ABC of Clinical Communication
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CHAPTER 1
Why Clinical Communication Matters
John Frain
University of Nottingham, Nottingham, UK
OVERVIEW
- The clinical interview is essential in collecting information about a patient and reducing diagnostic error.
- There is an evidence base for the skills that best facilitate collection of both the biomedical and psychosocial content of the patient's story.
- Good clinical communication underpins patient-centred care.
- Health professionals require continuing training in clinical communication in all its forms.
- Efficient information flow within the healthcare team is an essential component of patient safety.
- Respect for patients and colleagues is a prerequisite for effective clinical communication.
Clinical communication - a historical perspective
In the absence of defined physical examination methods and investigations, such as blood tests and imaging, interviewing the patient was the mainstay of diagnosing illness and managing disease. While we know little of the format of the doctor-patient encounter prior to the nineteenth century, listening was a virtue associated with the competent doctor. The doctor relied on the patient's description of symptoms to make a diagnosis. As only wealthier members of society could afford the services of a doctor, good communication skills were rewarded with greater employment. The apprenticeship model of medical training led to the role-modelling of these skills by senior doctors. While the doctor-patient relationship has evolved since then (see Figure 1.1), the 'history' remains the most important means of making a diagnosis.
Figure 1.1 Evolution of the doctor-patient relationship.
Source: Kaba and Sooriakumararan (2007). Reproduced with permission of Elsevier.
Improving knowledge of anatomy, physiology and the pathological basis of disease during the 1800s contributed to a structured clinical method consisting of a structured history and physical examination (see Box 1.1). William Osler, sometimes described as 'the father of modern medicine', took students from the lecture theatre to the patient's bedside so that students could talk to patients about their experience of disease and physically examine them for signs of the illness.
Box 1.1 The traditional model of a structured patient history
- Demographics
- Presenting problem(s)
- History of presenting problem(s)
- Past medical history
- Systems enquiry
- Family history
- Medications and allergies
- Social history
Source: Adapted from Stoeckle and Billings (1987). Reproduced with permission of Springer.
Even in an era of rapid change in the scientific basis of medicine, Osler's maxim to his students was: 'Listen to your patient; he is telling you the diagnosis.' In modern times, the history alone accounts for around 80% of diagnoses. Strikingly, increasing availability of diagnostic technology (e.g. laboratory tests and imaging) has not substantially altered this percentage.
It is worth considering what the healthcare professional wishes to derive from the patient interview or encounter. The purpose is to:
- Correctly diagnose the patient's illness.
- Avoid diagnostic error.
- Give the patient effective and appropriate treatment.
- Achieve the patient's adherence to treatment.
- Cure or mitigate the effect of the illness.
- Improve the patient's health status.
- Communicate care, concern and empathy.
Early studies of the consultation correlated the quality of the interview directly with the quality of clinical data collected (see 'Further resources'). An open-ended approach with the intention of allowing patients to identify problems of concern identified those problems well. The failure of professionals to allow patients to complete an opening statement during the consultation and an over-controlling approach (e.g. using closed questions) directly reduced the quality of information.
Poor-quality information results in a predisposition to diagnostic error, and the term 'clinical hypocompetence' has been used to describe this (see Box 1.2). While a biomedical perspective has contributed to improvements in diagnosis, the use of a solely biomedical approach risks being reductionist as it fails to take account of the patient's own experience, context and wishes. The power imbalance between the 'all-knowing' professional and the passive patient contributes to poorer outcomes. The post-war era saw the development of societal concepts such as greater self-determination, autonomy, gender rights and equality. This influenced healthcare as well, with the result of the model of the consultation we have today (see Chapter 2).
Box 1.2 Clinical hypocompetence in the medical interview
Physician-engendered defects in the interview are due to one or a combination of:
- Lack of therapeutic intent
- Inattention to primary data (symptoms)
- A high control style
- An incomplete database usually omitting patient-centred data and active problems other than the present illness
- A thoughtless interview in which the physician fails to formulate needed working hypotheses
Source: Adapted from Platt and McMath (1979). Reproduced with permission of American College of Physicians.
Even for the same illness, no two patients are going to give identical stories. Each will have a different experience of their symptoms and different concerns about their significance. Obeying Osler's maxim to listen requires seeing the patient's perspective and their own unique experience. If we needed to update Osler to make this clearer, we might say: 'Listen to your patient and see the illness through his eyes; he is telling you the diagnosis.'
The emergence of a bio-psychosocial-cultural model placed emphasis not only on what was the matter with the patient but also, as Engel (1977) famously described, what mattered to the patient. This evolved further into one that enabled patients to fulfil their potential and ultimately into 'patient-centred medicine' in which the patient has to be understood as a unique human being. This approach has been endorsed by patients and professional and regulatory bodies across the world and much research has explored the factors influencing patient-centredness (see Figure 1.2).
Figure 1.2 Factors influencing patient-centredness.
Source: Mead and Bower (2000). Reproduced with permission of Elsevier.
Patient-centred care entails involvement in discussion of treatment options and decision-making, as well as sharing of information, including records (see Chapter 4). Shared decision-making improves patient and professional satisfaction with the consultation. It involves a common acceptance of the problem, discussion of the available management options, including their benefits and risks, eliciting the patient's own views and preferences for these options and then agreeing on a management plan.
In some respects, we have proceeded forward to the past as the evidence supports the wisdom of Osler's advice. Research has identified the skills that best determine important biomedical and psychosocial data and thus facilitate diagnosis. Over the last 40 years we have developed an evidence base for clinical communication associated with higher patient satisfaction. Several consultation models have been developed which form the basis of undergraduate and postgraduate training (see Box 1.3). We consider one of these models in Chapter 2. Barriers to its successful implementation include a continuing strong emphasis on the biomedical perspective with its doctor-centredness, time pressures and lack of ongoing appropriate training.
Box 1.3 Models of the consultation
Established models include:
- Patient-centred clinical method (Brown et al., 1986)
- Three function model (Bird & Cohen-Cole, 1990)
- E4 model (Keller & Carroll, 1994)
- Calgary-Cambridge guide (Silverman et al., 1998)
- Patient-centred interviewing (Smith et al., 2000; Fortin et al., 2012)
- Four habits (Frankel & Stein, 2001)
- SEGUE framework (Makoul, 2001)
Source: Adapted from Brown et al. (2016). Reproduced with permission of Wiley.
Educational interventions to teach good communication skills have been evaluated and accepted as good practice. All UK medical schools now provide training in communication. The use of simulated patients and models of feedback are also accepted as the norm in many training programmes. Teaching clinical communication is discussed in more detail in Chapter 10. The European Association for Communication in Healthcare has defined the learning objectives in a proposed core curriculum across all the health professions (Box 1.4).
