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Communication skills 

Communication skills
Chapter:
Communication skills
Author(s):

James Thomas

and Tanya Monaghan

DOI:
10.1093/med/9780199593972.003.0001

11 October, 2018: This chapter has been re-evaluated and remains up-to-date. No changes have been necessary.

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date: 16 September 2021

Introduction

Communication skills are notoriously hard to teach and describe. There are too many possible situations that one might encounter to be able to draw rules or guidelines. In addition, your actions will depend greatly on the personalities present, not least of all your own.

Using this chapter

Throughout this chapter, there is some general advice about communicating in different situations and to different people. We have not provided rules to stick to, but rather tried to give the reader an appreciation of the great many ways the same situation may be tackled.

Ultimately, skill at communication comes from practice and a large amount of common sense.

A huge amount has been written about communication skills in medicine. Most is a mix of accepted protocols and personal opinion—this chapter is no different.

Patient-centred communication

In recent years, there has been a significant change in the way healthcare workers interact with patients. The biomedical model has fallen out of favour. Instead, there is an appreciation that the patient has a unique experience of the illness involving the social, psychological, and behavioural effects of the disease.

The biomedical model

  • Doctor is in charge of the consultation.

  • Focus is on disease management.

The patient-centred model

(see also Box 1.1)

  • Power and decision-making is shared.

  • Address and treat the whole patient.

Becoming a good communicator

Learning

As in all aspects of medicine, learning is a lifelong process. One part of this, particularly relevant to communication skills and at the beginning of your career, is watching others.

The student should take every opportunity to observe doctor–patient and other interactions. Look carefully at how patients are treated by staff that you come across and consider every move that is made...is that something that you could try yourself? Would you like to be treated in that way?

You should ask to be present during difficult conversations.

Instead of glazing over during consultations in clinic or on the ward round, you should watch the interaction and consider if the behaviours you see are worth emulating or avoiding. Consider how you might adjust your future behaviour.

‘Cherry-pick’ the things you like and use them as your own—building up your own repertoire of communication techniques.

Spontaneity versus learnt behaviours

If you watch a good communicator (in any field) you will see them making friendly conversation, spontaneous jokes, and using words and phrases that put people at ease. It seems natural, relaxed, and spontaneous.

Watching that same person interact with someone else can shatter the illusion as you see them using the very same ‘spontaneous’ jokes and other gambits from their repertoire.

This is one of the keys to good communication—an ability to judge the situation and pull the appropriate phrase, word, or action from your internal catalogue. If done well, it leads to a smooth interaction with no hesitations or misunderstandings. The additional advantage is that your mental processes are free to consider the next move, mull over what has been said, or consider the findings, whilst externally you are partially on ‘auto-pilot’.

During physical examination, this is particularly relevant. You should be able to coax the wanted actions from the patient and put them at ease whilst considering the findings and your next step.

It must be stressed that this is not the same as lacking concentration—quite the opposite, in fact.

Essential considerations

Attitudes

Patients are entrusting their health and personal information to you—they want someone who is confident, friendly, competent, and above all, is trustworthy. See Box 1.2 for notes on confidentiality.

Personal appearance

First impressions count—and studies have consistently shown that your appearance (clothes, hair, make-up) has a great impact on the patients’ opinion of you and their willingness to interact with you. Part of that intangible ‘professionalism’ comes from your image.

The white coat is no longer part of the medical culture in the UK. National guidance has widely been interpreted as ‘bare below the elbow’ with no long sleeves or jewellery. This does not mean that you should look scruffy, however. Many hospitals are now adopting uniforms for all their staff which helps solve some potential appearance issues. Fashions in clothing change rapidly but some basic rules still apply:

  • Ensure you have a good standard of personal hygiene.

    • Any perfume or deodorant should not be overpowering

    • Many people believe men should be clean-shaven. This is obviously impossible for some religious groups and not a view shared by the authors. Facial hair should, however, be clean and tidy.

  • Neutralize any extreme tastes in fashion that you may have.

  • Men should usually wear a shirt. If a tie is worn, it should be tucked into the shirt when examining patients.

  • Women may wear skirts or trousers but the length of the skirts should not raise any eyebrows.

  • The belly should be covered—even during the summer.

  • The shoulders, likewise, should usually be covered.

  • Shoes should be polished and clean.

  • Clean surgical scrubs may be worn if appropriate.

