Sending the right message

PATIENTS want to be treated by skilled and knowledgeable clinicians but this by itself is not sufficient. Patients also want to be treated with humanity, dignity and respect; they want to be fully informed, supported and listened to so that they can make meaningful and informed choices about their care.

In 2012 the General Medical Council report, The State of Medical Education, revealed there were proportionally more complaints about doctors than any other healthcare professional. Two of the top three complaints involved communication: ineffective communication (including failure to respond to concerns, provide appropriate information and listen) and lack of respect (including rudeness, failure to respect the patient’s dignity and work in partnership).

What steps can we take to deliver best practice?

Structuring the conversation

Evidence suggests that one of the simplest things we can do is to structure our consultations. The aim is to gather all information and concerns, from the patient’s perspective, before we give any information. This aids the disclosure of concerns. As soon as we provide any information and advice to patients, patient disclosure is reduced and we hear fewer concerns. The Calgary-Cambridge consultation model is useful, as is the Maguire model (see box, right). Both allow the doctor to direct and optimise the flow of information between patient and doctor.

Working with cues

To optimise either model of assessment, it is essential to be cue-focussed, as behind each cue may be a concern which needs to be identified.

Definition of a Patient Cue
A hint or clear expression of a negative emotion (verbal, vocal or non-verbal) which would need exploring to check for the presence of an underlying concern

Patients tend not to immediately and clearly disclose all their concerns even if we ask them to, instead they hint at worries and concerns to determine if the healthcare professional is interested.

Structure of an assessment interview (Maguire model)

Introductions
Names and role
Reason for the consultation
Time boundary

Gathering information
Background information
History of the illness including patient’s perspective and concerns

Assessing current situation
Current concerns Impact on life
Coping responses
View of the future

Information giving and plan of action
Tailor information
Share decision making
Negotiate plan of action

Closing
Summarise
Screen for further questions or concerns
Check how patient is left feeling

An important skill is therefore the ability to recognise and respond appropriately to patient cues. At each step in the model the doctor needs to recognise the patient’s cues and link their response to the cue. Communicating in this way about the issues that matter to the patient, detected via the cues (whether they are worries the patient came with or worries resulting from new information given), allows the concerns and needs of the patient to be identified and addressed appropriately.

Which cues?

Gathering information
It isn’t always feasible or practical to explore every cue but it is important to work with key cues that help to elicit the patient’s thoughts, feelings and concerns.

There is evidence that the acknowledgement and exploration of the first patient cue (verbal or non-verbal) is crucial because there is a 20 per cent decrease in cues provided by the patient if the first cue is not acknowledged or explored. Subsequent cues to work with are the strongest ones (which healthcare professionals tend to avoid). If in doubt, summarise the cues and ask the patient to prioritise. Working with the strongest cues and first cue (verbal or non-verbal) will optimise disclosure of concerns.

Giving information
Working with cues is also important when giving information and negotiating decisions with the patient. Acknowledgement of a patient’s cues increases the amount of information the patient is able to recall and increases their ability to make decisions.

Cues are a useful way of gauging patients’ reactions to what we say. These cues might include nods which may suggest agreement or understanding, but could also include frowns, agitations, blank expressions or reduced eye contact, all of which may imply confusion or distress with what is being said, or disagreement with a decision.

Key communication skills

To be sure of their meaning, cues need to be acknowledged, clarified and explored (ACE) using the skills below.

Using skills in context, i.e. to acknowledge and explore cues, significantly increases the disclosure of significant information from the patient and is key to a patient-centred approach.

     Skills to acknowledge

• Reflection
• Paraphrase
• Summary

     Skills to clarify and explore

• Open focused questions
• Educated guesses

Showing empathy and being supportive

Being empathic helps the patient to feel understood and cared for, and acknowledging emotions (cues) significantly increases information recall and enables the patient to process decisions more clearly.

      Empathic statements: examples

• I can see how upset you are.
• You sound upset, am I right?
• It sounds overwhelming.
• You say you are coping but I am getting the sense that you are finding it really hard. (Pause)

Difficult situations

Managing difficult communication situations normally refers to handling strong and difficult emotions exhibited by the patient or relative but it can also mean being asked difficult questions, or when patients or relatives make inappropriate demands. In all these situations the key is to work with the cues. Strong emotions need to be acknowledged, not ignored or minimised, and the concerns driving the emotion elicited and explored before any information is given. Being empathic throughout is crucial.

Handling difficult questions
Difficult questions or demands are often best treated as cues. Answering difficult questions may lead to breaking bad news or giving uncertain information. Typical questions can be “How long do I have?” “I am going to die, aren’t I?” Is it bad?” The key principle is to first acknowledge the importance of the question, then explore the question before giving information that addresses it (“explore before explain”). By exploring the question, the patient’s perceptions and concerns can be identified which will allow the question to be answered appropriately.

Breaking bad news
Bad news needs to be given in a way that allows the person to understand and manage what is being said to them and in a way that allows them to express their fears and concerns before any information and advice is given. This means it needs to be delivered slowly in small chunks and with compassion. The doctor also needs to actively elicit the patient’s new concerns and feelings (being guided by the patient’s cues) before moving into information giving and discussing and negotiating treatment options.

Improving skills

Learning to communicate effectively through experience alone has been shown to be ineffective when compared to other methods. Although a sound knowledge base and observation of good practice may facilitate change, experiential workshops which give participants a chance to practice, will optimise and maximise the ability to acquire, hone and maintain new skills.

Summary

A patient-centred approach using a structure for the consultation (“gather before give”), and facilitative skills linked to cues will: optimise disclosure of patient concerns, allow patient preferences to be heard, increase the likelihood of the patient understanding and recalling information, and participating in treatment decisions. A patient-centred approach is the key to best practice. It will increase the likelihood of the patient feeling satisfied with their care and feeling they have been treated as an individual with their wishes respected. It will also allow doctors to deliver tailored care with less risk of non-concordance with treatment.

       Summary of useful patient centred skills

• Actively elicit patient’s perspective and all concerns (gather information)
• Verbally acknowledge concerns by summarising and empathising
• Obtain permission to give information
• Pause frequently when giving information
• Obtain permission to give further information
• Check for new concerns and acknowledge
• Negotiate a plan
• Empathise throughout

Further reading

Assessing Patients with Cancer: the content, skills and process of assessment, Cancer Research UK Publication: (2nd ed 2008) maguireunit@christie.nhs.uk

Silverman J., Kurtz S., Draper J. (2008) Skills for communicating with patients (2nd edition), Radcliffe publishing: Oxford

Dr Claire Green, Nicky Schofield and Alison Fellows are trainers with the Maguire Communications Skills Unit, The Christie School of Oncology, Manchester