skills, and interviewing skillswhether associated with training or not) to searchEmbase, PsycINFO, and Medline over the past 10

years. We also searched the Cochrane database ofabstracts of reviews of effectiveness (DARE).

Deficiencies in communication

Box 1 shows the key tasks in communicating withpatients that good doctors should be able to perform.Unfortunately, doctors often fail in these tasks. Onlyhalf of the complaints and concerns of patients arelikely to be elicited.2 Often doctors obtain littleinformation about patients perceptions of their prob-lems or about the physical, emotional, and socialimpact of the problems.6 When doctors provide infor-mation they do so in an inflexible way and tend to

ignore what individual patients wish to know. They paylittle attention to checking how well patients haveunderstood what they have been told.2 Less than half ofpsychological morbidity in patients is recognised.7

Often patients do not adhere to the treatment andadvice that the doctor offers, and levels of patient satis-faction are variable.2 8

Reasons for deficiencies

Until recently, undergraduate or postgraduate trainingpaid little attention to ensuring that doctors acquirethe skills necessary to communicate well with patients.

Box 1: Key tasks in communication withpatients

Eliciting(a)the patients main problems; (b)thepatients perceptions of these; and (c)the physical,emotional, and social impact of the patients problemson the patient and family

Tailoring information to what the patient wants toknow; checking his or her understanding

Eliciting the patients reactions to the informationgiven and his or her main concerns

Determining how much the patient wants toparticipate in decision making (when treatmentoptions are available)

Discussing treatment options so that the patientunderstands the implications

Maximising the chance that the patient will followagreed decisions about treatment and advice aboutchanges in lifestyle

Summary points

Doctors with good communication skills identify

patients' problems more accurately

Their patients adjust better psychologically andare more satisfied with their care

Doctors with good communication skills havegreater job satisfaction and less work stress

Effective methods of communication skillstraining are available

The opportunity to practise key skills and receiveconstructive feedback of performance is essential

Cancer ResearchUK PsychologicalMedicine Group,Christie HospitalNHS Trust,Manchester

M20 4BXPeter Maguiredirector

Carolyn Pitceathlyresearch fellow

Correspondence to:P [email protected]

BMJ2002;325:697700

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Doctors have therefore been reluctant to depart from astrictly medical model, deal with psychosocial issues,and adopt a more negotiating and partnership style.2 6

They have been loath to inquire about the social andemotional impact of patients problems on the patientand family lest this unleashes distress that they cannothandle. They fear it will increase patients distress, takeup too much time, and threaten their own emotionalsurvival. Consequently, they respond to emotional cues

with strategies that block further disclosure (box 2).9

Even if doctors have the appropriate skills, theymay not use them because they are worried that their

colleagues will not give sufficient practical andemotional support if needed.10 Doctors may also notrealise how often patients withhold important infor-mation from them or the reasons for this (box 3).9

Skills needed to perform key tasks

Eliciting patients problems and concernsEstablish eye contact at the beginning of the consulta-tion and maintain it at reasonable intervals to showinterest.11 Encourage patients to be exact about thesequence in which their problems occurred; ask fordates of key events and about patients perceptions andfeelings. This helps patients to recall their experiences,feel understood,12 and cope with their problem.

Use active listening to clarify what patients areconcerned about9that is, respond to cues about prob-lems and distress by clarifying and exploring them.11

But avoid interrupting before patients have completedimportant statements.13

Summarise information to show patients they havebeen heard, and give them an opportunity to correctany misunderstandings.9 Inquire about the social andpsychological impact of important illnesses orproblems on the patient and family14; this shows thepatient that you are interested in his or her psychoso-cial wellbeing, and that of the family.

Giving informationCheck what patients consider might be wrong and howthose beliefs have affected them.15 Ask patients what

information they would like, and prioritise their infor-mation needs so that important needs can be dealtwith first if time is short.9 Present information bycategoryfor example, you said you would like toknow the nature of your illness. Check that the patienthas understood before moving on.16

With complex illnesses or treatments, check if thepatient would like additional informationwritten oron audiotape. However, if you have to give the patient

a poor prognosis, providing an audiotape may hinderpsychological adjustment.

Discussing treatment optionsProperly inform patients of treatment options, andcheck if they want to be involved in decisions. Patientswho take part in decision making are more likely toadhere to treatment plans.2 Determine the patientsperspective before discussing lifestyle changesforexample, giving up smoking.2

Being supportiveUse empathy to show that you have some sense of howthe patient is feeling (the experiences you describeduring your mothers illness sound devastating). Use

educated guesses too. Feed back to patients your intui-tions about how they are feeling (you say you are cop-ing well, but I get the impression you are strugglingwith this treatment). Even if the guess is incorrect itshows patients that you are trying to further yourunderstanding of their problem.

