HM Medical Clinic

 

Chec.meu.medicine.unimelb.edu.au

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september 2009
A pArtnership project:
University of technology, sydney (Uts) and family Planning nsW (fPnsW) Uts teAm: diana slade, hermine scheeres, helen de silva Joyce,
Jeannette mcgregor, nicole stanton and maria herke FpnsW teAm: edith Weisberg and deborah bateson

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We would like to thank the staff of Family Planning NSW, Ashfield who were partners in this project and who supported our research endeavours and allowed us to observe, tape and investigate the sexual and reproductive health consultations between doctors and clients.
At al times the staff and clients were remarkably generous, being prepared to share their experiences and their insights about the health consultations and to openly discuss the communication that occurs between the doctors and the clients.
The rich and authentic video and audio recorded data col ected as part of the research has enabled us to undertake a unique analysis of the language of the consultations between doctors and clients. We trust our observations and research findings will be useful to Family Planning organisations and to General Practitioners who undertake sexual and reproductive health consultations.
Funding for this project was generously provided by the University of Technology, Sydney through a Partnership Grant and by Family Planning NSW.
Note: Pseudonyms have been used throughout this report and in all other published material.
ISBN 978-1-86365-872-0 Document design: hummingstudio.com Developing effective communication Between Doctors anD clients next page
factors influencing overall effective communications aims of the Project sharing Understanding of client's Problem or concern recognising and validating client's concerns 1.2.1 data collection communication mismatches types of consultations length of consultations fPnsW – the organisation organisational culture values and beliefs of medical staff communication strategies in consultations communication difficulties in consultations communication strategies in consultations communicating medical knowledge 4.2.1 developing shared knowledge and shared 4.2.2 Providing and checking information has been 4.2.3 Presenting medical knowledge and expertise 4.2.4 indentifying, valuing and negotiating issues that are important to the client communicating the doctor-client relationship: rapport and empathy / sexual anD reproDuctive health consultations next page
Family Planning NSW (FPNSW), Ashfield, is a professional, col egial and friendly environment. Staff strive to create a context where reciprocal interpersonal relationships between clients and staff are integrated with medical expertise and practice next page
while the project focussed on the doctors and their communicative encounters with clients, staff involvement extended from the ceo of fpnsw to the nurses and clerical staff. sixteen fpnsw staff were interviewed, including doctors, a nurse, a clerical staff member and management. in addition, focus groups were held and non-participant observations of work practices and specific observations of consultations were carried out in order to familiarise the research team with the family planning context. twenty doctor-client consultations involving six individual doctors were video and audio recorded. the consultations, interviews and focus groups executive
were transcribed and analysed, field notes were taken and relevant documents were examined. the research was conducted over approximately one year. analysis of the data began during the data collection phase and continued for eight months after visits to the research site were completed. ethics clearance was obtained from both partner organisations, and the project followed rigorous ethical procedures. informed consent was obtained from participating clients and staff, transcripts were de-identified and all data were stored securely.
consultations were characterised by extremely high levels of communicative competence on the part of the doctors. there was a significant match between what the clients and doctors understood as the main messages and meanings of the consultations. Both clients and doctors expressed satisfaction with procedures and communication in terms of information and explanations given and received, examinations, length of consultation time, empathy, rapport and advice. the consultations at fpnsw are usually 30 minutes in length in order to accommodate training requirements. for practical national y and international y there is an increasing recognition of the reasons the taped consultations in the study were also 30 minutes critical importance and impact of communication within health care in duration and did not include a training practitioner. the positive settings. the link between ineffective communication, communication impact on communication of this extended time frame and the breakdowns, client dissatisfaction, negative client outcomes and critical limitations of translating the findings into time-poor settings including incidents is now well established, particularly within the acute care, general practice, are acknowledged. emergency and surgical contexts (eg nsw health 2005a; 2005b; a feature of the consultations was the way in which the rhodes et al. 2004). poor communication is the catalyst for most client doctors integrated medical expertise with a concern to establish an complaints (nhmrc 2004; nsw health care complaints commission interpersonal relationship that positioned the client as a confident and 2005; taylor et al. 2002), sometimes leading to costly litigation. knowledgeable partner. the doctors established rapport and empathy conversely, it is now well documented that effective communication with clients, while ensuring that medical content, processes and is a major contributor to client satisfaction with health care in general advice were explained in detail.
(o'Keefe 2001; salomon et al. 1999; sitzia and wood 1997).
each of the doctors, through a range of communicative the research site for this project, family planning nsw (fpnsw), strategies, ensured that clients were active participants in their own ashfield is a professional, col egial and friendly environment. staf strive healthcare and they strove to empower clients during all stages of the to create a context where reciprocal interpersonal relationships between consultations. this was achieved by: clients and staff are integrated with medical expertise and practice.
the professionalism and teamwork of the fpnsw staff were 1. developing shared knowledge and shared decision-making:
evident, and they demonstrated and articulated commitment to their » allowing space for a client to tell her story work, the organisation and their clients. staff showed an interest and » encouraging client participation and reflection through the use keenness to be involved in the project. evidence of this is the number of particular questions, statements and acknowledgements of doctors who agreed to have their consultations video-recorded, and » finding out what the client already knows their willingness to reflect on and discuss their communication with » moving from technical (medical) to common sense (everyday) researchers following the consultations.
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2. providing and checking information has been
Doctors often used a combination of strategies to check that clients understood » explaining processes regarding what wil happen next as well what was being explained or discussed. as about a client's condition and about the treatment and Non-verbal strategies further enhanced on-going management client empowerment, empathy and rapport.
» repeating key information verbally, checking and tracking questions and comments » providing written information to take away and using 3D » providing clear instructions for medication and other follow-up section 1 outlines the aims of the project and the research treatment, appointments, etc. methods. sections 2 and 3 of the report detail the purpose and type of consultations and interviews with staff. section 4 of the report 3. presenting medical knowledge and expertise:
describes the 20 doctor-client consultations including specific » making the reasoning processes for treatment, advice, etc. examples of the language and communication strategies the doctors available to the client used. section 5 discusses the post-consultation interviews with » communicating professional judgement sensitively doctors and clients. section 6 provides concluding comments and » asking for and valuing the client's knowledge and suggestions for professional development. the final section, section 7, outlines suggested recommendations.
a key outcome from the study is a detailed description and
4. identifying, valuing and negotiating issues that are
analysis of the interactions in fpnsw consultations, describing both important to the client:
the language and discourse features that constitute successful » negotiating between doctor and client about treatment interactions, as wel as the features that contribute to occasional » responding to a client's anxiety about her medical condition disparity between the messages conveyed and received by doctors » remaining non-discriminatory, non-judgemental, open and and clients. this, in turn, forms the basis of a framework for the description and analysis of doctor-client interactions applicable across a range of reproductive and sexual health contexts. the findings will the doctors used particular language choices to develop empathy contribute to professional development and service improvement and rapport including: approaches within fpnsw.
1. greeting the client with an informal introduction; using given the key recommendation arising from the project findings
names throughout the consultation; using we at key points in the is the design and delivery of two professional development modules for medical practitioners. the first module would explore in detail the 2. giving supportive, empathetic and reassuring feedback, verbally ways in which doctors can build an effective interpersonal relationship with clients at the same time as addressing clients' medical concerns. 3. expressing personal attitudes and values (doctor and client) the second module would build on the approaches and knowledge 4. mirroring the client's comments regarding symptoms, attitudes developed in the first module to produce video role-plays focussing on effective and less effective communicative situations. the role 5. interspersing some interpersonal chat with medical talk plays would be used for discussion and reflective activities.
6. using colloquial language and informal expressions7. using modality and modulation8. sharing laughter and jokes where appropriate9. using collaborative completions.
Doctors often used a combination of strategies to check that clients understood what was being explained or discussed. non-verbal strategies further enhanced client empowerment, empathy and rapport.
in some instances the practitioners gave very detailed and sometimes repetitive information which they were aware could overwhelm the client. occasional communication difficulties also arose with clients from cultural y and linguistical y diverse backgrounds when the framing of questions and statements was overly complex. Developing effective communication Between Doctors anD clients next page
Aims oF the project
the overall aim of the project was to understand how spoken messages are conveyed and received by doctors and clients in sexual health consultations. more specifically the aims were: 1. to describe and analyse the language and communication strategies used by doctors and and clients within consultations 2. to examine fpnsw consultations in terms of differing demographics, cultural and linguistic styles, beliefs and attitudes of both clients and doctors 3. through follow-up interviews, to analyse the congruence or disparity between the messages conveyed and received by both the research project focusseD on how communication doctors and clients.
unfolDs in consultations Between clients anD Doctors. the overall aim of the project was to unDerstanD how spoKen messages are conveyeD anD receiveD By Doctors anD clients in sexual health consultations at fpnsw, in ashfielD, syDney. in particular, the research centreD on DescriBing anD analysing the language anD communication strategies useD By Doctors anD clients within consultations to Discover the extent to which the data collection and analysis were carried out over a period of 12 all participants left the consultation with similar months from august 2007 to july 2008. the study used qualitative unDerstanDings or messages. ethnographic methods combined with discourse analysis and a study of non-verbal communication. the methods are outlined below.
initial familiarisation visits to the research site were undertaken which included an information session for staff outlining the project.
non-participant observations of the clinic at work, over a range of shifts, were undertaken.
field notes of familiarisation visits and observations were written.
interviews and focus groups
interviews, up to one hour in duration, were conducted with eight doctors, the chief executive officer, the Director of research, the senior medical coordinator, the medical Director, the Director of nursing, the clinic manager, a clinic nurse and the head receptionist.
staff focus groups, up to one hour in duration, were held with five doctors and management staff, including the medical Director, the Director of nursing, the clinic manager, the medical education coordinator and a clinic nurse.
post-consultation interviews, up to fifteen minutes in duration, were conducted with the doctors and clients who had been video-taped.
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twenty doctor-client consultations were video-taped and transcribed, involving six doctors and four of their clients.
observational notes were written by researchers during the video-taping.
interviews and focus groups were digitally recorded and transcribed.
a short take-away questionnaire was given to clients for follow-up comments.
the doctors participating in the videoed consultations were offered the opportunity to view and reflect on their consultations.
one-to-one meetings between doctors and one of the researchers were held to discuss and further reflect on consultations.
relevant clinic documentation was examined, including procedural guidelines and protocols, workplace policies, handouts and pamphlets.
the data were analysed in the following ways: Detailed discourse analysis was undertaken to identify the language and communication strategies used by doctors in the consultations.
interviews and focus groups were analysed for the themes that emerged.
observational notes were analysed to provide contextualised descriptions of the sociocultural conditions in which the consultations occurred.
relevant documents, including procedures and processes of consultations, leaflets and other information given to clients, were examined to provide wider contextual knowledge.
the most in-depth analysis was carried out on the consultation data. the interactions were professionally transcribed and the researchers then had both the videos and the writ en transcriptions of the consultations to examine. the theoretical approach to the discourse and language analysis was based on systemic functional linguistics, conversational analysis and pragmatics. the main focus of the linguistic analysis was on how the language of the consultations was structured and used in authentic sexual and reproductive health interactions. the focus was on how language makes meanings for the doctors and the clients in the social context of the consultation.
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the principal purpose of fpnsw consultations is to provide high-quality, evidence-based sexual and reproductive healthcare. the consultation data shows that doctors understand this purpose as involving medical and medically-related information, advice, discussion, explanation, procedures and treatment. however, it also shows foregrounding of interpersonal experiences and relationships through a focus on empathy and rapport, as seen in post-consultation remarks from one of the doctors: I think she told me what she wanted to tell me . I hope she took away a sense of being heard (post-consultation interview D2).
consultations this comment illustrates not only that the client is understood holistically,
but also that the consultation is understood as a site of interpersonal relations, as well as medically-related actions and information.
analysis of the consultations reveals them to be not only sites of high quality healthcare, but also sites that encourage and equip clients to become involved and to gain a sense of control in the section 2 proviDes an overview of the purpose anD type of decisions concerning their personal healthcare. fpnsw meDical consultations. while the principal purpose is to proviDe high-quality, eviDence-BaseD sexual anD one doctor explicitly described this process to her client during a reproDuctive healthcare. the consultation Data shows that Doctors are also aware of how important it is to Develop empathy anD rapport with clients. consultation This sort of thing is very much about you working out what is happening Data reveals four main categories of consultation which to you and what works for you and then us helping you to kind of fine will Be DetaileD in this section. tune it. But if it gives you a better sense of control over your life, then you can often make some changes in other areas that wil al ow you to have a more . consistently smooth existence (consultation c15). this was also recognised by the clients as seen in these remarks from two post-consultation interviews: Cause she said, like, she didn't push me into doing anything, she thoroughly explained what, which I did, as I said I did research so I sort of knew that there is things to do. And, as I said, because, and as she said, because I'm managing it that it's okay until it gets worse and I've got the option of coming, so that's good. It wasn't as if she was saying to me, oh, you have to do this or she was saying anything bad against it, which was really good, knowing that I can do either one or the other. And informed, yeah, properly. And I'll probably deal with my symptoms even better now knowing that that's just normal Analysis of the consultations reveals (post-consultation interview c14).
them to be not only sites of high quality Basical y … giving me the options, she's given me some materials to healthcare but also sites that encourage read about, read up on based on the questions I've asked about the and equip clients to become involved and contraceptives that I'm interested in. Um . and she's ordered tests to gain a sense of control in the decisions that I was hoping would be ordered in order to get some answers, concerning their personal healthcare. if there's any, to the main reason I'm here (post-consultation interview c05).
