Domain 1 Communication skills and the patient-doctor relationship

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Effective patient–doctor communication is the foundation for developing and maintaining successful therapeutic relationships. Communication is required at all stages of a general practice consultation,1–3 and is critical to the delivery of safe patient care.4 Consultation skills encompass communication skills, but also includes skills in structuring a consultation to ensure the best outcomes for patients. Consultation skills relate to areas such as identifying agendas, negotiating content, shared decision-making, time management and follow up. Ongoing education in communication and broader consultation skills is therefore essential for all general practitioners (GPs).5

Effective communication and consultation management benefit both the patient and the doctor. Good communication has been found to increase patient and doctor satisfaction and improve adherence to treatment, health outcomes and follow up. Patient-centred communication has also been found to decrease the likelihood of litigation and reduce consultation time.2,3,6 Communication failures can result in errors, misdiagnosis, inappropriate treatment, poor health outcomes and reporting/litigation.4

There is no single way GPs should communicate to be effective and build the patient–doctor relationship. Communication can take many forms, including verbal and non-verbal, and includes oral, written and body language. These need to be adjusted and tailored to each patient. Communication skills also need to be adapted to remote forms of consultations, such as telephone and video consultations.

Several guidelines have been developed through comprehensive research to establish a clear baseline for communication expectations.2 The Australian Commission on Safety and Quality in Health Care and the Australian Medical Association have released standards relating to safe and effective communication.4,7 The Medical Board of Australia's code of conduct also references the importance of effective communication.8
These guidelines suggest that effective communication requires a number of skills and attitudes, including, but not limited to:

  • carefully listening to the patient, not interrupting and not rushing2
  • being respectful and considering the patient’s unique psychosocial and cultural context and perspective2,3,6
  • responding empathically, especially in socioemotional exchanges2,3
  • asking open-ended questions to elicit additional issues or concerns from patients3
  • using reflective listening strategies, such as summarisation and reflection, and regularly ‘checking back’ with patients to ensure understanding2
  • providing clear and detailed information that is adapted to the patient’s level of health literacy and with consideration that English might be a subsequent language3
  • being aware of non-verbal communication, including the GP observing their own and the patient’s body language, and encouraging the patient to talk by using cues, such as nodding.2,3

Awareness of the communication needs of Aboriginal and Torres Strait Islander peoples and people from other culturally and linguistically diverse backgrounds is essential for effective general practice consultation management. Communication with individuals with cognitive or sensory impairments and other vulnerabilities (eg mental illness or history of trauma) might also need to be adjusted to meet the patient’s specific needs. Maintaining a patient-centred communication approach, developing cultural awareness and competency, effectively using interpreters where appropriate and scheduling long appointments when required will allow GPs to manage consultations in a culturally safe and respectful manner.

GPs also need to communicate appropriately with family members and carers and ensure that they meet their duty of care responsibilities. This includes confidentiality, establishing appropriate consent and the provision of concise and meaningful information. Effective communication with other health professionals also facilitates continuity of care and optimises clinical outcomes for patients.9

References
  1. Murtagh J. Consulting skills. In: Murtagh's General Practice. 6th edn. Sydney: McGraw Hill, 2017 [Accessed 1 October 2021].
  2. King A, Hoppe RB. Best practice: For patient-centred communication: A narrative review. J Grad Med Educ 2013;5(3):385–93. doi: 10.4300/JGME-D-13-00072.1.
  3. Warnecke E. The art of communication. Aust Fam Physician 2014;43(3):156–58.
  4. Australian Commission on Safety and Quality in Health Care. Communicating for safety standard [Accessed 1 October 2021].
  5. Levinson W, Lesser CS, Epstein RM. Developing physician communication skills for patient-centered care. Health Aff 2010;29(7):1310–18. doi: 10.1377/hlthaff.2009.0450.
  6. Mikesell L. Medicinal relationships: Caring conversation. Med Educ 2013;47(5):443–52. doi: 10.1111/medu.12104.
  7. Australian Medical Association. 10 minimum standards for communication between health services and general practitioners and other treating doctors. ACT: AMA, 2017 [Accessed 1 October 2021].
  8. Medical Board, Ahpra. Good medical practice: A code of conduct for doctors in Australia. 2020. [Accessed 5 October 2021].
  9. Scaioli G, Schäfer WLA, Boerma WGW, et al. Communication between general practitioners and medical specialists in the referral process: A cross-sectional survey in 34 countries. BMC Fam Pract 2020;21(54). doi: 10.1186/s12875-020-01124-x

