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Communication Skills in Clinical Practice (Doctor-Patient Communication)
KR Sethuraman KR
SECTION I: CORE SKILLS
1:
Doctor-Patient Communication: An Overview
UNDERSTANDING COMMUNICATION
The Process of Communication
Transfer and Sharing of Meanings
Perception
The Components of Communication
Source/Sender
Receiver
Channel
Message
Effects
Feedback in Communication
UNDERSTANDING DOCTOR-PATIENT COMMUNICATION
System Analysis of Doctor-Patient Communication
Doctor-Patient Interaction Analysis (Behaviour and Privacy)
Patients as Non-Persons
Information Needs During a Dyad
Approach to Doctor-Patient Dyad
Attributes of Effective Communication (“Voice of Medicine”)
Factors Influencing a Dyad
Categories of Doctor-Patient Misunderstanding
Language in Dyads
Closure of a Dyad
Patient Outcome in a Dyad
Good Doctor-Patient Relationship
Concept of Empathy
SUMMARY
EXERCISES
2:
Questioning Skills
THREE DIMENSIONS OF A QUESTION
Open-ended Question
Closed-ended Question
Direct Question
Indirect Question
The “if we knew” Technique
The Reference Base Technique
The Rough Estimate Technique
The Third Person Technique
Leading Question
Non-leading Question
Three-dimensional Analysis
EFFECTIVE QUESTIONING SKILLS
ADVANCED QUESTIONING SKILLS
Basic Qualifying Questions
Initial Contact
Assessing the Patient's Initial Receptivity
The Rephrased BQQ
The Customised BQQ
The Combined BQQ
The Indirect (Camouflaged) BQQ
Probing Questions
Problem-exploring Questions
Solution-exploring Questions
Multilayered Probing Question (MLPQ)
Value of Probing Questions
SUMMARY
PRACTICAL EXERCISES
3:
Listening Skills
EFFECTIVE LISTENING
Components of Listening
Tips for Effective Listening
ADVANCED SKILLS: EMPATHIC LISTENING
Purposes
Cultivating Empathy Skills
Levels of Empathy Response
First Level: Inaccurate Reflection or Distracting Comments
Second Level: Partly Understanding of the Patient's Feelings
Third Level: An Accurate Empathy Response that Captures the Patient's Feelings
Fourth Level: Adding to the Patient's Self-understanding
Fifth Level: Fantastic Insight
Problems in Empathic Listening
SUMMARY
PRACTICAL EXERCISES
Empathy Training
4:
Non-verbal Behaviour (NVB)
READING AND RESPONDING TO MAJOR NON-VERBAL SIGNALS
Closed versus Open Position
Possessions and Appearance
Distance and Direction
Language Proficiency and Hand Movement
Touching and Self-concept
Positive Signals
How to Respond
Thinking Signals
How to Respond
Signals of Disinterest and Restlessness
How to Respond
Confidence Signals
How to Respond
Signals of Scepticism
How to Respond
Negative Signals
How to Respond
Signals of Deception
How to Respond
Signals of Hurry
How to Respond
SPECIFIC NON-VERBAL SIGNS IN PRACTICE
The Eyes and The Face
Eye Contact
White of the Eye and Emotion
Gazing and Personality
Facial Expression and Rapport-Building
Facial Expression of Type A Personality
Omega Sign of Depression (Fig. 4.1)
Facial Expression in Pain
Faking and Suppressing Pain
Lie Detection
True and Deceptive Smiles
Chronic Blushing
Laughter
Laughter and Pain Threshold
Laughter and Stress Hormones
Humour as Therapy
Psychology of Crying
Crying and Expression
Weeping and Humour on Stress
Odour as a Signal
DOCTOR'S NON-VERBAL SKILLS AND PATIENT SATISFACTION
SUMMARY
PRACTICAL EXERCISES
5:
Answering Skills
ADVANCED SKILLS
Answering Objections
See the Objection as a Question
Turn the Objection into a Reason for following your Advice
Smoke Out all the Important Objections
Admitting to the Objection