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in the post-consultation interviews the clients themselves articulated pre-procedural assessment consultations where the doctor talks both medically oriented and interpersonal reasons for their visits through structured information about procedures and possible to fpnsw. they saw their needs as being met general y by the side-effects and problems after a client has made a decision, organisation and met particularly by the doctors. the following client for example, to have an intrauterine device or contraceptive comments reflect the success of the consultations in meeting procedural consultations where the doctor carries out a procedure such as inserting a contraceptive device. the No, I think she's pretty easy to talk to, really (post-consultation interview c01).
consultation may include a review of the client's medical history and a preliminary test such as a pregnancy test.
Because I think she fully explains to you, as she's like, sympathetic towards what you're saying and she real y does understand that consultations can be divided into steps or stages, each with a specific (post-consultation interview c14).
purpose, for example, history-taking or diagnosis. many of the stages are an integral part of al consultation types; however, there are . in some ways I feel that my, the reason I'm here hasn't been some sections of each of the consultation types that are distinctive. brushed under the carpet (post-consultation interview c05).
fpnsw doctors are often able to predetermine the consultation type, for example, through access to written information provided by their I think she explains it really well and I like the fact that she's honest and clients regarding their problem or concerns. this allows the doctor to says it's not perfect . her honesty about it, not like . she doesn't sugar prepare for the consultation. Doctors are aware that there are often coat it, she's more direct and that's the kind of [person] just say it, it's other reasons for the visit that may need to be drawn out.
not going to work, this could work (post-consultation interview c17).
explicit knowledge of the structure of consultations based on in situ investigation, may be useful in the following ways: And they didn't try and pretend they knew everything. She listened allowing consultation protocols and guidelines to be updated to and went, okay. And then she did . the others were . sort of like, take account of what is considered usual or good practice they listened but they, it felt like they were looking down at you giving doctors authentic examples to use in training and because you couldn't have really suffered that long professional development activities (post-consultation interview c17).
illustrating how a consultation that is often presented as a linear process, is quite complex due to, for example, the recursiveness types oF consUltAtions
coupling a reflexive approach with doctors' own practices to examine the coherence of their consultations; question the place the recordings and transcriptions of consultations reveal four broad of digressions; explore whether there are too many repetitions or categories of consultation for the purposes of linguistic analysis. recursions, and so on.
these categories reflect the study content and do not in any way attempt to describe the breadth of consultation types in the sexual and reproductive health setting. it is acknowledged that consultations wil always include a mix of category types and a broad mixed type consultation has been included in the analysis. it is also noted that counselling type consultations are not included in the study which most likely reflects the fact that clients seeking counselling for sensitive issues may have declined to participate in the study.
the broad categories are:
management consultations where the doctor and the client FPNSW doctors are often able to pre- explore options for managing issues such as fertility control or determine the consultation type, for example, menopause. for example, a client may be asking advice about through access to written information contraceptive options or management of side effects (appendix 2 provided by their clients regarding their contains an example of a management consultation) problem or concerns. This al ows the doctor Diagnosis and treatment consultations where clients are seeking to prepare for the consultation. Doctors are diagnosis and treatment for symptoms such as a vaginal discharge or urinary frequency aware that there are often other reasons for the visit that may need to be drawn out.
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Extra time enables the doctor to length oF consUltAtions
lead the client to an understanding of her condition, and to an informed decision, and one of the main factors supporting the client-centred approach of it further enables the doctor to validate what fpnsw consultations is the 30-minute timeframe al ocated to these the client is feeling. consultations. this relatively long consultation time reflects the fact that fpnsw is a training organisation and many of the consultations would include the presence of another health professional for training think that's where they come right into it when they say, you purposes. it is acknowledged that this generous time schedule is not know, this sort of yoghurt. reflective of most busy general practice set ings, and translation of the Client: We've done, when I was in the south of France I wasn't study outcomes into other settings needs to consider this difference. near a pharmacy and I had it and I used yoghurt and that== the 30-minute timeframe allows for consultations with many stages, some of which recur as the doctor and client explore multiple facets Client: Yeah. Only because I hadn't, you know, wasn't able to get of client concerns and care. a distinctive feature that may arise from to, and that did work, it really helped a lot. the longer timeframe, and the consequent capacity to recycle stages, Doctor: Yeah. So it sort of, you know, people ask, well, what if I drink is the number of client and doctor digressions. Digressions are one of all those yoghurt drinks and the Yukult sort of drinks. There's the strategies doctors employ to develop rapport and the timeframe actually no evidence to show that it actually affects you presents opportunities for this and other strategies to occur. vaginally, you know in that way. I mean, it's certainly healthy, the following extract could be seen simply as an example of a they're healthy sort of things to do but I don't know if it wil have digression or as an occasion where rapport between doctor and client much effect on the vaginal, sort of using the yoghurt locally. is being constructed: Client: Okay (consultation c02).
Client: But then it says here, instead of using commercial lubricants within fpnsw consultations the client is seen as an informed which contain preservatives or antiseptics, try using [ ] or decision-maker and many clients in the post-consultation feedback sessions commented that it is the extra time given to them that Doctor: You could try yoghurt. motivates them to come to fpnsw, as seen in this client comment: Client: Okay. [SMALL LAUGH]Doctor: But, yeah, I think== Um, I feel it's a bit more relaxed, with Family Planning. And there's no Client: The thing is, I wouldn't be doing it if it hurt anyway, so like, way I would've been able to spend so much time with my GP because what is the reason to use it in the first place? of course . I mean, I have a good relationship with my GP but, then, Doctor: This is, this is, the reason to use what? he's a very, very busy man and I just feel . I'm conscious that, okay, Client: Any kind of lubricant. there are a lot of clients waiting as wel so I just try and get straight Doctor: Well, you know, I was actually just reading about it, cause to the point to try and get out of there as fast as I can. And I think I do we spoke about it last week, I rang you last week when myself a disservice there so I thought, okay, I'll come here because the results came back, and I was just reading the latest on I know that I can take a bit more time and go through, you know, it and one of the points was, and I don't, can't explain to concerns I have and get some questions answered you why but they said that, you know, maybe using some (post-consultation interview c05).
lubrication with intercourse may actual y help. But I don't know the mechanisms with that== extra time enables the doctor to lead the client to an understanding of Client: ==Right, okay. her condition, and to an informed decision, and it further enables the Doctor: So you may decide not to worry about that part. With the doctor to validate what the client is feeling. yoghurt, with sex, in the old days, like when I first did Family Planning which was about 20 years ago, we used to say one client's post-consultation comment sums this up: you could actually dip a tampon into acidophilous yoghurt, just plain acidophilous yoghurt, put it inside your vagina and For me? Wel , I was very pleased with the results because it's like leave it in for sort of 10 minutes and then remove it and what I actually thought and, like, I found that no-one really understood it works on making the vagina, it changes the flora in the me fully like she did. So, and that it was, I wasn't going mad or vagina and thrush don't – the flora means the bugs, the anything like that. So, it's good to know that that's actually normal, normal bugs – or the equilibrium of the bugs and thrush that I'm experiencing. Because I actual y thought it was al in my don't like that. So it's actually changing the acidity of the head at one stage. Cause I used to get right, left and centre different vagina by using acidophilous yoghurt in that way. And I information. So, yeah (post-consultation interview c14).
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with more time, more questions are asked and answered, more the client comments and the consultation extracts above demonstrate information is given and more extensive time can be spent exploring how strongly the interpersonal is foregrounded, particularly in the the client's experiences, as seen in this exchange.
building of empathy and rapport between doctor and client.
Despite the relatively long timeframe allocated, consultations Doctor: So if there are times, you say there's many times where it occasionally and inevitably run overtime with clients left in the waiting hasn't been as bad as other times and you just, what, it just room prior to their al ocated appointment. as noted by several of the sort of settles down==and goes away? doctors, this can impede communication as clients may become Client: ==Yeah, yeah. irritated or angry.
Doctor: And how long does it take to settle down? in the data set of 20 recorded consultations, seven ran overtime. Client: Four days. the longest consultation ran for 47 minutes and 18 seconds and Doctor: Okay. And do you use anything else to sort of, you know, are was characterised by lengthy digressions and many recursions. it you applying anything else? So you're just leaving it alone. is interesting to note that 13 of the recorded consultations were Client: Mm. completed well within the 30-minute allocation, with most concluded Doctor: And just washing with water, is that right? within 22 minutes. Despite the shorter duration, these consultations Client: Yeah. were characterised by effective communication strategies and high Doctor: So nothing else? client and doctor satisfaction. it may be useful to explore different Client: No. ways the interactions can combine medical and interpersonal Doctor: Okay. experiences satisfactorily without lengthy digressions or recursions.
Client: But I think when I have (been) sore, as I say, wearing like lycra clothes, it probably does aggravate it a little bit. Doctor: Yeah, yeah. So when you, how many times have you actually gone to the chemist and had==treatment? Client: ==About six or seven times.
Doctor: And tell me what you've used.
Client: Canesten.
Doctor: And what sort of dosage?Client: Oh, the sort of three day one. And the last one I used the new pill you take. Doctor: So the (Diflucan)==Client: ==Yeah.
Doctor: with the Canesten or separately?Client: Yeah, with the cream so.
Doctor: Canesten. So it's usual y the three days, over the six of those times maybe you've used the three day== Client: ==Yeah, yeah.
Doctor: the vaginal?Client: Yeah, yeah.
Doctor: Yep. And the last time was the tablet and== the cream?Client: ==Yep.
Doctor: And when you use it, do you notice any difference?Client: Wel , obviously, yeah, it does goes away. When it's been that bad I generally tend to== Doctor: ==Does it go away fairly promptly? Like the next day or Client: No. Normally t wo days (consultation c02).
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FpnsW – the orgAnisAtion
in this section the interviews with staff and the focus group findings are discussed. many of the interviewed staff members have worked at fpnsw for 10 to 20 years or longer. in the interviews and focus groups, the overal organisation was assessed very favourably by those interviewed. the positive working environment, team support, extended consultation times and the general effectiveness of communication within fpnsw emerged as important features. the values and beliefs of interviews
the doctors regarding their work were emphasised in their responses. Doctors' concern with the whole client is evident in their views of the roles and relationships of clients and doctors, their awareness anD focus
of the importance of client empowerment and their attitudes of respect and tolerance. analysis of the interviews and focus groups reveals the following four main themes:1. organisational culture2. values and beliefs of medical staff3. communication strategies in consultations4. communication difficulties in consultations.
most of the interview questions related directly to communication. notably however, the first two themes emerged spontaneously, even though there section 3 iDentifies the themes that emergeD from were no specific questions focussing on the organisation or the values interviews anD focus groups conDucteD with fpnsw and beliefs of staff (see appendix 3 for interview questions).
staff. in particular the organisational culture, which was assesseD very favouraBly By staff, will Be DiscusseD. the values anD Beliefs of the meDical staff will Be DetaileD inDicating their concern for the whole client. effective communication within the organisation
fpnsw is perceived by staff to communicate effectively as an
organisation, as can be seen in these comments:
Communication-wise they've done their best to keep all channels open as much as possible for us (interview Dr4).
[It] impresses me the way communication happens here at FP (interview Dr7).
effective communication within fpnsw contributes to a feeling of being in a positive and supportive team environment, as communication is so important to teamwork. some of the comments about communication began with statements such as it's not perfect but .. staff commented on the effectiveness of the email system in keeping them informed, and on administrative and medical staff Doctors' concern with the whole meetings as an opportunities for grievances to be aired. critically, client is evident in their views of the roles staff felt comfortable in speaking up if there was a problem. staff and relationships of clients and doctors, talked about informal grapevine communication such as chats their awareness of the importance of in the tearoom, staffroom and corridors, or when cleaning up a room together. in addition, in terms of professional communication client empowerment and their attitudes regarding clients, doctors noted that all their peers were generally of respect and tolerance. good at writing up notes and were conscious of the fact that / sexual anD reproDuctive health consultations next page
The culture of the organisation and the doctors' beliefs and values provide the context and underpinning for the communication strategies used in the everything really clearly needs to be documented and you've got to a client has with the organisation. clerical staff commented on the keep great notes.
importance of treating clients with respect and dignity. they are aware the organisation itself features strongly in interview responses. that the way you welcome someone in sets a feeling of the whole Both clerical and medical staff recognise the importance of the process. in a practical sense, doctors know that reception will remind organisational context and how people work together professional y them if they have clients waiting, or wil make clients tea and coffee if they are waiting for a long time.
positive working environment
extended consultation times
all staff commented on the special working environment of fpnsw, Doctors recognise that they are really fortunate in having half-hour seeing it as a great environment to work in. staff expressed both appointments. they are aware that this is only possible because gratitude and pleasure to be working in the organisation, as stated by fpnsw has a further responsibility as a professional development and training organisation. many of the doctors have worked previously, or work concurrently, as general practitioners where they have much We actually work like a family . and being in a family of women, shorter consultation times. the doctors noted that they stil need to we're all very understanding of each other (interview Dr3).
maintain boundaries around time but one commented that she never felt rushed. most commented on the happy and friendly atmosphere eg We get on well and it has a good vibe. comments were made about fpnsw being a supportive place to work eg We all feel, I feel supported and vAlUes And belieFs oF medicAl stAFF
valued. support was seen as professional, with staff encouraged to undertake ongoing professional development, and also personal, comments made by the doctors exemplify a number of shared with doctors able to work part-time and flexibly as their family lives underlying values and beliefs.
were taken into account. comments were made about the lack of hierarchy within the organisation, eg Everybody's very open and we roles and relationships of doctors and clients
feel we can approach everyone. a clerical staff member stated I feel as doctors discussed the ways they communicated with clients, there at ease knocking on the CEO's door and having a chat . I think that's were often strong indications that they believe medical components something special. of consultations needed to be seen as arising from, or part of, an interpersonal relationship, as can be seen in the following comments: team support
a theme that emerges very strongly in the interviews is one of
The woman that's sitting here is so important for me (interview Dr8).
support. al members of staff from the head receptionist through to the ceo feel supported by other members of the fp team. the ceo Treat people as people [rather than what's wrong with them] (interview Dr5).
felt supported by the directors and noted that the dedication of senior staff is such that they're here and available if needs be. the head ethos of client empowerment
receptionist felt supported by her management – You know if you a strong theme is the perceived importance of client empowerment can't handle it, someone else can. the clinic manager stated that and autonomy. Doctors understand that clients should be active she is strongly supported by senior management. one of the nurses agents in decisions about their sexual and reproductive health, as commented – We're working with very senior and experienced people seen in these comments: that are available at the drop of a hat. the doctors felt supported by everyone including clerical staff, nurses, other doctors and A lot of the stuff we do here is about empowering women (interview Dr9).
all the doctors speak about corridor consultations, of being able Because it's their body, it's their decision at the end of the day (interview Dr4).
to seek immediate advice and assistance from other members of the team, if needed. respectful, non-judgemental, open-minded approaches
many doctors talked about the availability and approachability of Doctors are very aware of the need to approach each consultation the medical Director for consultation and debriefing, describing her with no preconceived views, as highlighted in these comments: as very approachable and very encouraging. Doctors spoke about the support they received from the nurses who prepared pathology, You leave it [judgement] at the door (interview Dr5).
followed up clients and filled the drawers with goodies.
the role of reception is crucial in the fpnsw team as the staff We're all different and we just have to accept the diversity of people members who work at and around the front desk are the first contact (interview Dr4).
