The art of communication

The role of communication in the general practice consultation

The importance of communication in general practice consultations can be shown by examining Australian General Practice consultation statistics.¹ These statistics reveal that almost two-thirds of the problems managed were done so without pharmacological treatment. The two most frequent clinical treatments in consultations are advice and counselling. Mental health consultations are common. Depression and anxiety feature in the top 10 most common problems managed with clinical treatments, such as advice and counselling. Psychological problems make up 12.1% of all encounters managed, and specific psychological counselling accounts for 6.6% of clinical treatments undertaken in general practice. There is a need for highly skilled communication in these consultations.

Effective communication has many benefits. A recent literature review² found that increased patient and doctor satisfaction, better adherence to treatment, improved follow up and decreased litigation are some of the benefits of a good patient–doctor relationship. In this review, Mikesell finds this caring relationship can be characterised by empathy and good communication. Evidence can give us the knowledge that exercise is at least as beneficial as antidepressants in treating depression.³ However, it will be the clinician’s skill in communicating this knowledge and motivating the patient to exercise that will produce the benefit. The skills and knowledge to diagnose diabetes and its complications can be highly developed, but without the communication skills that take a patient-centred approach to understand what this illness means to the patient, there is likely to be little understanding of the patient beyond knowing they have a disease.

There are also benefits for doctors. A study of primary care physicians found that undertaking an intensive education program in mindful communication improved patient outcomes and personal well-being for the doctors.⁴ The medical literature also provides reassuring evidence that an effective patient-centered model does not take more time.⁵ Good communication can improve outcomes for patients and doctors and deserves equal importance as developing clinical knowledge and procedural skill.

Indeed, the importance of good communication is so critical that Australian guidelines list effective communication as part of the required conduct for all doctors. This Australian Medical Council Code of Conduct outlines nine components of effective communication.⁶ These include listening to patients, respecting their views, encouraging open communication about treatment preferences, discussing management options, allowing patients to ask questions, ensuring understanding and being aware of language, cultural and communication issues. Despite there being a code of conduct, all too often these core components of effective communication are not used, even when treating our colleagues. A recent reflection in the Medical Journal of Australia⁷ outlined the impact of overlooking core skills such as introductions, empathy and respect. In that article a doctor reflected on her experience as a patient with cancer and stated, ‘I had the feeling that I had ceased to be considered as a whole human being, but had become, instead, a collection of body parts’.⁷ Empathy and validation could have transformed the experience. The need for good communication skills is clear. Consideration is now required for how to develop good communication skills.

The skills required for good communication

There is not simply one way doctors should communicate to be effective, but there are several guidelines. Developing these skills on an individual basis is when communication becomes an art. Every doctor can know the guidelines but developing and incorporating these skills into their consultations is an ongoing journey and a lifelong process of refining this art. Guidelines for communication emphasise the importance of verbal and non-verbal communication skills to build a shared understanding.^8,9 Open, attentive posture, eye contact, active listening and encouraging the patient to talk using cues such as nodding are all important non-verbal communication skills. Verbal cues can include beginning the consultation by encouraging the patient to tell their story without interruption and then asking further, open-ended questions to continue to bring out additional issues or concerns.⁹ If all issues are elucidated this may negate the need for unnecessary investigations and reveal psychological causes for physical symptoms. It may also prevent the patient returning with unresolved problems. In the Manual of Mental Health Care,¹⁰ Davies outlines the importance of listening and not interrupting to improve the likelihood of detecting mental illness. Once all the issues are elucidated, summarising and reflecting what has been heard is important to ensure a shared understanding.

Empathy is another essential skill. Empathy promotes professional satisfaction for the clinician and allows for more effective care, as patients are more likely to be open with an empathetic doctor.¹¹ Consideration of the patient’s perspective, development of trust and ensuring understanding of the patient’s story and psychosocial factors of health are critical elements in medical care.² Utilising these skills will enable good communication and promote an effective and therapeutic patient–doctor relationship.

