Diagnosis Lec#9 Tuesday 22/7

Communication skills and motivational interviewing

Communication is a 2 ways path, between sender & recipient, usually there is a message involved & happen in a medium. So It can happen in anyway; written, emails, meetings.

*Do we all know how to communicate? Actually it’s not that easy

Its one of the most important factors in delivery of dental care, about 50% of dentists felt

that they had received only fair or poor training in communication.

* Why do we need to communicate?

About 70% of lawsuits and medical problems were caused by communication issue (no explaining of procedure & risks associated, pt didn’t like how the dentist talk..)

In 2008 American Dental Education Association ADEA made a Competency about general dentists Communication and Interpersonal Skills, and dentists have to be competence enough to:

1 Apply appropriate interpersonal and communication skills.

2 Apply psychosocial and behavioral principles in patient-centered health care.

3 Communicate effectively with individuals from diverse populations. They have to know how to deal with different population

**Communication goals**

*Communication Pathways; how do we communicate

Verbal communication- the words we choose- .

Paraverbal Messages - how we say the words- the way we say the words, your tone, accent.

Nonverbal Messages - our body language

-Effective verbal messages should be:

~ Brief, clear, and organized

~ Free of jargon, free of confused unintelligible language

~ Do not create resistance, frighten, intimidate or upset the listener.

- Functions of verbal communications:

• Task ordering

• “What are we trying to accomplish?”

• Procedural .Ex; full mouth rehabilitation.

• Process orientation

• How we say something.

• Relational/influential. Ex; endo treatment needs 2 appointment

• Narrative

• Helps to describe the situation.

• Use of analogies, metaphors. Ex, why to use crown/fillings after endo.

Structures of Meaning in Verbal Communication

• Denotative Meaning: dictionary meaning.

• Connotative Meaning: Meaning depends on subjective reality and context.

Ex.: you don’t say “I’m going to give a shock” !! you say “I’m giving you an anesthetic”

Don’t say “I’m going to pull your tooth” >>> “I’m removing it”

Don’t say “I’m going to fill your tooth” >>> “I’m restoring it”

-Waiting room make as a reception area .. It has a psychological effect.

**Nonverbal Messages: Facial Expression, Postures and Gestures: كالم المريضمن بفهمه اللي المعنى الطبيب

About 93% of a message’s meaning is nonverbal!

There are 5 different ways for non verbal communication:

Facial Display; eye contact, facial expression

Body language

Paralanguage

Proxemics

Chronemics

1) Facial Display:Facial expressions-Dentist: smile & node your head , not talking with others while taking care of the pt.

Facial expressions- Patient : you should understand your pt.

Direct eye contact gives the pt the feeling of warmth, credibility and concern

Shifty eye (looking around) contact suggests dishonesty.

Downward gaze maybe a sign of submissiveness or inferiority or you don’t know what you’re doing

“Try to read your pt facial expression while your working”

2) Paraverbal Messages: the way you say the message; Paraverbal communication refers to the messages that we transmit through the voice tone, pitch, voices. Dialects, accent, pitch, tone, rate, pauses…etc

3)Body language: How you present yourself to the pt. that’s why you have to follow the dress code

Physical Appearance, Movement, Gestures.

4)Proxemics; space around the pt.

Patients have their own Personal space;invisible boundary that they create around themselves & differ from patient to patient.

Dentist needs to invade this space to provide treatment (some pt. welcome this invasion others don’t)

Verbal and nonverbal communications should mitigate the tension created by this encroachment of their personal space.

5) Chronemics: The use of time

• Wait time for patients communicate their value

• Waiting room

• Scheduling , for ex. If you give the pt. an appointment after 3 months he might think that you don’t care for him!

** Understanding Message Reception

55% Visually (facial expressions & body language)

33% Vocally (pitch, tone, volume) the pt might scream in French you’ll know he’s angry even if you don’t understand what he’s talking!

