Communication

Skills
in Clinical Practice
By
Dr P.N. Karimi
Objectives
At the end of the lecture the Learner should be able to describe:
1. C-L-A-S-S A protocol for all medical interviews.
2. S-P-I-K-E-S A protocol for breaking bad news to patients and family
members.
3. C-O-N-E-S A protocol for discussing a medical error with patients
and family members.
4. E-V-E A sub-protocol for any encounter when there are emotions
present.
Objectives ctd
5. B-U-S-T-E-R A protocol for challenging conversations with patients
and family members

6. B-A-L-A-N-C-E A protocol for cultural competence.

7. T-I-M-E-R A protocol for effective communication in supervision.

The C-L-A-S-S Protocol
Five Key Steps for Clinical Interviews
1. C - CONTEXT The physical set up of the area you choose for the
interview.
2. L - LISTENING SKILLS How to be an effective listener.
3. A – ACKNOWLEDGE How to validate, explore and address emotions and
concerns.
4. S - STRATEGY How to provide a management plan that the patient can
understand.
5. S - SUMMARY How to summarize and clarify the conversation ensuring
comprehension.
C-Context (setting)
A private area with no distractions
Physical Space
• Choose an area where you can have a private conversation.
• Your eyes should be at the same level as the patient and/or family
member (sit down if you need to).
• There should be no physical barriers between you.
• If you are behind a desk, have the patient and/or family members sit
across the corner.
• Have a box of tissues available.
C-Context ctd
Family Members/Friends
• The patient should be seated closest to you.
Body Language
• Present a relaxed demeanor.
• Maintain eye contact except when the patient becomes upset.
Touch
• Only touch a non-threatening area (hand or forearm).
• Be aware of cultural issues that may not allow touching.
L - LISTENING SKILLS
Be an effective listener.
Open Ended Questions
• “How did you manage with the new treatment?”
• “Can you tell me more about your concerns?”
• “How have you been feeling?”
Facilitating
• Allow the patient to speak without interrupting them.
• Nod to let the patient know you are following them.
• Repeat a key word from the patient’s last sentence in your first sentence
LISTENING SKILLS ctd
Clarifying
• “So, if I understand you correctly, you are saying…”
• “Tell me more about that.”
Time & Interruptions
• If there are time constraints, let the patient know ahead of time.
• Pagers and phone calls – don’t answer, but if you must, apologize to
the patient before answering.
• Try to prepare the patient if you know you will be interrupted.
A -ACKNOWLEDGE EMOTIONS
Explore, identify, and respond to the emotion
The Empathic Response
• Identify the emotion.
• Identify the cause of the emotion.
• Respond by showing you have made the connection between the emotion
and the cause.
“That must have felt terrible when...”
“Most people would be upset about this.”
• You don’t have to have the same feelings as the patient.
• You don’t have to agree with the patient’s feelings.
S –STRATEGY

Propose a plan that the patient will understand

The Plan
• Appraise in your mind or clarify with the patient their expectations of
treatment and outcome.
• Decide what the best pharmaceutical care plan would be for the
patient.
• Recommend a strategy on how to proceed.
• Evaluate the patient’s response.
• Collaborate and agree on the plan.
S -SUMMARY
Closing the interview
Final Thoughts
• Summarize the discussion in a clear and concise manner.
• Check the patient’s understanding.
• Ask if the patient has any other questions for you.
• If you don’t have time for further questions, suggest that they can be
addressed at the next appointment.
• Make a clear contract for a follow up visit.
The S-P-I-K-E-S
Protocol
Breaking Bad News
The S-P-I-K-E-S Protocol
• S - Setting Up the Conversation
• P- Perception
• I - Invitation
• K - Knowledge
• E - Emotions
• S - Strategy and Summary
S – SETTING
Secure an appropriate area for the discussion
• Have the conversation in a quiet undisturbed area.
• Prepare for what to say and anticipate the patient/family reaction.
• Have the key people (whom the patient wants) in the room.
• Seat the patient closest to you and have no barriers between you.
• Sit down, try to be calm, make eye contact.
P – PERCEPTION
Assess the patient’s understanding of the seriousness of their condition.
• Ask what the patient and family already know.
“Tell me what you understand about your condition so far.”
“What did the other doctors tell you?”
“I’d like to be sure we are on the same page with understanding your condition,
so can you tell me…”
• Assess the patient and family members’ level of understanding.
• Take note of discrepancies in the patient’s understanding and what is actually
true.
• Watch for signs of denial.
I – INVITATION
Get permission to have the discussion. "ASK BEFORE YOU TELL.”
• Set goals for the discussion - ask the patient if they want to know the
details of the medical condition/treatment.
• “I’d like to go over the results, would that be ok?”
• “Today my plan is to discuss…is that okay?”
• Accept the patient’s right not to know.
• Offer to answer any questions the patient/family member may have.
K – KNOWLEDGE
Explaining the facts
• Avoid medical jargon by explaining the facts in a manner that the patient
will understand.
• NOT: “You have a nuclear grade 1ER/PR positive spiculated 4-centimeter
lesion.”
• BETTER: “You have a fairly good sized tumor in your breast.”
• Fill in any gaps that were evident in the “Perception” stage.
• Present the information in small chunks.
• After each chunk, verify the patient’s understanding.
• “Are you with me so far?”
E – EMOTIONS
The Empathic Response – Be Supportive
• Deal with emotions as they occur (patients who are very emotional will not
comprehend what you say).
• Use open-ended and direct questions to explore what the patient is feeling.
“Can you tell me more about how you feel?”
“Did that make you angry?”
• Respond to emotions with empathic and affirming statements.
“I can see you weren’t expecting this.”
“Most people would be upset finding this out.”
E – EMOTIONS ctd
• Use “tell me more” statements.
• PT: “I don’t know how I’m going to tell my kids.”
• MD: “Tell me more about that.”
• Try to keep your own emotions from taking over.
• AVOID responding with false reassurance such as:
“Everything will be fine.”
“I’ve seen lots of miracles happen.”
Note: You don’t have to have the same feelings as the patient nor do
you have to agree with the patient.
S – STRATEGY & SUMMARY
Closing the interview
Strategy
• Decide what the best medical plan would be for the patient.
• Appraise in your mind or clarify with the patient their expectations of
treatment and outcome.
• Recommend a strategy on how to proceed.
• Collaborate and agree on the plan.
• Ask the patient to repeat to you their understanding of the plan.
• Have a clear treatment plan in writing for the patient to take home with
them.
S – STRATEGY & SUMMARY ctd
Summary
• Summarize the conversation.
• Offer to answer questions. (be prepared for tough questions):
PT: “Does this mean I’m going to die?”
MD: “Tell me more about what concerns you?”
PT: “Can I be cured?”
MD: “I’m sorry to say that it is unlikely. Our goal is to keep it in check.”
PT: “How long do I have to live?”
MD: “I can discuss that with you, but first tell me why you ask?”
The C-O-N-E-S
Protocol
When You Have to Tell
Introduction
• C- Context
• O- Opening Shot
• N- Narrative
• E- Emotions
• S- Strategy & Summary
Use the C-O-N-E-S Protocol when:
• Disclosing that a medical error has occurred
• There is a sudden deterioration in the patient’s medical condition
• Talking to the family about a sudden death
C – Context