  • Hair should be relatively conservatively styled and no hair should be over the face. It is advised to wear long hair tied up.

  • Your name badge should be clearly visible—worn at the belt or on a lanyard around the neck is acceptable depending on hospital policy.

    • Note that lanyards should have a safety mechanism which will allow them to break open if pulled hard. Most hospitals supply these—be cautious about using your own lanyard from a shop or conference

    • Wearing a name badge at the belt means people have to look at your crotch – not necessarily ideal!

  • Stethoscopes are best carried—worn at the neck is acceptable but a little pretentious, according to some views.

    • Try not to tuck items in your belt—use pockets or belt-holders for mobile phones, keys, and wallets.

Communication skills Psychiatry, paediatrics, and a handful of other specialties require a different dress code as they deal with patients requiring differing techniques to bond.

Timing

If in a hospital setting, make sure that your discussion is not during an allocated quiet time—or immediately before one is to start! You should also avoid mealtimes or when the patient’s long-lost relative has just come to visit.

Communication skills If taking the patient from the bedside, ask the supervising doctor (if not you) and the nursing staff—and let all concerned know where you have gone in case the patient is needed.

Setting

Students, doctors, and others tend to see patients on busy wards which provide distractions that can break the interaction. Often this is necessary during the course of a busy day. However, if you are intending to discuss a matter of delicacy requiring concentration on both your parts, consider the following conditions:

  • The room should be quiet, private, and free from disturbances.

  • There should be enough seating for everyone.

  • Chairs should be comfortable enough for an extended conversation.

  • Arrange the seats close to yours with no intervening tables or other furniture.

Avoid medical jargon

The problem is that medics are so immersed in jargon that it becomes part of their daily speech. The patient may not understand the words or may have a different idea as to the meaning.

Technical words such as ‘myocardial infarction’ are in obvious need of avoidance or explanation. Consider terms such as ‘exacerbate’, ‘chronic’, ‘numb’, and ‘sputum’—these may seem obvious in meaning to you but not to the patient. Be very careful to tease out the exact meaning of any pseudo-medical terms that the patient uses.

You may also think that some terms such as ‘angina’ and ‘migraine’ are well known—but these are very often misinterpreted.

Fear-words

There are certain words which immediately generate fear, such as ‘cancer’ and ‘leukaemia’. You should only use these if you are sure that the patient wants to know the full story.

Beware, however, of avoiding these words and causing confusion by not giving the whole story.

You should also be aware of certain words that people will instinctively assume mean something more serious. For example, to most people a ‘shadow’ on the lung means cancer. Don’t then use the word when you are talking about consolidation due to pneumonia!

The importance of silence

In conversations that you may have with friends or colleagues, your aim is to avoid silence using filler noises such as ‘um’ and ‘ah’ whilst pausing.

In medical situations, silences should be embraced and used to extract more information from the patient. Use silence to listen.

Practice is needed as the inexperienced may find this uncomfortable. It is often useful, however, to remain silent once the patient has answered your question. You will usually find that they start speaking again—and often impart useful and enlightening facts.

Remember the name

Forgetting someone’s name is what we all fear but is easy to disguise by simple avoidance. However, the use of a name will make you seem to be taking a greater interest. It is particularly important that you remember the patient’s name when talking to family. Getting the name wrong is embarrassing and seriously undermines their confidence in you.

Aside from actually remembering the name, it is a good idea to have it written down and within sight—either on a piece of paper in your hand or on the desk, or at the head of the patient’s bed. To be seen visibly glancing at the name is forgivable.

Standing

Although this might be considered old-fashioned by some younger people, standing is a universal mark of respect. You should always stand when a patient enters a room and take your seat at the same time as them. You should also stand as they leave but, if you have established a good rapport during the consultation, this isn’t absolutely necessary.

Greeting

Beware of ‘good afternoon’ and ‘good morning’. These can be inappropriate if you are about to break some bad news or if there is another reason for distress. Consider instead a simple ‘hello’.

Shaking hands

A difficult issue which, again, needs to be judged at the time.

Physical contact always seems friendly and warms a person to you—but a hand-shake may be seen as overly formal by some. It may be inappropriate if the patient is unable to reciprocate through paralysis or pain. Perhaps consider using some other form of touch—such as a slight guiding hand on their arm as they enter the room or a brief touch to the forearm.