7% Verbally (by words)

** RECEIVING MESSAGES

Listening ( while taking history)

Requires concentration and energy

Involves a psychological connection with the speaker

Includes a desire (show interest) and willingness to try and see things from another's perspective

Requires that we suspend judgment and evaluation عليه تحكم لا

***Listening Skills

• Do not let the mind wander. تسرح ال

• Put aside personal concerns while the patient is talking.

• Do not concentrate on formulating a reply.

• Concentrate on what the patient is actually saying.

• Communication should be Stress free, come from within

• Look as well as listen. المريض بضايق اللي شو

• Pick up both the verbal and nonverbal information the patient is transmitting.

** How do we learn:

80% occurs through sight alone

10% through hearing

** What makes a good communicator? >>>

**Effective Communication: It is two way, involves active listening.

It reflects the accountability of speaker and listener.

It is free of stress & It is clear.

Barriers to Effective Communication:

• Socio-economic level

• Education

• Cultural Diversity; cultures are really surprising, what seems right for you is wrong from their perspective, don’t argue and don’t negotiate.

**Cultural diversity: Differences in race, gender, cultural heritage, age(old pt.s are more difficult) , physical abilities, and spiritual beliefs are variations that must be appreciated and understood when working with patients and other staff members.

**How to develop your communication skills:

- Maintain eye contact with the audience

- Body awareness (clear body language)

- Gestures and expressions (positive)

- Practice effective communication skills

**Patient Education:

• Clinician-Centred, after you finish the treatment tell the pt. to brush his teeth, stop smoking..

Educational messages and direct advice provided using a unidirectional form of communication that attempts to persuade patients to comply with professional recommendations. It’s your duty to tell the pt. then he’ll either accept it or resist your advice

Traditional Patient Education: If you actually tell them they will have this disease they will accept your advice , If you teach them how, they will change. If you make them feel bad or afraid, they will change.

This way have a low success rate but it might work with some patients.

*Motivational Interviewing (MI): person-centred, goal-directed method of communication for eliciting and strengthening intrinsic motivation for positive change يغير قرر نفسه المريضpositively affect health behaviour change related to drug addiction, smoking, weight reduction, diabetes management, medication adherence, condom use, and oral health

concept of MI : that you relate the positive change with something they value. And they found that confrontational styles or direct persuasion are likely to increase resistance and should be avoided.

• It acknowledges the patient is the expert in their own life. In general, in psychology the human being have 3 needs :

The need of autonomy (self-directionm make their own decisions), the need of self efficient, and the need to communicate and socialize.

- Spirit of MI:

Yourself should be convinced about this philosophy, your equal to the patient and your talking as adult to adult.

In the clinic you don’t say auntie/ 3amo/ teta, you say Mr/Ms/Maddam.

• The clinician must abandon the impulse to solve the patient’s problems (often referred to as the “righting reflex”) and allow the patient to articulate his or her own solutions.

The Spirit of MI is based on three key elements:

I. Collaboration (Vs. Confrontation) between the therapist and the client; work as a team , be equal

II. Evoking or drawing out the client‘s ideas about change; (Rather than imposing ideas)

III. Autonomy of the client.(vs. Authority to the pt)

Appropriate position for a conversation:

clinician is facing the patient on the same seating level. Talking as adults maintains eye contact, establish verbal and non verbal communication.

Inappropriate position for a conversation:

the clinician is wearing a face mask and is at a higher level than the supine patient. Patient feels inferior!

***Principles of MI:

1. Express Empathy through acceptance, affirmation, open-ended questions and reflective listening. مثل سهل الموضوع لو المريضحتى مع oral hygiene, don’t judge تعاطف

2. Develop Discrepancies between current behaviour and important goals or values. Show difference between current status and ideal status or goal

3. Roll with Resistance and avoid arguing. go with the flow .

4. Support Self-efficacy and optimism. Enhance the patient’s confidence in their ability to make a change. Give the pt strength and enhance his confidence .

***Strategies:

• ORAS : O pen Ended Questions, Affirmations, Reflections, and Summaries

• Brief method to begin MI. You start with it.

• These are Core counsellor behaviours employed to move the process toward eliciting client “change talk” and commitment for change.

