CLINICAL COMMUNICATION
Alice Thacker (UK)

The General Medical Council (1993) consider effective and sensitive communication to be one of the "essentials of basic clinical method". "Doctors must be good listeners if they are to understand the problems of their patients and they must be able to provide advice and explanations that are comprehensible to patients and their relatives".

In 2001, the GMC augmented this with an outline of what constitutes good clinical care: "proficiency in communication skills, including the ability to obtain and record a comprehensive patient-centred history... professional attitudes and behaviour that facilitate effective and appropriate interaction with patients and colleagues ... Demonstrate respect for patients and colleagues that encompasses, without prejudice, diversity of background and opportunity, language, culture and way of life...".

The chapter focuses on certain practical aspects of ensuring ethical practice with individuals with cognitive and/or communicative disabilities.

Identifying yourself

In any situation, be sure to identify yourself as the doctor or medical student - a patient cannot make valid decisions if they are not sure who is informing, or questioning them. It may be helpful to briefly re-introduce yourself at the beginning of each contact, as many people have trouble remembering faces and names.


Eliciting and explaining

It is extremely important to allow patients to express their own perceptions of their problems. To this end, you should have a pen and paper on hand for yourself and the patient. Communication through pictures and written words is favoured by some people over spoken language. Prepared materials exist which may help patients to describe what they are experiencing, or what has happened to them:

The above examples are taken from the Books Beyond Words series (see References, below).

  

Pictures can be very useful in helping a person with language or memory problems to understand your message. Such materials are designed to show, for example, clinical procedures and outcomes in a concrete way.   When drawing an internal body part, always put it in context of the outer `body. That is, a drawing of a kidney or a lung in isolation will mean nothing to many people; show a "cutaway" view of the back or the chest, with anatomical landmarks, to aid understanding.

Concepts of time can be very difficult. Some patients may have little idea of such measures of time as weeks or months and may struggle to distinguish questions about a single event from questions about duration of a state or condition.

Techniques which you may find helpful include:
  • using pictures of sunrises or of beds to establish how many days or nights a symptom has persisted along with the question: "How many times have you gone to bed feeling this pain?".
  • linking symptoms to an "index event", that is, an event that is important to the patient and which they are therefore likely to remember, such as their birthday, a holiday, or the death of someone close to them. You will need to confirm the corresponding dates with a relative or carer.

In checking patients' comprehension, never be satisfied with asking, "Do you understand what I just told you?" Many patients will acquiesce and say "yes" in order to be agreeable, even though they have not in fact understood everything. It may be helpful to invite patients to say in their own words what they have heard. A sample consultation appears below.


Negotiating consent:

Capacity to make decisions:

Patients with intellectual disabilities and others who have lived in institutions may be unaccustomed to making choices, although they may be competent to do so. It can be useful to establish whether patients have experience of making decisions in daily life using concrete, mundane examples, such as; "Can you choose the clothes you wear? Can you say 'yes, I want to wear jeans today', or does someone else always choose for you?"

The benefits and risks of having the recommended treatment:

Patients may have a concrete view of the procedures that you are proposing. A person with intellectual disabilities may think only about the temporary pain of a procedure, and not be able to visualise the health problems that it prevents. You might need to present these in visual form - either using pictures or demonstrating procedures on yourself or a colleague.

When a person is refusing a blood test, for example, because of the immediate discomfort, it is helpful to demonstrate and emphasise that any distress is short-lived.


It is common for people with limited language to struggle with conditional statements, for example "If you don't have surgery that growth on your ovary will continue to get bigger and cause more pain".

Checking Comprehension:

When asked, "do you understand?" during a consultation, patients with intellectual disabilities may well answer in the affirmative.

A method found to be effective in determining whether the patient has understood and retained important information is to invite patients to repeat back what you have said, for example:

Doctor: Your right eardrum looks a bit inflamed because of a little infection. I'm going to give you some medicine that you need to take at home. First, a tablet to get rid of the infection. You take one tablet right after breakfast, one after lunch, and one after your evening meal. You should take them when your tum is full of food. You must take the full course of tablets. I'll also give you a bottle of eardrops. Put three drops in your ear in the evening, and then plug that ear with a little piece of cotton wool so the drops don't come out.
Okay? Do you understand?
Patient: Yes, thank you.
Doctor: I just want to make sure that I told you right. Can you tell me in your own words about the medication?
Patient: Well, I take one tablet after breakfast, another one after lunch, and another one after my dinner. And I have to put a drop in my ear after breakfast, at noon, and night. That's all.
Doctor: Um .. let me explain again about the drops .. you only put them in once a day, for example at home in the evening, but you put in three at a time. You're right about the tablets, though. Can you tell me, how long should you carry on taking the tablets?
Patient: Oh, I forget…. Until my ear is better?
Doctor: No, you must take ALL the tablets, just carry on three times a day until the bottle is empty, okay?
Patient: Okay, three drops, just one time every night, and take all the tablets in the bottle.

By using this method, the doctor discovered points which the patient had not understood. The doctor would not have got this information without asking, "do you understand?".

References:

General Medical Council (1993), Tomorrow's Doctors, London, GMC

General Medical Council (2001), Draft Recommendations on Undergraduate Medical Education. Consultation copy, London GMC


Illustrations from:

Hollins, S., and Sinason, V. (1992) Jenny Speaks Out. Books Beyond Words, Royal College of Psychiatrists/St. George's, University of London.

Hollins, S., and Sinason, V. (1993) Bob Tells All. Books Beyond Words, Royal College of Psychiatrists/St. George's, University of London.

Hollins, S., Bernal, J., and Gregory, M. (1996) Going to the Doctor. Books Beyond Words, Royal College of Psychiatrists/St. George's, University of London.

Hollins, S., Bernal, J. and Thacker, A. (1999) Getting on with Epilepsy. Books Beyond Words, Royal College of Psychiatrists/St. George's, University of London.


All titles in the Books Beyond Words series are available at £10 from:
The Royal College of Psychiatrists
17 Belgrave Square
London, SW1X 8PG
United Kingdom

Tel: 020 7235 2351 ext 146

This article first appeared on the site in 2002.

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