Remember also that members of some religious groups may be forbidden from touching a member of the opposite sex.

Introductions

This is a potential minefield! You may wish to alter your greeting depending on circumstances—choose terms that suit you.

Title—them

Older patients may prefer to be called Mr or Mrs; younger patients would find it odd. Difficulty arises with females when you don’t know their marital status. Some younger or married patients may find the term ‘Ms’ offensive.

Using the patient’s first name may be considered too informal by some—whilst a change to using the family name mid-way through the encounter will seem very abrasive and unfriendly.

There are no rules here and common sense is required to judge the situation at the time. When unsure, the best option is always to ask.

Title—you

The title ‘doctor’ has always been a status symbol and a badge of authority—within the healthcare professions, at least. Young doctors may be reluctant to part with the title so soon after acquiring it but, in these days when consultations are becoming two-way conversations between equals, should you really introduce yourself as ‘Dr’?

Many patients will simply call you ‘doctor’ and the matter doesn’t arise. The authors prefer using first names in most circumstances but some elderly patients prefer—and expect—a certain level of formality so the situation has to be judged at the time.

Introducing yourself by the first name only seems too informal for most medical situations. Some young-looking students and doctors, however, may feel the need to introduce themselves using their title to avoid any misunderstanding of their role—particularly since the demise of the white coat. Perhaps worth considering is a longer introduction using both your names and an explanation along the lines of ‘Hello, my name is Jane Smith, I am one of the doctors.’

General principles

Demeanour

Give the patient your full attention. Appear encouraging with a warm, friendly manner. Use appropriate facial expressions—don’t look bored!

Define your role

Along with the standard introductions, you should always make it clear who you are and what your role is. You might also wish to say who your seniors are, if appropriate.

Be sure that anyone else in the room has also been introduced by name.

Style of questioning

Open questions versus closed questions

Open questions are those where any answer is possible. These allow the patient to give you the true answer in their own words. Be careful not to lead them with closed questions.

Compare ‘How much does it hurt?’ to ‘Does it hurt a lot?’ The former allows the patient to tell you how the pain feels on a wide spectrum of severity, the latter leaves the patient only two options—and will not give a true reflection of the severity.

Multiple choice questions

Often, patients have difficulty with an open question if they are not quite sure what you mean. A question about the character of pain, for example, is rather hard to form and patients will often not know quite what you mean by ‘What sort of pain is it?’ or ‘What does it feel like, exactly?’

In these circumstances, you may wish to give them a few examples—but leave the list open-ended for them to add their own words. You must be very careful not to give the answer that you are expecting from them. For example, in a patient who you suspect has angina (‘crushing’ pain), you could ask, ‘What sort of a pain is it...burning, stabbing, aching, for example...?’

Clarifying questions

Use clarifying questions to get the full details, particularly if there are terms used which may have a different meaning to the patient than to you.

Difficult questions

Apologise for potentially offensive, embarrassing, or upsetting questions (‘I’m sorry to have you ask you this, but...’).

Reflective comments

Use reflective comments to encourage the patient to go on and reassure them that you are following the story.

Staying on topic

You should be forceful but friendly when keeping the patient on the topic you want or moving the patient on to a new topic. Don’t be afraid to interrupt them—some patients will talk for hours if you let them!

Eye-contact

Communication skills Make eye-contact and look at the patient when they are speaking.

Make a note of eye-contact next time you are in conversation with a friend or colleague.

In normal conversations, the speaker usually looks away whilst the listener looks directly at the speaker. The roles then change when the other person starts talking...and so on.

In the medical situation, whilst the patient is speaking, you may be tempted to make notes, read the referral letter, look at a test result, or similar—you should resist and stick to the ‘normal’ rules of eye-contact.

Adjusting your manner

You would clearly not talk to another doctor as you would someone with no medical knowledge. This is a difficult area, you should try to adjust your manner and speech according to the patient’s educational level.

This can be extremely difficult—you should not make assumptions on intellect or understanding based solely on educational history.

A safe approach is to start in a relatively neutral way and then adjust your manner and speech based on what you see and hear in the first minute or two of the interaction—but be alert to whether this is effective and make changes accordingly.

Interruptions

Apologize to the patient if you are interrupted.

Don’t take offence or get annoyed

As well as being directly aggressive or offensive, people may be thoughtless in their speech or manner and cause offence when they don’t mean to. As a professional, you should rise above this and remember that apparent aggression may be the patient’s coping mechanism, born from a feeling of helplessness or frustration—it is not a personal insult or affront.

