ABC of Clinical Communication

Nicola Cooper, John Frain, Nicola Cooper, John Frain

• Publisher: BMJ Books
• Year: 2017
• ISBN:
  9781119247005
• Edition: 1
• Topic: Medizin
• Subtopic: Klinische Medizin

Clinical communication underpins safe patient care. The effective health professional sees illness through the patient's eyes and understands what matters most to him or her. Effectiveness means gathering hard clinical data about the physical changes affecting the patient, understanding why the patient is concerned, conveying this to other health care professionals and involving the patient at every stage of management decisions.

The evidence for good clinical communication is well established, although there are challenges. While listening is the basis of sound diagnosis and clinical reasoning, its absence affects patient outcomes particularly when patients are not permitted to make their concerns known or when there are gaps in information flow or communication between the professionals caring for them.

The ABC of Clinical Communication considers the evidence pertinent to individual encounters between patients and their health professionals, how to achieve efficient flow of information, the function of clinical teams and developing a teaching programme. Topics covered include:

• The consultation
• Clinical communication and personality type
• Shared decision making
• Communication in clinical teams
• Communication in medical records
• Communication in specific situations, including mental health and end of life
• Teaching clinical communication

The chapter authors are clinicians involved in communicating with patients, research and training healthcare professionals of the future. This team reflects the multidisciplinary approach required to develop effective clinical communication.

CHAPTER 1
Why Clinical Communication Matters

John Frain

University of Nottingham, Nottingham, UK

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OVERVIEW

• The clinical interview is essential in collecting information about a patient and reducing diagnostic error.
• There is an evidence base for the skills that best facilitate collection of both the biomedical and psychosocial content of the patient’s story.
• Good clinical communication underpins patient‐centred care.
• Health professionals require continuing training in clinical communication in all its forms.
• Efficient information flow within the healthcare team is an essential component of patient safety.
• Respect for patients and colleagues is a prerequisite for effective clinical communication.

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Clinical communication – a historical perspective

In the absence of defined physical examination methods and investigations, such as blood tests and imaging, interviewing the patient was the mainstay of diagnosing illness and managing disease. While we know little of the format of the doctor–patient encounter prior to the nineteenth century, listening was a virtue associated with the competent doctor. The doctor relied on the patient’s description of symptoms to make a diagnosis. As only wealthier members of society could afford the services of a doctor, good communication skills were rewarded with greater employment. The apprenticeship model of medical training led to the role‐modelling of these skills by senior doctors. While the doctor–patient relationship has evolved since then (see Figure 1.1), the ‘history’ remains the most important means of making a diagnosis.

Figure 1.1 Evolution of the doctor–patient relationship.

Source: Kaba and Sooriakumararan (2007). Reproduced with permission of Elsevier.

Improving knowledge of anatomy, physiology and the pathological basis of disease during the 1800s contributed to a structured clinical method consisting of a structured history and physical examination (see Box 1.1). William Osler, sometimes described as ‘the father of modern medicine’, took students from the lecture theatre to the patient’s bedside so that students could talk to patients about their experience of disease and physically examine them for signs of the illness.

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Box 1.1 The traditional model of a structured patient history

• Demographics
• Presenting problem(s)
• History of presenting problem(s)
• Past medical history
• Systems enquiry
• Family history
• Medications and allergies
• Social history

Source: Adapted from Stoeckle and Billings (1987). Reproduced with permission of Springer.

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Even in an era of rapid change in the scientific basis of medicine, Osler’s maxim to his students was: ‘Listen to your patient; he is telling you the diagnosis.’ In modern times, the history alone accounts for around 80% of diagnoses. Strikingly, increasing availability of diagnostic technology (e.g. laboratory tests and imaging) has not substantially altered this percentage.

It is worth considering what the healthcare professional wishes to derive from the patient interview or encounter. The purpose is to:

• Correctly diagnose the patient’s illness.
• Avoid diagnostic error.
• Give the patient effective and appropriate treatment.
• Achieve the patient’s adherence to treatment.
• Cure or mitigate the effect of the illness.
• Improve the patient’s health status.
• Communicate care, concern and empathy.

Early studies of the consultation correlated the quality of the interview directly with the quality of clinical data collected (see ‘Further resources’). An open‐ended approach with the intention of allowing patients to identify problems of concern identified those problems well. The failure of professionals to allow patients to complete an opening statement during the consultation and an over‐controlling approach (e.g. using closed questions) directly reduced the quality of information.

Poor‐quality information results in a predisposition to diagnostic error, and the term ‘clinical hypocompetence’ has been used to describe this (see Box 1.2). While a biomedical perspective has contributed to improvements in diagnosis, the use of a solely biomedical approach risks being reductionist as it fails to take account of the patient’s own experience, context and wishes. The power imbalance between the ‘all‐knowing’ professional and the passive patient contributes to poorer outcomes. The post‐war era saw the development of societal concepts such as greater self‐determination, autonomy, gender rights and equality. This influenced healthcare as well, with the result of the model of the consultation we have today (see Chapter 2).

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Box 1.2 Clinical hypocompetence in the medical interview

Physician‐engendered defects in the interview are due to one or a combination of:

• Lack of therapeutic intent
• Inattention to primary data (symptoms)
• A high control style
• An incomplete database usually omitting patient‐centred data and active problems other than the present illness
• A thoughtless interview in which the physician fails to formulate needed working hypotheses

Source: Adapted from Platt and McMath (1979). Reproduced with permission of American College of Physicians.

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Even for the same illness, no two patients are going to give identical stories. Each will have a different experience of their symptoms and different concerns about their significance. Obeying Osler’s maxim to listen requires seeing the patient’s perspective and their own unique experience. If we needed to update Osler to make this clearer, we might say: ‘Listen to your patient and see the illness through his eyes; he is telling you the diagnosis.’

The emergence of a bio‐psychosocial‐cultural model placed emphasis not only on what was the matter with the patient but also, as Enge...