• Prepare for what to say and anticipate the patient/family reaction.

• Have the conversation in a quiet undisturbed area.
• Seat the patient closest to you and have no barriers between you.
• Sit down, try to be calm, maintain eye contact.
• Have a box of tissues available.
O – Opening Shot

• Alert the patient/family member of important news.

“This is difficult. I have to tell you what I found out about why your
mother is so ill.”
“This is hard, but I have some information to give you that is
important.”
“I must talk to you about your condition.”
“Thanks for coming in. I must tell you what is going on with your
father.”
N – Narrative Approach
• Explain the chronological sequence of events.
“As you know, your mother came in back in…”
“Then, we gave her… and there was little improvement.”
“Last night we….and I just found out that …”
“In other words, she received too much chemotherapy.”
• Avoid assigning blame and/or making excuses.
Narrative Approach ctd
• Emphasize that you are investigating how the error occurred.
“We started investigations and by the end of today I hope to be able
to answer your questions
as clearly as possible.”
“I hope by the end of today she will turn the corner and start
improving.”

• Offer a clear apology.

“I am really sorry that this has happened.”
E – Emotions
• Address strong emotions with empathic responses.
• Use the E-V-E protocol as soon as strong emotion occurs.
“I know it’s upsetting for you and it’s awful for me too.”
“I know this is awful.”
“It’s very rare, but it does happen and I’m sorry to say that it did.”
• Beware of being pushed into making promises you can’t deliver.
• Avoid reassuring the person that there’s going to be a good outcome
or that no harm was done.
S – Strategy & Summary
• Summarize the discussion and make specific plans for follow up.
• Let them know the situation is a priority.
“I am the doctor responsible for your mother so it is important that I
found out what happened.”
“I’ll be open and honest with you when I have all the facts.”
“I can guarantee we will do our best.”
“Here is what I propose we do.”
“Let’s meet at the end of today or I can call you when I know more.”
Strategy & Summary ctd
• If you don’t know the answer, say so and that you will attempt to find
out.
• Disclosing medical errors is now a standard. It’s not optional.
• Sensitive disclosures have a favorable impact on malpractice claims.
The E-V-E Protocol
Emotions
The E-V-E Protocol ctd
Three elements to use any time strong emotion occurs.
Explore the
• E-Emotion
• V- Validate the Emotion
• E- Empathic Response
 E – Explore

• Explore and identify the emotion (anger, sadness, etc.).

• Find out more about the emotion and what is causing it.
“Can you tell me more about how you feel?”

• Acknowledge the emotion.

“I can see that made you very angry.”
V – Validate

• Let the person know you understand the emotion was appropriate.
“I can understand how that would make you angry.”
“Most people would feel that way.”
 E – Empathic Response

• Respond in a way that shows you have seen the emotion and that
you can understand it.
“I’m sorry this has happened and I understand how it would make you
feel that way.”
“I hear what you’re saying. That must have been very difficult.”
“I get your point. It was obviously very upsetting.”
 Culturally
Competent
Communication
Balance Cultural Competence
 Fundamental Principles
• Cross-cultural medical encounters are increasing in multi-ethnic
societies.
• Cultural factors influence survival rates and patient/family quality of
life.
• Cultural competence is a set of attitudes, skills and knowledge that
can be acquired.
• Respecting cultural diversity is key to delivering comprehensive care
across the illness trajectory.
• Cultural competence promotes patient-centered care through
sensitive negotiation of therapeutic goals.
Areas to Cover in Taking a Cultural History
-“BALANCE”
B -Beliefs & Values (that influence perceptions of illness)
A- Ambience (living situation and family structure)
L- Language & Health Literacy (role of interpreters, accuracy of
translation, metaphoric meanings)
A- Affiliations (community ties, religious & spiritual beliefs)
N -Network (social support system)
C- Challenges (cancer-related risks of home, work & life conditions)
E- Economics (socioeconomic status & community resources)