Developing effective communication Between Doctors anD clients next page
Make people feel unjudged . that's very important in getting people » repeating information and getting clients to repeat information to open up . to have a genuine interest and an open mind is really » talking slowly important (focus group 1). » giving clients a range of ideas about their problem and the culture of the organisation and the doctors' beliefs and values » letting clients know they do not need to make a decision provide the context and underpinning for the communication strategies used in the consultations. » validating aspects of their lives eg amount of discharge and » checking that people understand information, procedures etc commUnicAtion strAtegies
» encouraging people to ring back if they have questions » telling clients they do not have to answer if they find it too there was a general feeling that we … pride ourselves on being good communicators. in the interviews the doctors raised, and expanded on, a large number of strategies they employed. the commUnicAtion diFFicUlties
culture of the organisation and the doctors' values and perspectives in consUltAtions
on the purposes of their work translated into an array of rapport and empathy strategies and client empowerment strategies used in the the fpnsw doctors were asked to reflect on any obstacles that affected communication with clients. they expressed a variety of concerns ranging from distractions and organisational factors to rapport and empathy building
issues related to client knowledge and culture: to build rapport and empathy doctors saw initial contact as important. » Knowledge, language and cultural barriers with clients from they talked about how they welcome clients, set clients at ease and language backgrounds other than english, or clients with encourage clients to tell their story, using the following strategies: limited educational backgrounds can cause communication » greeting clients with a smile and a handshake difficulties. in some cases there is a need to use interpreters » welcoming clients or family members to translate and interpret » introducing themselves, usually by first name » relatives in the room, such as children or husbands, can » starting with an open question which allows the clients to cause communication problems because you're not dealing dictate the consultation with one person, you're dealing with two. for example, if a » making eye contact mother accompanies her daughter the doctor may feel the » actively listening with no interruptions and giving clients extra need to advocate for the daughter without putting mother off » organisational factors such as keeping people waiting or » prompting clients to encourage further information interruptions from phone calls can lead to defensiveness and » observing body language and facial expressions to see if the doctor has to gain their trust again. the doctors were clients are, for example, anxious or tired aware of trying to develop rapport but being conscious of the » talking during examinations on interpersonal topics such as consultation timeframe recipes or children » information-giving means striking a balance between giving » Being friendly, open and encouraging.
enough information so that clients can make their own decisions and giving too much information and overwhelming them with information. the doctors were conscious of Doctors said they encourage clients to give them as much information their medico-legal obligations in consultations and feeling as possible by using the strategies outlined above. in turn, the doctors an education imperative to inform the client, while using try to impart as much knowledge as they can to enable clients to technical language.
make informed decisions about their diagnosis, treatment and any procedures. Doctors also explain at al stages of the consultation what will be happening next by: » advising clients when they are going to ask personal » explaining procedures or when things might be painful » giving written information such as fact sheets and care plans » using diagrams and models / sexual anD reproDuctive health consultations next page
commUnicAtion strAtegies
Doctors need to learn complex rhetorical strategies that enable them to work with clients in building the shared knowledge that is vital for an accurate diagnosis and an effective treatment plan. the doctor must establish a medical diagnosis, develop a management and/or treatment plan and give advice, while at the same time building an interpersonal relationship with the client to enhance client control analysis of
and empowerment regarding their sexual and reproductive health. it is the balance between these two aspects of the consultation that determines the effectiveness of the consultation.
communication the analysis of the consultations focuses on the balance between
the medical and the interpersonal aspects of the consultations. it describes how medical knowledge and expertise are articulated and performed by doctors through their probing of the medical concerns of the clients. this is then mapped onto the clients' representations of their subjective experiences of what their problems are.
a key reason for attending to the interpersonal aspects of communication in the consultations is to point out that communicative in section 4 the analysis of the consultation Data is wellbeing is part of the consultation experience. if a client feels that presenteD anD DiscusseD. the analysis contains examples rapport and empathy have been established, this contributes to their of interactions Between clients anD Doctors that satisfaction with the consultation. illustrate many of the points raiseD in the interviews, the discussion that follows explores how the medical content, particularly the communication strategies useD By developed through advice, information, procedures and medication, and the Doctors. the analysis concentrates on how to the interpersonal relationship between the doctor and the client, are characterise anD achieve an effective Doctor-client represented in the interactions that were observed and video-taped.
relationship, anD it DescriBes the Discourse anD language to examine the consultation talk, the communication strategies features of successful negotiations Between clients anD used by doctors are divided into two broad categories. the first Doctors in fpnsw consultations. relates directly to the medical aspects of the consultations, and the second relates more specifically to the interpersonal aspects that doctors incorporated into their biomedical expertise and practice during the consultations. the two categories are communicating medical knowledge, and communicating the doctor-client relationship: developing rapport and empathy. the key features of these two areas are: communicating medical knowledge
1. Developing shared knowledge and shared decision-making:
» allowing space for a client to tell her story A key reason for attending to the » encouraging client participation and reflection through the use of particular questions, statements and acknowledgements interpersonal aspects of communication » finding out what the client already knows in the consultations is to point out that » moving from technical (medical) to common sense (everyday) communicative wel being is part of the consultation experience. If a client feels that rapport and empathy have been 2. providing and checking information has been understood: established, this contributes to their » explaining processes regarding what will happen next as well as about a client's condition and about treatment and satisfaction with the consultation. on-going management Developing effective communication Between Doctors anD clients next page
» repeating key information verbally, checking and tracking communicatively allowing the client to share in the decision- questions and comments making is one of the key features of the consultations. it is noted that » providing written information to take away and using 3D most of the other points and strategies could be seen as contributing to developing shared knowledge and decision-making in that a concern » providing clear instructions for medication and other follow-up with client empowerment is an important goal in the work of fpnsw treatment, appointments, etc.
staf general y. notwithstanding this recognition, it is useful to draw out some particular ways shared knowledge/decisions are developed.
3. presenting medical knowledge and expertise: in the fol owing extract the doctor introduces the idea that the » making the reasoning processes for treatment, advice, etc. client is suffering from depression. this is a key moment in this available to the client consultation in terms of getting the client to think about something » communicating professional judgement sensitively that she has not actually raised with the doctor as a concern: » asking for and valuing the client's knowledge and experiences.
Doctor: ==Now. I'm just wondering. I'm going to put an idea, I'm 4. identifying, valuing and negotiating issues that are important to just going to talk about an idea . , I suggested that we try the anti-depressants because of its properties for managing » negotiating between doctor and client about treatment premenstrual symptoms and of course you just take it for » responding to a client's anxiety about her medical condition a short period of time when that's happening. Now, I'm » remaining non-discriminatory, non-judgemental, open and actually wondering whether we've actually uncovered that you've got a bit of real depression== Client: ==Mm. communicating doctor-client relationship:
Doctor: that is there all the time. developing rapport and empathy
Client: I think I [sighs], well, I suppose post-traumatic stress 1. greeting the client with an informal introduction; using given disorder is something that I had identified by a counsellor. names throughout the consultation; using we at key points in the Doctor: Yeah (consultation c15).
2. giving supportive, empathetic and reassuring feedback, verbally the doctor leads the client towards considering that she might be suffering from depression. the client's response demonstrates 3. expressing personal attitudes and values (doctor and client) that she takes up the idea and the consultation goes on to discuss 4. mirroring client's comments regarding symptoms, attitudes or continuing anti-depressant medication not only for its original treatment purpose – managing premenstrual symptoms – but also 5. interspersing interpersonal chat with medical talk to manage depression. however, interestingly, depression is not 6. using colloquial language and informal expressions mentioned again by name in the rest of the consultation.
7. using modality and modulation what is notable in this extract are the strategies the doctor uses 8. sharing laughter and jokes to inform and lead the client into new thinking about her health. the 9. using collaborative completions.
doctor builds up indirect and mitigating language, for example, just wondering . , just going to . , actually wondering . , a bit of . , into what follows are examples from the consultations of each of the a question that leaves openings for the client to agree or disagree, categories above. in appendix 1 we describe a consultation that to add, to make further suggestions, etc. the doctor could have demonstrated a combination of these strategies.
chosen to make statements such as ‘your symptoms show that you are depressed' or ‘i think you are suffering from depression', or she could have asked a direct question such as ‘Do you think you are commUnicAting medicAl knoWledge
depressed?' in both these cases, the doctor would be positioning herself as a more definite assessor of the client's problem, and the opportunity to deviate from the ‘diagnosis' is limited.
developing shAred knoWledge
there are also examples in the consultation of the doctor And shAred decision-mAking
handing over control to the client very explicitly. this can be seen in comments such as: this broad category constitutes an overall framing for the consultations. fpnsw doctors empower clients by enabling and encouraging Doctor: And I'd like to know how you would feel about that them to be part of the decision-making process about their own (consultation c15). sexual and reproductive health. / sexual anD reproDuctive health consultations next page
FPNSW doctors empower clients by enabling and encouraging them to be part of the decision-making process about their own sexual and reproductive health. Doctor: I think you've got good insight, yeah (consultation c15).
Client: So there's not a lot of dif erence between how I feel when I have my period and when I took the first half of the tablet, it Doctor: Al right. Wel , look, I think we'l agree that you do it the way was almost identical that you've outlined to me. And maybe do it over another, Doctor: Right say, three months. And then let's review it (consultation c15).
Client: And . then when, when I stopped taking it after a few days I actually had a bit of a backlash of mood swings from the data, four discourse strategies have been identified that And I actually had a friend point out to me how erratic I was doctors use regularly to build shared knowledge and decision-making: being and . I don't know, maybe it's better to actually halve the dose again and then come of it real y slowly or whether I Allowing space for a client to tell her story
shouldn't take it as a full time thing. a common strategy used by al the doctors and used repeatedly by Client: Okay (consultation c15).
the same doctor in the one consultation, is eliciting and incorporating the client's ‘stories' into the medical encounter. Doctor: So we can start. Gemma, thanks very much for doing al of Doctors allow clients to talk at length about issues and this. How can I help you today?
concerns; they encourage and give space for client questions, as well Client: You called me because you've got the results back saying that as a chance to reflect on their experiences. you received the thrush results, that there was a moderate for example, an opening is created by the doctor through the amount of ==thrush so you wanted to see me following kinds of questions early in the consultation: Doctor: ==mm hm, mm hm, mm hm.
Client: and then also you said you wanted to do a recheck because Doctor: Now, how are you actually going? (consultation c05).
you thought there could be (a possibility of) polyps. Doctor: That's right, yep, yep. So, when I saw you== Doctor: And what kind of a day are you having, Alyssa? (consultation c05).
Client: ==and I had to go to get the breast ultrasound ==Doctor: ==Yep Doctor: How can I help you today? (consultation c18).
Client: which I have done.
Doctor: And that was normal. these open questions invite a narrative from the client. in the two Client: It was normal and they have said that I could have a (fine examples below, the clients are firstly given an opening to talk and needle) if I want to be 100% and I'm waiting to book that then encouraged to continue their stories through the supportive at the moment but I'm quite confident and comfortable that comments by the doctors that do not impede the communicative flow: Doctor: Okay so they gave you the option to have the (fine needle). Doctor: What side effects did you have?
Client: I didn't go to Sydney breast clinic in the end, I went to, I just Client: Well, initially, headaches. got a referral from my doctor. I was just too, the logistics of Doctor: Yeah? getting down here== Client: Also sleepiness. And morning fogginess, basically. Doctor: ==too far away. I'm one of those people, I open my peepers and I'm all, I'm Client: It was just too hard to get it done and rather than wait, wait, wait, wait, wait, I thought I'l go and have it done and if I'm not Doctor: Right. happy with the results then I'l make an appointment to go to Client: Ah, [LAUGHS] them there. I just didn't want it to be like two months by the Doctor: So you're a== time and then I'm worrying about it. Client: ==I might be grumpy but I'm there. Doctor: Sure, sure (consultation c02).
Doctor: Yeah.
