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“In
every art there are few principles and many techniques.”
- Dale Carnegie
1.Introduction
Today I am going to
share some fundamentals on an important subject of communicating
with our patients. Our syllabus at undergraduate (BHMS) level or
at Post – graduate (M.D.) level doesn’t contain the subject of
communication although we get very few points on case taking.
Case – taking in homoeopathy is a multi-dimensional complex
process, which demands the full exploration of a human being in
its totality. It is not merely gathering of some symptoms here
and there through a certain frame of questions. To be frank with
you when I began my homoeopathic career, I was unaware of the
depth of case – taking and communication skills. My entire
interview was based on questions alone and I used to bombard my
patients with innumerable, stereotyped, successive spells like
Rawalpindi Express of Shoaib Akhtar(a fast baller in the game of
cricket). I was not concentrating on length and accuracy but on
speed. This resulted in many fours and sixes as there were many
‘Sachins’( a popular batsman in cricket) in my patients. I lost
many matches and yet I was confused: why I lost? Why those
dropouts occurred?
I started looking
seriously and I found that communicating with the patient has a
heavy bearing upon physician – patient interaction. Now I
realize that communication is a critical component of all
medical interactions, it is not “just talking” and that
communication is the keystone of the doctor-patient
relationship.
All human activities
are based on environmental experiences which in turn is the
result of communication. We are the result of our sanskaras
(training) and environmental interactions. Communication is at
the root of what we are.
The field of
communication is fast moving and rapidly growing. The population
explosion, information explosion and compelling competitiveness
are important factors of today’s world and the need of
appropriate communication has tremendously increased.
2.
Communication: Meaning
The term
communication is grossly overworked. Everything; from
billboards, to encyclopedias, to television, to holding hands;
is communication. However, exchange of words only doesn’t
constitute ‘communication’. The word ‘communication’ originates
from Latin term “communicare” or “communico” which means TO
SHARE. When a patient communicates his grievances, his
complaints, his painful experiences from his life, he is
actually SHARING with the physician. SHARING
involves a deeper process of human interaction and relation.
Webster dictionary
defines communication as “the interchange of thoughts or
opinions”. Interchange: to inform, tell, express, or show in
order to get a reaction or a response. It also means to listen,
understand, weigh or evaluate. Charles Estes defines
communication “------ the reception, digestion, and transmission
of meanings, attitudes and feelings through words, gestures and
symbols.”
Communication has a
basic attribute of enlargement of feelings, facts, attitudes and
ideas. So when a physician starts interrogating, the patient is
unearthed, unfolded and he appears as a living vibrating
individual; his facts are known, his inner feelings are brought
on the surface, his attitudes and inclinations are understood
and his ideas are known.
The system of
communication is commonly owned, accepted and recognized by the
concerned. It enables them to acquire, exchange, store, retrieve
and process the information. It is a network of interactions and
both the physician and the patient keep on changing their roles.
Communication is not
a momentary event; in fact it is a momentary intensification of
a continuing, cumulative process that starts even before actual
communication takes place and continues even after it has
occurred. Communication is not merely transmission of meaning
from one person to another through symbols. It involves the
pathway Source
à
Sender
à
Sent
à
Received
à
Receiver
à
Result. It takes place not only through words, but also through
attitudes, feelings and actions.
“The success of
communication is measured not only in terms of the effective
transmission of the message but also the achievement of intended
result.” This sentence indeed is the crux. Only concentrating on
sending the message, a physician shouldn’t feel relaxed; he must
also concentrate on what is the net result of communication.
This net result is the feedback which every patient gives to a
physician.
The ways in which a
physician communicates with a patient significantly affect
1. The adequacy of
the clinical interview
2. The accuracy of
detection of ‘problem’
3. The patient’s
understanding and compliance to the physician’s advice
4. Patient
satisfaction
There are two
critical skills - Active listening and Feedback.