Let the Patient Answer his Own Objection
Agree with the Patient about Something
Repeat the Objection in your own Words before Answering
Eliminate Objections with Probing Questions
Deny the Objection
Get into the Right Mental Attitude and Stay in it
Responding to Disagreements
Tackle the Big-picture First
Agree on the Higher Purpose First
Conveying Commitment (4 plus Yes)
Using 4-plus Yes in Patient Care
SUMMARY
EXERCISES
Simulation Role-play
Doctor's Answering Skills
Skills in Conveying Affirmation
Skills in Answering Objections and Disagreements
6:
Information Sharing: Models and Methods
SUMMARY
PRACTICAL EXERCISES
7:
Rapport Building Skills
ADVANCED SKILLS
Dealing with Patient Personality Types
Superior Type
Hysterical Type
Impulsive Type
Masochistic Type
Shy Type
Suspicious Type
Controlling Type
Dependent Type
Uses and Limitations
Influence of Doctor's Personality
Fine-tuning Your Language (Neurolinguistic Programming)
Speaking a Patient's Language
Visual Language
Auditory Language
The Action and Feeling Language
Eliciting Unvoiced Concerns
Agenda and Expectation
Voices of Medicine and Life-world
Eight Questions to Unravel “Patient agenda”
SUMMARY
PRACTICAL EXERCISES
8:
Counselling Skills
COUNSELLING THEORY
What is Counselling in Health Care?
Counselling Approaches: Formal
Cognitive Approach
Gestalt Therapy
Behavioural Therapy
Psychoanalytic Therapy
Counselling Approaches: Non-formal
Adlerian
Person-Centred (Rogerian)
Client's Responsibilities in Counselling
Common Difficulties in Counselling
Defence Mechanisms
COUNSELLING-PRACTICE
Family Planning (FP) Counselling
General Principles
Element of Counselling: The “GATHER Approach”
Genetic Counselling
Use a Non-directive Approach
Anticipate Logical Mismatch
Take the Clients Seriously
Respect Couple's Informed Decision
Strike a Partnership Deal
Use Shared Model of Decision Making
Narratives and Self-disclosure in Counselling
Advanced Skills for Effective Storytelling
9:
Skills of Persuasion
THE ART OF PERSUASION
Ethos
Logos
Pathos
Harnessing Pathos: How Can you put Pathos to Work in your Therapeutic Advice to your Patients?
PRACTICE OF PERSUASION
Learning the Techniques of Persuasion
Attribution versus Persuasion
Use of Fear in Persuasion
The ‘Sleeper Effect’ (Why Persuasion may not Last)
Persuading a Procrastinator
Coaxing a Strong Yes from Your Patient
Persuading for Organ Donation
ADVANCED SKILLS OF PERSUASION
Mental Judo
Practising Mental Judo
Taking the Initiative
Refocusing Patient's Sense of Reality
Ethical Considerations
PRACTICAL EXERCISES
SECTION II: CLINICAL APPLICATIONS
10:
Reassurance of the Worried Well
DEALING WITH THE “SYMPTOMATIC NORMAL”
PRACTICAL EXERCISES
11:
Talking with Parents
DEALING WITH A DYING CHILD
Be Patient
Dealing With the Family of A Dying Child
Be the Constant Factor
Be Supportive
Promote Good Communication
SUMMARY
EXERCISES
12:
Handling the Elderly
SUMMARY
PRACTICAL EXERCISE
13:
Communicating Prognosis, Hope and Risk
PROGNOSIS
Medical Predictions Based on Six Groups of Data
Natural History of the Disease
Time of Presentation
Patient Particulars
Indicators of Severity
Curability of the Disease
Biological Variability
HOPEFULNESS
Hex Death (Do not kill hope)
Hope, Healing and Health
Three Dimensions of Hope
Personal Dimension
Situational Dimension
Interpersonal Dimension
COMMUNICATING RISK
Perception of Risk
Language of Risk
Hazard
Risk
Threat Perception
Distortions in Risk Perception
Group vs Individual Risk
Talking to the Patients on Risks
Serious-Non-Serious
Avoidable-Unavoidable