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP. These are expressed as core competencies that are required of a GP across all clinical consultations, interactions and contexts. These core competencies are further detailed as measurable core competency outcomes.

Communication and the patient–doctor relationship
Core competencies Core competency outcomes
  The GP is able to: 
  1. GPs communicate effectively and appropriately to provide quality care
  1. communicate with patients in a clear, respectful, empathic and appropriate manner
  2. communicate effectively in challenging situations
  3. use a clear and considerate approach when communicating with family, carers and others involved in the care of the patient
  4. communicate effectively and respectfully to address complaints and concerns
  5. communicate effectively and safely via electronic media
  6. use appropriate resources to communicate effectively where there is disability, impairment or language barriers

Rural health
  1. communicate effectively with other health professionals using available infrastructure
  1. GPs use effective health education strategies to promote health and wellbeing
  1. consider the patient’s level of health literacy, acknowledging that these factors can influence a patient’s experience of illness and health behaviours
  2. draw on a range of interview and counselling approaches to support patients to optimise health behaviours
  3. use planned and opportunistic approaches to provide screening, preventive care and health-promotion activities
  1. GPs communicate in a way that is culturally safe and respectful
  1. communicate in a way that is respectful and responsive to the sociocultural context and beliefs of the patient
  2. incorporate sociocultural elements to tailor health education to the local context

Aboriginal and Torres Strait Islander health
  1. communicate with Aboriginal and Torres Strait Islander patients in a culturally safe and respectful manner
  1. GPs provide the primary contact for holistic and patient-centred care
  1. conduct a consultation that is aware and appropriate to the needs of the patient
  2. provide continuity of care through timely referral and follow up
  3. use a patient-centred approach to consultation, identifying and addressing the patient agenda to develop patient-centred management plans with the patient, their families or carers
  4. listen to and acknowledge the illness experience from the patient’s perspective
  5. understand different consultation models and identify the most appropriate for the situation

Aboriginal and Torres Strait Islander health
  1. establish an effective and culturally safe therapeutic relationship with Aboriginal and Torres Strait Islander patients
Rural health
  1. provide quality care in a rural and/or remote community

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. The best way to learn communication and consultation skills is by observation – observing others and getting others to observe you, then reflecting on and incorporating their feedback.
  2. Be curious about your patients – think beyond their presenting complaint and try to understand their beliefs, experiences, social situation and culture. Remember that you too have your own ideas, beliefs, past experiences and culture that will influence how you interact with others. Even how you are feeling at the time has an impact, especially if you are running behind, haven’t eaten or are tired.
  3. Don’t be distracted by the computer. Check the records before the patient comes in, then turn away from the screen and let the patient tell their story. Focusing on the patient and letting them tell their story doesn’t take long, gives you a lot of information, and shows that you are interested and listening to what they say. You will also pick up non-verbal cues that might otherwise be missed.
  4. Don’t skimp and leave out examination. It could be as simple as checking vital signs, but it shows you are interested and thorough, and it can turn up some unexpected results like raised blood pressure or atrial fibrillation. Your examination findings and the history are important in developing a management plan; if you try to develop a management plan before you have all the relevant information, something might turn up to change the plan, and then you have to start again.
  5. Develop appropriate communication techniques to manage uncertainty; for example, how to communicate that a diagnosis is unclear or that further investigation is needed. Also, be comfortable with letting the patient know that not everything will be completed in one consultation, and that they need to return for review, either because you have gathered further information or because they have several different issues to deal with.
  6. Remember to explore and address the patient’s concerns, ideas and expectations of the consultation. Patients need to be heard and understood, as well as agree with the diagnosis and management plan. Listening, summarising and reflecting are essential in this. At the end of a consultation, if the patient repeats a question or doesn’t seem to agree with the management plan, don’t ignore this. They might not have understood or agreed with you or have a concern that you haven’t addressed.
  7. Be prepared to adjust your communication style and the content of the consultation to the patient and the situation. For instance, how you talk to a 75-year-old male may be different to a 15-year-old female. A patient who returns for results may have developed a new problem or concern since the last visit, and it might be more important to manage this first. The skills you use in communicating with colleagues or other health professionals will be different to those you use with patients.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Domain 1 Communication skills and the patient-doctor relationship

