Communication skills play an important role in general practice. Good communication skills can improve patient compliance and overall satisfaction and a lack of these skills can increase medical error. Physical knowledge is growing and driving the perception that communication is peripheral, especially among medical trainees and junior physicians. This skill is often overlooked as easy or self-explanatory. However, the application of communication skills are very important while the development of these skills require a process. Furthermore, practicing communication skills alone cannot reduce medical error. A better understanding of the developmental process and concepts will result in more flexibility and better application. This article reviews five steps to understand the different level of communication skills logically (i.e., medical humanities, principles of family medicine/general practice, clinical methods, and counseling micro skills to clinical applications). The aim is to find a style in clinical consultation that comfortable and right for each physician.
Keywords: Communication skill; Family medicine; General practice; Learning method
Communication skills are considered an extremely important technique in family medicine/general practice, it likes operation in surgery. However, it is easy to overlook. Many errors in medical practice have their origins in communication failure . Evidence supports that poor communication between physicians and patients is an important attributing factor , while good communication is associated with benefits such as an improvement of clinical outcomes, a reduction in medical errors, and facilitation of self-management and preventive behaviors [3-5]. Physicians’ explanatory behaviors accompanied by the process of explaining and listening to patients markedly reduces the risk of a negligent care decision . Open-ended question formats are associated with the satisfaction of patients and similar time is spent compared with closed-ended question formats .
Communication and humanities are actually marginalized . Yet, medical humanities may play a critical role in general medical culture and educating for democracy is improving communication . It reveals that communication skills have unique position in family medicine/general practice based on the developmental process. From the medical humanities, framework and concept of family medicine/general practice, then action are generally developed.
The evaluation of communication skills is increasingly becoming a part of efforts to improve the quality of health care worldwide , while some articles revealed communication skill deficits in senior medical students , doctors in training  and early-term general practitioners . The study of medicine changes in response to many influences including some that are scientific and technological while others are social. Different methods to enhance communication skills include role play, group work and available teaching technologies . But one article revealed that the frequency of teaching by teachers is unlikely to give trainers sufficient opportunity to develop their consultation skills . Although there are plenty of methods and textbooks to help us understanding communication skills in family medicine/general practice, a logical thinking makes us more flexible in its application.
This article briefly organizes five steps and showed how to understand the different level of communication skills, it is medical humanities, principles of family medicine/general practice, clinical methods, and counseling micro skills for clinical application (Figure 1). Medical humanities are the origin of communication skills, principle of family medicine /general practice is framework, clinical method and counseling micro skills are basic concept of application and clinical application is clinical practice. Although there are five steps to understand the clinical communication skills, there is no fixed sequence. It may be ascending or descending order based on physician’s experience and background.
Figure 1: Five steps of understanding communication skills.
Medical humanities are concerned with “the science of the human”, including the humanities, social science, arts and their application. Medicine changes are based on health-related events, the successful control of major infectious diseases in the earlier years of the twentieth century, while physicians are now mostly faced with chronic diseases, developmental disorders, behavioral disorders, accidents, and a different range of infectious diseases . Medical humanities are leading the growth of specialization, including general practice/family medicine.
Medicine requires a medium for the translation of clinical scientific knowledge into patient care and that medium may be the humanities . This indicates that medical work must balance “cure (biomedical)” and “care (communication)”, especially in family physician who manages any health problems. Each patient has their specific need that is related to ethnic origin, social class, age, sex, nature of illness religious affiliation, personality and environmental factors. However, similar health problem in different people presents with different illness behavior, one of the important task in general practice/family medicine is balance between the “cure” and “care”. Communication skills are a useful technique to connect these.
One critical review concluded that a persistent empathy decline might be explained as an effect of the growing polarization of biomedical elements and leads to the perception of communication and humanities as peripheral . However, medical humanities are a core integrated provision for medical education, which reduces the gap between biomedicine and human sciences . As one article suggests, medical error may be reduced in the future not by specifically focusing on the teaching of communication skills but by teaching about cultural and institutional barriers and the acceptance of responsibility for medical error . We can conclude that more understand the origin or development of family medicine/general practice, more flexible to apply the communication skills.
Principle of Family Medicine/General Practice
In the evolution of “the science of the human,” principles of family medicine/general practice are the defining characteristics of a specialty. Family medicine/general practice are skilled in comprehensive, first contact, and continuing care with any undiagnosed health concern not limited by original problem (i.e., biological, behavioral or social). It also includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, schools, telehealth, etc.) . It revealed that family medicine/general practice has many tasks and may not be necessary to meet specific patient needs, but good communication skill can reduce this conflict.
A consensus on principles of family medicine emerged in the 1990s from Barbara Starfield’s four pillars of primary care as follows: first contact care, continuity, comprehensiveness and coordination . However, this is not a complete picture of family medicine. A research article in 2016 presented the five principles of family medicine/general practice as follows: compassionate care, a generalist approach, continuity of a relationship, reflective mindfulness and lifelong learning . However, none is unique to family medicine/general practice, and each principle is different from the clinical methods used to operationalize these ideas. The key words here are responsibility, collaboration, respect and dignity, and information sharing that govern our actions.
