Skills for communicating with patients

317 Pages·2013·3.09 MB·English

by  Juliet Draper, Suzanne M. Kurtz, Jonathan Silverman

Skills for
Communicating
with Patients

Third Edition

Jonathan Silverman
Suzanne Kurtz
Juliet Draper

Forewords by Professor Myriam Deveugele
and Dr Anthony L Suchman

NEW AND UPDATED
EDITION
Skills for Communicating with Patients, Third Edition is one of two companion books on
improving communication in medicine which together provide a comprehensive approach
to teaching and learning communication skills throughout all levels of medical education in
both specialist and family medicine. Since their publication, the first edition of this book
and its companion, Teaching and Learning Communication Skills in Medicine, have become
established standard texts in communication skills teaching throughout the world.

This substantially expanded third edition has been fully updated in relation to the current
literature and revised to reflect the explosion of research on healthcare communication
since the second edition was published in 2005. It incorporates considerable evidence
in support of the skills of the Calgary–Cambridge Guides, offering a comprehensive and
now even more evidence-based delineation of the skills that make a difference when
communicating with patients.

It explores the specific skills of doctor–patient communication and provides wide-ranging
evidence of the improvement that those skills can make to health outcomes and everyday
clinical practice. It is unique in providing a secure platform of core skills which represent
the foundations of doctor–patient communication.

Skills for Communicating with Patients is essential reading for learners and healthcare
professionals at all levels.

‘Skills for Communicating with Patients is an outstanding resource in which clinicians
in any health profession and at any level of experience can find insights to help them
advance their communication competence. It offers very specific, practical descriptions
of communication techniques and the evidence base in which they are grounded... While
Skills for Communicating with Patients focuses on dyadic interactions between patients
and clinicians the communication skills it describes apply equally well to any kind of
collaboration: conducting rounds, exploring a disagreement with a colleague, or developing a
process improvement plan.’ From the Foreword by Anthony L Suchman

‘The importance of this skills-based consultation model cannot be overstressed. The
Calgary–Cambridge Guides describe the core skills useful for all learners and teachers in
medical sciences, for all levels of education, for specialists as well as for family doctors. These
skills are useful in all conditions.’ From the Foreword by Myriam Deveugele

Other bOOkS OF reLAteD intereSt

Teaching and Learning Communication Skills in Medicine, Second Edition

Suzanne Kurtz, Jonathan Silverman and Juliet Draper

Patient-Centered Medicine: Transforming the Clinical Method, Third Edition

Edited by Moira Stewart, Judith Belle Brown, W Wayne Weston, Ian R McWhinney,
Carol L McWilliam and Thomas R Freeman

Communication Skills in Mental Health Care: an introduction

Edited by Xavier Coll, Alexia Papageorgiou, Ann Stanley and Andrew Tarbuck

Skills for Communicating with Patients
Silverman Kurtz Draper
Third
Edition

Skills for Communicating with Patients

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Skills for Communicating
with Patients

Third Edition

Jonathan Silverman
Associate Clinical Dean and Director of Communication Studies
School of Clinical Medicine, University of Cambridge, UK
President- elect, European Association for Communication in Healthcare

Suzanne Kurtz
Professor Emerita
University of Calgary, Alberta, Canada
Clinical Professor and Director of the Clinical Communication Program
College of Veterinary Medicine, Washington State University, US

and

Juliet Draper
Retired General Practitioner
Past Director, Eastern Deanery Cascade Communication Skills Teaching Project, UK

Forewords by
Professor Myriam Deveugele
Professor in Communication in Health Care
Department of Family Medicine and Primary Health Care, Ghent University, Belgium
President, European Association for Communication in Healthcare

and

Anthony L Suchman MD, MA
Organisational Consultant, McArdle Ramerman Center
Clinical Professor of Medicine,
University of Rochester School of Medicine and Dentistry,
Rochester, NY, US

CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742

© 2013 by Jonathan Silverman, Suzanne Kurtz and Juliet Draper
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Version Date: 20160307

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Contents

Foreword by Myriam Deveugele
vi
Foreword by Anthony L Suchman
viii
Preface to the third edition
x
Preface to the second edition
xi
About this book
xv
About the authors
xvi
Acknowledgements
xvii

Introduction
1

1
Defi ning what to teach and learn: an overview of the
communication skills curriculum
7
Introduction
7
More effective consultations
8
Improved health outcomes
8
A collaborative partnership
9
Plan of chapter
10
Types of communication skills and how they interrelate
10
The problem of separating content and process skills in
teaching and learning about the medical interview
12
An overall curriculum of doctor–patient communication skills
14
The Calgary–Cambridge Guide
14
The enhanced Calgary–Cambridge Guides
16
The need for a clear overall structure
27
Choosing the process skills to include in the communication
curriculum
29
The research and theoretical basis that validates the inclusion
of each individual skill
30
Underlying goals and principles of communication that
helped in choosing the skills
31
Skills and individuality
32
Relating specifi c issues to core communication skills
33
Summary
34

