EVIDENCE INFORMED PRACTICE

the patient. The aim of this process is not just to regurgitate exactly what was said, but is a more dynamic response, which also allows the therapist to provide encouragement, support and advice.

A practitioner could quickly learn the skill of reflective listening. Try matching not only their body language (if open), but also the patient’s vocal tonality and choose similar constructive vocabulary. Attentive listening is not rushed, so avoid talking over or at the patient with fast complex dialogue, as patients will find this tiring or confrontational. In essence, a practitioner with the skill of reflective listening will reap the rewards of building a trustful and respectful relationship with their patient. Practise this by trying the practical challenge on reflective listening (Box 1).

SKILLED THINKING Skilled thinking is the art form where a practitioner intelligently responds to the information provided by the patient. It’s not just a matter of giving clever answers, but the practitioner replies using a combination of their wisdom, clinical experience and medical knowledge. Therefore, you should adapt and change your choice of questions in response to your patient’s answers, body language and non-verbal cues, rather than using a mandatory list of standard history-taking questions. Allow room for the patient to reflect

on what’s been said. Try to avoid a constant barrage of questions to the patient, but allow a natural, free flowing conversation, as ‘skilled thinking will only be possible if you are skilled in active listening’. A skilled thinker’s reply could also lead into the next relevant question or even a series of questions, like a professional snooker player would already have mentally analysed the next few moves in advance. Two old proverbs are still relevant to this art form, ‘You have two ears and one mouth’ and ‘Think before you speak’. Sometimes a short pause before a response, often called ‘active silence’, will enhance your skilled thinking.

HOW WE MAKE THE ‘WHAT’ EFFECTIVE After many years spent studying to qualify in your chosen field, the

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skills, knowledge and experience are ‘what’ we want to bring to patients. Communication is therefore how we make this ‘what’ effective (1). Without making this ‘what’ effective

you could be the most academic student from your graduation class, yet you will make little impact in your day-to-day practice unless you can communicate effectively with real patients.

NON-VERBAL COMMUNICATION CAN BE SUBTLE We have all relied on our non-verbal communication skills when assessing a patient where there is a language barrier. However, it is very easy for these subtle skills to slip when talking to someone in our first language. Clinical intuition is thought to be an advanced communication skill to detect non-verbal signs of communication linked with physical symptoms. Often therapists miss vital behavioural clues given by patients; having the ability to recognise these subtle clues improves with more clinical experience. Non-verbal behavioural clues often

missed: n Creating more personal space n Closed body language n Reducing direct eye contact n Quieter voice, change in vocal pitch n Slowing of speech, being unclear n Patient not retaining accurate historical information.

Check your skills in non-verbal communication with the practical challenge in Box 2.

MISCOMMUNICATION The term miscommunication in reality means that both parties have left a conversation with a different

BOX 1: PRACTICAL CHALLENGE – REFLECTIVE LISTENING

Ask a colleague to tell you about a short but significant event in their life, and then try to repeat, paraphrase and summarise what they just told you. Then ask this colleague if there were any gaps or differences between the original portrayed story and your paraphrased version.

(Record this exercise on an dictaphone to get feedback)

BOX 2: PRACTICAL CHALLENGE – NON- VERBAL COMMUNICATION

Ask a colleague to sit directly in front of you to act as the patient. Then ask them to have a closed body posture, reply with short answers and avoid direct eye contact, while you ask them a series of subjective questions about a pretend or old injury.

Then repeat the same questions with an open posture, relaxed clear dialogue, using reflective listening and skilled thinking, etc…

Even in this role-play exercise, you will notice the difference in how much more information was gathered by incorporating the skills of advanced communication.

(Record this exercise on a video clip to get feedback)

SKILLS WILL IMMEDIATELY IMPROVE YOUR PRACTICE

interpretation or perception of the dialogue spoken. After some time to reflect, therapists should be encouraged to discuss with their patients any small differences in understanding that may have previously arisen, at their next follow-up appointment. The majority of formal written complaints to health professional bodies each year are resolved once an independent third party intervenes to resolve a simple breakdown in communication between the therapist and patient that frequently started as miscommunication.

PATIENT–THERAPIST PARTNERSHIP To avoid miscommunication a successful medical encounter requires effective communication between the patient and the therapist. If the patient can trust the therapist a natural ‘partnership’ can develop. In this partnership, the patient will frequently perceive that the medical encounter was a success, especially if the patient received a comprehensive physical examination, was educated about the nature of their condition and was given a working hypothesis to address their physical problem.

D’Ambrosia (2) recognised the importance of a successful medical encounter where the patient is

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IMPROVING YOUR COMMUNICATION