Communication Skills in Hospital Posts
develop your GP consultation skills in your hospital posts
Why are communication skills important?
If you don’t spend time gathering the right data, you end up on the wrong track which will make you do things that either don’t help the patient or may in fact harm them.
What's wrong with the traditional method?
The traditional method of communicating is where the doctor asks about the presenting complaint, followed by a series of specific structure questions around the history of the presenting complaint. This is then followed by a PMH, DH, SH and Examination.
The problem with this method is that
- It relies on the doctor asking questions and the patient answering them. Sometimes, a patient will have some vital piece of information to tell you but this method doesn’t give them the opportunity to speak freely. It constrains them to talk about what the doctor wants to know.
- The traditional method is an inefficient system because it relies on you asking questions in a ‘stab in the dark’ sort of way. Wouldn’t it be better to simply allow the patient to talk freely and then ask the right questions to fill in the gaps?
- For instance, with the old method you would say…
- ‘You’ve had some vomiting – yes? And how many times did you vomit? And what colour was it? Was there any blood in it?’.
- A more efficient system would let the patient speak freely and the doctor asks questions afterwards to fill the gaps.
- ‘Oh doctor, this vomiting is really bad’. (Doctor says ‘Mmm… tell me more’)
- ‘Well it started last night and I’ve vomited 6 times so far and it’s really green in colour but luckily it’s started to calm down now.’
- Doctor: ‘It’s good it’s calming down. By the way, was there any blood in it?’.
- Can you see how more effective and less exhausting this alternative method is?
But I'm too busy and the environment is pressurised!
Keep an Open Mind
Time and time again, I hear GP trainees say ‘It’s all very well practising these communication skills in a GP post where there’s lots of time, but in the hospital setting, I am dealing with either emergencies or lots and lots of patients. It’s simply not possible to do communication skills to the level GPs do them in a hospital setting’. All I ask you to do for the moment is just to put that view to one side for a moment and adopt a more neutral stance before you continue to read on. It is indeed possible to do! You just need to have faith in yourself. And it’s a much more enjoyable way of consulting.
Let’s Dispel a Couple of Myths
- I am too busy dealing with emergencies where you need to get information fast rather than engage in fluffy dialogue.
Clearly, if you have an emergency, you have to deal with it and make stabilising the patient the priority. And that often means cutting down the time you spend gathering information so that you can quickly get on with managing the patient. However, not all of the cases you are dealing with in hospital are emergencies. Would I be right in saying that a good 70% of your patient contacts will be with patients who are not in an acute critical condition? Many of those who are acutely unwell – will you not be following them up the day after when the ‘acuteness’ is over? - The pressure of work is heavy – I see lots of patients and there isn’t the time to do all this communication skills lark to the level you do it in General Practice where you have more time.
Well, let me tell you that most GPs see 18 patients within 3 hours. Do you see this level of patients in that amount of time in the hospital setting? And yet we spend on average around 15 minutes with each patient. So, how is it that we can engage in deep communication skills in less time than you have? The answer = because engaging in dialogue is a more effective way of taking a history. I know you think that engaging in communication skills to the level that we GPs do them will taken tonnes of time and that your workload and work pressure will become unmanageable as the backlog of patients build up. Please believe me when I say that this is a perception, and not the reality.
So, what do we suggest?
Good communication is all about encouraging a true two-way discourse (dialogue) so that you only have to ‘fill in the gaps’ through asking the right questions at the right time. In this way, your clerk-ins will take half the time and be more accurate! Don’t believe me? Look at this clip of an ENT consultant consulting with a patient in the A&E department. Notice how she not only takes a history, but examines and teaches medical students well within 10 minutes.
Watch this clip:
In the video, you see how the ENT consultant gently explores the patient’s thoughts and concerns. In doing so, she builds a good rapport with her – and it doesn’t take that long either (about a minute!). She also picks up on the patient’s non-verbal signs and can see how upset/shocked she is. None of this is complicated stuff – all the ENT consultant is doing is verbalising what she sees and acknowledging what the patient might be feeling or thinking – encouraging the patient to open up further. In this clip, the ENT consultant says ‘I can see you getting anxious…’ and then notice how the patient really opens up about things around work etc. The doctor then explains what her own concerns are: ‘My worry is that xxxxx’ and then responds to the patients concerns: ‘Is it difficult to take time off? What can be done about work?’. And although the patient is reluctant to admission, she agrees knowing it’s for the best. The interaction is smooth and easy – just the way it should be.