Client: Whereas, yeah, it took me a while to wake up, which wasn't elicitation can occur throughout the consultation. in the following a bad thing because my biggest problem is actually insomnia, extract the doctor creates the opportunity for the client to elaborate on which really impacts quite a lot on my health and which her experiences with a specialist: just worsens as the PMT sets in, which is, like I said, very prolonged. Um. the problems I had was actual y coming of it Doctor: ==And he examined your breasts?
and when I actually got my period . Client: He examined that one there, which he had no issues with at Doctor: And stopping . all and that one there, which because I didn't have my notes Client: Again, I stopped taking it as soon as I got my period but when from last time or my scan from my ultrasound because I I have my period I felt like I've been hit by a bus anyway don't know what happened after the move, where they went, Doctor: Right he wasn't able to say definitely this is the one that (the fine Developing effective communication Between Doctors anD clients next page
Doctors al ow clients to talk at length about issues and concerns; they encourage and give space for client questions, as well as a chance to reflect on their experiences. needle) for because I think he was saying it was in a different FigUre 1: QUestions, stAtements And AcknoWledgements
oF doctors And clients in one consUltAtion in FpnsW
position of the [ ] and obviously because when I had it done before I was just post breast feeding so that's probably why. So he said, if you want to be 100% sure, have the (fine needle). But I just, I didn't think I need to go there because I feel quite comfortable. Bear in mind, there's no family history, these are not new lumps, they haven't got any bigger. Doctor: Yep. Yep.
Client: And I've had tests on them before. I felt quite comfortable (consultation c02).
in the course of this client's story, it becomes clear that she has her own ideas about her condition and possible treatment. she does not think she needs to have a fine needle biopsy, and she feels she knows what is happening with her body. thus, the space opened by the doctor, fol owed by listening to the story, al ows the client to present herself as observant, knowledgeable, having opinions about treatment and in charge of her own body.
importantly, the clients are able to tel their story without interruption, unless the doctor wants something clarified to aid her understanding. the story-telling is enhanced by the doctor's supportive comments, including mm, hmm, yes, okay, right, all right, etc., in figure 1 the frequency of questions, statements and comments that encourage rather than impede the communicative flow.
acknowledgements in another consultation is mapped. the figure shows that the doctor asked relatively few questions encouraging client participation and reflection through the use
(26 in all), and made 67 sta tements over a 15-minute period. in of particular questions, statements and acknowledgements
this interaction, the doctor asked more questions and made more the client sharing in the decision-making is achieved through, and statements than the client, however, the client did play a large indicated by, the use and frequency of particular kinds of questions, contributory role.
S he doctor did not domina te the talk and encouraged the number and type of statements and acknowledgements made by the client to offer opinions, state her views and preferences about the the doctor and client, and the length of the doctor and client turns. this management of her sexual health, and to participate in the decision- analysis of the kinds of utterances made by the doctors and clients making process. there was an ongoing build up of rapport between is cal ed a move analysis. a detailed move analysis of each of the client and doctor, and an inf 0 ormality was maintained throughout.
doctor-client transcripts indicated that the doctors asked relatively few the types of questions asked by doctors obviously vary questions, showing that they did not dominate the talk. this also shows according to the kind of information that they want to establish (see that the clients were encouraged to offer opinions, to state their views appendix 6 for further information on questions). Doctors used a and preferences about management or treatment, and to participate in number of different types of questions in the consultations recorded: the decision-making process.
for example, in one 15-minute consultation (see appendix 2), open questions such as So, how, how've you found it? and What the doctor asked only 15 questions, which is in marked contrast to side effects did you have? and Now, what can I do for you today, the other fpnsw medical consultations. in the same consultation Alexandra? were used initial y to establish the client's broad medical there were 41 acknowledgements of the client's contribution and 19 concern. they were also used throughout the consultation to statements by the doctor. interestingly, the client in this interaction encourage clients to provide background information relevant to the made 36 statements, gave 13 answers and asked one question. also noteworthy is the length of the client turns in this same consultation closed questions such as Did he actually give you the Implanon, (see cs and ca in appendix 2). this is also an indication of the degree have you actually got it with you today? and Is that okay? were used to which the doctor opens out space for the client to talk.
to probe for more specific information similarly, in a 33-minute consultation, although there were 48 assumptive questions – which are questions in statement form questions from the doctor, the client asked 15 questions and made that make particular assumptions and only al ow for a yes/no 81 statements. the doctor gave 84 acknowledgements, constantly answer – were used to check information, or to check the doctor's supporting and encouraging the client to tell her narrative about her understanding. for example, No diabetes in yourself? and So you health concerns, and validating her own views about the treatment.
had it removed in September? / sexual anD reproDuctive health consultations next page
Clients are encouraged to reflect on their problems and to make their own decisions. open questions give clients discretion in relation to their responses, Finding out what the client already knows
and allow them the space to tell their stories. Both closed and Doctors ask open questions draw out prior knowledge of symptoms, assumptive questions tend to limit a client's response to yes or no.
il nesses, treatments, and so on. so, for example, in assessment a significant feature of consultations is the way in which clients consultations, doctors asked clients what they knew about particular feel free to ask questions, which is also an indicator of the reciprocity contraceptive methods and devices: How did you hear about the in the consultations. the fol owing examples occured in the same Implanon? and Have you come across Implanon before? (consultation c11).
this strategy immediately suggests the client has something to contribute, rather than simply being a receiver of information, while Client: I train in martial arts, will I be okay to do exercise tonight? at the same time it gives the doctor a starting point for discussion (consultation c06).
or information-giving. it is based on the sound pedagogical principle that understanding is enhanced if new knowledge is introduced by Client: [It] goes between the muscles layers? (consultation c06).
relating it to what the learner/receiver already knows. it also gives the doctor an opportunity to ensure the client does not have underlying Client: So would it delay it, having this on or it just will come on misconceptions or misinformation.
once the breastfeeding stops?== (consultation c06).
moving from technical (medical) to common
many of the doctors invited questions from the clients at various sense (everyday) concepts
points during the consultations, as seen in these examples: a common complaint from clients about their medical encounters is the amount of technical language or jargon that is used and Doctor: Okay? So, have you got any other questions about it? which they often do not understand. in the consultations it was (consultation c02).
observed that doctors were careful to explain terms they felt might be unfamiliar to clients. they did this by embedding the explanation Doctor: I'll let you have a read of that and I'll just write the script for into the conversation so that it did not seem patronising or reduce the Nystatin and ask me if you've got any questions (consultation c02).
sense of client empowerment. some examples are: Doctor: . so, I'm going to get you to sign a consent form if that's Doctor: So we define the change into menopause which is, as you okay. Do you have any questions? (consultation c01).
say, peri-menopause, when your periods start to change
(consultation c14).
clients are encouraged to reflect on their problems and to make their own decisions. clients are provided with information but during the Doctor: So you get what we call anovulation, it means no egg
consultations client responsibility is also supported by: (consultation c14).
1. posing alternative questions: Doctor: . inflammation is when you get swelling and pain
Doctor: Are you happy to continue taking it like this on for the time (consultation c21). that you're premenstrual for a few months to see how you go? Or would you prefer to take it consistently? Because Doctor: This is nitrous oxide, this is exactly what we breathe in the
[both], you know, I think there's evidence that you could do air but it's compressed == into a cold spray (consultation c12).
it either way (consultation c15).
Client: Well, everyone that I know just, they go creepy-crawlies? . 2. asking clients directly to reflect on their own experiences: Doctor: . and the name of it is formication . because it's like
Client: Because I put on about nearly 30 kilos== ants crawling under the skin and ants are made of == Doctor: ==Yep. formic acid (consultation c14).
Client: So I thought that might've been, you know, a contributing factor to that. Doctor: And do you think it was, when you look back on that?
providing And checking inFormAtion
Client: Looking back, I think it was in combination with other life style hAs been Understood
factors as wel because I was studying and working ful time. But at the same time, I was, at that time walking about two hours a consultations always contain a large amount of information from day and I didn't real y see much of a change in my weight so I the doctor. Doctors are acutely aware that clients are likely to be just wanted to eliminate that as a, you know, I guess one of the overwhelmed with different kinds of information, and at different [risks] or one of the contributing [things] (consultation c01).
levels of importance. Developing effective communication Between Doctors anD clients next page
Doctors recognise that client understanding is crucial and they incorporate several strategies into their interactions with clients to ensure they follow what is being said and what is happening. Doctors recognise that client understanding is crucial and they Doctor: . basical y they say, as with any product that is applied to incorporate several strategies into their interactions with clients to the mucosal surface, so the skin or the vagina there, oh, ensure they follow what is being said and what is happening. hang on . [READING] Nilstat is virtually non-toxic, non- information in these encounters may be medical or procedural, sensitising and is well tolerated by all age groups== and it shifts from technical explanations, to instructions for treatment, Client: ==Okay. to keeping the client informed as to what is happening during their Doctor: even on prolonged topical administrations, so prolonged examination. several ways that information giving and checking doses. If irritation during vaginal, intra-vaginal use should occurs are discussed below.
Client: Okay. explaining processes regarding what will happen next as
Doctor: Okay? It's going to be hard if you feel irritated there well as about a client's condition and about the treatment
and on-going management
Client: ==To know whether, yeah. Okay. throughout the consultations, doctors talked about processes in Doctor: But, yeah, still worth pursuing. terms of what to expect about symptoms, treatment, and follow- Client: Worth a try. Definitely. up. for example, in the fol owing extract, the doctor explains the Doctor: Okay? consultation process: what is going to happen next (an examination), Client: No problem, thank you. So I don't have to come back really and what should follow (an appointment next week for further unless, you know, with that, if I can get that sorted I don't need treatment). she also reassures the client about the expected positive to come back till I have my smear in two years? (consultation c02).
change in her condition: During examinations, doctors are careful to inform the client of what Doctor: Okay. Now, what I'd like to do first is just inspect the area to expect and what they are doing from moment to moment: and make sure we're dealing with what you've mentioned . So, what, we'll do is we'll do as much as we can today Doctor: Okay, so it's two fingers of cold jel y, okay? . You right? and I'd like you to actual y come back so we can do a little (consultation c05).
bit more next week. Okay? Again, remember, this virus will slowly disappear with time . (consultation c12).
Doctor: What I need to do now is just introduce the finger, but I do need to put a bit of pressure from the top (consultation c13).
the use of we draws in the client as an active agent in the procedure, juxtaposed with the use of I when the doctor's professional expertise the client is even being prepared for the amount of information to be is foregrounded. in the next extract from a different consultation we is presented, and the number of questions that will be asked: used to refer to the fpnsw doctors as an organisational entity. here, it is policy that is being explained with the weight of medico-legal Doctor: I'm going to bombard you with questions and information ramifications underlying the comments: (consultation c01).
Doctor: So the whole counselling session beforehand, which is finally, doctors usually spend some of the consultation time writing also part and parcel of Family Planning Policy, for anybody – recording information, writing prescriptions, and associated texts – having any sort of form of invasive procedure . we like to and they signal this to the client. this serves to undermine the often inform our patients and ensure they are aware of all the uncomfortable feeling that silences induce, while at the same time pros and cons, side effects, what wil happen on the day. So the client is made aware of what notes are being recorded, as in the you're not just coming in and having it done, you're given a following example: chance to think about your choice (consultation c11).
Doctor: . so, it says identify present contraception, so can I write
the doctor enables the client to negotiate by providing explanations abstinence, is that okay? about these processes: what is happening throughout the consultation, Client: Abstinence [LAUGHS], it's right (consultation c01).
treatment and ongoing management. an example follows: Doctor: Okay? So, what I'm going to write in the notes is that
Doctor: This tel s you every possible . I think it's mostly local so we need to, like we've done al the talking bits of this but sometimes you can actually get . a little bit of soreness, we need to examine you. And when we examine you we'll you know, if you're getting a reaction to it. But generally it's check your blood pressure and do your weight and then fairly well tolerated. after that we can insert the IUD. Client: Okay. Client: Okay (consultation c01).
/ sexual anD reproDuctive health consultations next page
repeating key information verbal y, checking
Doctor: I can give you a little booklet about hormone
and tracking questions and comments
replacement therapy. I know you've done a lot of research Key information is repeated in consultations and sometimes from one already (consultation c14).
consultation to the next as a checking and confirming strategy: Doctor: And I've got some information here that I can give you
Doctor: . so we went through a little bit about your history last
to take away and read about all that because I can imagine week but could I just go over that a little bit? (consultation c01).
there's a lot to take in (consultation c12).
Doctors repeat what clients say to ensure they clearly understand: providing clear instructions for medication and other
follow-up treatment, appointments, etc.
Doctor: Do you have one every month or have you had == providing instructions and guidelines for action is often embedded Client: ==Every month
in explanations of what to expect or what will happen next. however, Doctor: Every month == you have a bleed? (consultation c08).
examples are presented below where the client needs to act: following doctor-generated information, doctors sometimes ask Doctor: But what I will do is I'll, at the end of the session today I'll questions to ascertain understanding and/or agreement: consent you, give you a script so you'll know to pick one up Client: Yep. Doctor: Does that sound okay? (consultation c12).
Doctor: Okay. And then the very next thing will be to book you in for the next available insertion. It has to fit at a particular time in Doctor: Do you have any questions you want to ask me? I mean your cycle as well, okay? (consultation c01).
please ask me as we go through this (consultation c01).
