Communication skills

Why communication matters

• Good communication improves diagnostic accuracy, adherence, satisfaction and outcomes, and reduces complaints and litigation. Most complaints against doctors concern communication rather than technical skill.
• A good doctor–patient relationship rests on trust, empathy, respect, honesty, confidentiality and listening.

Structure of a consultation

• Calgary–Cambridge model: initiate the session, gather information, examine, explain and plan, close; while providing structure and building the relationship throughout.
• Closing includes safety-netting (what to do if things change) and checking the patient is satisfied with the plan.
• ICE: explore the patient's Ideas, Concerns and Expectations.
• Biopsychosocial model: illness is understood through biological, psychological and social factors, not disease alone (the biomedical model).

Questioning and listening

• Behaviours to avoid in an interview: interrupting early, leading or multiple questions, medical jargon, judgemental comments, looking at the screen or phone, premature reassurance.
• Active listening: attentive silence, eye contact, nodding, picking up verbal and non-verbal cues, paraphrasing and summarising. Non-verbal behaviour (posture, tone, facial expression) carries much of the emotional message.
• Check understanding with chunk and check and teach-back. For language barriers use a professional interpreter, not family members (and never children), especially for sensitive or complex matters.
• Face-to-face verbal communication supported by written information is the most effective way to explain a diagnosis or plan.

Empathy versus sympathy

• Empathy is understanding the patient's feelings from their point of view and showing that understanding. Sympathy is feeling sorry for them.
• The empathic response names the emotion and invites more: to "I'm scared this lump is cancer", the best reply is "You sound worried. Can you tell me more about what is worrying you?" Premature reassurance ("I'm sure it's nothing") or immediate facts close the conversation.

Breaking bad news: SPIKES

• Reactions include shock, denial, anger, tears and bargaining; respond to the emotion before giving more facts.
• Collusion: when relatives ask that the patient not be told, explore their fears and explain your duty; ask the patient how much they want to know. A capable patient who asks must be told honestly, while a patient's own wish not to know is respected.

Counselling

• Counselling helps a person explore their problem and reach their own decision; the counsellor does not decide for them.
• Person-centred approach: empathy, unconditional positive regard and genuineness (congruence).
• Non-directive counselling (for example genetic counselling): balanced information without pushing a choice.
• Pre- and post-test counselling for HIV and genetic tests.
• Fertility counselling: about 80–85% of couples conceive within one year of regular unprotected intercourse and over 90% within two years, so investigation usually starts after one year (earlier if the woman is over 35 or there is a known problem).

Behaviour change

• Stages of change: precontemplation, contemplation, preparation, action, maintenance, with possible relapse. Match the intervention to the stage (raise awareness in precontemplation; build a plan in preparation).
• Motivational interviewing: express empathy, develop discrepancy between goals and behaviour, roll with resistance, support self-efficacy; uses open questions, affirmations, reflective listening and summaries.
• Brief intervention for alcohol: feedback, responsibility, advice, a menu of options, empathy, self-efficacy.
• Health belief model: perceived susceptibility, severity, benefits and barriers, cues to action and self-efficacy predict health behaviour.

Models of the doctor–patient relationship

• Shared decision-making is the modern ideal: the doctor brings evidence, the patient brings values; decision aids help.
• Paternalistic care (doctor decides) is appropriate only when the patient cannot take part.
• Transference: the patient projects feelings about past figures onto the doctor; countertransference is the doctor's emotional reaction to the patient.
• Sick role: rights (exemption from normal duties, not blamed for the illness) and obligations (to want to get well and to seek and cooperate with help).

Adherence

• Compliance (adherence) is the extent to which a patient's behaviour (taking medicines, following diet or lifestyle advice, attending appointments) matches agreed medical advice. About half of patients with chronic illness do not take medicines as prescribed.
• Factors that worsen adherence: complex regimens, many daily doses, side effects, poor understanding, health beliefs, cost, depression, cognitive impairment, poor rapport.
• The single most effective step for an elderly man missing doses on eight tablets five times a day is to simplify the regimen (fewer drugs, once or twice daily, combination tablets), plus pill organisers and clear written instructions. Poor adherence is often mistaken for treatment failure.

Difficult situations and professional boundaries

• Angry patient: stay calm, ensure safety, listen without interrupting, acknowledge feelings, apologise for distress (not an admission of liability), explain, agree a plan, inform about the complaints procedure.
• Errors: duty of candour: tell the patient, apologise, explain, report and learn.
• Gifts and conflicts of interest: decline any gift, trip or payment linked to prescribing; prescribing must be based only on the patient's interest. Declare unavoidable interests.
• Adapt communication for hearing impairment, learning disability and telephone consultations (confirm identity, safety-net).

Remember Open questions first, empathy before information, warning shot before bad news, and the patient decides.

Exam trap The activity–passivity model is for the unconscious patient; mutual participation is for chronic disease.

Exam trap Use a professional interpreter, not a relative, for important discussions.

How FCPS asks about this

• "I'm scared this lump is cancer": empathic reply: "You sound worried. Tell me more?"
• First step in breaking bad news: a private, uninterrupted setting with time; then establish what the patient knows.
• Unconscious trauma patient: activity–passivity model.
• Elderly man missing doses on a complex regimen: simplify to fewer daily doses.
• Drug company offers a trip for prescribing more: decline; conflict of interest.
• Sick role: being excused from usual obligations, with a duty to seek help and want to recover.
• Best statement about counselling: it helps patients reach their own informed decisions.