Linda Finemann, DVM, DACVIM (Oncology)
Ethos Veterinary Health, LLC; Washington State University
Posted on 2018-06-05 in Client Care
Clinical communication skills are extremely important. This blog post covers five core clinical communication skills: asking open-ended questions, reflective listening, eliciting client perspective, non-verbal communication, and empathy. For each skill, we will define what the skill is, why it should be used, and how to do so. While we will focus our conversations on clinical contexts, the same skills are used in managing people, teams and conflict.
Before diving into the skills, let’s consider why clinical communication skills bring value to medical care and your business. The primary goal in focusing on communication skills is to improve clinical outcomes, which may include decreased risk of medical errors, greater adherence to medical recommendations, higher client satisfaction, higher net promotor scores for clients and employees, more effective team communication and morale, and increased efficiency. In human medicine, there is an increasing awareness of how critical communication skills are, and there is a body of literature showing that use of communication skills leads directly to happier and healthier patients and caregivers. From a business standpoint, satisfied clients are less likely to lodge complaints, pay their bills, and return to your practice, and employees are more likely to stay.
We can think about clinical communication skills as bridging the gap between evidence-based medicine and the individual patient/client. One study looking at dental and surgical patients found that only 30% of clients adhered to post-procedural recommendations. Those that had clear instructions were 7-fold more likely to adhere to recommendations. Those clients that adhered had trust in the care provided, which was manifested in increased client satisfaction, a foundation of relationship-centered care, longer appointment times, and expressions of empathy and a feeling of not being rushed. Another study in veterinary oncology clients and patients showed a correlation between clinical outcomes and communication skills. When communication was tailored to the client, they gained a clear understanding of the cancer, that was enhanced by using the client’s preferred means of hearing information. The clinicians also communicated in a direct, yet empathetic style, and found relevant past experiences to share. Using these tools of effective communication allowed the clients to make informed decisions, have trust in the treatment plan, and a greater ability to cope with the pet’s condition, making them more likely to commit to and follow through on therapy.
Delivering information effectively requires some understanding about differences in learning styles. Some different styles include auditory, written, visual, kinesthetic, big-picture or detail oriented, and personality type. DiSC is a system of thinking about communication styles as they relate to personality type, and is geared towards how we communicate at work. Having familiarity with this framework may help you begin to see how you can flex your own communication style to meet client’s needs. Here is a link to a free online DiSC test: https://discpersonalitytesting.com/free-disc-test/
In human and veterinary medicine, the older style paternalistic approach is giving way to relationship- centered communication. The driver in human medicine has been partly a reflection of reimbursement rates for medical services now being tied to patient satisfaction scores. In veterinary medicine, competition has increased and with the wide reach of social media and online references, client satisfaction has become an area of focus.
Another way to think about communication styles in healthcare is in the context of the type of situation a client and patient are presenting for. For example, in dealing with an acute situation, the care team will need to act quickly as an expert in charge, helping the clients to reach a decision in a matter of minutes. On the other end of the spectrum, patients with chronic diseases instead need a facilitator to help them manage the disease on their own terms. At both extremes, building a foundation of trust is essential to success.
The Calgary-Cambridge Guide was first described in 2003, and provides a context for thinking about clinical communication. In it, Suzanne Kurtz describes parallel processes that are occurring in the exam rooms: while we are gathering a history, performing a physical and developing an assessment and plan, we are synchronously providing needed structure to help move the interaction along and building a relationship with the client.
For each of the skills we will discuss today, we’ll focus on defining what the skill is, discuss why we should use it, and practice how to do so.
Non-verbal communication is all the behavioral signals that go on between individuals during an interaction, except what is stated verbally. This skill is the foundation for effective relationship building. One reason that this skill is so important is that when there is dissonance between verbal and non-verbal communication, the latter is what is most influential. Some studies suggest that up to 93% of the message comes from non-verbal cues when there is disagreement between verbal and non-verbal communication. When working on non-verbal communication, start by raising your level of awareness through observation. Then, follow your observations with a verbal check-in to verify your findings. The third step is to start to notice your own non-verbal communication and the impact it has on others. One powerful non-verbal technique is to consciously pause during interactions. By doing so, you open space for the other person to speak and share their thoughts that otherwise might get missed. In one study, interruptions occurred in 55% of appointments, and 72% of clients did not get a chance to come back and finish their thoughts. In that study, veterinarians interrupted clients after an average of 15.3 seconds, which is similar to what happens with physicians and patients, where the average time until interruption is 12-18 seconds.
Asking open-ended questions
An open-ended question is a question without a predefined format for the answer. It is an unstructured question which permits the respondent to answer without the questioner shaping the content. These questions usually begin with words like how, what, when, where or why, or phrases such as tell me about that, or say more. An open-ended question is exploratory in nature. Open-ended questions are used to gain the client’s perspective on medical and social factors which may be important in decision-making. As a manager or leader, this skill is useful in preventing or resolving conflict on teams as well. Using open-ended questions helps a client or employee feel heard, leading to higher satisfaction. Interestingly, using open-ended question helps to improve efficiency in the exam room, which may seem counter-intuitive. In one study, failure to use open-ended questions resulted in a 4-fold increase in having a new concern voiced at the end of the interview. The technique for using open-ended questions involves starting with broad open-ended questions (“casting a net”) and then following up with clarifying questions which are more closed, and focused on details.
Reflective listening involves paraphrasing what is heard to check for understanding. Using reflective listening ensures that the client or employee feels that they’ve been heard, and provides an opportunity for them to make corrections if needed. This form of active listening creates a sense of relationship-based communication, helping to form a foundation of trust. When using this skill, a clinician or manager might use phrases like, “I think what I heard is…do I have that right?”