Doctor: Now, how to look after that area. It is real y important that Doctor: Got any other questions about that, Alyssa? (consultation c05).
you don't irritate it with whatever you're using for washing . what I normal y recommend to women is don't put notably, all the doctors repeatedly asked the clients if they understood anything down there that you wouldn't put on your face information and if they had any questions – often several times in one . Okay. The reason being it's the same sensitive skin consultation. in nearly every case there was little or no response from we're dealing with . The best thing that you could use is the client in the form of questions at these points. it may be useful something really, really mild. So Sorbolene . (consultation c12).
to think about using different strategies to check understanding as research into this type of questioning shows that the fpnsw experience of lack of response is common. this might be due, in part, to clients presenting medicAl knoWledge
feeling that they do not want the doctor to repeat things they have already gone through. nevertheless, information is remembered best when something has to be done with it – some activity is required.
making the reasoning processes for treatment,
advice, etc. available to the client
providing written information to take away and using 3d models
Doctors ensure that they explain to clients the reasons for their Doctors do not rely on the verbal alone for giving information and suggestions or recommendations for particular courses of action. explanation. they complement complex verbal information with Doctors try to verbalise their reasoning processes as clearly as demonstrations using models of parts of the body. thus, the client is possible to give clients full information, options and so on. able to see and touch as well as hear the information: in the following example, the doctor is explaining medication – an anti-fungal cream – and in doing so she shares her own thinking Doctor: So, Implanon. Okay. It's a rod about this size, this is a explicitly with the client, manifested in I was actually thinking of just sample, okay, have a feel of it, okay? (consultation c11).
giving it to you because I wonder . and again later I wonder .
Doctor: So just going through this IUD business, I'l just show you
Doctor: But I, because this showed moderate growth, the options of what it looks like (consultation c01).
treatment are, I mean, you've had a lot of Canesten. There is a different sort of cream cal ed Nystatin that we can use at the end of a consultation the client is often given written for 14 days. information in the form of an a4 sheet with diagrams and written information, booklets or pamphlets. clients are encouraged to read Doctor: 14, no, no, 14 days so you could try it now so we try and the material at home and to phone if they have any further questions actually get on top of it, treating you with this Nystatin which or they do not understand something: is a vaginal cream. Developing effective communication Between Doctors anD clients next page
Doctors try to verbalise their reasoning processes as clearly as possible to give clients ful information, options and so on. Client: What's it for? probably benefit you if you have a chat to your GP about Doctor: It's an anti-fungal sort of cream, it works in the same way maybe getting a referral and seeing what medications as Canesten but it's a different medication. would best suit you now, eight years down the track . Client: Do you use it as a preventative or for . ? (consultation c13).
Doctor: Wel , I was actual y thinking of just giving it to you because I wonder whether you've got the thrush in your system. Asking for and valuing the client's knowledge and experiences
Client: Mm. another way that doctors show they want to tap into clients' actions, Doctor: I mean, you might want to wait and see what happens and thoughts and beliefs is by asking them about their actions and I can give you a script for it, that's one option. You know, if thoughts. a client's responses are often followed up by a validating, you have a flare up, then go for that. I wondered whether supportive or empathetic comment by the doctor: the thrush was resistant to the Canesten cause you've had it six to seven times and it seems to be recurring . because Doctor: When you feel a little mood change, how do you
when I swabbed you and even though you didn't have symptoms, you have a moderate growth of thrush there. I Client: . I just do things so that I don't become stressed or mean, it's either== overwhelmed . Client: ==Yeah, I don't mind, I'll try anything. Doctor: Yep. Good on you. It sounds like you really are very
Doctor: one or the other so you might decide, no, I'll just do my wel informed about yourself and your condition and
sugar, avoid the lycra, get the lycra off as soon as I can. you know how to cope (consultation c11).
Client: Wel , I'l do that as wel anyway but I don't mind trying the treatment ==as well (consultation c02).
Doctor: What's made you decide then to go down this road?
Client: I think my periods are, um, just, they're a little bit, little bit
communicating professional judgement sensitively
heavier, nothing dramatically changed. even though client empowerment and autonomy are paramount, Doctor: Yeah. there are occasions when doctors display professional judgement Client: Um, the first, the first significant day of bleeding is a, is a bit that cuts across a client's suggestion, or try to lead the client into a heavier and more painful. particular course of action: Doctor: Okay.
Client: And I just thought, look, I'm . probably is [ ] that like the, Client: . because I was even looking into natural hormones . the natural family planning is affecting our sex life . And if I Doctor: so, we are not . we don't prescribe the natural ones
can improve my periods as well that would be == here because there are some safety issues with them .
Doctor: ==Which it should, hopefully should do (consultation c16).
so we would preferentially use the commercial preparations (consultation c14).
Doctor: Yep, okay. And what didn't you like about the Implanon?
Client: Well, I just thought it contributed to my weight gain.
Doctor: . keep in mind that because you are using, well, you're Doctor: Yep. infrequently using the condoms, you are putting yourself
Client: After having the first child. So I just wanted to remove every at risk. Okay? So I'm just trying to give you some
other factor== information regarding your risks and how to best protect Doctor: ==Yep, yep. yourself, really, more than anything else. Client: Because I put on about nearly 30 kilos== Client: Yeah. Doctor: ==Yep. Doctor: Okay, so, condoms offer a form of protection for both Client: So I thought that might've been, you know, a contributing yourself receiving a new infection and also for your partner factor to that. getting an infection . so it is important to keep that at the Doctor: And do you think it was, when you look back on that?
back of your mind (consultation c12).
Client: Looking back, I think it was in combination with other life style factors as well because I was studying and working occasionally, there is a situation where the doctor admits she does fulltime. But at the same time, I was, at that time I walking not have particular knowledge, and needs to point the client towards about two hours a day and I didn't real y see much of a a different kind of expertise: change in my weight so I just wanted to eliminate that as a, you know, I guess one of the [risks] or one of the Doctor: Okay. Wel , look, to be honest, eight years on one contributing [things] (consultation c01).
medication can be a long time because new up and
coming medications come up all time. It, I'm sorry, I'm
not actually an expert in this area . I think it would
/ sexual anD reproDuctive health consultations next page
the doctor may even position the client as the expert: of identification, the doctors take these issues seriously and engage in discussion about them. this may involve, for example, negotiation Doctor: All right. Now, you're absolutely sure it's warts we're
of treatment, or validating concerns.
dealing with? Client: Yes (consultation c12).
negotiating between doctor and client about treatment
in a client-centred approach to treatment, one strategy is to elicit and
one aspect of validation is the need to tap into client belief systems and validate the client's own view about what is the appropriate treatment mental representations of il ness (cicourel 1993). in the fol owing excerpt for their own healthcare. in the following excerpt the doctor validates the client puts forward a proposition that yoghurt might be a more natural the client's way of dealing with her problem, and respects her lubricant to use while suffering from thrush and, rather than dismissing comments about suggested treatment: this proposition outright, the doctor takes the time to discuss it: Client: I think I [SIGHS], well, I suppose post-traumatic stress Client: But then it says here, instead of using commercial lubricants disorder is something that I had identified by a counsellor. which contain preservatives or antiseptics, try using [ ] or Doctor: Yeah. yoghurt. You could try yoghurt. Client: I wouldn't begin to know what to do about it apart from Doctor: Okay. [SMALL LAUGH] But, yeah, I think== trying to manage it by keeping my stress levels down. Client: The thing is, I wouldn't be doing it if it hurt anyway, so like, Doctor: Yeah, which is good. That's a really important thing to do.
what is the reason to use it in the first place? Client: And that's what I try and do. But it's really difficult in this Doctor: This is, this is, the reason to use what? sort of day and age, you know, it's like . ==you know, Client: Any kind of lubricant. there's always something. Doctor: Wel , you know, I was actual y just reading about it, cause Doctor: ==I'm starting to wonder whether you might be, you might we spoke about it last week, I rang you last week when find it a benefit to actually take this for a period of time. And the results came back, and I was just reading the latest on I'd like to know how you would feel about that. it and one of the points was, and I don't, can't explain to Client: Well . I wouldn't necessarily be in agreement with taking a you why but they said that, you know, maybe using some full dose. lubrication with intercourse may actual y help. But I don't Doctor: No, I don't think so== know the mechanisms with that== Client: ==Cause I think it's too strong. Client: ==Right, okay. Doctor: because you actually had a few side effects, I agree with
Doctor: So you may decide not to worry about that part. With the that (consultation c15).
yoghurt, with sex, in the old days, like when I first did Family Planning which was about 20 years ago, we used to say you another example shows the doctor negotiating medication that could actual y dip a tampon into acidophilous yoghurt, just the client ends up rejecting in favour of the option of moving a plain acidophilous yoghurt, put it inside your vagina and leave contraceptive device into the other arm: it in for sort of 10 minutes and then remove it and it works on making the vagina, it changes the flora in the vagina and Doctor: . if I give you the tablets for a week, you come back and see thrush don't – the flora means the bugs, the normal bugs me next Friday . if not I take it out and put it into the other side – or the equilibrium of the bugs and thrush don't like that. Client: Mm. so you think with tablets it will (fix) it or . ? So it's actually changing the acidity of the vagina by using Doctor: Well it will relieve the pain and it will help the inflammation. acidophilous yoghurt in that way. And I think that's where And it might fix it. Um, I can't guarantee that . they come right into it when they say, you know, this sort of Client:: Mm. yoghurt (consultation c02).
Doctor: But I would be happy to remove it and put it in the
other arm then.
Client:: Yeah, it's better than take tablets . yeah, I don't like take identiFying, vAlUing And
negotiAting issUes thAt
Doctor: Right (consultation c21).
Are importAnt to the client
sometimes a client may be quite forthright in her views about Doctors at fpnsw know that it is crucial to their work to ensure they preferred treatment: understand as much as possible about their clients. Doctors probe for information and are alert to signs that help Doctor: Okay, So, do you want any help with that or are you okay identify things that are important to the client. Beyond the processes with that, you think you can manage it? Developing effective communication Between Doctors anD clients next page
Doctors at FPNSW know that it is crucial to their work to ensure they understand as much as possible about Doctors are skilled at recognising concerns and at validating them. Client: Well, I don't really want anything that's synthetic
remaining non-discriminatory, non-judgemental,
Doctor: Okay. open and respectful
Client: See, that was my point.
closely aligned with valuing issues that are important to the client Doctor: That's all right (consultation c14).
is the ethos of remaining non-judgemental about a client's activities and values. this can be seen in the way the doctors talk about and negotiation may also be characterised by an open invitation to the respond to information, symptoms and tests for sexually transmitted client to suggest further treatment or action: diseases, contraception and similar issues. in the example below, a test is suggested by the doctor for chlamydia – a suggestion that Doctor: But tell me where you're up to now, Charlene, and what
carries an implication of possible risk taking – however there is no you'd like to do (consultation c17).
comment other than a concern with the client's health: responding to a client's anxiety about her medical condition
Doctor: Okay. And the other thing is, as you leave today, if you wish, clients often come for a consultation because they are worried about and again I don't want to force this upon you but it is just symptoms they are experiencing. they may be explicit about their something to think about . total y up to you, doing the worry, or it may be that the doctor picks up on an anxiety during the chlamydia test which is a simple urine sample == consultation that has a different explicit purpose. all four recorded Client: ==Mm hm. consultations with one doctor included client anxieties – one was Doctor: because chlamydia is a type of infection that tends to sit implicit and drawn out by the doctor, and three were explicitly referred quietly (consultation c12).
to by the clients. Doctors are skil ed at recognising concerns and at validating them. the extract also constructs client autonomy by emphasising that having the test is the client's decision: if you wish . , don't want to Doctors may ask leading questions to encourage an explication of a force this . , to think about . , totally up to you . . interestingly, concern, for example: the doctor's use of the mitigating little to describe the test, and the way she ends the interaction with a statement about the condition's Doctor: . have you got, what kind of things were you worried about insidious nature, gives an indication of her professional opinion, or have you got any family history of problems [ ]? regarding the uptake of the suggestion.
(consultation c05).
the report now turns to the second category of communication strategies by exploring the development of rapport and empathy in more they also try to alleviate worries by referring to the unlikelihood of a detail. the following section presents examples from the consultations problem, while at the same time suggesting the condition is checked to highlight specific interpersonal language features that doctors use across the different types of consultations. it should be noted that these strategies are not necessarily distinct from those discussed above. rather, Doctor: Uterine, uterine cancers aren't very common or they're just they represent a different cut of the data – the strategies are more not very common in young [healthy] women. But you still explicitly linguistic. it is often a combination of these strategies that works need to get everything checked (consultation c05).
together to communicate the doctor-client relationship.
there were a number of examples of doctors validating clients' symptoms by referring to the experience as a common or normal one: commUnicAting the doctor-client
relAtionship: rApport And empAthy
Doctor: . sometimes you can actual y just get, oh, you can get a little, you can get a little bit of bleeding between your empathy is the ‘process for understanding an individual's subjective periods and it doesn't necessarily mean you've got anything experiences by vicariously sharing that experience while maintaining an serious going on (consultation c05).
observant stance. it is the knowing of the experience of another which comes from experience, fantasy and emotion' (Zinn 1993, p. 306).
