Improving your communication skillsBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e357 (Published 25 January 2012) Cite this as: BMJ 2012;344:e357
- Matt Green, medical publishing director, BPP Learning Media, London,
- Teresa Parrott, consultant psychiatrist, Pluscarden Clinic, Dr Gray’s Hospital, Morayshire, Scotland, UK,
- Graham Crook, retired consultant general medical physician and chest physician, Spain
The authors of the book Effective Communication Skills for Doctors, Teresa Parrott and Graham Crook, explore, together with Matt Green of the BPP University College’s School of Health, the art of clear communication in medicine and the steps that doctors can take to improve their communication with patients, family, and colleagues
A large and compelling evidence base in communication science shows that communication is vitally important to doctors and patients. However, this research also shows that changes are needed in the attitudes and skills that underlie the way doctors communicate. For this reason, training in communication skills has become an increasingly prominent part of undergraduate and postgraduate medical training.
It has been found that the communication skills of medical students who have not had this training actually get worse as they progress through medical school. So, whether you are a specialty trainee, foundation doctor, or medical student, it is never too soon to start fine tuning your skills. Doing this will give you a head start in enhancing your personal development and in progressing your professional career.
What is effective communication all about?
In these times of austerity measures and efficiency drives, we’re getting good at making the most of what we have—we are all mindful of delivering efficient services with scarce resources. However, we are not so good at making the most of what we are. In terms of communication, this means being able to give people the information they need in a clear and concise manner and with the right attitude. Good communication leads to more satisfying interaction with colleagues, helps you to manage your time better, and makes you a more effective team member and leader.
Learning to communicate effectively means making the most of every opportunity to interact with others: to be positive and encouraging to your team, to show empathy and concern to your patients, and to be able to deal with demands and difficult emotions. Having an understanding of what type of communicator you are and being able to identify the ways in which better communication can lead to better outcomes will help you to maximise your personal effectiveness in many different situations, giving you the advantage in interviews, assessments, and in the day to day workplace.
When do you need to start thinking about your communication skills?
At no stage in our careers should we stop developing and learning about communication. Research has shown that poor communication can contribute to burnout among consultants, dissatisfaction among patients, lack of compliance, and medicolegal problems. Improved communication skills could have a positive effect on all these.
Curriculum changes at medical school have led to a much earlier focus on the teaching and assessment of communication skills. Throughout your medical career, your interactions with others will be observed and measured through exams, supervision, workplace based assessments, and appraisals. In the foundation years you will be expected to develop generic communication skills as outlined in Good Medical Practice. In your e-portfolio you will reflect on your own performance. At specialty training interviews you will be asked to describe examples of when you have failed to communicate appropriately. At interview, your leadership skills, initiative, empathy, and team playing will be tested—how you motivate others, negotiate, and deal with conflict.
How does patient feedback influence your practice? How do you manage stress? These are questions about communication skills. Knowing some of the theories and research in the field will help you to become more confident in discussing the underlying issues. In this way, improving your communication skills raises the profile of other areas of your portfolio.
At all stages of your medical training there is an expectation that you can identify your weaknesses and discuss plans for improvement. The Medical Leadership Competency Framework, introduced in 2008, encourages self awareness—that is, knowing your own strengths and weaknesses. It entails realising the effect of your behaviour on others and the influence of your own emotions and prejudices on your judgments and behaviour. The aim of increasing self awareness is to be able to manage the impact of your emotions in your day to day practice—and to improve your relationships overall.
Top tips for effective communication
Use clear language: Avoid jargon and tailor your language to your patients’ understanding and information needs.
Be conscious of your non-verbal communication: It is important to maintain eye contact—reading notes or looking at the computer screen may convey negative messages.
Negotiate an agenda: Ask patients what they need from the consultation, and explain what can be covered. Few doctors explain the purpose of the consultation or the time available, and less than one quarter negotiate over treatment.
Establish a dialogue: Determine whether your patient agrees with the diagnosis and management plan. Patients who disagree with the diagnosis probably won’t adhere to the treatment.
Be flexible in your consultation style: Tailor your approach to the individual patient. A more directive style may be appropriate for patients who want less involvement in decision making. A supportive style—listening attentively and asking questions about psychosocial issues—helps facilitate the disclosure of sensitive information.
Provide the information that patients want: Doctors tend to talk too much about drug treatment, whereas patients want to know about causes and the likely diagnosis and prognosis. They want more openness about side effects and advice on how to relieve pain and emotional distress and what they can do for themselves. Providing this information helps their symptoms, reduces distress, improves physiological status, reduces hospital stay and use of analgesia, and improves quality of life.
Reflect on the outcomes of your interactions with others: Why do some doctors work well and others not so well? Communication difficulties are one of the main reasons that patients complain about doctors. The most common criticism is not about the doctors’ competence but that they have failed to listen or to offer sufficient explanation.
