Communication theory models—outside the face-to-face consultation
Associate Professor, Office of Postgraduate Medical Education, Room 210, Mackie Building K01, University of Sydney, NSW 2006, Australia
E-mail: jthistle{at}med.usyd.edu.au
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Abstract |
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 TOP Abstract The GP curriculum and...Box 1. The breadth...The breadth of interactionsCommunication, miscommunication...Patient-doctor consultations by...Communication within the primary...Referral to other health...Confidentiality and...References |
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The fundamental interaction at the core of general practice is the consultation between patient and doctor. To achieve the optimal outcomes from such encounters for both parties, the general practitioner (GP) must be a good communicator. Moreover, the skilled GP needs to be able to facilitate patients to share their stories and to share in decision making with regards to management. The majority of communication skills training programmes focus on face-to-face patient–doctor communication but there are also skills for other interactions to be learnt, practised and developed. The process of communication is also varied—verbal and written, telephone and electronic, to one person and to groups, to lay people and to professional colleagues, to fluent English speakers and to speakers with English as a second language. This article reviews the process of communication outside the consultation room.
The curriculum statement on the consultation includes the following:
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In relation to the focus of this paper, I will be concentrating on the specific outcomes below. In terms of the context of the consultation, there are the following outcomes related to interacting with other professional colleagues:
- Working successfully as a member of the primary care team
- Working successfully with colleagues in secondary care and elsewhere
- Working successfully with a range of other professionals such as Social Services.
This means recognizing that ‘working successfully’ involves:
- Understanding the role of professional colleagues and where their expertise lies
- Drawing on this expertise as appropriate
- Treating colleagues with consideration and respect
- Understanding interprofessional boundaries with regard to clinical responsibility and confidentiality.
Working successfully in a team and with colleagues requires similar but additional communication skills to those employed in consultations with patients.
In terms of the structure of the consultation there is:
- Understand how consultations conducted via remote media (telephone and email) differ from face-to-face consultations and demonstrate skills that can compensate for these differences.
These consultations at a distance require additional skills also to compensate for the loss of non-verbal communication/body language.
In terms of professional behaviour there is:
- Making timely and appropriate referrals using relevant information.
Doctor–patient communication
Doctor–patient's family/carers
Doctor–doctor
Doctor–other health professional
Within a team
Writing medical records—paper or electronic Legal
With the media With authorities and organizations, e.g. police, GMC and defence body Dealing with complaints
Whistle-blowing Running/chairing meetings Teaching
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The breadth of interactions |
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TOPAbstractThe GP curriculum and...Box 1. The breadth...The breadth of interactionsCommunication, miscommunication...Patient-doctor consultations by...Communication within the primary...Referral to other health...Confidentiality and...References |
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Doctors must develop the ability to communicate with diverse individuals, groups and organizations and to work in teams. Medical students begin to learn and practise these skills during their undergraduate training. However, at university, communication skills sessions tend to focus on communication between doctor and patient. While more recently the focus has begun to broaden, there are many situations and diverse interactions requiring good communication, each of which has its own potential pitfalls (Box 1). Not all these are covered before qualification, and many are often not encountered in real-life settings until the foundation years or during vocational training.
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Communication, miscommunication and patient safety |
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TOPAbstractThe GP curriculum and...Box 1. The breadth...The breadth of interactionsCommunication, miscommunication...Patient-doctor consultations by...Communication within the primary...Referral to other health...Confidentiality and...References |
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There is a growing body of evidence on the effects of good and bad communication on patient outcomes and doctor stress. Estimates of the effects vary but one North American work published in 2002 suggested that 80% of medical errors might be traced back to failure of communication (Rosenthal and Sutcliffe, 2002). This was 6 years ago but unfortunately there are published reports each year showing that, in spite of enhanced training, miscommunication still occurs. While professional jargon is often to blame for misunderstandings between doctor and patient, the problem of communication shortfalls between different health professionals is also a major contributing factor to patient safety adverse events.