How to acquire the skills

Effective training methodsBox 4 lists the teaching methods for helping doctors toacquire relevant communication skills and stop usingblocking behaviour.1 17These methods have been usedin undergraduate and postgraduate teaching.18 19 Agood doctor, wanting to audit and improve his or her

skills, should ensure that any course or workshop theyattend includes three components of learning:cognitive input, modelling, and practice of key skills.

Cognitive inputCourses should provide detailed handouts or shortlectures, or both, that provide evidence of current defi-ciencies in communication with patients, reasons forthese deficiencies, and the adverse consequences forpatients and clinicians. Participants should be toldabout the communication skills and changes inattitude that remedy deficiencies and be given evidenceof their usefulness in clinical practice.

Box 2: Blocking behaviour

Offering advice and reassurance before the mainproblems have been identified

Explaining away distress as normal

Attending to physical aspects only

Switching the topic

Jollying patients along

Box 3: Reasons for patients not disclosingproblems

Belief that nothing can be done

Reluctance to burden the doctor

Desire not to seem pathetic or ungrateful

Concern that it is not legitimate to mention them

Doctors blocking behaviour

Worry that their fears of what is wrong with themwill be confirmed

Box 4: Effective teaching methods

Provide evidence of current deficiencies incommunication, reasons for them, and theconsequences for patients and doctors

Offer an evidence base for the skills needed toovercome these deficiencies

Demonstrate the skills to be learned and elicitreactions to these

Provide an opportunity to practise the skills undercontrolled and safe conditions

Give constructive feedback on performance andreflect on the reasons for any blocking behaviour

Clinical review

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ModellingTrainers should demonstrate key skills in actionwithaudiotapes or videotapes of real consultations. The

participants shoulddiscuss the impact of these skills onthe patient and doctor.

Alternatively,an interactive demonstrationcan beused. A facilitator conducts a consultation as he or shedoes in real life but using a simulated patient. Theinterviewer asks the group to suggest strategies that heor she should use to begin the consultation.Competing strategies are tried out for a few minutesthen the interviewer asks for peoples views andfeelings about the strategies used. They are asked topredict the impact on the patient. Unlike audiotaped orvideotaped feedback of real consultations, the patientcan also give feedback. This confirms or refutes thegroups suggestions. This process is repeated to workthrough a consultation so that the group learns aboutthe utility of key skills.

Practising key skillsIf doctors are to acquire skills and relinquish blockingbehaviour, they must have an opportunity to practiseand to receive feedback about performance. However,the risk of distressing and deskilling the doctor must beminimised.

Practising with simulated patients or actors has theadvantage that the nature and complexity of the taskcan be controlled. Time out can be called when theinterviewer gets stuck.The group can then suggest howthe interviewer might best proceed. This helps to mini-mise deskilling. In contrast, asking the doctor to

perform a complete interview may cause the doctor tolose confidence because errors are repeated.

Asking doctors to simulate patients they haveknown well and portray their predicament makes thesimulation realistic. It gives doctors insights into howpatients are affected by different communicationstrategies.

For a simulation exercise to be effective, doctorsmust be given feedback objectively by audiotape orvideotape.19 To minimise deskilling, clear ground rulesshould be followed:x Positive comments should be offered about whatstrategies (oral and non-oral) were liked and why

x Constructive criticism should be allowed only afterall positive comments have been exhaustedx Participants offering constructive criticisms shouldbe asked to suggest alternative strategies and givereasons for their suggestionsx Any blocking behaviour should be highlighted andthe interviewer asked to consider why it was used(including underlying attitudes and fears)x The group should be asked to acknowledge if they

have used similar blocking behaviour and whyx To reinforce learning, the doctor should be asked toreflect on what he has learned, what went well, andwhat might have been done differently.

Context of learningSome doctors feel safer learning within their own dis-cipline.20 Others welcome the challenge of learning

with those from other disciplines, such as nursing21;multidisciplinary groups enable doctors to understandand improve communication between disciplines. Therelative merits of these two different environments hasstill to be determined.

Doctors are more likely to attend workshops orcourses in communication skills if they know that sub-

stantial time will be devoted to their own agenda. Thus,they should be asked to identify the communicationtasks they want help with.These will commonly includethe tasks discussed already plus more difficultsituations, such as breaking bad news, handling anger,and responding to difficult questions.

Limiting the size of the group to four to six partici-pants creates the sense of personal safety required forparticipants to disclose and explore relevant attitudesand feelings. It also allows more opportunity topractise key communication tasks.22

Facilitators who have had similar feedback trainingare more effective in promoting learning than thosewho have not.23 Residential workshops lasting threedays are as effective as day workshops lasting five days.21

Whether longer courses are more effective than work-shops plus follow up workshops needs to bedetermined.