2
Initiating the session
35
Introduction
35
Problems in communication
35
Objectives
36
Skills
37

iv Contents

‘What’ to teach and learn about the initiation: the evidence for
the skills
38
Preparation
38
Establishing initial rapport
39
Identifying the reason(s) for the consultation
42
Summary
57

3
Gathering information
59
Introduction
59
Problems in communication
59
Objectives
61
The content of information gathering in medical interviews
62
The traditional medical history
62
The disease–illness model
64
An alternative template for the content of the information-
gathering section of the interview
69
The process skills of information gathering
72
Exploration of the patient’s problems
73
Additional skills for understanding the patient’s perspective
88
Putting the process skills of information gathering together
101
The complete versus the focused history in information gathering
103
The effect of clinical reasoning on the process of information
gathering
106
Summary
108

4
Providing structure to the interview
109
Introduction
109
Objectives
110
Skills
111
‘What’ to teach and learn about providing structure: the evidence
for the skills
112
Making organisation overt
112
Attending to fl ow
117
Summary
118

5
Building the relationship
119
Introduction
119
Problems in communication
122
Objectives
123
Skills
124
‘What’ to teach and learn about building the relationship: the
evidence for the skills
125
Using appropriate non- verbal communication
125
Developing rapport
133
Involving the patient
146
Summary
148

Contents v

6
Explanation and planning
149
Introduction
149
Problems in communication
149
Objectives
155
The content of explanation and planning
156
The process skills of explanation and planning
157
Providing the correct amount and type of information
161
Aiding accurate recall and understanding
171
Achieving a shared understanding – incorporating the
patient’s perspective
177
Planning – shared decision making
188
Options in explanation and planning
207
Summary: explanation and planning is an interactive process
213

7
Closing the session
215
Introduction
215
Objectives
215
The process skills for closing the session
216
‘What’ to teach and learn about endings: the evidence for the skills 217
Summary
221

8
Relating specifi c issues to core communication skills
223
Introduction
223
Specifi c issues
224
Breaking bad news
224
Cultural and social diversity
233
Age- related issues
240
– communicating with older patients
241
– communicating with children and parents
244
The telephone interview
248
Patients with mental illness
251
Medically unexplained symptoms
259
Other communication issues
260
Further reading
261

References
263
Index
295
Author index
302

Foreword by Myriam Deveugele

There used to be a time when medical professionals were at the centre of care.
The professionals, mostly doctors, undertook the history taking and investiga-
tion from their own point of view, in order to make a diagnosis. They told the
patient what to do, how and when. Healthcare providers hoped or believed that
the patient would follow their instructions. And if the patient was not relieved of
the symptoms or if the disease could not be cured, it was thought to be due to the
patient’s poor compliance. Is this a caricature or an old- fashioned view? Of course
it is. Even in ancient times medical professionals tried to do the best they could to
help the patient.
Nevertheless times have changed. Research on provider–patient communica-
tion reveals that the patient is an important co- player in the medical consultation.
He or she is the ‘expert’ and best placed to tell about his or her body functioning,
about the complaint, about the reason for looking for help. Therefore terms such
as ‘patient/person/people- centred care’ are adopted, even by important bodies
such as the WHO. We know that effective communication has important benefi ts
for both patient and caregivers. You can fi nd a research overview on this topic in
the fi rst chapter.
Moreover, people live longer and as a consequence have more co- morbidity
and suffer more from diseases that often cannot be cured. Quality of life becomes
more and more a core issue in health sciences. If a serious condition cannot be
ameliorated, the patient is the only one who can give an idea of his or her most
important wishes for the remaining time. If a medical professional has to deal with
a patient who has two or more health issues for which the ordinary treatments
are contradictory, the only person able to help is the patient. At that moment the
best way to handle this problem is to listen to the patient, to his or her wishes, to
make decisions on what and how to treat together with the patient.
These new insights need a changing attitude from all players in the medical fi eld,
patients and healthcare professionals. The patients have more responsibility, have
to be more prepared before entering the consultation and have to be willing to
engage in the conversation. The caregiver needs to establish a good relationship,
to be able to listen, to discover the reason(s) for the encounter, to give informa-
tion and to discuss and share the decision making with both patients and other
healthcare providers, in combination with good medical reasoning and medical
technical skills.
Since healthcare professionals have always demonstrated their compassion and
care for the patient, one could argue that these insights, attitudes and behaviours
will easily be achieved. As a consequence, a book on ‘skills for communicating with
patients’ would then be unnecessary. We all know that this premise is incorrect
– attitude and behaviour change do not follow automatically out of knowledge.
Change needs training. Communication is more than being nice, communication
deals with core skills that need to be learned.
Therefore, I am happy that Jonathan Silverman, Suzanne Kurtz and Julie