Emma is a 15 year old who presents with menorrhagia and dysmenorrhoea. Her periods are irregular; the last was six weeks ago. She attends with her mother.

Questions for you to consider Clinical exam assessment area Domains

How will you manage this consultation to ensure that everyone’s agendas are met?

What communication strategies will you use with Emma and her mother? What specifically will you say to them?

If Emma were an Aboriginal or Torres Strait Islander person, how might this affect your approach? What if she were from a culturally or linguistically diverse background?

If she had an intellectual disability, how might this affect this consultation?

  1. Communication and consultation skills
1,2,5

How would you ask Emma about her sexual history?

How would you assess her understanding of her periods and sexual health?

If she told you that she is sexually active, how would you explore her understanding and concerns?

How might you explore the possibility of sexual abuse? 

How would you explain any examinations or investigations that you wish to do?

  1. Clinical information gathering and interpretation
2

If Emma has a positive pregnancy test, how would you discuss the results?

How would you explain contact tracing if she has a positive chlamydia test?  

If she does disclose sexual abuse, what would you say to her and her mother?

If she is not pregnant and you consider she might have polycystic ovary syndrome, how would you explain this condition?

  1. Making a diagnosis, decision making and reasoning
2

How would you discuss contraception?

What would you say if Emma wishes you to prescribe the oral contraceptive for her periods and possible contraception, but her mother does not want her to take the pill?

How would you know if they agree with your management plan?

  1. Clinical management and therapeutic reasoning
2

Are there any resources you could give Emma with further information about her periods, contraception and sexual activity/health?

What if Emma were from an Aboriginal and Torres Strait Islander, or other cultural, background?

How will you engage her in a discussion about safe sex? What screening might you consider and how would you explain this to her?

  1. Preventive and population health
1,2,3

Do you find these conversations difficult? How might you learn more and practise your communication?

How might your personal beliefs and culture influence how you manage this situation?

How might you manage if this consultation was added as an extra to your morning session?

  1. Professionalism
4

What would you say to Emma about confidentiality?

What would you say to her mother if she rings for her daughter’s results?

Consider you are working in a small country town and Emma’s mother is friends with your practice manager. What would you say if Emma asks you not to write about her sexual activity in your notes as she is concerned her mother will find out? 

  1. General practice systems and regulatory requirements
5

What would you say to assess and ensure you have informed consent for any examination or investigation?

  1. Procedural skills
2

How would you explain the differential diagnoses if Emma’s pregnancy test is negative?

What would you tell her about safety netting and follow up?

How would you ensure that she understands?

  1. Managing uncertainty
2

If Emma presented with hypotension, abdominal pain, and had a positive pregnancy test, how might this affect your communication and how you manage this consultation?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Review some consultation models and use one to analyse your own consultations. You can find a guide to some different consultation models in the learning resources section of this unit.

  • Overall, what areas do you think you do well? What areas do you think you need to improve on? How might you do this?

Ask your next 10 patients to give you feedback on a consultation. (See if your practice has a feedback/suggestion form. If not, consider creating a printed form to allow patients to give anonymous feedback.)

  • What areas were they most satisfied with? What areas were they least satisfied with? Does this surprise you? Is there anything you could do differently?