Cross-cultural communication

Cultural background and tradition may have a large influence on disease management. Beliefs about the origin of disease and prejudices or stigma surrounding the diagnosis can make dealing with the problem challenging.

Be aware of all possible implications of a person’s cultural background, both in their understanding of disease, expectations of healthcare, and in other practices that may affect their health.

Above all, be aware of prejudice—yours and theirs.

Body language: an introduction

Body language is rarely given the place it deserves in the teaching of communication skills. There are over 600 muscles in the human body; 90 in the face of which 30 act purely to express emotion. Changes in your position or expression—some obvious, others subtle—can heavily influence the message that you are communicating.

We’ve all met someone and thought ‘I didn’t like him’ or alternatively ‘she seemed trustworthy’. Often these impressions of people are not built on what is said but the manner in which people handle themselves. You subconsciously pick up cues from the other person’s body. Being good at using body language means having awareness of how the other person may be viewing you and getting your subconscious actions and expressions under conscious control.

If done well, you can influence the other person’s opinion of you, make them more receptive to your message, or add particular emphasis to certain words and phrases.

Touching

Touching is one of the most powerful forms of non-verbal communication and needs to be managed with care.

  • Greeting: touch is part of greeting rituals in most cultures. It demonstrates that you are not holding a weapon and establishes intimacy.

  • Shaking hands: there are many variations. The length of the shake and the strength of the grip impart a huge amount of information. For added intimacy and warmth, a double-handed grip can be used. For extra intimacy, one may touch the other’s forearm or elbow.*

  • Dominance: touch is a powerful display of dominance. Touching someone on the back or shoulder demonstrates that you are in charge—this can be countered by mirroring the action back.

  • Sympathy: the lightest of touches can be very comforting and is appropriate in the medical situation where other touch may be misread as dominance or intimacy (you shouldn’t hug a patient that you’ve only just met!). Display sympathy by a brief touch to the arm or hand.

Open body language

This refers to a cluster of movements concerned with seeming open. The most significant part of this is the act of opening—signalling a change in the way you are feeling. Openness demonstrates that you have nothing to hide and are receptive to the other person. Openness encourages openness.

This can be used to calm an angry situation or when asking about personal information.

The key is to not have your arms or legs crossed in any way.

  • Arms open: either at your side or held wide. Even better, hold your hands open and face your palms to the other person.

  • Legs open: this does not mean legs wide but rather not crossed. You may hold them parallel. The feet often point to something of subconscious interest to you—point them at the patient!

Emphasis

You can amplify your spoken words with your body—usually without noticing it. Actions include nodding your head, pointing, or other hand gestures. A gesture may even involve your entire body.

Watch newsreaders—often only their heads are in view so they emphasize with nods and turns of their heads much more than one would during normal conversation.

  • Synchrony: this is key. Time points of the finger, taps of the hand on the desk, or other actions with the words you wish to emphasize.

  • Precision: signal that the words currently being spoken are worth paying attention to with delicate, precise movements. You could make an ‘O’ with your thumb and index finger or hold your hands such that each finger is touching its opposite counterpart—like a splayed prayer position.

Eye level

This is a very powerful tool. In general, the person with their eye level higher is in control of the situation.

You can use this to your advantage. When asking someone personal questions or when you want them to open up, position yourself such that your eyes are below theirs—meaning they have to look down at you slightly. This makes them feel more in control and comfortable.

Likewise, anger often comes from a feeling of lack of control—put the angry person in charge by lowering your eye level—even if that means squatting next to them or sitting when they are standing.

Conversely, you may raise your eye level to take charge of a difficult situation: looking down on someone is intimidating. Stand over a seated person to demonstrate that you are in charge.

Watch and learn

There is much that could be said about body language. You should watch others and yourselves and consider what messages are being portrayed by non-verbal communication.

Stay aware of your own movements and consider purposefully changing what would normally be subconscious actions to add to, or alter, the meaning of your speech.

Interpreters

Official communicators are bound by a code of ethics, impartiality, and confidentiality—friends and relatives are not.

It is often impossible to be sure that a relative is passing on all that is said in the correct way.