Foreword by Myriam Deveugele vii

Dr aper have made the effort to publish a third edition of their very important book
on communication skills. Although the Calgary–Cambridge Guides and the two
companion books describing their approach (this book and Teaching and Learning
Communication Skills in Medicine) were already established as standard texts in many
medical curricula and were referred to as ‘the fi rst entirely evidence- based text-
book on medical interviewing’, this third edition incorporates the latest research
on medical communication. This resulted in, on the one hand, added evidence
and on the other some changes to the application of skills themselves, especially
shared decision making, risk communication and health literacy, all topics gaining
in importance and receiving more attention.
The importance of this skills- based consultation model cannot be overstressed.
The Calgary–Cambridge Guides describe the core skills useful for all learners and
teachers in medical sciences, for all levels of education, for specialists as well as for
family doctors. These skills are useful in all conditions. Core skills pertain in dif-
fi cult and challenging circumstances although it might be necessary to use them
with greater intensity and awareness.
The book you have in your hands gives an answer to the challenge healthcare
providers encounter when conducting accurate, effective and effi cient medical
consultations.
I wish you as much pleasure in reading this important work as I had myself.

Myriam Deveugele
Professor in Communication in Health Care
Department of Family Medicine and Primary Health Care,
Ghent University, Belgium
President, European Association for Communication in Healthcare
July 2013

Foreword by Anthony L Suchman

Nothing in healthcare is more important than good communication.
Healthcare is by defi nition interpersonal – one person seeking care from another.
Without good communication, healthcare is at best wasteful and at worst dan-
gerous. Everything depends upon the degree to which the patient and clinician
understand each other accurately, develop a shared understanding of the patient’s
illness and commit to work together on a course of treatment.
We’re not talking about good bedside manner here, a quaint term that connotes
a nice but optional fl ourish. We’re talking about clinical outcomes. Every bit of
biomedical technology (the hard stuff) must be deployed within a social context
of effective communication and relationships (the soft stuff) if it is to be safe and
successful. There are no exceptions. The time of disdaining communication skills
as ‘touchy feely’ is over. Communication competence is a critical component of
clinical competence, and the commitment to assess and improve one’s communi-
cation competence is a core element of professionalism.
Skills for Communicating with Patients is an outstanding resource in which clini-
cians in any health profession and at any level of experience can fi nd insights to
help them advance their communication competence. It offers very specifi c, prac-
tical descriptions of communication techniques and the evidence base in which
they are grounded.
The methods described here will make you a better practitioner. They will also
add to the quality and satisfaction of your professional life. For example, to cite
one of my own personal favorites, a technique called screening, described on p. 52
ff, helps me elicit the patient’s full agenda early in the visit, before I’ve committed
all our time to the very fi rst issue mentioned, which often is not the most impor-
tant one. This is the single most powerful tool I possess for staying on schedule
and avoiding the stress of running late. Another of my favorites is the approach to
breaking bad news. Before I had any skills, I feared such situations, felt incompe-
tent, rushed through them and undoubtedly added to my patients’ suffering. But
now, equipped with the principles and skills described on p. 224 ff, I know what
to do, so I can be calmly present to my patients during a time of great need. I can
be of much greater service and a previously dreaded situation is now a source of
great meaning.
While Skills for Communicating with Patients focuses on dyadic interactions between
patients and clinicians the communication skills it describes apply equally well to
any kind of collaboration: conducting rounds, exploring a disagreement with a col-
league, or developing a process improvement plan. Attending to content and process,
to task and relationship are essential skills for success in this age of system- based
care. Individuals, teams and even organizations must manage their interdepend-
ence better than they ever have before if they are to implement new models of care,
interprofessional education and translational science. It’s all about relationships.
For the clarity, timeliness and intellectual rigor of this book, the authors, Jonathan
Silverman, Suzanne Kurtz and Julie Draper, deserve our deep appreciation. The

Foreword by Anthony L Suchman ix

appearance of the third edition – a spectacular sign of success – is an opportunity
to celebrate their achievement, their ongoing dedication and their enormous con-
tribution to the fi eld of healthcare communication.

