Communication Skills in Case Taking

(This lecture given by the author before Homoeopathic Research Institute, Satara has been transcribed by his students).                         

"In every art there are few principles and many techniques."

                                                                                              - Dale Carnegie

Introduction         

Today I am going to talk on a fundamental 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. It is not merely gathering of some symptoms through a certain frame of questions. To be frank with you when I began homoeopathic practice, I was unaware of the depth of case - taking and communication skills. My entire interview was based on questions alone and I was bombarding my patients with innumerable, stereotyped, successive spells like Rawalpindi Express of Shoab Akthar. I was concentrating not on length and accuracy but on speed. This resulted in many fours and sixes as there were many 'Sachins' in my patients. I lost many matches and yet I was confused: why I lost? Why were there drop-outs?

I started looking seriously and I found that communicating with patients has a heavy bearing upon physician - patient interaction. Now I realize that communication is a critical component of all medical interaction, it is not "just talking" and that communication is the keystone of the doctor-patient relationship.

The term communication is grossly overworked. Everything from billboards, encyclopedias, to television, to holding hands is communication. However, exchange of words only doesn't constitute 'communication.' The word 'communication' originates form Latin term "communicare" or "communico" meaning 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, of human 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 a patient, a patient is unearthed, unfolded and then he appears to him as a living vibrating individual whose facts are known, whose inner feelings are brought onto the surface, his attitudes and inclinations are understood and his ideas are known.      

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 ---- Sender -----Sent------Received ------Receiver-----Result       

"The success of communication is measured in terms of not only the effective transmission of the message but also the achievement of intended result." This sentence indeed gives the crux. Only concentrating on sending the message, a physician shouldn't get relaxed; he must concentrate also on what is the net result of communication. This net result is the feedback which every patient gives to a physician.

There are two critical skills - Active listening and Feedback.

I give pivotal importance to listening. A homoeopathic physician who sits on a chair with holistic philosophy in the 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 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 means merely picking up sound vibrations while listening means making sense out of what we hear. Hearing is related with 'ear' functioning while listening is related with 'ears, brain and mind'.

"Active listening is an important way to bring about changes in people. Despite the popular notion that listening is a passive approach, clinical and research evidence clearly shows that sensitive listening is a most effective agent for individual personality change and group development"( Rogers and Farson).

To be an active listener, following skills will help a homoeopathic physician.

• Make eye contact
  
• Exhibit affirmative head nods & appropriate facial expressions.
  
• Avoid distracting actions or gestures
  
• Ask questions
  
• Paraphrase
  
• Avoid interrupting the patient
  
• Don't over talk
  
• Make smooth transactions

The Second critical skill is Feedback. The process of interview evokes innumerable responses from a patient. Some responses may not be likened but a physician has to keep his mind balanced. A physician must remember, "Positive feedback is more readily and accurately perceived than negative feedback."

1. Focus on specific behavior
   
2. Keep feedback impersonal
   
3. Keep feedback goal-oriented
   
4. Make feedback well-timed
   
5. Ensure feedback positive
   
6. Direct forward behavior 

 The word feedback relates to the reflection of a patient. When the interview is continued, the dynamic interaction occurs. Varied responses are evoked by both the patient and the physician. The feedback is of 6 points.

1. Focus on specific behaviour :-

There are 3 questions, why, how and when? 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". These are the statements of a patient. What doctor should do about this? 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!

2. 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. It's like not getting 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 as a person 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 his disposition. He should find out why a patient is hatred. The phenomenon of development of this hatred feeling may itself unlock a case. For the selection of a similimum, it is extremely important to find the inner personality characters.

3. Keep feedback goal oriented :-

The goal of the interview is to seek A 2 : that is Accurate and Adequate data. The goal is to understand the patient as he is. For example, 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 :-

A patient takes an appointment and is very punctual, but anyhow he has to sit for a long time. A patient expresses his resentment. Now the physician should take this feedback into consideration and should honor the punctuality of a patient in the subsequent follow-ups.

5. Ensure Feedback Positive :-

Once the goal is fixed and it is understood that the feedback should not be perceived in a personal way, it is possible to ensure the feedback positive. In positive feedback the physician acts more as a learner, as a care-taker and as a trustworthy human being.

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." Ensuring the feedback positive helps to develop favourable attitude.

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 behaviour has to be followed.

The reflective technique of communication often is very useful in forwarding the interview in a right manner.

Communication skills are not innate or fixed. They can be learned or improved and consequently the physician can improve the health outcomes.

Adherence
Every physician has insecurity in his mind. Whether my patient will stick up to me or will he leave? Insecurity hovers. Anxiety state develops. And the reaction develops "today's patients do not adhere." Remember that "poor adherence can be attributed to patient characteristics" is a myth. In fact no consistent relationship has been shown between adherence and

• Age
  
• Gender
  
• Social / economic status
  
• Marital status
  
• Personality traits (introverted, gregarious etc.)

Then what does affect adherence?

• The patients' perception of the seriousness of the disease
  
• The patients perception of the efficacy of the treatment
  
• The duration of the treatment and illness
  
• The complexity of the regimen
  
• The relationship with a physician

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

Barriers to communication

When I started practice I was not aware of 'barriers' to communication. I found that there are some patients to whom I was unable to communicate. In some patients I was right at selection of remedy or at 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 follow-ups. The dropouts in my practice taught me to see the barriers, which are collectively termed, as Noise . These are as follows:

• Absence of a common frame of reference.
  
• Badly encoded messages.
  