Sometimes, the patient’s children are used to interpret—this is clearly not advisable for a number of reasons. This not only places too much responsibility on the child but they may not be able to explain difficult concepts. In addition, conversations about sex, death, or other difficult topics may be unsuitable for the child to be party to.

Using an official interpreter

Before you start

  • Brief the interpreter on the situation, clarify your role and the work of the department, if necessary.

  • Allow the interpreter to introduce themselves to the patient and explain their role.

  • Arrange seating so that the patient can see the interpreter and you equally.

  • Allow enough time (at least twice as long as normal).

During the exchange

  • Speak to the patient, not the interpreter. This may be hard at first, but you should speak to and look at the patient at all times.

  • Be patient, some concepts are hard to explain.

  • Avoid complex terms and grammar.

  • Avoid jargon.

  • Avoid slang and colloquialisms which may be hard to interpret correctly.

  • Check understanding frequently.

Finishing off

  • Check understanding.

  • Allow time for questions.

  • Communication skills If the conversation has been distressing, offer the interpreter support and let their manager know.

Written information

  • If interpreting written information, read it out loud. The interpreter may not necessarily be able to translate written language as easily.

  • Many departments and charities provide some written information in a variety of languages—some also provide tapes. You should be aware of what your department has to offer.

Communicating with deaf patients

People who are hard of hearing may cope with the problem by using a hearing-aid, lip-reading, or using sign language. Whichever technique is used (if any), some simple rules should always apply:

  • Speak clearly but not too slowly.

  • Don’t repeat a sentence if it is misunderstood—say the same thing in a different way.

  • Write things down if necessary.

  • Use plain English and avoid waffling.

  • Be patient and take the time to communicate properly.

  • Check understanding frequently.

  • Consider finding an amplifier—many elderly medicine wards will have one available.

Lip-readers

Patients who are able to lip-read do so by looking at the normal movements of your lips and face during speech. Exaggerating movements or speaking loudly will distort these and make it harder for them to understand. In addition to the points already mentioned, when talking to lip-readers:

  • Maintain eye-contact.

  • Don’t shout.

  • Speak clearly but not too slowly.

  • Do not exaggerate your oral or facial movements.

British Sign Language (BSL)

  • It should be appreciated that BSL is not a signed version of English—it is a distinct language with its own grammar and syntax.

  • For BSL users, English is a 2nd or 3rd language so using a pen and paper may not be effective or safe for discussing complex topics or gaining consent.

  • Seek an official BSL interpreter, if possible, and follow the rules on working with interpreters.

Telephone communication

The essential rule of confidentiality is that you must not impart personal information to anyone without the express permission of the patient concerned—except in a few specific circumstances.

  • You must not give out any confidential information over the telephone as you cannot be sure of the identity of the caller. All communication should be done face-to-face. This may cause difficulty if a relative calls to ask about the patient, but you should remain strict.

  • If telephone communication is essential but you are in doubt as to the caller’s identity, you may wish to take their number and call them back.

SBAR

SBAR was created as an easy to remember mechanism to frame conversations and install some uniformity into telephone communication, particularly those requiring a clinician’s immediate attention and action. There are 4 sections to help you order the information with the right level of detail and reduce repetition.

S: Situation

  • Identify yourself (name and designation) and where you are calling from.

  • Identify the patient by name and the reason you are calling.

  • Describe your concern in one sentence.

Include vital signs where appropriate.

B: Background

  • State the admission diagnosis and date.

  • Explain the background to the current problem.

  • Describe any relevant treatment so far.

You should have collected information from the patient’s charts, notes, and drug card and have this at your fingertips. Include current medication, allergies, pertinent laboratory results, and other diagnostic tests.

A: Assessment

  • State your assessment of the patient including vital signs, early warning score (EWS), if relevant, and your overall clinical impression and concerns.

You should have considered what might be the underlying reason for the patient’s current condition.

R: Recommendation

  • ‘I think the problem is...’.

  • Explain what you need and the time-frame in which you need it.

  • Make suggestions and clarify expectations.

  • ‘Is there anything else I should do?’

  • Communication skills Record the name and contact details of the person you have been speaking to.

  • Communication skills Record the details of the conversation in the patient’s notes.

Other specific situations

Talking about sex

This is a cause of considerable embarrassment for the patient and for the inexperienced professional. Sexual questions are usually inappropriate to be overheard by friends or relatives—so ask them to leave. Your aim is to put the patient at ease and make their responses more forthcoming.