Review the last five patient referrals you have written. Try to include referrals to other specialists and allied health referrals.

  • Is the reason for the referral clear? If you received this referral letter, is there enough information for you to manage or would you want to know anything else? Are there any important pieces of information missing for example, smoking, alcohol, allergies, medication lists, social situation? How might this affect your referrals in the future?
With a supervisor

Ask your supervisor to observe your consultations. Then change over and observe your supervisor consulting. Another option is to videotape your consultations and review them with your supervisor or a colleague. Be aware that there are legal considerations in videotaping consultations, and you should be familiar with the requirements of the state or territory in which you work. You could also discuss with your supervisor any opportunities to observe others in the practice, including any allied health workers.

  • What did your supervisor think you did well? What did they think you didn’t do so well? Did that match how you felt about the consultation? What suggestions for improvement did you discuss?
  • From watching your supervisor or others, what tips or phrases or ways of discussing things do you think might be helpful for you to use?

Discuss the common cultural groups that present in your practice. Research the cultural beliefs in relation to healthcare and reflect on how these are different to your own. With your supervisor, discuss one of your cases with a patient from a different cultural background to yours.

  • Thinking of the patient’s understanding of their symptoms and management plan, how might their culture have affected the consultation? Is there anything that you could do differently? Does your supervisor have any suggestions or tips?
  • How might you improve your communication with patients from this group?
  • Does your supervisor know of any local groups you could visit to learn more about their culture?

Discuss other patient groups where you might need to adjust communication style or language to ensure it is effective and inclusive. Some examples include adolescents; elderly patients and LGBTIQ+ or neurodiverse people.

  • What challenges have you had when communicating with any of these groups? How do you adjust your communication?
  • Does your supervisor have any advice or tips that you could try?  

Explore the concept of health literacy and how it influences healthcare. Look at the factors that affect health literacy and how level of literacy might influence health. Present a case to your supervisor where health literacy was an important factor in the consultation.

  • How do you adjust your communication and consultation to the patient’s health literacy? Does your supervisor have any suggestions about how to do so?
  • Do they have any further examples or resources that might help?
In a small group

Develop a list of situations that members of the group have found challenging (eg giving bad news, aggressive patients, etc). Discuss some ways to manage these situations. Role-play some scenarios that involve these situations and try some of the different techniques that have been suggested to manage the consultation. Get feedback from the group and the role-players.
Note: Some members of the group may find some situations personally confronting, so it is important that members of the group be aware of this and create a safe space for each other.

  • What worked well? What was less effective? Are there any techniques that you could use in your own consultations?

Video some role plays of consultations and analyse them together as a group. You could use some of the scenarios from the previous exercise. Try looking at the video without the sound to observe the non-verbal communication. Then listen to the video and see how your observations fit with the verbal communication. 

  • What body language did you observe? Did the ‘patient’ seem to be engaged? Why/why not? How did this match with what was said during the consultation? How might you manage this if there is a mismatch?
  • What tips did you pick up that might help you in the future?

Discuss cases the group members have seen where a lifestyle change was discussed with a patient. Using the stages of change model, analyse what stage in the change cycle the patient was at and what techniques were used to motivate them.

  • Was the approach effective? Why/why not?
  • Does the group have any suggestions to motivate patients or to help patients maintain change?
With a friend or family member

Ask a friend or family member to tell you about a time they had a conversation that they found challenging. This doesn’t need to be a medical conversation. For example, it could have been with a work colleague, family member or friend.

  • Why was the conversation challenging? What helped and what hindered the conversation? What was the outcome? Did they learn anything from the experience?
  • Is there anything you could use in your approach to challenging consultations?

Ask a friend or family member about their experiences with communication in medical settings. 

  • What do they think is the most important thing a doctor can do to show that the patient is being listened to and has been heard?
  • How does the use of the computer impact on communication?
  • What does your friend/family member think is the most important element to gain their trust and engagement in a consultation? 

