Mutual Communication
Senior Doctor Hana Mihulová, MD
Institute of Psychology and Psychosomatics

Communication SKILLS
nare parts of interpersonal behaviour that have positive influence on its process,
nhelp us to establish and develop good communication with the patient in a clinical practice
nare verbal (formulation of the message) or non-verbal (listening, empathy)
ntogether with human attitude towards man they are basis of psychotherapeutic approach.
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Doctors Who Communicate Efficiently
nare able to listen
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nare empathetic
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ndo not interupt the patient when s/he is speaking

LISTENING Means
nto listen to the other person actively
nto listen to WHAT S/HE IS SAYING
nto perceive HOW S/HE IS SAYING IT (mimics, movements)
nIt is an ability to identifiy unconscious latent messages.
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LISTENING
nThere are severals categories present in the patient‘s verbal message – it is a survey of
nwhat happended to the patient
nwhat the patient did (connected with responsibility, imagination, daydreaming, plans …“I think
this will never happen to me again.“)
nwhat the patient experienced (direct description of feelings or non-verbal manifestation)
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When LISTENING
nwe can pay bigger or smaller attention to the message.
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nINFLUENCE:
sociocultural, education, life experience, physical and psychological disposition
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nThat is why you observe your feelings when you are talking to the patient (it is easier to avoid
projection).

RESPECT
nIt is closely connected to listening.
nIt is an attitude, approach to the other person, appreciation of the other person.
nIt is apparent from our behaviour.
nWe are showing “I am here for you now“.
nIt is a basis for us to approach the patient truly.
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EMPATHY
nmeans to identify with someone‘s state of mind
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nWhen we are empathetic, we know what the other is going through, however, we do not have the same
experience (unlike when we are sympathetic).
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How to show EMPATHY
nIdentify an emotion,
nthink about what is happening in the patient,
nrefer to what you can see,
ncheck if your judgement is correct,
nshow understanding, respect, offer support and cooperation.

Expressing UNDERSTANDING
nUnderstanding must be shown.
nIt represents a feedback from an important person.
nIt means assurance that you understand  feelings, opinions…
nIt is a reward and a completely new positive experience.
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INTERPRETATION
nIs a clarification of connections which the patient has not been aware of so far.
nImportant is chosen formulation and suitable moment of communicating it.
nWe usually do not use the first person.
nIf the patient accepts the interpretation, release and a feeling of relief follow.
nAn interpretation should have the form of a suggestion, notice or hypothesis (if it is longer)
nIt can frustrate the patient (it does not always offer a clear answer).

INTEREST, SUPPORT, ADVICE
nInterest in the patient is mainly non-verbal, it must not have the form of pushing.
nWithin the support we remind the patient of positive aspects of his/her life, we avoid utterances
which might disturb his/her internal balance
nDirect advice – in case of diet, regime, medication, crisis situation
nIn case of problems of psychological character we avoid advice, instructions – we help the patient
to be able to help himself.

The Most General Rules of Correct Communication
nBe aware of what you want to say.
nDecide when and where to give the information.
nDecide on the best way to give the information.
nRemember that facts which are clear to you do not have to be clear to the other person.
nSpeak clearly and comprehensibly, adapt the level of the message to the patient‘s intellect,
thinking and emotions.
nChose an appropriate tempo and tone of speach.

It Is Important to
nkeep an adequate eye contact,
ncheck non-verbal expressions,
ntake into consideration the patient‘s feelings,
ngive the patient enough space to express himself/herself,
ncheck if s/he accepted and understood the information.
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In Interpersonal Contact
nverbal messages take place,
nnon-verbal messages are usually given and accepted unknowingly.
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nIf they are in mutual harmony, we speak about congruence, if the oposite is true, we speak about
incongruence (e.g. an unexpected visit)

Doctor – Patient RELATIONSHIP
nThis relationship is determined by role – expected and required behaviour connected to a certain
status of a man in society.
nDevelopment of a relationship is accompanied by asymetry – influenced by the doctor‘s education,
experience, personality and social status.
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Doctor‘s ROLE
nspecialist, expected to be dominant, decisive, active
non the other hand understanding, personally interested and able to provide quick and painless
help,
nbut also self-secrificing, selfless to the patient, responsible.