Using new skills in practice

Practising communication skills with simulatedpatients leads to the acquisition of skills and the relin-quishing of blocking behaviour. However, doctors donot transfer these learned skills to clinical practice ascomprehensively as they should.24 Offering doctorsfeedback on real consultations should ensure moreeffective transfer of skills.

ALFRED

PASIEKA/SPL

Access to training

Sources of information

Administrators of postgraduate centres

Advertisements in professional journals

Well established courses

Medical Interview Teaching Association, London

Cancer Research UK Psychological MedicineGroup, Manchester

Cancer research UK Psycho Oncology Group,Brighton

Clinical review

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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 abouthow they are communicating and obtain more valida-

tion 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.

PM is also professor of psychiatric oncology at the University ofManchester.

Competing interests: None declared.

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18 Aspegren K. Teaching and learning communication skills in medicineareview with quality grading of articles. Medical Teacher1999;21:563-70.

19 Maguire P, Roe T, Goldberg D, Jones S, Hyde C, ODowd T. The value offeedback in teaching interviewing skills to medical students. Psychol Med1978;8:695-704.

20 Fallowfield L, Jenkins V, Farewell V, Saul J, Duffy A, Eves R. Efficacy of a

Cancer Research UK communication skills training model foroncologists: a randomised controlled trial. Lancet2002;359:650-6.21 Maguire P, Booth K, Elliott C, Jones B. Helping health professionals

involved in cancer care acquire key interviewing skillsthe impact ofworkshops. Eur J Cancer1996;32a:1486-9.

22 Parle M, Maguire P, Heaven C. The development of a training model toimprove health professionals skills, self-efficacy and outcome expectan-cies when communicating with cancer patients. Soc Sci Med1997;44:231-240.

23 Naji S, Maguire GP, Fairbairn S, Goldberg DP, Faragher EB. Trainingclinical teachers in psychiatry to teach interviewing skills to medical stu-dents.Med Educ1986;20:140-7.

24 Heaven C. The role of clinical supervision in communication skills train-ing [PhD thesis]. Manchester: University of Manchester, 2001.

The good doctor around the world

What do medical traditions around the world have to say aboutthe necessary qualities of the good doctor? Two Sanskrit textsthat form the basis of ayurveda (the Indian Hindu medicaltradition) state that students embarking on an apprenticeship to

become a vaidya (an ayurvedic physician), must vow to respectpatients and be abstemious, modest, courteous, and selfcontrolled. They must also make a concern for the health of sickpeople their sole aim. In textual sources for unani tibb, theGraeco-Arabic medical tradition practised in South Asia, idealqualities of the hakim (an unani physician) include compassion,restraint, probity, moderation, self restraint, humility, and lack ofambition (other than to do good). In ayurveda, unani, andtraditional Chinese medicine, doctors should aid the needy andtreat the sick without discriminating on grounds of wealth or

background. These classical traditions also expect theirpractitioners to continue their self education so that they improve

learning and technical skills; knowledge and expertise are valuedin most medical systems worldwide.

Although UK patients value knowledge and technical ability,communication and being listened to is similarly highly rated. Bycontrast, in rural Rajasthan, India, patients regard the ability of adoctor to diagnose their ills by taking their pulse without theneed for them to speak as the sign of a truly good physician.Practitioners of siddha medicine, a South Indian Tamiltherapeutic tradition based on the writings of Hindu yogis, alsoclaim to learn everything about a patients internal state just byfeeling the pulse.

A theme found in most medical traditions and therapeuticpractices worldwide is that healing abilities involve special wisdom

and insight. In many traditions, such powers are couched in areligious or metaphysical idiom, but there are clear resemblancesto the special, extra qualities cited as characteristic of the gooddoctor among the BMJs respondents to the question of what is agood doctor in this weeks letters section. Across cultures specialhealing powers are also often associated with the potential to doharm. In northern India, for example, the sayana bhopa (wise andcunning priest) can kill through sorcery as well as heal. Again,analogous fears exist over the negative potential of Western

biomedicines power, evidenced in the growing concerns overmalpractice and in attempts at regulation. The dark side of

biomedical healing is most sinisterly expressed in the archetypalspectre of the British general practitioner and mass murdererHarold Shipman.

Helen Lambert senior lecturer in medical anthropology, Department ofSocial Medicine,Bristol University, Bristol

We welcome ar ticles of up to 600 words on topics such asA memorable patient, A paper that changed my practice, My mostunfortunate mistake, or any other piece conveying instruction,pathos, or humour. If possible the article should be supplied on adisk. Permission is needed from the patient or a relative if anidentifiable patient is referred to. We also welcome contributionsfor Endpieces, consisting of quotations of up to 80 words (butmost are considerably shorter) from any source, ancient ormodern, which have appealed to the reader.

Clinical review

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