• Disturbance in transmission channel.
  
• Poor retention (esp. in face to face communication).
  
• Inattention by the receiver.
  
• Premature evaluation of the message.
  
• Unclarified assumptions.
  
• Mistrust between sender and receiver.
  
• Different perceptions of reality
  
• Semantic difficulties.
  
• Vagueness about the objectives to be achieved.
  
• Misinterpretation of the message.
  
• Clash of attitudinal nuances of the sender and receiver.
  
• Psycho - physical factors.
  
• Selection of wrong variety of language.

Now I focus on the factors, which produce the Noise , and I see that the communication is barrier-free and smooth.

Homoeopathic interview: qualities desired

• Well-defined ego and not to be over involved
  
• Healthy attitude towards patient
  
• Empathy, sensitivity and sensibility
  
• Sufficient intelligence to understand and co-ordinate in a coherent way
  
• Interview skills for warm and effective communication both verbal and non-verbal
  
• Maintaining professionalism, open and trusting way
  
• Ability to create supportive climate in interview to be able to make patients express their true feelings and honest opinions without fear of rejection or censure
  
• Knowledge of related subjects: clinical, para-clinical, homoeopathic, social, psychology etc.
  
• A calm, quiet, balanced mind and yet alert
  
• Jovial, charming, cheerful communication
  
• Awareness and observational eye
  
• Precision of mind
  
• Asking the right question(s) at right time
  
• Appropriate use of memory box

Now  if  you  think  that  you  know  the  basics  of  communication,  you  know  key

communication skills and now you are in a position to take an interview, you may face a lot of difficulties; for, you must know communication techniques.

These are as follows-

1. Facilitation - Verbal or non-verbal communication that encourages the patient to elaborate.
2. Open-ended Questions - Requests stated in general terms for non-specific information.
3. Direct Questions - Are those that ask patient for specific information. There should not be leading questions; they should give a graded response than yes or no.
4. Support - Indicates physician's interest and concern and his willingness to help the patient.
5. Empathy - Communication that expresses understanding of and sympathy for the patient's feelings.
6. Silence - Expresses a range of responses from total disinterest to active concern. It gives the patient a chance to explore and express deeper.
7. Reflection - A response from the physician that repeats, mirrors or echoes a portion of what the patient has just said; useful in eliciting both facts and feelings.
8. Clarification - A response that asks the patient for further information and explanation for the sake of clarity.
9. Confrontation - A technique that brings the patient face to face with the patient. Should be used with caution.
10. Hypothetical - If patient is not coming out with hard facts, this technique may help in selected cases.
11. Summation - Reviews the information that has been given by the patient.
12. Interpretation - Formulation by the physician of data, events or thoughts into terms that make the patient aware of their inter-relationship.

I briefly outline some of the qualities needed on the part of a physician for homoeopathic interview.

Some questions discussed in the lecture

1. Absence of Common frame of reference :-

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 favourable and there are no obstacles.

Example: The sitting posture between a patient and a physician must be face to face. If a physician is looking at north-west and a patient at south-west, it is not a congenial frame of reference. Strong smell coming from slums can be an irritating experience for both a patient and a physician. The word common represents at least the prescribed notions of the expected environmental settings.

2. Badly encoded messages :-

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 themselves. The coding of message must be in the format which is digestible by a patient.

3. Disturbances in transmission channel:-

This relates to the interferences that are from various sources. Frequent ringing tones, vehicles on the road, T.V. or radio in the clinic making big sounds, receptionist interrupting, the students asking questions in between etc.etc.

4. Semantic Difficulties:-

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 - the patient and the physician must have at least working knowledge of the meaning of words.

Example: A patient from Tamilnadu speaks in Tamil language with a Maharashtrian physician who doesn't know tamil. This will be the semantic difficulty.

Sir, in communication techniques, what do your mean by "OPEN ENDED QUESTION?" (Requests stated in general term for non-specific information). Example?

Answer: Open ended questions give a wide platform to talk with free association.

Example: A patient is telling about pain in abdomen and open ended question is "Tell me more about your pain?"

A patient is narrating grief incidence but in a brief way then O-E-Q is- "Tell me more about your grief".

The benefit of O-E-Q is that there is no bombardment of questions and a physician does not restrict a patient in the golden cage of questions. The ventilation of patient's thoughts and emotions occur spontaneously, freely and adequately.

Hypothetical: In order to explore the true portrait of the patient's mental state, an imaginary situation is produced by a physician. e.g. In order to understand what exactly happens when a patient develops anticipatory anxiety, physician puts up the scenario before the patient, like a patient undergoing an air-travel for the first time or a patient is caught in an accident etc.

Summation: It's like summing up in a concise way and again asking the patient to comment. Summation is useful for facilitation and classification.

The major barrier to communication is the self-concept . We know that whatever concept an individual has of himself, he clings to, shutting out data that are not congruent with it.

One more major barrier to clear, undistorted communications results 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. We tend to believe people who we define as "experts."

No communication is free from emotions , either on the part of the sender or the receiver. Emotions form part of the "modifiers" system that screens transmissions and inputs.

I briefly outline some of the qualities needed on the part of a physician for homoeopathic interview.I have applied all these techniques and knowledge in my interview chamber and I have found them extremely beneficial. I request you, the readers, to apply these techniques and send me your feedback.

My friends, remember that to explore the human being is not an easy task. One has to change his personality, look within himself, banish his prejudices, wrong notions or beliefs and go ahead with vigour. Amen!