2.a.Listening:
Eloquent silence
I give pivotal
importance to listening. It is the most important ingredient of
communication. I have found that most of the homoeopaths are
relatively poor listeners. There is a wrong belief that
communication means verbal exchange. Hence there has always been
emphasis on verbalization. A homoeopathic physician who sits on
a chair with holistic philosophy in his mind, who has to deal
with the patient from totalistic viewpoint, who has to keep his
awareness fully to focus on emotions, on every body movement,
gestures, postures, speech modulations etc., has to be a good
listener. It is said that a knowledge-seeker has to be a good
listener. The process of case taking is a knowledge-seeking
process. Ultimately it is the patient who gives knowledge to a
homoeopathic physician.
Major difference
between ‘hearing’ and ‘listening’ must be understood. Hearing
alone is not listening. Hearing is merely picking up sound
vibrations while listening is making sense out of what we hear.
Hearing is related with ‘ear’ functioning while listening is
related with ‘ears, brain and mind’.
The greatest stumbling block to real communication is the
one-sided nature of talking. Truly effective communication can’t
be a monologue in which only the speaker is at work. It must be
a dialogue. Listening is an active pursuit. It’s demanding, hard
work. Establishment of Rapport and building of relationship are
the outcome of a good listening.
2.b..Listening:
mirror and sounding board
A homoeopathic
physician as a good listener should play the role of both mirror
and sounding board that throws back a reflection of the patient,
giving him a chance to see and listen himself in a way that
might not otherwise be possible. A mirror doesn’t add anything
of its own. It only reflects as it is! Hahnemann’s requisite of
‘unprejudiced observer’ is akin to the concept of a physician
acting as a mirror.
“Active listening is
an important way to bring about changes in people. Despite the
popular notion that listening is a passive approach, clinical
evidence and research clearly shows that sensitive listening is
the most effective agent for the change of individual
personality and group development ”( Rogers and Farson).
To be an active
listener, developing following skills will help a homoeopathic
physician.
·
Making an eye
contact.
·
Exhibiting
affirmative head nods & appropriate facial expressions.
·
Avoiding distracting
actions or gestures.
·
Asking questions.
·
Paraphrasing.
·
Avoiding
interrupting the patient.
·
Avoiding overtalking.
·
Making smooth
transitions.
2.c.Feedback
The Second critical
skill is Feedback. The process of interview evokes
innumerable responses from a patient. Some responses may not be
acceptable but a physician has to keep his mind balanced. A
physician must remember, “Positive feedback is more readily and
accurately perceived than negative feedback.”
2.d.Skills for
feedback
·
Focusing on specific
behavior
·
Keeping feedback
impersonal
·
Keeping feedback
goal-oriented
·
Making feedback
well-timed
·
Ensuring feedback
positive
·
Directing forward
behavior
·
Using humor in
interaction
-
Focus on specific
behavior
There are 3
questions, why, how and when of Feedback. Let us take an
example.
A flatterer is
sitting before you as a patient. He is pleasing you, “How
wonderful! Doctor, you are great, what a nice interview”. What a
physician should do about such statements? Instead of engaging
himself in appeasement of his own ego from the emotional
overtone, the physician should focus on the specific behaviour
that is flattery. In other words, explore the rubric and the
personality of the patient.
-
Keep feedback
impersonal
A physician is one
who has to keep balance between his subjectivity, his
emotionality and his professionalism. He must be able to look at
the patient as he is. It is here that Hahnemann expects
from him the state of being unprejudiced. In the above example
of flattery, a physician should not feel himself great and
excited. He must look at it impersonally. He should not get
carried away. Keeping the feedback impersonal is reflective of
maturity on the part of a physician. Finally his goal in
practice is to treat the patient and this goal must not be
forgotten.
Let us take another
example: Interview begins and patient starts abusing the medical
profession, “You all are blood suckers”. The physician should
not take this statement in the personal context. He should
understand that a patient has strong antipathic notions against
the medical profession. The hostile attitude of a patient should
make a physician to find out disposition. He should find out why
a patient has developed hatred or resentment. For the selection
of similimum what is necessary is to find the inner personality
characters.
-
Keep feedback goal
oriented
The goal of the
interview is to seek A2 : that is Accurate
and Adequate data. The goal is to understand the patient
as he is e.g.: In the flattery example the goal is to know the
dimensions of flattery i.e. why he developed this disposition?