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For example, the Bristol enquiry into the performance of paediatric heart surgeons concluded that lack of communication was a factor in the poor outcomes and significantly that there was poor communication between the different health professionals caring for the patients. Following Bristol and other similar events, patient safety is high on the agenda of the health service. Step 5 of the National Patient Safety Agency's (NPSA) ‘Seven steps to patient safety’ is ‘Involve and communicate with patients and the public’. In a move away from the traditional way of doing things—never admit blame—the NPSA recommends apologizing to patients and carers following adverse events. ‘Central to the NPSA's strategy to improve patient safety is our commitment to improving communication between health care organizations and patient and/or carers when a patient is moderately harmed, severely harmed or has died as a result of a patient safety incident ... this communication is known as being open’ (2005).
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Patient–doctor consultations by distance |
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TOPAbstractThe GP curriculum and...Box 1. The breadth...The breadth of interactionsCommunication, miscommunication...Patient-doctor consultations by...Communication within the primary...Referral to other health...Confidentiality and...References |
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The two main types of these interactions are by telephone and, more recently and increasingly, by email. Telephone calls maybe initiated by the patient, practices that have a dedicated time for patients to ring for advice or results, or by GPs, phoning to check on a patient following a consultation or to give results. Telephone consultations are usually convenient for both parties and may save time. They can, however, generate anxiety and lead to mistakes. Diagnosing over the phone can be fraught with difficulty. Doctors worry about missing serious conditions as they are not able to examine the patient or even check the patient's appearance (Foster et al., 1999). While the patient's history is of fundamental importance, the inability to carry out even the most minimal of examinations leads doctors to be cautious of making a diagnosis (Hannis et al., 1996). Telephone consultations can precipitate mistakes both with patients well known to the GP and those whom the GP has not seen before. If the doctor does not have the patient's records at hand, this is even more likely to cause a problem. Telephone consultations should therefore only be undertaken in certain circumstances (Box 2).
Box 2. Reasons to carry out telephone consultations
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The procedure for a telephone consultation is shown in Box 3. The consultation should be of comparable length to a face-to-face interaction for the same problem (Car and Sheikh, 2003). GP registrars might consider audiotaping some of their consultations with the patient's permission to gain feedback on the process from their trainer or peers.
| Box 3. Telephone consultations (adapted from Thistlethwaite and Morris, 2006) Procedure
Communication skills on the phone
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Similar considerations apply to speaking to other health professionals and organizations on the phone. You and the other party should exchange names and designations, and you need to establish the reason for the call and your expectations from the call. When calling a large organization, you may pass through several people until you reach the person you require. Ask this person, in case of follow-up, if there is a direct line to save time. We all know the frustrations of waiting for many minutes to get through to first a real person and then the right person. It is worth thinking if you do not wish any phone calls to be put through when you are consulting with a patient—unless they are from another doctor. Talking on the phone in front of a patient has confidentiality repercussions and cannot be done in comfort. Callers should be asked to leave their name, number, reason for call and when they will be available for follow-up.
Emails and the Internet are increasingly dominating our professional lives. Cyber-savvy patients are also likely to want to interact with their GPs through this accessible and convenient means. The main drawback is again lack of visual cues but there is also the lag time between question and response as well as possible issues relating to confidentiality. Moreover, a patient who knows the practice, or individual doctor's, email address is able to make contact from almost anywhere in the world. While this is also true of the telephone, time differences make phone calls less likely. Interesting dilemmas are raised by this ease of access—whose responsibility is the patient if he or she is outside the practice area? How do you know the patient has received your reply? Within what time frame should an email be answered? Possibly the only safe uses of email are to give normal test results, make appointments, order repeat prescriptions and answer simple medical questions. The practice information technology computer system should have a facility to log that an email has been received by the patient—but of course this does not mean it has been read or understood.
A systematic review of email consultations in health care in the UK concluded that successful use of emails depends on both the doctor and patient having a clear understanding of its role, advantages and limitations (Car and Sheikh, 2004a). General practices need to develop a protocol for the use of email and this information should be given to patients (Car and Sheikh, 2004b). Guidelines are available, for example those from the American Medical Association, summarized in Box 4. Advice for patients and practice staff in relation to confidentiality are shown in Box 5.