Apologise when mistakes occur: Apologising and expressing regret at the suffering experienced by a patient is not an admission of liability. Ineffective communication is the single largest factor behind litigation by patients. Good communication, including effective apology, can avert or help end conflict, especially litigation. It never does any harm to apologise—for yourself or on behalf of colleagues.
Empathise and listen: Your relationship with the patient is vitally important. It facilitates therapeutic space in which patients can express their concerns and receive support and advice. Empathy is the ability to understand what another person is experiencing and to communicate that understanding to the person. As the patient begins to relate his or her story, it is necessary to silence our own internal talk, including the diagnostic reasoning process, which can interfere with our ability to listen.
Mindful practice: This is your ability to observe not only the patient but your own performance during the consultation. Mindful doctors can easily be identified by patients and colleagues—they are present, attentive, curious, and unhindered by preconception.
Establish rapport: Recognition and explicit acknowledgment of the emotional content in your patient’s story is particularly important in establishing rapport. Doctors often respond to emotional cues by offering premature reassurance, explaining away distress as normal, attending to physical aspects only, switching the topic, or “jollying” patients along.
Communication is important in all aspects of your training, and learning more about communication skills will help you perform better in exams, assessments, interviews, and appraisals—as well as in your day to day practice. Maximising your effectiveness in communication not only enhances your personal performance in many different spheres but also improves your relationships with patients and facilitates career progression.
Balint M. The doctor, his patient and the illness. Churchill Livingstone, 1957.
Charon R. Narrative medicine: a model for empathy, reflection, profession and trust. JAMA 2001;286:1897-902.
DiMatteo MR. Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. Med Care 2004;42:200-9.
Disiker R, Michiellute A. An analysis of empathy in medical students before and following clinical experience. J Med Educ 1981;56:1004-10.
Fallowfield LJ, Hall A, Maguire P, Baum M, A’Hern, RP. Psychological effects of being offered choice of surgery for breast cancer. BMJ 1994;309:448.
Fallowfield L, Jenkins V, Farewell V, Saul J, Duffy A, Eves R. Efficacy of a Cancer Research UK communication skills training model for oncologists: a randomised controlled trial. Lancet 2002;359:9307.
Frenkel DN, Liebman CB. Words that heal. Ann Intern Med 2004;140:482-3.
Haidet P, Paterniti DA. “Building” a history rather than “taking” one: a perspective on information sharing during the medical interview. Arch Intern Med 2003;163:1134-40.
Kaplan SK, Greenfield S, Gandek B, Rogers WH, Ware JE. Characteristics of physicians with participatory decision-making styles. Ann Intern Med 1996;124:497-504.
Kaplan SH, Greenfield S, Ware JE Jr. Impact of the doctor-patient relationship on the outcomes of chronic disease. In: Stewart M, Roter D (eds). Communicating with Medical Patients. Sage Publications, 1989:228-45.
Kindelan K, Kent G. Concordance between patients’ information preferences and general practitioners’ perceptions. Psychol Health 1987;1:399-409.
Kinnersely P, Edwards A, Hood K, Ryan R, Prout H, Cadbury N, et al. Interventions before consultations to help patients address their information needs by encouraging question asking: systematic review. BMJ 2008;337:a485.
Maguire P, Fairbairn S, Fletcher C. Consultation skills of young doctors: benefits of undergraduate feedback training in interviewing. In: Stewart M, Roter D (eds). Communicating with medical patients. Sage Publications, 1989:124-37.
Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ 2002;325:697-700.
Matthews DA, Suchman AL, Branch WT Jr. Making “connexions”: enhancing the therapeutic potential of patient-clinician relationships. Ann Internal Med 1993;118:973-7.
Meryn S. Improving doctor patient communication. BMJ 1998;316:1922.
NHS Institute for Innovation and Improvement, Academy of Medical Royal Colleges. Medical leadership competency framework. 2008. www.institute.nhs.uk/assessment_tool/general/medical_leadership_competency_framework_-_homepage.html.
Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians interviewing skills and reducing patients’ emotional distress: a randomized clinical trial. Arch Intern Med 1995;155:1877-84.
Royal College of Physicians. Improving communication between doctors and patients. RCP, 1997.
Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ 1995;152:1423-33.
Stewart M, Brown JB, Boon H, Galajda J, Meredith L, Sangster M. Evidence on patient-doctor communication. Cancer Prev Control 1999;3:25-30.
Tomm K. Interventive interviewing: part III. Intending to ask lineal, circular, strategic, or reflexive questions? Fam Proc 1988;27:1-15.
Wissow LS, Roter DL, Wilson MEH. Pediatrician interview style and mothers’ disclosure of psychosocial issues. Pediatrics 1994;93:289-95.
Zoppi K, Epstein RM. Is communication a skill? Communication behaviors and being in relation. Family Med 2002;34:319-24.
Competing interests: TP and GC’s book Effective Communication Skills for Doctors is published by BPP Learning Media, whose medical publishing director is Matt Green ().