Doctor: So, really what's happening to you is absolutely normal Brock and salinsky (1993, p. 245) define empathy as ‘the skills used . and it's not very pleasant [referring to client's peri- to decipher and respond to the thoughts and feelings passing from the menopausal symptoms] (consultation c14).
client to the physician.' empathy should be distinguished from sympathy.
factors influencing rapport and empathy include time constraints, Doctor: mean, it doesn't mean that you're abnormal by having it situational constraints, language barriers, intercultural differences, (consultation c01).
socio-economics, field specificity (eg fpnsw versus general practice), and other variables such as the gender and experience of the doctor. / sexual anD reproDuctive health consultations next page
Doctors make particular language choices. These include using informal and col oquial language, addressing the client by first name, giving supportive feedback, valuing the client's concerns, initiating and responding to interpersonal chat and using humour and laughter. other factors include the purpose of the visit and the client's name. examinations are often unpleasant and stressful experiences wish or understanding of what the relationship should be. an for the client and the doctors respond intuitively by using interpersonal important factor is the doctor's willingness to engage with the strategies. the distribution of client first name examples is illustrated client on a social level. it is accepted by both client and doctor that in the figure below for one doctor-client consultation.
the doctor's role is that of the expert with medical knowledge and Doctors always go out to the waiting room to meet and bring the experience in dealing with a range of medical issues and processes. client into the consultation room personal y. they also accompany the thus, to enable clients to make decisions about their own healthcare, client back to the reception area at the end of the consultation. the it is necessary to reduce any distance between doctor and client. client is not presented to the doctor by a nurse or a clerical worker – Doctors make particular language choices. these include using actions that would reinforce hierarchical positions. During these times informal and colloquial language, addressing the client by first name, there is the opportunity for informal chat and greetings.
giving supportive feedback, valuing the client's concerns, initiating Doctors use different kinds of informal greetings – the two and responding to interpersonal chat and using humour and laughter. extracts below include the word nice to indicate a positive appraisal of the encounter. the second example also tells the client that the doctor greeting the client with an informal introduction; using
remembers her – she is not just another unknown person.
given names throughout the consultation; using we at
key points in the consultation
Doctor: Okay. So it's nice to meet you (consultation c14).
heightened personalisation in consultations is achieved in a number of ways and has the effect of assuring the client that the doctor is giving Doctor: So, nice to see you again. I think I saw you on the 1st
undivided attention to her, as well as making the consultation friendlier. February (consultation c15).
according to poynton (1990, p. 214): ‘full forms of given names are not simply class markers . they are a means of maintaining distance in social the use of we is commented on several times in discussion of the relations, along with other lexis conventionally referred to as formal'.
data. Doctors use it particularly to construct solidarity and create an all the doctors introduce themselves with their first name and environment where the client is a co-investigator of her own condition they all use the client's first name as well. for example: and a co-producer of her own treatment: Doctor: Okay, so Noreen, I'm Bonnie, hi.
Doctor: . the problem with menopause is it comes at a time in our Client: Hi, Bonnie. life when we're usually trying to deal with a million other
Doctor: Now, you're here for a pap test, is that right? things as well (consultation c14).
Client: Yep.
Doctor: Yep. Anything else we're doing today? (consultation c07).
Doctor: You want to see what's going on don't you? . We both
want to see what's going on (consultation c21).
Doctors make a point of using the client's first name from the outset: Doctor: All right. Well, look, I think we'll agree that you do it the way
Doctor: Hi, Jade, is it? (consultation c13).
that you've outlined to me (consultation c15).
Doctor: Now, what can I do for you today, Alexandra? (consultation c11).
the third extract is interesting in the shifts the doctor makes from I to we to you to denote both roles and relationships.
the use of a client's first name continues throughout the consultation, for example in the history-taking stage: FigUre 2.
doctor nAming Use by stAge
Doctor: So you know if your, with your bleeding, Alyssa, have you
oF the consUltAtion (consultation c05)
got, what kind of things were you worried about or have you got any family history of problems [ ]? (consultation c05).
and then in the examination stage: Doctor: And I know you can feel me doing it, Alyssa (consultation c05).
the use of a personal name (vocatives) varies according to the stage of the consultation, with the examination stage presenting the 70 octors using the client's first Developing effective communication Between Doctors anD clients next page
giving supportive, empathetic and reassuring feedback,
Client: Seven times. verbally and non-verbally
Doctor: That's too many, isn't it?
the seating arrangements of the consultations help construct a Client: And by then they said they'd go . try and get blood from supportive context: the doctor and client sit quite close to one another somewhere else because my veins were that bad . (notwithstanding the small space of the consultation room and the Doctor: Yeah (consultation c17).
presence of the camera and researcher), and they sit facing one another with only a very small section of a desk separating them. in expressing positive attitudes constitutes a specific form of feedback addition, the doctors continually make eye contact with clients and to clients. even though this strategy could be seen as part of giving often nod – especially when clients are recounting something that is supportive, empathetic and reassuring feedback, it is a significant embarrassing or worrying them. occasional y the doctor touches the feature of the doctors' responses to clients in that they use positive client on the arm or shoulder at these times.
comments that are evaluative and regularly express attitudes: the consultations are dialogues that consist of turns taken by each of the participants. as clients talk, doctors provide instant Doctor: Because you are absolutely right (consultation c11).
feedback that what the client is saying is important, valued, okay, and so on. throughout the consultations, doctors use short, positive Doctor: Oh, I don't blame you, I don't blame you! (consultation c11).
feedback markers such as mm, okay, yes/yeah, all right. these let the client know the doctor is listening and that that they can continue Doctor: Excellent. All right (consultation c11).
speaking. examples of different kinds of feedback include: acknowledgments: where the doctor claims agreement or Doctor: Okay. Well that sounds great (consultation c11).
understanding of the previous turn eg mm, yeah assessments: when the doctor shows appreciation in some way Client: No, no, no. I mean of the night. Um, not wearing like a panty of what has just been said eg excellent, wonderful, exactly liner during the day. newsmarkers: where the doctor marks what the client says as Doctor: Yeah. news eg really, is it! Client: And using QV wash. non-verbal vocalisations eg laughter. Doctor: Okay.
Client: And I haven't had thrush since I came back. there are numerous points in the consultations when the doctor Doctor: That's really good, isn't it?
specifical y responds to a client's comment or concern in supportive Client: Mm hm. and empathetic ways. this sometimes takes the form of reassuring Doctor: That's excellent (consultation c17).
the client by suggesting that many others share similar worries: expressing personal attitudes and values (doctor and client)
Doctor: So you know you're not going crazy [LAUGHS]. A lot of
a characteristic feature of the fpnsw consultations is the frequent women actually come in say, oh my gosh, what's going on use of attitudinal language by the doctors to express their attitudes with me? (consultation c13).
and values. this in turn encourages the client to feel able to express their own attitudes and emotional reactions. a short extract from a During an examination, the doctor lets the client know she is familiar with consultation appears below that illustrates the build up and sharing a feeling and then immediately offers an appreciative comment as well: of attitudinal language. individual moves and turns from this extract are cited as examples of specific strategies elsewhere in section Doctor: I can appreciate that that's really uncomfortable . all
4, however, it is useful to see the development of rapport in the right? (consultation c12).
interaction as it unfolds. the full transcript of this consultation appears in appendix 2 in the final example of a longer interchange, the doctor makes where there were 30 expressions of attitude from the doctor and the language choices that offer supportive feedback in every turn: client in the first 28 turns. in the 15 minute consultation there were 194 expressions of attitude. Client: I got quite ill.
Doctor: It's not a very nice test.
Doctor: So, nice to see you again. I think I saw you on the 1st of
Client: It wasn't so much the test, um, they had trouble getting the Client: Yeah, yeah. You trialled==[ ] Doctor: Yeah. That's partly why it's not such a nice test.
Doctor: ==Trialing the [ ] to see if we could help your premenstrual
Client: Seven. Doctor: Oh no.
Client: Yes. / sexual anD reproDuctive health consultations next page
Doctor: So, how, how've you found it? Client: Which is a bit of a joke ==
Client: Well, I took it as suggested and the first half tablet it was Doctor: ==I know, it's a total joke (consultation c16).
like I got hit by a bus. But that's okay because I felt like
throwing myself under one anyway==
Client: But then my friend said it's normal because it's a Doctor: ==Right. dangerous day. [BOTH LAUGH]
Client: so I guess, yeah. [LAUGHS] Very apt. [LAUGHS] Very apt.
Doctor: Yeah, yeah. Could be the dangerous day, that's right
Doctor: We'd better get onto Sydney Transport eh?
(consultation c08).
Client: Well, side effects actually wear off.
Doctor: What side effects did you have?
Client: I don't think I've seen iron on it, I will have a look.
Client: Well, initially, headaches. Doctor: Have a look (consultation c14).
Doctor: Yeah?
Client: Also sleepiness. And morning fogginess, basically.
Client: . But, like, it goes over the top.
I'm one of those people, I open my peepers and I'm all, I'm Doctor: Yeah, == it's almost like Client: == and goes bang again. Doctor: Right. Doctor: You have a mini manic period
Client: Ah, [LAUGHS] Client: Yeah, It's like a manic sort of up and down. I mean I
Doctor: So you're a== wouldn't be prepared to sort of label myself but it really Client: ==I might be grumpy but I'm there.
does seem to coincide with the cyclical == things. Doctor: Yeah. Doctor: == Yes, it sounds like it does (consultation c15).
Client: Whereas, yeah, it took me a while to wake up, which wasn't a bad thing because my biggest problem is
interspersing interpersonal chat with medical talk
actually insomnia, which really impacts quite a lot on
empathy and rapport may be established by the doctor chatting with my health and which just worsens as the PMT sets in,
the client about aspects of either of their lives, unrelated to the illness. which is, like I said, very prolonged. Um.the problems I
it is also during these moments of informal conversations that shared had was actually coming off it and when I actually got
knowledge is built up. my period== shared knowledge, as well as putting people at ease, is Doctor: ==And stopping. impossible without conversation (hein & wodak 1998). ‘it is here that Client: Again, I stopped taking it as soon as I got my period but when we learn of shared experiences and feelings' (spiro 1992, p. 843). I have my period I felt like I've been hit by a bus anyway.
in most of the consultations there are examples of this interpersonal Doctor: Right. chat, that is, interchanges between the doctor and the client about things Client: So there's not a lot of difference between how I feel when I
not directly related to or important for the issue at hand. for example: have my period and when I took the first half of the tablet, it was almost identical. Doctor: . and I detect an accent. Doctor: Right. Client: Yeah, from England. Client: And . then I, when, when I stopped taking it after a few Doctor: From England. And you're here just travel ing or == you've days I actually had a bit of a backlash of mood swings.
made the move? (consultation c12).
Doctor: Right.
Client: And I actually had a friend point out to me how erratic I
engaging in interpersonal chat puts the client at ease and minimises was being and . I don't know, maybe it's better either to
hierarchical roles. this is particularly so when the doctor relates to her actually halve the dose again and then come off it really
own experiences. for example: slowly or whether I shouldn't take it as a fulltime thing
(consultation15).
Doctor: I think that's very true. No, I've been interested to see
how my mother's been dealt with in hospital too and ==
mirroring client's comments regarding symptoms,
(consultation c15).
attitudes or concerns
mirroring is a strategy that occurs when doctors repeat something
Doctor: If you're anything like the normal sort of brides to be that,
the client has said. in a conversation it shows a wil ingness to myself was included . things can go a bit wild (consultation c11).
participate in the other person's experience. in the consultations doctors frequently mirrored their clients' expressions explicitly as in Using colloquial language and informal expressions
the first three extracts, or sometimes rephrased what the client said a characteristic of the consultations is the informality exemplified as in the fourth extract: in several of the categories and strategies discussed so far. overall, Developing effective communication Between Doctors anD clients next page
Empathy and rapport may be established by the doctor chatting with the client about aspects of either of their lives, unrelated to the illness. It is also during these moments of informal conversations that shared knowledge is built up. the doctors use col oquial and sometimes even slang expressions to these instances work to reduce anxiety to some extent, as well as develop rapport and to enhance understanding. for example: establishing a friendly atmosphere. for example: Client: So oral sex? Client: Well my mother had a very early menopause . Doctor: Oral or even fingers and things like that (consultation c11).
Doctor: How early's early?Client: Wel , she never had her periods return after I was born . so Doctor: Should be fine. [Just if you want] to keep the pressure uh she was born in 23 and I was born in 58 so that made bandage on to prevent any swelling and stuff (consultation c06).
Doctor: Mm? Doctor: You'd sort of be saying whoopee (consultation c18).
Client: Yeah. So .
Doctor: Was it a shock having you born was it? I'm kidding
Doctor: So we then recommend non-, sort of making up their
own lubes . with whatever it is (consultation c18).
Client: [LAUGHS] Yes that's right.
Doctor: I'm kidding (consultation c18).
Doctor: Pants and undies off . no, hang on, we'll do the top first
(consultation c18).
Client: I used to go to the Chatswood one, Killarney, so it's about 40 minutes, 45 minutes. So, I only got three months supply, Doctor: I know you've come for your breast check because last time so. But I was having== when you came I had a look at the notes and the nurses Doctor: ==Punitive, isn't it? [LAUGHS] (consultation c20).
said that your breasts felt a little bit lumpy (consultation c19).
Client: Well, I took it as suggested and the first half tablet it was Doctor: And when you're ready give me a yell and we'll give you
like I got hit by a bus. But that's okay because I felt like some treatment (consultation c12).
throwing myself under one anyway== Doctor: ==Right. Using modality and modulation
Client: so I guess, yeah. [LAUGHS] Very apt. [LAUGHTER] Very apt.
modality and modulation are language features that make statements Doctor: We'd better get onto Sydney Transport eh? (consultation c15).
less definite, or introduce an element of possibility. examples include may, might, perhaps, can, would, should, I think, where in each case Using collaborative completions
a space is created for another view, belief, opinion, etc., and for a further strategy that demonstrates that the doctor and client are disagreement by the other person in the conversation. Doctors use this interacting closely and developing a shared understanding of what strategy to express a range of possible reasons for client symptoms: is being said is the use of collaborative completion where the doctor completes the client's utterance. (note that the client can also Doctor: I think the commonest reason for getting a little bit of
complete what the doctor is saying).
spotting, just as a one off, is probably no reason at all.