Box 4. Guidelines for email consultations (from Robertson, 2001)
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Box 5. Emails and confidentiality
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Communication within the primary health care team |
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TOPAbstractThe GP curriculum and...Box 1. The breadth...The breadth of interactionsCommunication, miscommunication...Patient-doctor consultations by...Communication within the primary...Referral to other health...Confidentiality and...References |
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Twenty-first century health care delivery relies on teamwork. The patient–doctor relationship may be the focus of general practice, but the GP could not function without a team of receptionists, nurses and allied health professionals, not to mention the wider team which might include secondary care, pharmacists and social workers. Teamwork and collaboration aims to achieve better outcomes for patients, who should be thought of as members of the team. Health professionals have overlapping but also different knowledge and skills, so should work together complementing each other's roles. In particular, patients should not be given conflicting advice by different team members. Excellent GPs recognize that they do not have all the attributes required to deliver complex health care. Interprofessional teamwork involves health professionals working with and respecting each other, with common goals and agreed methods of working. This is a move away from the more traditional health care model in which each health professional worked within his or her own silo, aiming to maintain profession-specific autonomy and values (Hall, 2005). Skills for working collaboratively are listed in Box 6.
Box 6. Working collaboratively (Norsen et al., 1995)
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Communication is a key requirement of good teamwork. Face-to-face interaction between team members is the optimal process but this is not always feasible. Therefore, other channels of communication need to be put into place. Leadership and accountability need to be defined. This may be fairly easy within the immediate primary health care team but communication with secondary care is often fraught with difficulty.
In most cases, a doctor will be the team leader, however, increasingly this is not necessarily the case. Teamwork requires negotiation and conciliation skills with each member of the team having a duty of care to the patient and to each other. The three requirements for a well-functioning team are shown in Box 7. If these are not met, patient safety becomes an issue and members have less job satisfaction (Dawson et al., 2007).
Box 7. Requirements for a functioning team (Dawson et al., 2007)
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Referral to other health professionals |
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TOPAbstractThe GP curriculum and...Box 1. The breadth...The breadth of interactionsCommunication, miscommunication...Patient-doctor consultations by...Communication within the primary...Referral to other health...Confidentiality and...References |
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While such referrals may take place by phone, they are most often conducted through referral letters. Writing a good referral letter is an art. While a GP may think—well the patients can fill in the gaps when they are seen—we know that patients do not always remember important information about their histories, including what investigations they have had, what medication they have been given or the exact chronology of events. The patient's story and interpretation of problems is of utmost importance and should be listened to carefully by any new professional. However, referral letters are complementary to this process and should contain certain information. Studies have shown that not even the reason for referral is included in each letter—how does the specialist then know what you and the patient are expecting? Very rarely do letters to or from secondary care include what the patient has been told, some do not include drugs or test results (Tattersall et al., 2002). Pro forma letters help improve the quality of information (Jenkins et al., 1997) and many computer programs in use in general practice now include such templates.
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Confidentiality and communication |
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TOPAbstractThe GP curriculum and...Box 1. The breadth...The breadth of interactionsCommunication, miscommunication...Patient-doctor consultations by...Communication within the primary...Referral to other health...Confidentiality and...References |
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The GMC's publication Duties of a Doctor includes the requirement for doctors to ‘respect and protect confidential information’. I have mentioned this above in relation to electronic communication. However, there are also issues in relation to teamwork and modern practice. Another GMC document, Confidentiality: Protecting and providing information, is very helpful. It stresses that ‘Doctors hold information about patients which is private and sensitive. This information must not be given to others unless the patient consents or you can justify the disclosure.’ GPs need to consider who else should have access to the information they elicit from patients. This information may be passed on in referral letters, when discussing cases at primary care team meetings and often, inadvertently, in reception. Think of who might access the referral letter (a particular problem if faxed or emailed) or who might be listening to discussions in public places. While patients might expect that other health professionals they consult would have some of their medical information, they may not wish for more sensitive details to be passed on. Many GPs now dictate referrals during consultations, so that the patient is aware of what the letter contains.
Key points
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References |
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TOPAbstractThe GP curriculum and...Box 1. The breadth...The breadth of interactionsCommunication, miscommunication...Patient-doctor consultations by...Communication within the primary...Referral to other health...Confidentiality and...References |
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