Patient‘s ROLE
nSubordination, ability to bear something.
nNowadays, the patient is expected to be active in the cooperative effort to recover.
nPatient expects positive social response  – time off, presents, pity.
nsecondary profit from the illness, tertiary profit from the ilness
nThe illness isn‘t his/her fault, s/he isn‘t responsible for his/her behaviour
nS/he wants to recover, will cooperate.

The Patient Expects from the Doctor
ninterest
nquick recovery
nelimination of symptoms
nkeeping secret
nsupport and important information
nThe more s/he feels to be a patient, the more s/he submits and follows recommendations

The Doctor Expects from the Patient
nsubordination
ngradual improvement of health condition
nx prolonged problems are frustrating for the doctor
ncounts on full cooperation
ntrue information
nwillingness to be examined

P-D Cooperation - Models
nPATERNALISTIC model
n- doctor and illness oriented
ntraditional, without a dialogue, the doctor relies on himself, leads, determines
nThe doctor is authoritative.
nIt is a relationship of a parent and an adolescent.
nThe patient is in a dependent and less responsible position.

P-D Cooperation - Models
nPARTNER model
n- patient oriented
nThe doctor cooperates, makes agreements, is interested in the family, finds a solution together
with the patient.
nfunctioning personal relationship, holistic medicine
nThe doctor is not authoritative.
nIt is a relationship between adults.
nThe doctor helps the patient to help himself/herself.

P-D Cooperation
nis a result of mutual relationship and communication,
nwe refer to it as COMPLIANCE
nit is stated that 30-50% patients treated as outpatients do not observe recommendations and
medication,
nnot observing grows with complexity of treatment.
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Cooperation is Influenced by
npersonality traits of the doctor and the patient,
nTRANSFER – the patient projects his/her experience from previous relationships with important
people to the relationship with the doctor,
nANTI-TRANSFER – the doctor projects an experience with a similar person.
nThese processes may be both, conscious and unconscious, and can influence the cooperation
positively, negatively or ambivalently.

Cooperation is Influenced by
ncommunication barriers connected with:
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nage
nsensory and mental defects
nmental disorder
nlanguage limitation

How to Improve Cooperation
nSuggest an easy medical procedure (divide the steps into more consultations).
nProvide the medical procedure in a written form (information, leaflets).
nDescribe the expected direction of treatment, time schedule.
nDescribe possible side effects.
nAsk the patient to think about potential obstructions and work together on adjusting the regime.
nAsk for feedback (make sure that the patients understands and knows)
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DISSATISFIED Patient Says
nthe doctor:
nwas distracted, absent-minded,
nrushed the patient,
nduring the consultation was on the phone, spoke to other members of the staff,
ndid not explain why he prescribed medication,
nexamined without saying why,
ndid not listen.

SATISFACTION of the Patient
ngrows when the doctor:
n is friendly, not rude,
ngives the patient complete information,
ntreats the patient as an equal,
nlistens to the patient,
nis interested in the patient as a person, encourages him to ask questions, uses an understandable
vocabulary.
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Medical CONVERSATION
nis a way of oral communication and social interaction between two and more persons which takes
place for a specific purpose.
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nThe center of the conversation are questions.

Questions
nOpen: “Tell me more about how you feel…“
nAdditional: “And when is the mood the worst? … have you slept well today?“
nCatalogue: chooses from more than two possibilities – “Is the pain dull, burning, stabbing…?“

Questions
nAlternative: “Does it pull you forward or backward when you are walking? “
nSympathetic: “I think you feel disappointed because the recovery does not proceed as expected…“
nSuggestive – not recommended because they impose the answer –“Are you feeling well?“

The Funnel Strategy
nA conversation technique in which you proceed from general questions to more detailed ones.