Sometimes I think they think it's hormonal and related
Client : My last visit my blood pressure was too high for==
to ovulation, it's probably the commoner thing. Which it
Doctor: ==The pill? (consultation c20).
kind of could be, given the timing of what you've looked at
(consultation c05).
non-english speaking background clients
notwithstanding the communicative effectiveness of the fpnsw
or to suggest a possible course of action: consultations and the satisfaction with the organisation as a whole commented on by clients and observed by the researchers, there are Doctor: So that's something you need to maybe sort of discuss
always opportunities for behavioural and/or organisational learning with him a bit further or at least . (consultation c11).
leading to change and improvements. in one consultation with a client from a language background sharing laughter and jokes
other than english, the post-consultation interview data showed that casual conversations between friends are characterised by both the doctor and the client felt that communication had been about shared laughter and jokes that express solidarity, friendship and 80 per cent successful. interestingly, there was agreement about the an inclusiveness that is valued by most human beings. in the effectiveness of the communication, and importantly the doctor was consultations, even when the client was very worried about an acutely aware of the issue.
issue, the examination was unpleasant, or the encounter included the transcript for this consultation reveals that there were two ongoing health concerns, there were often shared jokes and laughter. particular features of the interaction that posed difficulties for the / sexual anD reproDuctive health consultations next page
In the consultations, even when the client was very worried about an issue, the examination was unpleasant, or the encounter included ongoing health concerns, there were often shared jokes and laughter. client. the first is the use of ellipsis by the doctor. ellipsis is a form there were a number of further examples including: of abbreviated language where part of the utterance or sentence is omitted. for example, asking a one-word question Operation? with a Doctor: Planned caesarean? rising inflection at the end of the word to denote that it is a question, Doctor: Just that one? rather than asking in full Did you have an operation? el ipsis is a Doctor: Use that exact one? common feature of conversation – a kind of short cut that makes the Doctor: Different one? talk flow. however, it also depends on a lot of assumed knowledge Doctor: Every month? of language – both vocabulary and grammatical structures. there Doctor: So never had one before? are always gaps in language knowledge for speakers who are not as Doctor: Pulling out? culturally and linguistically proficient as first language english speakers. Doctor: Take any medication? examples of elliptical questions from this consultation appear below: Doctor: Rough? (consultation c08).
Client: . maybe most I don't understand and so you have to slowly== often, as in this case, the problem is not picked up because it does Doctor: ==Just let me know. not become explicit. the person/client may understand some of the Client: Yeah, okay, okay. elliptical questions, and/or they may not signal misunderstanding Doctor: So, you've come to talk about the Mirena? either by a query or a response that is clearly inappropriate. Client: Mm hm. Yeah. Because I just get married about half a year. the second feature that causes problems is the use of complex Doctor: Yep. questions and statements. these are utterances that contain two Client: And ah, and . my husband and me decided in two years we or more distinct questions or statements with different content or want to have a baby so now I don't want to have baby any difficult rephrasing. for example, How long were you in labour before more. Yeah. they did the caesarean, do you know? How long were you getting the Doctor: Right. Have you got any kids? pain for? attempting to process the information is demanding, and the Client: Yeah. I've got one. reframing of labour as pain in the second question may hinder rather Doctor: Oh, you have got one child? What year were they born? than aid comprehension. further examples appear below: Client: Mm?Doctor: What year were they born? Doctor: Operation? You had a caesarean? Client: Oh, in China. Doctor: What about any problems with your bowels when you get Doctor: How old?
that, like going to the toilet doing a poo, any == changes Client: She's born in 1998. Doctor: 1998. Doctor: And when you do bleed for that one day is it heavy, do you Client: Ten years. have to change the tampons or the pads quite often or Doctor: Right, okay. every few hours? Client: Yeah. Doctor: And have you ever had a pregnancy in the tube? Like, in Doctor: And was that a normal pregnancy? Any problems?
there. Any problem pregnancies like that? Client: No. Doctor: There's a copper IUD, which might be like what you had in Doctor: Did you have the baby vaginally? China, and there's that one, which is a hormone. Client: No . Mm, it means? Doctor: And because it's hormones there's some people, not very Doctor: Normally, out the vagina==
many, skin problems, decreased interest in sex, weight Client: ==No, no, no, no. problems, that sort of thing. Doctor: Operation? You had a caesarean?
Doctor: There's small chance that when they put it in they would Client: Yeah, yeah. damage your uterus, okay, and so if that happened you Doctor: Okay. Do you remember why? would have to go to hospital. Very rare, less than one in one Client: Oh, because his head== thousand women. Doctor: ==Yep. Doctor: I'm not the one doing it, like I say, I'l give you the name of Client: Up. the doctor who will but it will be more hard than a woman Doctor: Too high? who's had a baby through the vagina. (consultation c08) Client: So, it's, yeah, so . (kind of) normal.
Doctor: How long were you in labour before they did the caesarean, do Doctors are aware that they sometimes overwhelm clients with you know? How long were you getting the pain for? information and explanations. this occurs particularly in the pre- Client: Um . I didn't feel any pain when I'm [ ] my daughter and just, I procedural assessment consultations when doctors must give clients decided which day I go to hospital. (consultation c08).
clear information and explanations about the pros and cons of a Developing effective communication Between Doctors anD clients next page
particular treatment; for example, different forms of contraception, (what they are, how they work, what can be expected in terms of processes, and so on). this context is a site for introducing complexity, and there is the temptation to use el ipsis to cut down the amount of doctor talk, and not appear to be lecturing the client. Further communication strategies
Developing awareness of one's own ways of communicating is a
first step to thinking about possible changes. strategies that are
specifically helpful, other than taking care with complex utterances
and ellipsis include:
signposting or signalling, where doctors announce what they are going to say next structuring information as coherently as possible and in a logical order thinking critically about digressions by balancing the need for understanding key information with developing rapport checking understanding by moving beyond simply asking Is that clear? or Do you understand? one way to check is to ask the client to repeat key points or information supplementing talk with other modes of information giving, such as written material to take away and/or demonstrating with models exploring critically how much is too much information exploring whether the generic staging could be more efficient ensuring an elicitation of what the client already knows and using this as a starting point.
in summary, a key outcome from the study is a detailed description and analysis of the interactions in fpnsw consultations, describing both the language and discourse features that constitute successful interactions, as well as the features that contribute to occasional disparity between the messages conveyed and received by doctors and clients. / sexual anD reproDuctive health consultations next page
the aim of the post-consultation interviews was to determine whether the doctors and clients came away from consultations with similar ideas of the content covered, issues and problems raised and discussed, possible treatment and/or fol ow-up procedures and so on. further, the interviews tried to capture if the communication was perceived to have been generally successful or not, and on what basis the doctors and clients came to their views. notably, the doctors were quick to reflect on what could have worked better, and many were keen to discuss the consultations immediately with the researcher.
the 10 to 15 minute post-consultation interviews occurred immediately following the consultations. two researchers were involved with one interviewing the doctor and the other interviewing the client. the interviews comprised a series of specific questions consultation (see appendices 4 and 5) and, when possible, they were recorded
and later transcribed. the researchers also wrote notes during and interviews
after the interviews. the transcripts and notes were later analysed by thematically matching the responses of the clients and doctors. they were further analysed by identifying recurring themes across the witH clients client comments and the doctor comments.
the main finding is that there was a high level of congruence between messages given and received by both doctors and clients. anD Doctors
FActors inFlUencing overAll eFFective
the interview questions included questions about the overall effectiveness of the communication. clients tended to answer this question by articulating reasons for choosing to come to fpnsw: what section 5 presents a Discussion of the post-consultation they perceive to be the professional and interpersonal communicative interviews with Doctors anD clients. analysis of the competence of the doctors. the fol owing are examples of how the interviews with clients anD Doctors confirms that clients talked about this communicative competence.
generally Both groups felt that the consultations were successful. as one client explains "i felt that i got what i fpnsw doctors are specialists in reproductive and sexual health: You feel confident that what you're coming here for are what they're experts in (post-consultation interview c18).
not only are the doctors specialists, they are female specialists. the consultations are perceived to be an environment in which women can talk to women about women's issues: Me is how I am and I'm sexist. Where it's, like, I needed a female. My male doctor is very good and he said to me, he openly admits, I can't do this, I don't know enough about this field, you need to go somewhere else. But he said but it would be nice if I could have the results (post-consultation interview c17).
I don't like going to my GP for my pap smear. I would prefer to come to Family Planning (post-consultation interview c07).
Developing effective communication Between Doctors anD clients next page
There is a high level of congruence between messages given and received by both doctors and clients. clients feel listened to: We say what we want to each other (post-consultation interview c03).
I felt like she heard me (post-consultation interview c11).
clients also commented on the favourable organisational features that provide a supportive context, with clients preferring to visit fpnsw rather They listen (post-consultation interview c17).
than their gp for sexual and reproductive health issues. this is because: clients are given time to tell their story and to ask questions: gp consultations are seen to be less anonymous: She really takes time to explain things and make sure I've understood But I do have a new GP and I'm sure if I went to her she would be . asks lots of questions. And that's why I come here really (post- fabulous. But I don't, I don't go to her just, I don't know. I feel like I'm consultation interview c10).
anonymous here, do you know what I mean? Whereas she knows me from everything else (post-consultation interview c15).
I had the opportunity to ask questions and they don't rush you (post-consultation interview c11).
gps have long waiting times and shorter consultation times so they are rushed for time: Doctors give clear explanations about process and procedures: They get you in, they get you out (post-consultation interview c09).
She did my pap smear and found some concerns that I had been expecting but she explained those clearly and has given me a referral Because usually when you go to GPs it's, like, tell your problem then, (post-consultation interview c18).
like, yeah, yeah, yeah and then go out (post-consultation interview c03).
client concerns are validated: I mean, I have a good relationship with my GP but, then, he's a very, very busy man and I just feel . I'm conscious that, okay, there are a [they] don't just brush you away (post-consultation interview c10).
lot of patients waiting as wel so I just try and get straight to the point to try and get out of there as fast as I can. And I think I do myself a clients feel that they can trust the doctors: disservice there so I thought, okay, I'l come here because I know that I can take a bit more time and go through, you know, concerns I have I feel like I can trust her (post-consultation interview c10).
and get some questions answered (post-consultation interview c05).
I didn't feel like she was giving me advertising answers . I felt like gps are not specialists in the field and many are perceived to be she was actually doing it from real experience and with real women poor communicators: (post-consultation interview c11).
Well, my GP, the one now that I see, she sort of said, look, I know, but I like the fact she doesn't think she's God and says, it may not work . I don't think she's as intense as [doctor name removed] is because and if it doesn't, we'll try something else (post-consultation interview c17).
she does a lot of other stuff as well, so, you know. And she was actual y, when I said to her, cause I felt a bit funny saying to her that Doctors make clients feel comfortable talking about difficult issues: I was coming here because it's my own initiative that I did it, and she said to me, oh, that's a good idea . She was very pleased that I was She was very relaxed and very open, I felt, and very soft actually coming here (post-consultation interview c14).
(post-consultation interview c11).
one vignette illustrates many of the points outlined above.
She put me at ease [by body language, tone of voice, smiley, friendly, a client came to fpnsw after suffering recurrent thrush for professional] (post-consultation interview c12).
twelve years. she had been told previously, by a male gynaecologist, that she was a wet, moist person with tendencies to thrush and [she] I felt I could come here without shame or embarrassment would have to deal with it. another doctor had told her that if she kept (post-consultation interview c15).
having children that it would regulate her body. the fpnsw doctor gave her some ideas about how to deal with the thrush and this clients feel empowered and able to have control over the consultation was a follow-up visit a month later: decision-making process: . because I've suffered for twelve years . everyone I went to . they She didn't push me into anything (post-consultation interview c14).
just say, you know what, that's what happens with women . cause / sexual anD reproDuctive health consultations next page
Client's comments from the post- consultation interviews provide strong evidence that the FPNSW doctors actually do what they say they do. when she [the FP doctor] realised how bad I was, it was sort of like, prescription to deal with this particular issue ‘okay you've been uncomfortable, you're chronic and how do you (post-consultation interviews c15).
function'? . that's what she said to me, ‘how do you deal with this'? . and it wasn't ‘you've done it all wrong and it was your fault' . Doctor: She basically came for the results of tests that we did. And she just sort of said, ‘right, let's try' and gave me about five different I wanted to check something that I saw last time when we things to try . I went out that day and did everything she said to examined her so we did that. (post-consultation interviews Dr4).
do. And from two days on from after that I have not had thrush (post- Client: We looked at the results of al the tests I'd had . she consultation interview c17).
examined me to check that what she thought was probably a blood clot . not a polyp (post-consultation interviews c10).
the client was happy, not only because her symptoms had abated, but also that her problem had been taken seriously and her concerns were listened to and validated.
recognising And vAlidAting
in the staff interviews, doctors discussed their values and beliefs regarding clients and outlined the communication strategies they use in the consultations. the client often did not initially express their real symptoms or one question towards the end of the post-consultation interviews concerns. these could be implicated throughout the course of the with the doctors asked them whether they thought anything had interaction and/or picked up from non-verbal cues. for example, been left unsaid in the consultation and the most common responses doctors accurately detected the unspoken anxieties of clients, such as were yes or probably. thus the doctors are acutely aware that issues, a fear of cancer.
concerns, symptoms, worries and anxieties that clients bring with in the examples below the consultation data shows that the them to the consultations are not always brought to the surface. this clients presented physical symptoms as the issues for discussion and recognition contributes to the efforts made by the doctors to listen concern in the consultations. and observe as carefully as possible throughout the consultation.