  • The key is to ask direct, clear questions and show no embarrassment yourself.

  • You should maintain eye-contact.

  • You should also show no surprise whatsoever—even if the sexual practices described differ from your own or those that you would consider acceptable.

  • Try to become au fait with sexual slang and sexual practices which you might not be familiar with previously.

    • A failure to understand slang may lead to an immediate barrier in the consultation.

  • In general, you should not use slang terms first. You may wish to consider mirroring the patient’s speech as you continue the conversation.

Angry patients

Use body language to take charge of the situation without appearing aggressive. Throughout the exchange, you should remain polite, avoiding confrontation, and resist becoming angry yourself.

  • Look to your own safety first.

  • Calm the situation then establish the facts of the case. Anger is often secondary to some other emotion such as loss, fear, or guilt.

  • Acknowledge their emotions.

    • ‘I can see this has made you angry’

    • ‘It’s understandable that you should feel like this.’

  • Steer the conversation away from the area of unhappiness towards the positive and plans to move the situation forward.

  • Don’t incriminate colleagues—the patients may remember your throw-away comments which could come back to haunt you. Avoid remarks like ‘he shouldn’t have done that’.

  • Emphasize any grounds for optimism, or plans for resolving the situation and putting things right.

Breaking bad news

Breaking bad news is feared by students and, indeed, no-one likes doing it. However, knowing that you have broken difficult news in a sensitive way and that you have helped the patient through a terrible experience can be one of the most uplifting aspects of working in healthcare.

Before you start

  • Confirm all the information for yourself and ensure that you have all the information to hand, if necessary.

  • Speak to the nursing staff to get background information on what the patient knows, their fears, and details of the relationship with any family or friends who may be present.

Choose the right place

  • Pick a quiet, private room where you won’t be disturbed.

  • Ensure there is no intervening desk or other piece of furniture.

  • Arrange the chairs so that everyone can be seen equally.

  • Hand your bleep/mobile phone to a colleague.

Ensure the right people are present

  • Invite a member of the nursing staff to join you—particularly if they have already established a relationship with the patient.

    • Remember, it is usually the nursing staff that will be dealing with the patient and relatives when you have left so they need to know exactly what was said.

  • Would the patient like anyone present?

Establish previous knowledge

It is essential to understand what the patient already knows. The situation is very different in the case of a patient who knows that you have been looking for cancer to one who thinks their cough is due to a cold.

How much do they want to know?

This is key! Before you consider breaking bad news, you have to discover if the patient actually wants to hear it.

  • Ask an open question such as:

    • ‘What do you know so far?’

    • ‘What have the other doctors/nurses told you?’

  • You can also ask directly if they want to hear bad news. Say:

    • ‘Are you the sort of person who likes to know all the available facts and details or would you rather a short version?’

Honesty, above all else

  • Above all, you should be honest at all times. Never guess or lie.

  • The patient may break your pre-prepared flow of information requiring you to think on your feet. Sometimes you simply can’t stick to the rules above. If asked a direct question, you must be honest and straightforward.

Warning shots

You should break the news step-wise, delivering multiple ‘warning shots’. This gives the patient a chance to stop you if they’ve heard enough, or to ask for more information. Keep your sentences short, clear, and simple.

You could start by saying that the test results show things are more ‘serious’ than first thought and wait to see their reaction. If they ask what you mean, you can tell them more, and so on.

Communication skills Inexperienced practitioners sometimes feel that they ‘ought’ to tell the patient the full story but they must understand that many people would much rather not hear the words said aloud—this is their coping strategy and must be respected.

Allow time for information to sink in

You should allow time for each piece of information to sink in, ensure that the patient understands all that has been said, and repeat any important information.

Remember also that patients will not be able to remember the exact details of what you have said—you may need to reschedule at a later time to talk about treatment options or prognosis.

Don’t rush to the positive

When told of bad news, the patient needs a few moments to let the information sink in. Wait in silence for the patient to speak next.

The patient may break down in tears—in which case they should be offered tissues and the support of relatives, if nearby.

If emotionally distressed, the patient will not be receptive to what you say next—you may want to give them some time alone with a relative or nurse before you continue to talk about prognosis or treatment options.

Above all, you should not give false hope. The moment after the bad news has been broken is uncomfortable and you must fight the instinctive move to the positive with ‘there are things we can do’, ‘on the plus side...’, ‘the good news is...’, or similar.