This clip is taken from : Good Practice: Communication Skills in English for the Medical Practitioner by Marie McCullagh and Ross Wright, available from Cambridge University Press
Although the doctor in this consultation did not explore the past medical history, drug history or do a review of systems, this is what she actually managed to do in 5 MINUTES:
- The Presenting Complaint
- History of the Presenting Complaint (simply by allowing the patient to talk, and encouraging her)
- Examination
- Social History (work related concerns)
- The Patient’s Ideas, Concerns and Expectations
- Explaining the Management Plan
Now that’s a lot for 5 minutes. See, I told you it was possible (and not particularly that difficult either). Now it’s over to you – you decide for yourself whether you want to give this a shot and whether you want to make your working life easier or harder.
Conclusion
In General Practice training (and indeed your GP exams), there is a heavy focus on communication/consultation skills. This is our bread and butter. We regard this of extremely high importance – as much as clinical knowledge. Why? Because if you don’t gather the right data in the first place, you will end up with the wrong diagnosis and/or management plan. That ends up leading to errors which then leads to medico-legal claims. Do you want the headache of that lurking in the background?
The GP way of consulting is actually not just applicable to General Practice. There is absolutely no reason why you can’t do it in your hospital posts. You cover the same ground as in the traditional model (PC, HPC, PMH, DH, SH etc), but THE WAY YOU DO IT is different. Instead of going down an overwhelming number of questions (which, to the patient will feel like an interrogation at a time when they are most vulnerable), the GP approach offers true 2-way dialogue in which the patient offers you most of the jigsaw pieces in their life’s puzzle and you just merely have to fill in the gaps.
And remember, GPs consult in 10-15 minutes and do so very effectively because of this method. I wish I had done this when I was an ST trainee rather than spending 40 minutes clerking a patient in whilst knowing there were 8 others that needed clerking in too!
Have an open mind…. just try it…. you’ve got nothing to lose, but plenty to gain. And when you come to GP land in ST3, you’ll already have been half-skilled up. And half-read for CSA!
Where can I learn more? Any further resources?
- There is a fabulous teaching resource set by Marie McCullagh and Ross Wright: It’s called ‘Good Practice: Communication Skills in English for the Medical Practitioner’. For more information, click here. To buy it, click here (and click on the green book icons)
- London Deanery have produced two video resources that are pretty good
- ‘Words in Action’ – a resource to aid to communication skills training. The DVD uses real consultations recorded in the multi-cultural London borough of Lambeth to examine closely and systematically what goes on in conversations with patients who speak limited English, or who have a very different style of communicating from their GPs.
- ‘Doing the Lambeth Walk’ – a companion resource aimed at doctors new to UK general practice. The DVD and accompanying booklet encourage practitioners to reflect on how they use their communication skills in English, manage the consultation and share decision-making with patients. It will help practitioners ‘tune in’ to the different ways in which patients speak and develop the skills needed to prevent and repair misunderstandings.
- Each costs £5 but buy both for £8.50 (incredibly cheap!). To order your copies, please contact Dale Burton at dale.burton@londondeanery.ac.uk or phone 020 7866 3123 or complete the slip below and return to Miss Dale Burton, 2nd Floor, London Deanery, Stewart House, 32 Russell Square, London WC1B 5DN
- Other good DVD resources are
- Effective Consulting:The Five Key Tasks by Haymarket Medical
- Effective Consulting: Interpersonal Skills for the CSA by Dr. Peter Tate
- Again, both are available to buy here
- Particularly good books for starting to learn about communication skills are:
- The Doctor’s Communication Handbook by Peter Tate
- The Inner Consultation by Roger Neighbour
- The Naked Consultation by Liz Moulton
- You can order any of these here
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