Types of Conversations
nfocused on gaining information – opening (screening) conversation, anamnestic conversation
ngiving information – instructions, closing conversation
npsychotherapeutic – non-directive empathetic conversation, supportive, convincing

Stages of Conversation
nEstablishing a contact (pleasant environment, feeling of safety)
nClarification of the problem
nThe actual examination (respecting intimacy, shyness)
nTherapy

Stages of Conversation
n1) Establishing a contact:
-Greeting
-Calling by name
-Introducing and shaking hands
-Showing the patient to the place of conversation
-Communicating a time plan and financial aspects
-Taking a listening, empathetic position
-Starting the conversation with the phrase: “Tell me what is bothering you?“
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DO NOT FORGET about
nA welcoming sympathising smile
nA firm and supporting handshake
nA good eye contact
nSetting the place of the consultation
nPersonal interest (look for something you have in common, do not write, listen)
nEncouragement
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Stages of Conversation
n2) Describing the problems:
-Give some space, listen (the first 3 minutes)
-React, encourage (I see, I understand …), your interest must be apparent
-Use open (Wh) questions
-Paraphrase (so you felt miserable…)
-Express your interest in a topic that is important for the patient but s/he is embarrassed to
speak about
-Summarize the problems
-Ask the patient what he thinks about his problems
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Stages of Conversation
n3) Clarification of the problem:
nIt is necessary to look for the center of the problem, what bothers the patient the most.
-Concentrate on what the patient is saying, what the doctor sees and feels and express it.
-Use verbal and non-verbal clues.
-Ask an open question – “Tell me more about..
-Ask for clarification – “What do you mean by that? “
-Comment according to non-verbal clues – “It seems to me that you are especially bothered by this…“

Efficiency of Conversation Increases
nif you are able to:
nfind the center of the conversation and stick to the topic – be in charge of the conversation,
ncalmly and politely ask about what you want to learn (“Yes, but I would really like to know about
your sleep. “),
nreview the main purpose of the conversation,
nget back to the center of the conversation.

Stages of Conversation
n4) Finishing:
-It is important to agree with the patient on a diagnose and a type of treatment.
-Review the treatment plan.
-Ask if the patient asked about everything he needed to.
-Ask what s/he understood and how.
-Presuppose questions.
-Set the content and date of the following consultation.
-Express your hope in success and say goodbye.
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Communicating Unfavourable News
nGeneral principles:
nEnough time, quiet place
nPrepare for giving the actual information.
nConsider the personality, intellect, awareness and social situation of the recipient.
nTry to prepare for the reaction of the recipient.

General Principles
nThe person who looks after the patient gives the information – with empathy and authenticity.
nThe message has to be understandable and exact. Do not use specialized language.
nInformation should be brief, answers extensive.
nAs a matter of principal tell the truth with respect to the prognosis.
nProvide space for questions.
nIt is necessary to reflect feelings.
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In Case of Extremely Unfavourable News
nNon-directive, empathetic conversation
nBy prior psychological guidance
nThe precondition is that the patient (relative) has inwardly matured.
nDo not prevent them from an emotional response.
nGive support, be empathetic. The recipient can fully rely on you.
nContinuous psychological care

Kübler - Ross
1.Shock – denial and withdrawing into isolation
2.Revolt – reaction of anger and envy towards healthy people
3.Bargaining – willingness to give everything for the illness
4.Depression – sadness, feeling sorry for things that are ending
5.Acceptance

Sources (1)
nVymětal, J.: Lékařská psychologie. Praha, Portál 2003
nBeran,J.: Psychoterapeutický přístup v klinické praxi. Jinočany, H&H 1996.
nBouček J.a kolektiv.: Lékařská psychologie. Olomouc 2006.
nHonzák, R.: Komunikační pasti v medicíně. Praha, Galén 1997
.
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Sources (2)
nKratochvíl, S. :Jak žít s neurózou.Praha, Portál 2000.
nKřivohlavý, J.: Jak si navzájem lépe porozumíme. Praha, Svoboda 1988.
nKřivohlavý, J.: Povídej – naslouchám. Návrat 1993.
nLinhartová, V.: Praktická komunikace v medicíně pro mediky, lékaře a oš. Personál. Praha Grada
Publishing a.s. 2007

Thanks for Your Attention
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