As discussed above, medical work demands a balance between “cure” and “care,” and a clinical method is the concept of how to apply the principles of family medicine/general practice. Suitable clinical method helps us to make a reasonable decision making. However, family physicians are available for all types of problems and there is no predetermined order in consultation . In patient-centered clinical methods, physicians seek to both understand patients’ experiences of illness and to make a diagnosis. Cues presented by patients guide physicians to aspects of their problems that demand the most attention. This approach is more appropriate than the conventional clinical method for broad-based disciplines such as family medicine .
Patient-centered clinical methods were associated with improved health status (less discomfort, less concern, and better mental health) and increased efficiency of care (fewer diagnostic tests and referrals) . In addition, the entire consultation is also a part of the therapeutic process  but it is applied differently in each field of medicine. Because a diagnostic process is usually a statement of probability rather than certainty in family physicians, a hypothetico-deductive approach to problem solving is integral to the patient-centered method .
Figure 2 is the summary of patient-centered clinical method with integral hypothetico-deductive approach to problem solving [1,22]. The key is to allow as much as possible to flow from the patient, including the expression of feeling. Cues come in a variety of different forms, including verbal and nonverbal cues (e.g. what we see, smell, hear, and feel about patients and their story). Failure to take up the cues is a missed opportunity to gain insight into the illness. Suitable cue acquisition can obtain or formulate patient’s R. I. C. E (Reason, Idea, Concern and Expectation). Hypotheses, which can be broadly classified into biomedical or psychosocial categories, are generated and rank ordered on the basis of the cues acquired and knowledge. Then test the hypotheses being considered and is based on the science of probability. Finally, family medicine/general practice gets the idea of what course the consultation is likely and searches common ground. Good communication skill can make this procedure smoothly.
Figure 2: Patient-centered clinical method with integral hypothetico-deductive approach to problem solving.
The major errors in decision making are related to poor communication skill, such as missing or ignoring cues, failure to generate the correct hypothesis, premature closure the hypothesis, not listening and not considering the needs and desires of the patient . Patient nonadherence is often a direct result. However, all of these errors can revised by good communication skills.
Counseling Micro Skills
In order to make a correct decision making and improve patient’s adherence, good communication skills are essential. Counseling micro skills are basic skills that is the element of communication during consultation. The aim is to allow as much as possible to flow from the patient including the expression of feeling. An effective application of counseling micro skills facilitates a strong therapeutic alliance and contributes to positive therapeutic outcomes . Most counseling programs today use the micro skill approach to train students to generate these transformations . There are countless micro skills; some counseling micro skills are specific to the process of psychotherapy, while others are universally practiced by all health professionals . Active listening, nonverbal communication, silence, and empathy are the core counseling micro skills. However, each micro skill has an intrinsic meaning. For example, active listening is the foundational micro skill required to foster a therapeutic alliance with patients . This skill is often overlooked as easy or self-explanatory. However, it is not simply an accurate repetition of words. Rather, active listening is dependent on the clinician being fully present to the patient being able to manage internal thoughts, dialog, and distractions to fully concentrate on the patient .
Finally, all micro skills have to be combined in clinical consultation. For example, swimming can be described in terms of rules for correcting imbalance, breathing and adjustments made by the body floating on water. However, focusing on special components may actually cause sinking. Similarly, each consultation is different and one cannot conduct a consultation while trying to keep in mind the subsidiary rules and components .
Based on the counseling micro skill, different communication skills have been developed such as shared decision-making, identification of the patient’s agenda, a safety net, acceptance of uncertainty and attainment of common ground. We have to apply these skills in each clinical consultation.
The opportunity to practice and receive constructive feedback on performance is essential. Practicing communication skills with simulated patients can lead to the acquisition of skills and the relinquishment of blocking behavior . Current evidence supports that patient-centered communication skills may be promoted through communication skill training in general practice . Objective feedback through role play , audiotape or videotape is effective . However, one article revealed that physicians do not transfer these learned skills to clinical practice as comprehensively as they should . The actual situation in clinical communication is different from other form of training method. Each clinical consultation is influenced by physician factors (e.g. sleepiness, burnout, expertise and cognitive load), patient factors (e.g. presentation complexity, diagnostic suggestion and background) and clinical environment (e.g. appointment length, setting and functionality of electronic health record) . Everyone is unique, physician as well. We can’t just copy the communication skills from our teachers. Therefore, recurrent practice, feedback and self-awareness from clinical consultations should ensure a more effective transfer of skills. And physician can find a style in consultation that comfortable and right for them.
Clinical communication skills are unlike everyday conversation. There is affected by many unpredictable factors and no fixed format. Although there are lots of method to learn communication skills, it is difficult to develop the personal right and comfortable style. Understanding the five steps of clinical communication skills logically makes us more flexible in its application.
All work was done by Kwong Ho Tam.
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