Communication: Skills development

How is the clinical consultation like a game of tennis? A good coach can help, says GP and trainer Dr Malcolm Thomas

COMMUNICATING effectively with patients is important. Everyone says so. The GMC has progressively refined their undergraduate curriculum to reflect it. The GDC now recognises this for dental students. Postgraduate training programmes increasingly teach and assess relevant communication skills.

Yet qualified GPs and hospital practitioners – whether medical or dental – have few training opportunities to further their abilities.

Maybe it doesn’t matter. Maybe communication can’t be taught. Or perhaps, if it is taught, it just leads to the ‘Have a nice day’ culture.

Why communication matters

The clinical consultation is an artificial business at the best of times. It’s not a chat with a mate, or a business meeting, or a lecture (although at times it may contain elements of any of these).

So if it is an artificial situation, perhaps a bit of artifice would not go amiss.

Certainly research shows that specific aspects of the consultation are related to improved clinical outcomes and reduced medico-legal risk. We know the sorts of behaviours that help clinicians to discover clinically relevant information in the fastest way. We have clues to the ways in which patients can be put more at ease and reveal their deeper concerns. We know something about how to explain and give information to patients. And we have some good evidence to help us make individualised plans with patients, which improve the odds that they will stick to the plan we hatch.

To take a specific example, interpersonal skills are known to be important in drawing out clinically relevant information from patients. Deliberately asking for the full range of patient concerns at an early stage is related to finding out more information and missing less of what is crucial. In fact, Heritage and colleagues1 reported the specific value of a single word in their study. They found that asking “Was there some other concern that you wanted to mention today?” was a more productive question than “Was there any other concern that you wanted to mention today?”

And which of us has not experienced the power of picking up on a look, a hesitation, a word. Something along the lines of:

Doctor: “You seem a little worried …”
Patient: “Well … What do you make of this?” [exposes suspicious skin lesion]

Explanation scenarios

To take another example, most doctors and dentists have a series of well-polished, standard little mini-lectures covering 95 per cent of all clinical encounters. In my experience as a coach, these ‘explanation scenarios’ typically contain a fair bit of information that the patient is not interested in – at the same time failing to reveal or answer the patient’s main questions. Research backs this up.

So why not avoid this and sometimes save a little time by: 

  • asking the patient what they want to know 
  • finding out what the patient already does know 
  • organise our explanations to fill the gaps 
  • make a small number of well-organised points 
  • make use of pictures, models and lists.

These are all skills that can be taught, learned and improved – no matter what level the learner starts at. And we have some pretty good evidence of which teaching and learning methods produce the best outcomes in practice.

Talking tennis

It turns out that the best approach to improving communication skills focuses on behaviours, because these can be analysed and potentially changed. This behaviourist approach has injected life into teaching and training, especially for medical students and GP registrars. It finds its most comprehensive expression in the Calgary Cambridge framework.

The Calgary Cambridge authors brought together their combined experience of UK and North American research and teaching on the clinical consultation. In particular, they searched through the literature to find evidence about which skills doctors and dentists should use when communicating with their patients. A parallel search was conducted to discover the teaching and learning methods that have best been shown to help clinicians pick up new skills to use in daily practice with their patients.

This collaboration resulted in two books of which one – Skills for Communicating with Patients2 – is the most comprehensive statement of the evidence and is required reading for all practising clinicians.

A fair analogy to the behaviourist approach can be made with the game of tennis. People vary in their natural ability to play tennis, but most ablebodied people would be able to play the game. No matter how innately talented you are, however, coaching and practice improve your tennis.

And here’s the thing. An ordinary player, with good coaching and practice, will soon overtake a naturally gifted player who isn’t coached. Furthermore, practising without coaching usually leads to a plateau in performance and the ingraining of bad habits. What does this mean for doctors and dentists?

The clinical consultation has some analogies with a tennis game. There are usually two players, and the play passes from one to the other in turns. The analogy only goes so far – after all there aren’t many forehand ground strokes (or overhead slams, let’s hope) in the typical consultation. But for a tennis player, it is ideal to have your own coach – to review your performance regularly and then design specific training and practice which addresses any concerns agreed between coach and ‘player’ (clinician). This is expensive in time and money and probably beyond what most clinicians will sign up to at the present time.

The next best thing for a tennis player or a clinician would be a series of master classes, where specific aspects would be taught to a small group with a trainer who could respond to individual learning needs. Such training is becoming more available for doctors and dentists.

In summary the interpersonal behaviours needed by doctors and dentists to have safe, effective clinical consultations can be analysed, coached and learned. No matter how gifted you already are, you can improve your effectiveness and reduce your risk.

  • Dr Malcolm Thomas is a GP and founder of the training company EPI


1. Heritage J et al. Reducing Patient’s Unmet Concerns in Primary Care: the Difference One Word Can Make. J. Gen. Int. Med. 2007; 22: 1429-33
2. Silverman J, Kurtz S, Draper J. Skills for Communicating with Patients. Radcliffe Press, Oxford. 2nd edn 2004