What are the consequences of this as far as his family and
social interactions are concerned? There should be pertinacity
in achieving the goals. For a physician who has trained himself
in making the vision of totality clear, this becomes easier as
goals are known.
4. Make Feedback
well-timed
Let us take an
example here- A patient takes an appointment and is very
punctual, but anyhow he has to sit for a long time. He expresses
his resentment to the physician. The physician must take this
feedback into consideration and should honor the punctuality of
a patient in the subsequent follow-ups.
It is the presence
of mind of the physician that makes the feedback well-timed.
5. Ensure Feedback
Positive
Once the goal is
fixed and it is understood that the feedback should not be
perceived personally, it is possible to ensure a feedback
positive. In positive feedback the physician acts more as a
learner, as a care-taker and as a trustworthy human being.
For Example:
Mother-in-law and Daughter-in-law are at cross with each other.
New daughter-in-law behaves arrogantly and in the interview
Mother-in-law expresses the agony and goes to the extreme to
knock out DIL out of the house. The physician advises her not to
take an extreme stand. MIL sarcastically expresses, “It is
better for you to give an advice by just sitting on a chair”.
The physician should take this statement lightly. He should try
to understand the dynamic relations, try to explore the
personality profile and in the subsequent follow-ups should make
a statement in a laughing tone, “I am just giving you an advice
by sitting on a chair.”
6. Direct forward behaviour
The physician must
be greedy in eliciting the data. A patient often becomes
disorganized, wanders here and there, doesn’t stick to any
specific issue and doesn’t narrate the totality. It is here that
direct forward behavior has to be followed.
The reflective
technique of communication as well as resonant body language is
very useful in forwarding the interview in right direction.
Guidelines for
receiving feedback
·
Taking criticism as
advice
·
Summarizing the
criticism accurately and succinctly
·
Leaning forward in
conversation
·
Smiling at
appropriate time
·
Asking for specific
suggestions of ways to improve
·
Thanking the person
if you feel the criticism or advice useful
·
Always being a
learner
Communication skills
are not innate or fixed. They can be learned or improved and
consequently the physician can improve the health outcomes.
4.
Adherence
Every physician has insecurity in his mind. Whether my patient
will stick with me or will he leave? Insecurity hovers. State of
anxiety develops. And the reaction develops, characteristics” is
a myth. In fact no consistent relationship is seen between
adherence and the following factors:
·
Age
·
Gender
·
Social / Economic
status
·
Marital status
·
Personality traits
(introverted, gregarious etc.)
Then what affects
adherence?
Patient’s adherence
would depend on the following factors:
·
The duration of
treatment and illness.
Skills for improving
Adherence
-
Demonstrate
compassion
-
Communicate:
§
Personal concern for
the patient
§
Personal interest
with patient’s well being
§
Activate patient’s
motivation
§
Share responsibility
with the patient
§
Discuss the
patient’s beliefs
8. Barriers to
communication
When I started
practice I was unaware of ‘barriers’ to communication. I found
that there are some patients with whom I was unable to
communicate. In some patients I was right at the selection of a
remedy or repetition, but not knowing how to handle the patients
through positive communication. Subsequently I understood that
good communication skills are required not only in the first
interview but also in subsequent follow-ups. The dropouts in my
practice taught me to see the barriers, which are collectively
termed as Noise.
8. Noise
Now let’s focus on
the factors, which produce the “Noise” and see that the
communication is smooth and free of any barriers.
·
Absence of a common frame of reference.
-
Badly encoded
messages.
-
Disturbance in
transmission channel.
-
Poor retention
(esp. in face to face communication).
-
Inattention by a
patient or a physician.
-
Premature
evaluation of the message.
-
Unclarified assumptions.
-
Mistrust between a
patient or physician.
-
Different
perceptions of reality
-
Semantic
difficulties.
-
Vagueness about
the objectives to be achieved.
-
Misinterpretation
of the message.
-
Clash of
attitudinal nuances of the patient and physician.
-
Psycho - physical
factors.
-
Selection of wrong
variety of language.
The frame of
reference relates to the environmental setting in which the
interview take place. The concept is that the environment must
be congenial for the free ventilation of patient’s narration.