• Change talk involves statements or non‐verbal communications indicating the client may be considering the possibility of change.

>>Ask open-ended questions: Approaching the patient with multiple closed-ended questions (question that will be answered with “yes” or “no”) sets the patient’s role to be a rather passive one. In contrast, open-ended questions invite thought, collaboration, and effort on the part of the patient.

• Example:

• “How do you feel about your smoking?”

• ؟ دخان تبطل (yes/no) بدك

• ؟ بالتدخين رايك (open ended) شو

>> Affirmation: if anyone of us have a negative attitude & someone told him its wrong he’ll get irritated & defensive even if they’re wrong.

Acknowledging the patient’s strengths and appreciation of his or her honesty will decrease defensiveness, increase openness, and the likelihood of change.

It assists in building rapport and in helping the client see themselves In a different, more positive light.

Facilitating the MI principle of Supporting Self-efficacy.

• Example:

“You’re telling me clearly why you’re not very concerned about your toothbrushing and I appreciate that honesty.”

>>Reflections" or reflective listening is perhaps the most crucial skill

Ex of reflective listening: . pt told you that he cant quit smoking so you rephrase his story and focus on negatives and positives by this way the pt feels that you are really listening and understood it from pt perspective.

• It has two primary purposes.

• Empathy:

• Reflective responses

Appropriate reflection:

• (1) captures the underlying meaning of the patient’s words,

• (2) is concise,

• (3) is spoken as an observation or a comment , not a judgment

• (4) conveys understanding rather than judgment.

Example: “You really seem to have lost hope that you can ever really quit smoking.”

>> Summarize :emphases on his weakness and direct him to change talk

• Summarizing the patient demonstrates interest, organizes the interview, and gets things back on track if necessary, Highlights strength and weakness.

Example: “So there’s a big part of you that doesn’t feel ready to change right now. You really enjoy smoking, but you have been a little worried by the way some people react when they find out that you smoke. Is that about right?”

***Change talk: is the patients’ expressions of desire, reason, ability or need to make a change in their oral health behaviours.  نفسه بتغير النية

• Expressions of change talk may come naturally as a result of open-ended questions and reflections or can be further elicited through the use of directed questions. How to know if the pt is ready to change :

• Preparatory Change Talk

• Desire (I want to change)

• Ability (I can change)

• Reason (It’s important to change)

• Need (I should change)

• Implementing Change Talk

• Commitment (I will make changes)

• Activation (I am ready, prepared, willing to change)

• Taking Steps (I am taking specific actions to change)

How to evoke change talk :

• Why would you want to make this change? (ex; smoking leads to cancer and bad oral hygiene ..)

• If you did decide to make this change, how might you go about it in order to succeed?

• What are the three best reasons for you to do it?

How important would you say it is for you to make this change, on a scale from 0 to 10, (ex: to quit somking:4 , how to make 7or10? pt might say I don’t know how , or I need motivation..) where 0 is not at all important, and 10 is extremely important?

MI strategies in delivery of Oral Health advice:

• The key components of brief MI which can be applied for the delivery of oral health information and advice are: 

1. Ask Permission; Do you mind if I talk to you about your smoking condition? If no then drop it if yes go to step2

2. Elicit Provide Elicit (using OARS), open ended Q; Why do you smoke, what feeling dose it give you, give me 3 reasons why you think you should quit smoking..then give info about how to quit “ you heard from other pt that patches are helpful”

3. Explore Options, change talk

4. Affirm Commitment.

Something special in our country, that patients listen to their neighbours more than doctors as they feel that doctors need their money or students need to practice on them or you just want to get rid of him, so if you look from the patient perspective you will gain a lot.

If a patient “rejects” the information it is important not to get into a debate.

- Note: The doctor was just reading the slides, I tried to include everything, please refer to slides (esp. last ones as they are some cases you should know the type of question) in the exam the doctor will provide you with a case and ask about it, and in the clinics he might be your pt and should know how to deal with him using the methods we learnt.

Aroob Al Hyari.

Best of luck !