Empathy is the ability to see something through someone else’s perspective. Empathy statements name and appreciate another person’s point of view. It is not necessary to agree with another person’s perspective to feel empathy. Showing empathy is a key part of garnering trust and building a relationship, leading to improved clinical outcomes and greater client and caregiver satisfaction. In one study, empathy statements occurred in only 7% of veterinary appointments. One way to learn to show empathy is the inhale-exhale technique. During the inhale, listen to the story and take it in, paying attention to the other person’s thoughts, feelings, and values. While doing so, imagine what it would be like to be in their situation. On the exhale, report your understanding through your words and non-verbal actions.
Communication skills are like any other technical skill: they take practice and feedback to hone them. Consider creating a specific plan to practice, and engaging your team to provide feedback to help you improve.
Eliciting client’s perspective
Eliciting client’s perspective is about learning what the client’s ideas and beliefs are, what concerns and expectations they have, and how their pet fits into their life, and what they are feeling about these things.
The 3 components of gathering information in taking a history include the biomedical data, the client perspective, and the background information. Biomedical data is focused on thing like the presenting complaint and details of the events that led up to the visit. The background information is about previous medical problems, current medications, etc. Eliciting the client’s perspective aims to understand what the other factors are that will contribute to a client’s decision-making process, and include ideas and beliefs, concerns, expectations, effects on their and their family’s life, and any emotions or feelings they may be experiencing.
There are two main approaches to eliciting the client’s perspective. The first is to directly ask the client what their ideas, concerns, expectations and feelings are. The second is to focus on verbal and non-verbal cues, then further investigate what is observed. Talking about feelings is often very difficult for healthcare providers. When ready to move on, consider using an empathetic statement of acknowledgement of the emotion shared and then ask permission to move to the next steps.
How do we know that our attempts at communication have been successful? Look for repetition of words or non-verbal cues. Repetition usually indicates that the person we are interacting with has not felt heard. When you notice repetition, address any unresolved issues by acknowledging them and diving deeper. Communication skills are just like any other learned skill: they require practice. Make a commitment to focusing on one skill at a time, and develop your own plan for feedback and monitoring successful adaptation of these skills into your daily life.
- Abood SK. Increasing adherence in practice: making your clients partners in care. Vet Clin North Am Small Anim Pract 2007;37(1):151-64.
- Britten N, Stevenson FA, Barry CA, et al. Misunderstandings in prescribing decisions in general practice: qualitative study. Brit Med J 2000;320(7233):484-8.
- Dowell J, Jones A and Snadden D. Exploring medication use to seek concordance with ‘non-adherent’ patients: a qualitative study. Br J Gen Pract 2002;52(474):24-32.
- Dysart LM, Coe JB, Adams CL. Analysis of solicitation of client concerns in companion animal practice. J Am Vet Med Assoc. 2011;238(12):1609-15.
- Kanji N, Coe JB, Adams CL, Shaw JR. Effect of veterinarian-client-patient interactions on client adherence to dentistry and surgery recommendations in companion-animal practice. J Am Vet Med Assoc. 2012; 240(4):427-36.
- Kurtz S, Silverman J, Benson J and Draper J. Marrying content and process in clinical method teaching: enhancing the Calgary-Cambridge Guides. Acad Med. 2003;78(8): 802-9.
- Lussier MT and Richard C. Because one shoe doesn’t fit all: a repertoire of doctor-patient relationships. Can Fam Physician. 2008;54(8): 1089-92, 1096-9.
- Menendez ME, Chen, NC, Mudgal, CS, et al. Physician Empathy as a Driver of Hand Surgery Patient Satisfaction; J Hand Surg Am. 2015;40(9):1860-5.
- Oyama MA, Rush JE, O’Sullivan ML, et al. Perceptions and priorities of owners of dogs with heart disease regarding quality versus quantity of life for their pets. J Am Vet Med Assoc. 2008;233(1):104-8.
- Shaw JR. Vet Clin North Am Small Anim Pract. Four core communication skills of highly effective practitioners. 2006;36(2):385-96.
- Shaw JR, Adams CL, Bonnett BN, et al. Use of the roter interaction analysis system to analyze veterinarian-client- patient communication in companion animal practice. J Am Vet Med Assoc. 2004;225(2):222-9.
- Stoewen DL, Coe JB, MacMartin C, et al. Qualitative study of the communication expectations of clients accessing oncology care at a tertiary referral center for dogs with life-limiting cancer. J Am Vet Med Assoc. 2014;245(7):785-95.
- Tambyln R, Abrahamowicz M, Dauphinee D, et al. Physician scores on a national clinical skills examination as predictors of complaints to the medical regulatory authorities. J Am Med Assoc. 2007;298 (9):993-1001.
About the author
Dr. Fineman has 20 years of experience in specialty and emergency private practice. In addition, she was a practice owner of a 60 veterinarian multi-specialty practice in the Bay Area of California. After relocating to Denver, Colorado, Dr. Fineman was Medical Director at VCA Alameda East, a 45 doctor practice. Dr. Fineman is an Adjunct Professor at Washington State University, where she spends time each year working with sophomore veterinary students in their introduction to clinical problem-solving and client communication using simulated cases. She also works with Colorado State University as a coach in the junior clinical communications lab and the FRANK communications training program. Dr. Fineman lives in Denver, Colorado, with her husband, two cats, a Doberman, and six chickens. She enjoys international travel, bird-watching and hiking.