The patient should feel that the environment in the clinic is
favorable and there is no obstacle. The common frame of
reference implies the context in which communication takes
place. Both the patient and physician must be able to focus
their mind meaningfully on the message if the context is
well-defined
Example: The sitting
posture between patient and physician must be face to face. If
physician is looking at north-west and patient at south-west, it
is not favorable frame of reference. The room should have a
refreshing odor. Strong smell can be an irritating experience
for both the patient and physician. The word common represents
at least the prescribed notions of the expected environmental
settings.
It is the
fundamental right of a patient to get all the message of a
physician in clear terms. Many physicians have the habit of
talking in a rapid way or they talk as if muttering with the
self. The coding of message must be in the format which is
digestible by a patient.
This relates to the
interferences that are from various sources. Frequent ringing
tones, vehicles on the road or T.V. or radio in the clinic
making big sounds, receptionist interrupting, the students
asking questions in between etc.
The language is the
prized possession of a human being, but it is the complex way of
communication. Each word has many meanings and both patient and
physician must have at least working knowledge of the meaning of
words. The semantic difficulties relate to the use of
ambiguous expressions or highly specialist vocabulary which is
inappropriate to the situation. Language is the most
widely used instrument of communication. It is one of the most
prized possessions of Man. It acts as a repository of wisdom, a
propeller for the advancement of knowledge and a telescope to
view the vision of the future. Selection of a wrong variety of
language results in poor rapport. It is always better to speak
in the language of a patient as it gives a feeling of closeness.
Example: A patient
from Tamilnadu speaking in Tamil language with a Maharashtrian
physician. This will be the semantic difficulty experienced by a
physician.
The differences of
the physician and the patient may result in attitudinal clashes
and consequently the communication suffers. The generation gap
between a patient and a physician, the urban and village culture
and samskaras are responsible for differences in attitudes.
These relate to
mental or physical states like fatigue, previous unpleasant
experiences, inability of the patient to tune himself with the
physician etc.
The major barrier to
communication is the self-concept. We know that an
individual clings to concept he possesses about himself,
overlooking the data that is not congruent with it.
Another major
barrier to clear, undistorted communication unfolds from the
role relationships, or status differences, of individuals
involved in inter-personal communication. Credibility of the
source also affects communication. Generally speaking,
individuals of high status are accorded greater credibility.
Usually, we believe people who we define as “experts”.
No communication is
free from emotions, either on the part of a patient or a
physician. Emotions form a part of the “modifiers system” that
screens transmissions and inputs. A physician has to balance
between his emotive field of operation and professionalism.
9. Basic Qualities
of communication
1. Positive and
attractive qualities
Warmth Honesty
Friendliness Exciting
Interest
Knowledgeable
Organized Creativity
Confident Inspiration
Openness Authenticity
Warmth,
friendliness, honesty, openness
put us at ease.
These qualities actively invite us to get closer, creating an
environment in which we can relax our guard and relate more
directly and openly.
Exciting, creative
and interest
promise pleasure and tranquilizes us in a feeling of
anticipation and a curiosity about what comes next.
Knowledgeable
and / or confident are very reassuring. One listens with
trust. Organized satisfies the brain’s need for order and
logic delivered in the format.
Authenticity
gives us confidence that what we see is indeed what we get, that
we’re down to bedrock; this is a truthful person speaking,
without subterfuge i.e. excuse.
Inspiration
appeals to our deeply rooted willingness to follow a person or
rise above our own thoughts and to absorb other’s enthusiasm.
2. Negative and
turn-off qualities
Pompous Vague
Unenergized Complexity
Patronizing Unsure
Formal
Irrelevance
Stuffy
Monotonous
Hyper-Intense Nervousness
Closed Synthetic
Formal and stuffy
styles
show us someone operating from a rigid set of rules unrelated to
the situation at hand.
Closed and synthetic
are bothersome. Who is the person? How can I predict anything
about what he / she really means, feels, believes in?
Pompous behavior
tries to set the speaker apart and steps above the listener.
This creates two problems; Firstly, the listener questions who
put him/her up there and on what evidence? Secondly, who
automatically wants to look up to someone before you yourself
have designated him / her worthy?
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