Anthony L Suchman MD, MA
Organisational Consultant,
McArdle Ramerman Center
Clinical Professor of Medicine,
University of Rochester School of Medicine and Dentistry,
Rochester, NY, US
July 2013

Preface to the third edition

Skills for Communicating with Patients is one of a set of two companion books on
improving communication in medicine that together provide a comprehensive
approach to teaching and learning communication throughout all three levels of
medical education (undergraduate, residency and continuing medical education)
and in both specialist and family medicine. Since their fi rst publication in 1998, this
book and its companion, Teaching and Learning Communication Skills in Medicine, have
become established as standard texts in communication skills teaching throughout
the world, ‘the fi rst entirely evidence- based textbook on medical interviewing’
(Suchman 2003). For notifi cation of digital developments relating to both books,
please refer to www.radcliffehealth.com.
Since we wrote the second edition in 2005, there has been a considerable
and sustained increase in research on healthcare communication, with approxi-
mately 400 papers per year listed on Medline on physician–patient relations and
communication. In this edition, we have attempted to fully update our text to
incorporate the research evidence that has accumulated during the last eight years.
Updating the literature has added considerable evidence in support of the skills of
the Calgary–Cambridge Guides but has resulted in very few changes to the skills
themselves. The guides, which hold a central position in both books, continue to
offer a comprehensive and now even more evidence- based delineation of the skills
that make a difference in communicating with patients. We have not redesigned
the structure of the book, which remains very similar to the second edition and is
described in detail in our earlier Preface.
Much of the research evidence over the last few years has related to the bur-
geoning fi elds of shared decision making, explanation of risk and health literacy.
This is refl ected in Chapter 6 (‘Explanation and planning’) having the most new
references added. However, we have incorporated new research into all chapters
in this book and we hope this will enable learners and teachers to fully under-
stand the evidence base behind contemporary medical interviewing and health
communication.

Jonathan Silverman
Suzanne Kurtz
Juliet Draper
July 2013

Preface to the second edition

In producing the second editions of both evidence- based books, we seek to refl ect
developments and changes since the 1998 editions were published regarding:

●
research on communication in healthcare

●
theoretical and conceptual approaches to communication in healthcare

●
medical and educational practices

●
healthcare systems and other contexts where health communication occurs.

There have been enormous advances in the fi eld of communication skills teaching
in the last six years. Communication programmes have become a part of main-
stream education at all levels of medical training and in many countries. Certifying
summative assessment of communication skills has become an established com-
ponent of many undergraduate curricula and residency training programmes,
both locally and nationally. There has been increasing development of courses for
faculty in communication skills teaching. And there continues to be an explosion
of research in this arena, with over 2000 papers listed on Medline on physician–
patient relations and medical education with respect to communication over the
last six years.
The second editions of these two books refl ect all of these developments. We
have updated both books in relation to the current burgeoning research evidence
and to changes in teaching and assessment practices. We have of course also been
developing our own teaching over the last six years and have included many ideas
that have been borne of that experience.
This labour of love has had many benefi ts for the authors of these books. We
have learned much from professional colleagues, both in writing and in person,
and we have benefi ted greatly from suggestions and ideas from our readers. We
have enjoyed immensely the opportunity to refl ect on our teaching approaches
and consider the evidential base again. We have valued the chance to consider,
conceptualise and formalise our varying experiences over the last few years. We
hope that our readers enjoy the fi nal product as much as we have constructing it.
Here, we would like to explain the rationale for the two books and briefl y outline
the changes we have made to the second editions. In the fi rst edition of our com-
panion book, Teaching and Learning Communication Skills in Medicine, we examined
how to construct a communication skills curriculum, documented the individual
skills that form the core content of communication skills teaching programmes
and explored in depth the specifi c teaching and learning methods employed in this
unique fi eld of medical education. Our fi rst book presented:

●
an overall rationale for communication skills teaching – the ‘why’, the ‘what’
and the ‘how’ of teaching and learning communication skills in medicine

●
the individual skills that constitute effective doctor–patient communication

●
a systematic approach for presenting, learning and using these skills in practice

xii Preface to the second edition

●
a detailed description of appropriate teaching and learning methods, including:
–
innovative approaches to analysis and feedback in experiential teaching
sessions
–
key facilitation skills that maximise participation and learning

●
principles, concepts and research evidence that substantiate the specifi c teach-
ing methods used in communication skills programmes

●
strategies for constructing a communication skills curriculum in practice.