Much medical literature has been dedicated to exploring the skills required for open, effective communication with patients. The Toronto consensus statement on patient–doctor communication¹² was published more than 20 years ago. This statement was based on research gathered since the 1970s and has produced the formative textbook of patient-centred care, now in its second edition and widely used in medical education.⁵ Patient-centred care explores patients’ concerns, seeks to understand the whole person and their experience of illness, to foster a shared understanding to prevent or manage health problems and enhance the ongoing patient–doctor relationship. The Calgary–Cambridge¹³ guide provides a curriculum for teaching the skills required for good communication with patients. It also provides evidence-based guidelines and highlights the benefits of more effective and efficient consultations. This guide, also frequently used in medical education, outlines the skills required and gives a framework for clinical consultations. The skills required are divided into three types: 1) content skills are what doctors communicate; 2) process skills are how doctors communicate; and 3) perceptual skills are what the doctor is thinking and feeling. The focus is on process skills, but this broad understanding of the skills required for good communication allows consideration of the barriers to effective communication. Underlying attitudes, assumptions, previous experiences, personality, language barriers, education level and emotions all impact on the consultation. Little has changed in the core skills required for good communication; however, the literature has continued to strengthen our knowledge that the patient-centred model of communication is beneficial, effective, efficient and in itself therapeutic.

A therapeutic patient–doctor relationship uses the clinician as a therapeutic intervention and is part of the art of communication. This art will be developed over time and be individualised, but has several components in common. It utilises an effective patient–doctor relationship to provide clinical treatment in a medical consultation where the focus is on whole patient care and healing, rather than fixing a problem. This is of particular relevance in mental health consultations where the focus is on a healing journey allowing recovery, not a ‘broken’ patient who needs ‘fixing’. Commonly in mental health consultations there is no single clinical treatment that facilitates recovery but, rather, an ongoing therapeutic relationship combined with evidence-based psychological strategies and, where required, pharmacological treatment. A qualitative study of healing relationships in primary care has attempted to analyse how healing patient–doctor relationships are developed. This study found that trust, hope and a feeling of being known were important for healing to occur.¹⁴ Despite all the technological advances of recent decades, caring, compassionate doctors remain the best therapeutic tool in medicine.

The importance of education in communication skills

Ongoing education in communication skills is very important throughout undergraduate and postgraduate medical education. The Medical Deans of Australia and New Zealand have developed competencies for medical graduates. The ability of a student to communicate effectively is one of the core competencies that has been translated into required student learning outcomes for medical education.¹⁵

The focus on communication skills continues into postgraduate general practice education. The Royal Australian College of General Practitioners curriculum¹⁶ outlines five domains of general practice relevant to every patient interaction. These domains represent a ‘critical area of knowledge, skills and attitudes necessary for competent unsupervised general practice’. Domain 1 is communication skills and the patient–doctor relationship. The training guidelines of The Royal Australian and New Zealand College of Psychiatrists (RANZCP) share this focus on communication skills. The RANZCP curriculum¹⁷ outlines the ability to demonstrate an empathetic approach and a finely developed ability to communicate as a requirement of basic psychiatry training. These professional guidelines emphasise the importance of education in communication skills as ongoing professional development for medical practitioners.

The focus on good communication skills and the importance of developing an effective patient–doctor relationship now also extend into government documents. The Australian Commission on Safety and Quality in Health Care now has a website dedicated to better health outcomes from developing patient-centred care. Key principles are dignity, respect, encouraging active patient participation in health decisions, communicating and sharing information, and fostering collaborations with patients.¹⁸ Improved adherence to management, reduced morbidity and improved quality of life for patients are some of the benefits of patient-centred care.¹⁹ Recently, there has also been interest in formal training inter-physician communication, to reduce the occurrence of medical errors and improve patient care through enhanced communication between doctors.²⁰ Perhaps the next area of focus for medical education will be to enhance the already considerable work done in improving communication with patients.

Conclusion

Hippocrates said, ‘Cure sometimes, treat often and comfort always’. These words, said in ancient times, remain true for modern medicine. The ability of a doctor to provide comfort through their presence and their words is a fundamental component of good medical care. Developing the skill of effective communication is an art to be fostered and refined over time, focusing on patient-centred care. Practicing patient-centred medicine transforms the clinical consultation, taking no more time but bringing benefits for the patient and doctor. Open, effective communication is vital for all areas of medicine and particularly in mental health.

Competing interests: None.
Provenance and peer review: Not commissioned; externally peer reviewed.