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Understand essential communication skills, including verbal, non-verbal and written skills:
    • Verbal skills, such as appropriate use of questions, active listening, reflecting and summarising, empathy and clear use of language.
    • Non-verbal skills, such as understanding visual cues, body language, eye contact, posture and facial expressions.
    • Written skills, such as the patient record and communication with other health professionals.
  • Recognise and work to address barriers to communication where possible. Potential barriers include:
    • time pressures
    • use of the computer
    • personal beliefs and culture
    • physical and situational factors
    • use of stigmatising language
    • the patient’s previous experiences with healthcare, and their basic health literacy.
  • Understand various consultation models and develop an approach that incorporates the following key components:
    • consultations that are patient centred, including respecting the patient’s choices
    • acknowledgement that both patients and doctors have agendas, and negotiation of those agendas
    • exploration and incorporation of the patient’s ideas, concerns and expectations
    • appropriate examination
    • shared decision-making by collaboratively developing management plans that include the patient’s perspective, their sociocultural background and the impact of local (especially rural/remote) issues
    • inclusion of timely referral, safety netting and follow up.
  • Develop skills in having challenging conversations due to:
    • specific patient factors or groups
      • children or adolescents
      • patients with a disability that impacts on communication, such as intellectual disability, vision or hearing impairment, cognitive impairment
      • patients with physical symptoms attributed to stress or mental health conditions
      • patients who have experienced the consequences of trauma
      • patients with an unclear diagnosis
      • patients for whom there is a need to communicate bad news to or to discuss end-of-life decisions
      • patients who are distressed or patients with mental health conditions
      • patients who are angry or aggressive
      • patients requesting drugs of dependence
      • patients with a complaint or concern, including critical or potentially critical incidents
      • patients who are unmotivated or disengaged
      • patients with unrealistic expectations (eg requests for certificates or tests that are not warranted, or those with a list of problems to manage in one consultation)
      • patients for whom there is concern about safety, such as suicide risk or risk of abuse
      • culturally and linguistically diverse patients with diverse health belief systems
      • patients with an Aboriginal or Torres Strait Islander background
      • patients whose primary language is not English, including the appropriate use of interpreters
      • LGBTIQ+ patients
      • patients with health beliefs and treatment preferences different to your own
    • specific situations:
      • consultations conducted remotely, such as using telehealth or by telephone
      • working in a multidisciplinary team to ensure care coordination, such as in aged care facilities or palliative care
      • consultations where others are present, such as carers, parents or family members
      • emergencies
    • specific concepts that need to be discussed:
      • explanation of risk
      • consent and confidentiality
      • explanation of procedures.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
How language can create stigma and impact patients, and alternatives for better outcomes.  Managing multimorbidity and encouraging behavioural change through the use of motivational interviewing. The stages of behavioural change and using motivational interviewing. An approach to communicating bad news. Effective communication with Aboriginal and Torres Strait Islander patients. A UK analysis of some consultation models, why they are useful and how they can help (as well as their limitations). Many points are relevant to Australian general practice.
Denness C. What are consultation models for? InnovAiT 2013;6(9):592–99.
Textbooks
  • Murtagh J. Consulting skills. In: Murtagh's General Practice. 7th edn. Sydney: McGraw-Hill Education, 2018.
  • Murtagh J. Communication skills. In: Murtagh’s General Practice. 7th edn. Sydney: McGraw-Hill Education, 2018.
Online resources
A mental health first aid resource on suicide prevention that includes how to talk to a patient about suicide. Various resources on communication skills, especially for international medical graduates.  A factsheet about managing requests from patients for drugs of dependence. A range of resources to help develop communication skills for serious illness. Information about consultation models. A guide to the use of inclusive language. Tips and links for responding to patients who request tests that are considered inappropriate. 
Learning activities
  • The Royal Australian College of General Practitioners. gplearning:
An overview of communication skills in general practice consultations with application to everyday and more challenging situations.
    • Communication skills in general practice
Effective communication in the palliative care setting as important for good quality care.
    • An approach to timely palliative care consultations
This core unit relates to all other units.
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/domain-1 27/09/2022