Communication as a tool in clinical practice

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    Failure of communication between the doctor and the patient/next of kin is a frequent cause of complaints. Good communication, on the other hand, is a source of patient satisfaction, better health for the patient and self-efficacy in the doctor. How can the training in communication skills for doctors be facilitated? Diakonhjemmet Hospital has chosen to introduce mandatory training courses in clinical communication for all newly employed doctors. In this article we will describe the course, its implementation and the experience gained from it.

    Today’s patients are active participants in their own treatment. With defined rights, backed by strong user organisations and better access to knowledge about their own disease, patients today have far better preconditions for participating actively in their own treatment. This new patient role requires a reorientation of the doctor’s role as well, with more emphasis on communication and interaction skills, and such skills must be trained and maintained through practice.

    The current situation with regard to diseases, with a growing number of cases of chronic illness, implies a number of new challenges not only for the patient, but also for the health services. The patients’ ability to take care of their own health, perhaps also to be their own therapist, such as in the case of diabetes, is crucial for quality of life and prognosis. This means that we should turn our attention not only to the suffering body, but also to the person who is in charge of it. We need to see what he or she needs in order to follow up the treatment, perhaps by changing his or her lifestyle and starting to exercise. To succeed in this, communication is a good tool. Good communication with the patient results in fewer complaints (1), better patient satisfaction and compliance (2) and better treatment, coping and health (3, 4).

    Through its Clinical Health Psychology Project, supported by the ExtraStiftelsen Health and Rehabilitation Trust and the Directorate of Health, Diakonhjemmet Hospital has been able to provide training courses in clinical communication for doctors. In this article we will describe the efforts in implementing the communication course «Four Habits» in a busy hospital setting.

    Four Habits

    Four Habits

    The training course is based on the US health organisation Kaiser Permanente’s «Four Habits» model (5), and has been adapted to Norwegian conditions by a team headed by Professor Pål Gulbrandsen (6). The teaching programme has been tested in a randomised study at Akershus University Hospital (7). The study showed a change in the doctors’ behaviour towards communicating more in line with the four good habits. The improvement was reflected in patient satisfaction as well as in the doctors’ perception of self-efficacy. The training course is based on the idea that practising simple, basic skills improves the effectiveness of the consultation. The four good habits are: Invest in the beginning, explore the patient’s perspective, demonstrate empathy and invest in the end.

    The first habit involves building trust by being polite, present and facing the patient while obtaining an overview of the health problem that the patient presents. The doctor starts by asking open-ended questions to elicit the patient’s concerns and, together with the patient, establishes an agenda that provides a framework for the consultation and the matters to be prioritised. Here, it is essential to clarify the expectations that the patient has for the consultation.

    The second habit concerns exploring the patient’s notions, ideas and interpretations of his or her health problem, and attempting to clarify how this interferes with daily activities. The doctor must ask specifically about the patient’s ideas and how he or she understands the cause of the affliction. Questions could also include the ideas of the next of kin, irrespective of whether these are present or not.

    The third habit concerns demonstrating empathy and being emotionally present, exploring the patient’s emotions and using words and body language to validate the patient’s experience. The doctor must look and listen for the patient’s emotions and spoken or non-spoken hints. This requires eye contact and attentiveness to one’s own emotional reactions.

    The fourth good habit includes seeking to provide relevant information, involving the patient in decisions and finding out any possible obstacles to compliance. This includes explaining the reason for taking various tests, possible adverse effects and verifying that the patient has understood the information, which may present a challenge in case of serious illness and a poor prognosis. This final habit involves recognising the patient’s own resources. After all, the patient is the one who needs to comply with the treatment, possibly involving a change of lifestyle, a change in habits, keeping motivation up and coping with everyday life. A recognition on the part of the doctor of this challenge and the patient’s resources to cope with it promotes compliance with the advice provided.

    A comprehensive review of the research literature concludes that communication training must include independent activity with feedback over at least one full day in order to have any effect (8), while a review of communication training in oncology recommends three days (or more) to ensure a change in the participants’ behaviour (9).

    Experience from the model

    Experience from the model

    At Diakonhjemmet Hospital, the «Four Habits» training courses have been arranged once each semester since 2012, and four course sessions have been held so far. The course instructors have undergone a two-day training programme, and a specialist in psychology/psychiatry and a senior consultant share the management responsibility for each group. Feedback from participants indicates that the training course is perceived as useful and as providing concrete tools for use in everyday practice. The emphasis on clinical communication fits well into the hospital’s long-term efforts with regard to values, quality and patient safety. The close association with the hospital’s values, and not least the support provided by the director and the management group, have proven crucial. In addition, the use of local course instructors and the relevance for clinical work have been key factors. All the hospital’s three clinical departments have provided a senior consultant to act as course instructor. The course content also keeps circulating between the sessions when instructors and participants meet in the hospital corridors and work together on a daily basis. This ensures another kind of ownership to the topic of communication than would have been the case had the training courses come in the form of a «product» purchased from an external supplier.

    Other important factors are that the course has been previously tested in another Norwegian hospital with documented effect, and that the course is specially adapted to doctors. An application has been submitted for the course to earn merit, with optional sessions for the specialties in question. The training in communication skills has been based on well-known doctor-patient encounters, partly drawn from personal experience. We believe that this promotes the experience of its relevance and benefits for everyday practice. The implementation in clinical practice is an ongoing and challenging task. Diakonhjemmet Hospital has chosen to give priority to communication by continuing to provide the «Four Habits» training course to its doctors while also expanding it to interdisciplinary courses.


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