In the second edition of our companion book, we have:

●
fully updated the research evidence throughout the book

●
rewritten Chapter 2 to incorporate a new enhanced version of the Calgary–
Cambridge Guides that was introduced in 2003 (Kurtz et al. 2003) (these new
guides form the centrepiece of both of our second editions; the original Calgary–
Cambridge Guides were developed to delineate effective physician–patient
communication skills and provide an evidence- based structure for the analysis
and teaching of these skills in the medical interview; the enhanced versions
more explicitly delineate the content and process of medical communication,
promoting a comprehensive clinical method that explicitly integrates traditional
clinical method with effective communication skills)

●
considerably expanded our discussion of the value and use of simulated patients
in Chapter 4

●
redesigned Chapters 5 and 6 to enable a more comprehensive discussion of the
analysis and feedback of communication skills and the strategies for facilitating
experiential teaching sessions in different learning contexts

●
amplifi ed our discussion of curriculum and programme development across all
levels of medical education, fi rst describing common elements that run across
curricula in Chapter 9, and then offering specifi c strategies for communication
teaching and learning at the different levels of medical education in Chapter 10;
given the wide- ranging and burgeoning changes regarding communication
teaching at the residency level, we have specifi cally included a number of cur-
riculum and programme suggestions that have been implemented in specialist
and primary care residency programmes

●
provided a new expanded chapter on the increasingly important fi eld of assess-
ment of communication skills (Chapter 11)

●
included a new chapter on facilitator training and faculty development which
expands our discussion of this important topic (Chapter 12)

●
expanded our vision of where communication training is headed next
(Chapter 13).

The fi rst edition of our second book, Skills for Communicating with Patients, undertook
a more detailed exploration of the specifi c skills of doctor–patient communication.
We not only examined how to use these skills in the medical interview, but also
provided comprehensive evidence of the improvements that communication skills
can make both to everyday clinical practice and to ensuing health outcomes. The
fi rst edition presented:

●
the individual skills that form the core content of communication skills teach-
ing programmes

Preface to the second edition xiii

●
an overall structure to the consultation which helps to organise the skills and
our teaching and learning about them

●
a detailed description of and rationale for the use of each of these core skills in
the medical interview

●
principles, concepts and research evidence that validate the importance of the
skills and document the potential gains for doctors and patients alike

●
suggestions on how to use each skill in practice

●
a discussion of the major role that these core communication skills play in tack-
ling specifi c communication issues and challenges.

In the second edition of this book, we have:

●
fully updated the research evidence throughout the book

●
redesigned the structure of the book and each individual chapter to incorporate
an enhanced version of the Calgary–Cambridge Guides that was introduced in
2003 (Kurtz et al. 2003), described in detail in Chapter 1

●
ensured that the entire book now describes a comprehensive clinical method,
explicitly integrating traditional clinical method with effective communication
skills

●
expanded Chapter 3 (‘Gathering Information’) to consider both the content and
the process skills of information gathering, the complete vs. the focused history
and the effect of clinical reasoning on communication process skills

●
separated the material on structuring the interview into a separate chapter
(Chapter 4), rather than a subsection of information gathering, and concep-
tualised it as a continuous thread running throughout the interview just like
relationship building

●
added to our consideration of relationship building in Chapter 5 the need to
enhance relationships and co- ordination within healthcare organisations and
with communities, as well as between patients and clinicians

●
deepened the exploration in Chapter 6 (‘Explanation and Planning’) of the
increasingly important and linked issues of shared decision making, concord-
ance and explanation of risk

●
explored in more detail in Chapter 8 how to approach specifi c communication
issues in the medical interview and their relationship to the core process skills
of the Calgary–Cambridge Guides.

We encourage our readers to study both volumes. While at fi rst glance, it would
appear that this volume might be exclusively for learners, and our companion vol-
ume exclusively for teachers, this is far from our intention.

●
Facilitators need as much help with ‘what’ to teach as with ‘how’ to teach. We
demonstrate how in- depth knowledge of the use of communication skills and
of the accompanying research evidence is essential if facilitators wish to max-
imise learning in their experiential teaching sessions.

●
Learners need to understand ‘how’ to learn as well as ‘what’ to learn.
Understanding the principles of communication skills teaching will enable
learners to maximise their own learning throughout the communication cur-
riculum, improve their own participation in that learning, understand the value

xiv Preface to the second edition

of observation and rehearsal, provide constructive feedback and contribute to
the formation of a supportive climate.

In communication skills teaching there is a fi ne line between teachers and learn-
ers. Teachers will continue to make discoveries about communication throughout
their professional lives and to learn from their students. Learners not only teach
their peers but also soon become the communication skills teachers of the next
generation of doctors, whether formally, informally or as role models. No doctor
can escape this responsibility.

Jonathan Silverman
Suzanne Kurtz
Juliet Draper
September 2004