Justifiable-Unjustifiable
Acceptable-Unacceptable
Quantifying Risks
Some Examples
SUMMARY
PRACTICAL EXERCISES
14:
Religion, Faith and Culture in Health Care
HANDLING SUPERSTITION AND “BENIGN MAGIC”
CULTURAL INFLUENCES IN HEALTH CARE
South Asian Cultural Aspects of Health Care
Medical Care and Professionals
Mental Health
Hospitalisation
Gender and Privacy
Maternal and Child Health
Cultural Orientation
Arab Culture (Applies to Several other Traditional Muslim Families)
Traditional Healing
Modern Medical Care
Maternal and Child Health
Social Customs
Death
Cultural Barriers to Health Care
Modern Medical Care
Gender
Privacy
Maternal and Child Health
Mental Health
Diet
Cultural Orientation
SUMMARY
PRACTICAL EXERCISES
15:
Dealing with Chronic Disease and Dying
CHRONIC OR INCURABLE DISEASES
Communication Strategy
Dealing with Cancer
Patients' Perspectives when Faced with Cancer
Common Communication Problems
Breaking Bad News
Denial
Collusion
Steps in Dealing with Collusion
Difficult Questions
Dealing with Difficult Questions
Major Emotional Reactions
Other Problems of Conveying Bad News
Barriers to Discussing End-of-Life Care
Discussing Quality of Death Concerns
Self-test for Doctors during Difficult Dyads
DEALING WITH DEATH
Communication of Neonatal Death
Dealing with Relatives during Resuscitation
Dealing with the Bereaved Relatives
Preparation before Meeting the Relatives
Talking to the Bereaved
Anticipate and Handle Common Reactions
Showing the Body of the Diseased
Other Information and Follow-up
Prepare for Special Problems
Promoting Organ Donation
Emotional Costs to Professionals
SUMMARY
PRACTICAL EXERCISES
16:
Non-compliance and Deception
NON-COMPLIANCE
Why Non-compliance Occurs
How to Prevent Non-compliance
Two Techniques for Inducing Compliance
How to Handle Irrational Moves by a Patient
DEALING WITH DECEPTIVE PATIENTS
Common Pitfalls
Mistaking Good Rapport for Compliance
Assuming Compliance in Tacit Patients
Mistaking Patients' Appreciation for Compliance
Strategies for Handling Deceptive and Hesitant Patients
Deepen the Dialogue from a Friendly Chat to a Professional Call
Make Decision-making Appear Smart
Get the Patients on your Side
Bring up Objections yourself
Stage a Gentle “Confrontation”
Finalise the Level of Commitment
Tactics to Adopt when you Lose Patients to Follow-up
Closure of the Dyad with Hesitant Patients
PRACTICAL EXERCISES
SECTION III: BEYOND COMMUNICATION
17:
Dealing with Patient Dissatisfaction
SUMMARY
PRACTICAL EXERCISES
18:
Negotiating Skills
SUMMARY
PRACTICAL EXERCISES
19:
Patient-centred Practice
TIPS FOR PATIENT-CENTRED PRACTICE
PREVENTING PATIENT DROP-OUT
Common Reasons for Losing Patients to Follow-up
Reorienting Health Care to Patient Satisfaction
Be Interested
The Patient Deserves your Best at all Times
Shift the Responsibility only when Needed
Do not be too Busy for your Patients
The Patient is not Always Right
The Patient is Never Totally Wrong
If you must use Technology, make it User-Friendly
Say what you will do, and do what you Say
Keep Private Things Private
Be Proactive
SUMMARY
PRACTICAL EXERCISES
Sample Survey and Group Discussion
Simulation Role-play
20:
Prudent Practice
SUMMARY
EXERCISES
21:
Telecommunication in Health Care
PROBLEMS AND ATTITUDES
Some Solutions
SUMMARY
PRACTICAL EXERCISE
ANNEXURES
1:
Transactional Analysis: Understanding Human Interaction
SUMMARY
PRACTICAL EXERCISES
2:
Multi-dimensional Model of Health Care
Postscript
INDEX
TOC
Index
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