Questions about time

‘How long have I got?’ is one of the most common questions to be asked—and the hardest to answer.

  • As always, don’t guess and don’t lie.

  • It’s often impossible to estimate and is perfectly acceptable to say so. Giving a figure will almost always lead to you being wrong.

  • Explain that it is impossible to judge and ask if there is any date in particular that they don’t want to miss—perhaps they want to experience Christmas or a relative’s birthday.

Ending the conversation

Summarize the information given, check their understanding, repeat any information as necessary, allow time for questions, and make arrangements for a follow-up appointment or a further opportunity to ask questions again.

Obviously, you shouldn’t make promises that you can’t keep. Don’t offer to come back that afternoon if you’re going to be in clinic!

Law, ethics, and consent

No discussion of communication skills would be complete without mention of confidentiality, capacity, and consent. It is also worth knowing the four bioethical principles about which much has been written elsewhere.

Four bioethical principles

  • Autonomy: a respect for the individual and their ability to make decisions regarding their own health.

  • Beneficence: acting to the benefit of patients.

  • Non-maleficence: acting to prevent harm to the patient.

  • Justice: ‘fairness’ to the patient and the wider community when considering the consequences of an action.

Confidentiality

Confidentiality is closely linked to the ethical principles described above. Maintaining a secret record of personal information shows respect for the individual’s autonomy and their right to control their own information. There is also an element of beneficence where releasing the protected information may cause harm.

Breaking confidentiality

The rules surrounding the maintenance of confidentiality have been mentioned. There are a number of circumstances where confidentiality can, or must, be broken. The exact advice varies slightly between different bodies. See the links under ‘further reading’. In general, confidentiality may be broken in the following situations:

  • With the consent of the individual concerned.

  • If disclosure is in the patient’s interest but consent cannot be gained.

  • If required by law.

  • When there is a statutory duty such as reporting of births, deaths, and abortions and in cases of certain communicable diseases.

  • If it is overwhelmingly in the public interest.

  • If it is necessary for national security or where prevention or detection of a crime may be prejudiced or delayed.

  • In certain situations related to medical research.

Consent and capacity

There are three main components to valid consent. To be competent (or have capacity) to give consent, the patient:

  • Must understand the information that has been given.

  • Must believe that information.

  • Must be able to retain and weigh-up the information.

In addition, for consent to be valid, the patient must be free from any kind of duress.

Communication skills It should be noted that an assessment of capacity is valid for the specific decision in hand. It is not an all-or-nothing phenomenon—you cannot either have ‘capacity’ or not. The assessment regarding competence must be made for each new decision faced.

Young people and capacity

  • All persons aged 18 and over are considered to be a competent adult unless there is evidence to the contrary.

  • People aged between 16 and 18 are treated as adults (Family Law Reform Act 1969). However, the refusal of a treatment can be overridden by someone with parental responsibility or the courts.

  • Children of 16 and younger are considered competent to give consent if they meet the three conditions mentioned previously. Their decisions can be, however, overridden by the courts or people with parental responsibility.

Gillick competence

In 1985, the well-known Gillick case was considered by the House of Lords and from this two principles (often known as the Fraser Guidelines) were established:

  • A parent’s right to consent to treatment on behalf of the child finishes when the child has sufficient understanding to give consent themselves (when they become ‘Gillick competent’).

  • The decision as to whether the child is Gillick competent rests with the treating doctor.

Powers of attorney

People lacking mental capacity may need someone to manage their legal, financial, and health affairs. This is done through power of attorney as laid out in the Mental Capacity Act 2005.

Enduring powers of attorney (EPA)

Before 2007, people could grant EPA so a trusted person could manage their finances. Those with EPA do not have the right to make other decisions on a person’s behalf.

Lasting powers of attorney (LPA)

Property and affairs LPA

Those with property and affairs LPA can make decisions regarding paying bills, collecting income and benefits, and selling property, subject to any restrictions or conditions the patient may have included.

Personal welfare LPA

This allows the ‘attorney’ to make decisions relating to living situation and other personal care. They can also make medical decisions if this power has been expressly given in the LPA.

Further reading

There are many other complex topics in this area and the law varies between countries and even between regions within the UK. We suggest the following as a good start:

Notes:

* Watch the first few minutes of the 1998 film ‘Primary Colors’ which demonstrates the different uses of touch during handshakes.