Sunday, March 07, 2010

Communication Skills

Although good doctor-patient communication is an important component of good medical practice, such good communication in an emergency department setting poses some very unique challenges:

1. Mismatch between physician's and patient's expectations.
- Most patients in emergency department come with sudden, often unexpected, serious illnesses (including trauma). Such sudden nature results in an inadequate time for the patient and relatives to adjust or even to swallow the bitter reality,

- Secondly, some patients may have problems with the way they are triaged; most patients that come to the emergency department have the perception that they are suffering from an urgent illness (although in actual case, they may not be so).

Such mismatches can often be compounded with:
- Social
- Cultural and
- Language differences between the doctor and the patient

- Thirdly, not only that the patient does not have much of a choice when it comes to treatment options in emergency department due to the probable sudden nature of their illnesses, they also do not get to choose their doctors and nurses, in fact, often do not get to choose the hospitals/medical centres/clinics that they want to go.

- One of the suggestions to reduce such mismatch is have a perceptual shift analogous to the gestalt figure and background concept. Rather than perceiving the disease as the central figure, and the patient as the background, the physician should perceive the patient as the figure and the disease as the background.

2. Disruptive nature of the interview
From my own personal experiences, I had occasions where I had to temporarily pause my interview with my Green Zone (stable) patients, just to attend to the "buzzer call" when a critically ill patient newly arrive at the Red (critical) zone, even when I was not in-charge of Red Zone during that particular day. This is due to the fact that resuscitation of a cardiac arrest or critically ill patient always involve a team-effort, requiring more than one pair of hands.

It was only when the patient in Red Zone is stabilized, that I resumed my interview with my patient in Green Zone. Such is the nature of working in an environment when there was inadequate number of doctors on duty during a shift.

Such irritating interruptions may result in further negative perception among patients towards their doctors in emergency departments.

Different types of questions are intended to elicit different types of response from the patients. For example:

Open questions to allow the patient to express their own thoughts and feelings, e.g. 'How have you been since we last saw you?', 'Is there anything that you want like to mention/know?'

Closed questions are requests for factual information, e.g. 'Where is the pain?', 'When did this pain start?', 'Are you getting better?'

Leading questions invite specific responses and suggest options, e.g. 'You'll be glad when this treatment is over, won't you?'

Reflecting questions help to develop or expand topics, e.g. 'Can you tell me more about your surgery?'

Breaking Bad News
A major challenge in emergency departments is breaking bad news.

A strategy employed by the oncologists in breaking bad news to patients and relatives is the S-P-I-K-E-S strategy.

S = Setting (a conducive setting with privacy)*
P = Perception (the adage "before you tell, ask" holds true; find out how much do the patient and relatives know)
I = Invitation ("invite" the patient to want to know the amount of information that they are comfortable to take in)
K = Knowledge (break the information into smaller chunks; allow the patient and relatives to digest first, pause, ask question to ensure good understanding)
E = Empathy (the doctor should listen and identify types of emotions involved, as well as to demonstrate and express to the patient).
S = Summarize before ending the discussion. Allow patient/relatives to ask questions.

*For setting, this can be further delineated into
P= Privacy - invite the patient/relative to a place of privacy before breaking the news (e.g. counseling room, "grieving" room)
I = Involve significant others - allow the patients to invite his/her family members that he/she feel should be around
L = L - Look attentively, get distractions away for time being (switching off handphone); "just be around" for the patient
L = L - Listen attentively
S = S -sit down at the same eye-level with the patient; avoiding sitting across the patient with a "barrier" in between).

Click here to download an excellent article on SPIKES strategy.


Kim Yen said...

thanks Dr. Chew.=)

sumaiyah said...

thank you Dr.Chew..
God Bless U

allanb said...

nice blog, very informative.. thanks for sharing!..

Rabiha said...

There another way of remembering is the 6P's.
P- prepare yourself ( know the patient, the illness, the treatment, the outcome).
P- prepare setting ( privacy quiet , chair, tissue paper)
P-prepare patient/ family ( ask if they need someone else, then ask about their knowledge and what they know, or informed regarding the illness/ situation. then give information in small chunks and easy to understand, )
p- provide information( tell them what happen, the treatment the result, outcome)
P-provide support ( empathy, ask them how they feel, ....what they aspect, their need, patient will....)
P-prepare what will happen after this / after interview ( transport, rehab, social worker for more counselling)
S- summary


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