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).