Doctors move beyond a purely medical consultation to pick up it is evident that the clients interviewed choose to attend fpnsw concerns to do with emotions and a sense of self. they focus on the for specific reasons related to both the professional and interpersonal whole person in their dealing with physical symptoms. communicative competence of the doctors.
these shifts are foregrounded by both doctors and clients in the clients' comments from the post-consultation interviews, together with the actual consultation data, provide strong evidence one client commented that she wanted to discuss symptoms that the fpnsw doctors actually do what they say they do. that she felt were peri-menopausal. the client's symptoms had been dismissed previously by her gp as anxiety: shAred UnderstAnding oF
Doctor: I think she needed validation for what she was going through client's problem or concern
. I was wanting to get across to her that what's happening to her is actually normal. (post-consultation interviews Dr2).
all clients interviewed feel that the doctor understood their main reason for attending the clinic. how doctors articulated clients' main Client: I found that no-one really understood me fully like she did. concerns matched their clients' explication of these concerns. three So, and that it was, I wasn't going mad or anything like that. examples below illustrate this matching: So, it's good to know that that's actual y normal . I actual y was going through what I was saying I was going through Doctor: So the consultation was involved basical y in explaining what (post-consultation interviews c14).
an IUD's all about and how it works and its side-effect and risks and benefits and pros and cons. (post-consultation interviews Dr4).
a second client presented with concerns about intra-menstrual bleeding: Client: The purpose of my visit was to be counselled on the pros and cons of going for using the IUD as a contraception . Doctor: I suppose I interpreted her presentation as being that she the doctor pretty much explained all the details . what the didn't just want to leave it and see what happened . I think effects are and how it works (post-consultation interviews c01).
what I probably did was validate her concerns (post-consultation interview Dr6).
Doctor: She's here about her premenstrual symptoms . and she had come back for a review because I put her on some medication to take. (post-consultation interviews Dr2).
Client: It was a follow-up consultation. I had been given a Developing effective communication Between Doctors anD clients next page
there were minor communication mismatches in a few consultations. after one consultation with a client, whose first language was not english, the doctor stated that she felt that the client had only understood 80 per cent of the consultation and the client agreed she had only understood 80 per cent. interestingly, while the consultation may not have been entirely successful in terms of effective communication, the doctor was aware of the gap, so much so that both the doctor and client separately offered the same percentage as a measure of what had been understood.
in a second consultation the doctor commented that she felt it was important for the client to understand that she was engaging in potential y risky sexual behaviour. however, the client did not mention this in the post-consultation interview. the doctor had not in this instance communicated her message regarding risky behaviour effectively, although it is also possible that the client felt this was too embarrassing to bring up in the post-consultation interview.
Doctors move beyond a purely medical consultation to pick up concerns to do with emotions and a sense of self. They focus on the whole person in their dealing with physical symptoms. / sexual anD reproDuctive health consultations next page
in many medical consultations in other contexts there is a concluDing
gap between what the clinicians think they have meant and what meanings are actually constructed by the client. what is significant in the doctor-client consultations in fpnsw and in the follow up interviews with doctors and clients is the high level of concordance between what was actually said in the consultations and what the participants remembered as being the main points. therefore, fpnsw can feel confident that clients, overall, are likely to take away understandings that doctors intended.
this project incorporated different approaches to individual and organisational learning. firstly, the research included ongoing meetings, discussions and some informal presentations of data the fpnsw consultations involveD in this research are, with and to fpnsw managers and doctors. this enabled sharing of without exception, instances of exemplary communicative ideas, raising of issues, particular focuses and so on. these activities practice. each consultation achieveD effective meDical also built a joint investigative relationship where what is important Diagnosis anD treatment, at the same time BuilDing up to fpnsw could be foregrounded at al times. it also enabled a effective interpersonal relationships. co-productive relationship with all participants offering insights and ideas. this approach to the study precludes more traditional practices of researchers imparting their findings to the researched. notably, the approach fits well with the underpinning philosophy of empowerment it is the balance between the medical and the interpersonal that that is the ethos of the organisation. determines the effectiveness of a consultation. establishing an finally, an important part of co-production in research is creating interpersonal relationship with a client has implications beyond making opportunities for the participants – in this case the doctors who were the person ‘feel good' about his or her experience. we propose that recorded and video-taped – to reflect on their practices. in this project positive interpersonal relationships between doctors and clients result the doctors were given copies of their consultation transcripts and in more col aborative interactions which create a reciprocal flow of their consultation videos, and they were invited to spend one-to-one information. in turn, this produces better clinical outcomes such as time with one of the research team to discuss communication issues, mutually agreed treatment plans and better client compliance. strategies and successes that emerged. these reflexive sessions focussed on what the doctors wanted communicating care is just as important as delivering care.
to discuss, together with how the analysis has been carried out by the interpersonal skills are usually described as spoken communication researchers. this ensured that the discussions began with what the skills involved in the establishment and maintenance of effective doctors think and know (as in the consultations themselves), and what relationships between people. in the medical context this is often they want to know, understand and do. the richness of this reflexive represented as the ‘therapeutic relationship', ‘therapeutic alliance' or approach enables ideas for change, further professional development ‘client rapport.' as suggested by leach (2007, p. 70) it is ‘a trusting and other future directions to emerge collaboratively. connection and rapport established between therapist and client through col aboration, communication, therapist empathy and mutual understanding and respect'.
findings from this project can be used by fpnsw for the ongoing further exploration of the relationship between the medical professional development of doctors. the effective communicative and the interpersonal in health care settings will, we feel, develop and interpersonal strategies used by fpnsw doctors can be built understandings of what constitutes effective communication. this, in explicitly into training courses that fpnsw currently offers to gps turn, has implications for client safety and satisfaction.
for sexual and reproductive health (see section 7 recommendations).
Developing effective communication Between Doctors anD clients next page
What is significant in the doctor-client consultations in FPNSW and in the follow up interviews with doctors and clients is the high level of concordance between what was actually said in the consultations and what the participants remembered as being the Design anD Delivery of two professional Development moDules for meDical practitioners that focus on strategies to enhance effective communication in consultations.
1. A module that explores in detail the ways in which
2. A module that would build on the approaches and
doctors can build an effective interpersonal relationship
knowledge developed in the first module to produce
with clients at the same time as addressing clients'
video role-plays focussing on effective and less effective
medical concerns. it would include strategies for:
communicative situations. the role plays would be used
for discussion and reflective activities. this module
» sharing knowledge and decision-making » providing information effectively and checking information is » Design and scripting of scenarios » ensuring clients have presented concerns, and asked » technical production pressing questions » reflexive activities » checking clients have understood technical terms, diagnosis, » role-playing activities.
treatment, procedures etc » Demonstrating medical expertise together with empathy and » using communicative time efficiently regarding amount and depth of information, explanation, and discussion » communicating diagnoses, particularly bad news » valuing and validating clients' concerns and issues » integrating ‘chat' into more formal talk » communicating with clients whose dominant language is not english – reducing ellipsis and reducing the number of complex questions and statements.
/ sexual anD reproDuctive health consultations next page
epstein, rm, morse, Ds, frankel, rm, frarey, l, anderson, K and Beckman, hB (1998) awkward moments in patient-physician communication about hiv risk. Annals of Internal Medicine, 128(6), 435-442 engestrom, y, engestrom, r and Kerosuo, h (2003) the discursive construction of collaborative care. Applied Linguistics 24, 286-315.
fairclough, n (2003) Analyzing Discourse: Textual analysis for social research, new york: routledge gott, m, galena, e, hinchliff, s and elford h (2004) opening a can of worms: gp and practice nurse barriers to talking about sexual health in primary care. Family Practice, 21(5), 528-536 references cited in the report and / or consulted greenfield, s, Kaplan, sh, ware, j, yano em and frank hjl (1988) patients' ainsworth-vaughn, n (2003) the discourse of medical encounters. in: D participation in medical care: ef ects on blood sugar control and quality of schiffrin, D tannen and he hamilton (eds), The Handbook of Discourse life in diabetes. Journal of General Internal Medicine 3, 448-457 Analysis (pp 453-46), oxford: Blackwell halliday, maK (1994) An Introduction to Functional Grammar, london: Britt, h, miller, gc, charles, j, pan, y, valenti, l, henderson, j, Bayram, c, o'halloran, j and Knox, s (2007) Bettering the Evaluation and Care of Health: General Practice Activity in Australia 2005/06: A joint report by the hein, n and wodak, r (1987) medical interviews in internal medicine: some University of Sydney and the Australian Institute of Health and Welfare, results of an empirical investigation, Text, 7, 37-65 canberra, act: aiwh hinchliff, s, gott, m and galena, e (2004) gps' perceptions of the gender- Brock c and salinsky j (1993) empathy: an essential skil for understanding related barriers to discussing sexual health in consultations - a qualitative the physician-patient relationship in clinical practice Family Medicine, 25, study. European Journal General Practice, 10(2), 56-60 iedema, r (2005) medicine and health: intra-and inter-professional cicourel, a (1993), hearing is not believing: language and the structure of communication. in K. Brown (ed.), Encyclopaedia of Language and belief in medical communication in a. todd and s fisher (eds) The Social Linguistics (pp 745-751). oxford: elsevier Organisation of Doctor-Patient Communication, 2nd ed. (pp 49-66), ablex: norwood Kaplan, sh, greenfield, s and ware je (1989) assessing the ef ects of physician-patient interactions on the outcome of chronic disease. Medical creswell, jw (2007) Qualitative Inquiry and Research Design: Choosing Care 27: s110-s127 among five approaches, thousand oaks, california: sage leach mj. (2007) revisiting the evaluation of clinical practice. International Department of employment, science and training (Dest) (2003) National Journal of Nursing Practice 13(2): 70-74 Research Priorities. http://www.dest.gov.au/priorites accessed april 10th, 2007 lit le, p, everit , h, wil iamson, i, warner, g, moore, m, gould, c, ferrier, K and payne, s (2001) observational study of ef ect of patient-centredness Donovan, jl and Blake, Dr (1992) patient non-compliance: Deviance or and positive approach on outcomes of general practice consultations. BMJ reasoned decision-making? Social Science & Medicine 34, 507-513 323, 908-911 Developing effective communication Between Doctors anD clients next page
national health and medical research council (nhmrc), (2004) sitzia j and wood, n (1997) patient satisfaction: a review of issues and Communicating with Patients. canberra: commonwealth of australia concepts, Social Science & Medicine, 45(12), 1829-1844 nsw health (2005a) Patient Safety and Clinical Quality Program: First report spiro, h (1992) what is empathy and can it be taught? Annals of Internal on incident management in the NSW public health system 2003-2004, Medicine, 116, 843-846 north sydney: Dept of health, nsw stewart, ma (1995) ef ective physician-patient communication and health nsw health (2005b) Health Care Complaints Commission Annual Report, outcomes: a review. Canadian Medical Association Journal, 152(9), 1423- 2004-2005, north sydney: Dept of health, nsw nsw health (2006) NSW Sexually Transmissible Infections Strategy 2006- sun, Bc, adams, j, orav, ej, rucker, Dw, Brennan, ta and Burstein, hr 2009 (pD2006_071), north sydney: Dept of health, nsw (2000) Determinants of patient satisfaction and wil ingness to return with emergency care. Annals of Emergency Medicine 35, 426-434 o'Keefe, m (2001) should parents assess the interpersonal skil s of doctors who treat their children: a literature review, Journal of Pediatrics and Child taylor, Dm, wolfe, r and cameron, pa (2002) complaints from emergency Health, 37(6), 531-538 department patients largely result from treatment and communication problems. Emergency Medicine Australasia, 14:1, 43-49 orth, rs, stiles, wB, scherwitz, l, hennrikus, D and valbona, c (1987) patient exposition and provider explanation in routine interviews and world health organization (who) (2004) Reproductive health strategy: To hypertensive patients' blood pressure control. Health Psychology 6, 29-42 accelerate progress towards the at ainment of international development goals and targets (who/rhr/04.8) poynton, c (1990) address and the semiotics of social relations: a systemic-functional account of address forms and practices in australian english. phD world health organization (who) (2007) The WHO Strategic Approach to thesis, Department of linguistics, university of sydney Strengthening Sexual and Reproductive Health Policies and Programmes (who/rhr/07.7) rhodes, Kv, vieth, t, he, t, miller, a, howes, Ds, Bailey, o, walter, j, frankel, r and levinson, w (2004) resuscitating the physician-patient relationship: Zinn, w. (1993) the empathic physician Archives of Internal Medicine, 153, emergency department communication in an academic medical center. Annals of Emergency Medicine, 44(3), 262-267 saloman, l, gasquet, i, mesbah, m and ravaud, p (1999) construction of a scale measuring inpatients' opinion of quality of care. International Journal for Quality in Health Care, 11(9), 507-516 schoen, c, osborn, r, huynh, pt, Doty, m, Zapert, K, peugh, j and Davis, K (2005) taking the pulse of health care systems: experiences of patients with health problems in six countries, Health Affairs Web Exclusive w5-509 silverman, D (2005) Doing Qualitative Research: A practical handbook, london; thousand oaks, california: sage silverman, D (2006) Interpreting Qualitative Data: Methods for analysing talk, text, and interaction, london; thousand oaks, california: sage / sexual anD reproDuctive health consultations next page
role played by the client, who made many more statements about her health/emotional state than did the doctor, who encouraged her to develop lengthy turns at talk. this approach reflects the family planning ethos of empowering clients, so that they act as co-agents appenDix 1.
in the problem solving and decision-making processes. importantly, the doctor did not dominate the talk, but opened it up to al ow the client space in which to develop her narrative, to offer opinions and to analysis of a clearly state her preferences for treatment. the strategies employed
by the doctor are discussed in detail below.
open questions give the client discretion in relation to
their response, and allow the client to tell their story:
So, how, how've you found it? What side effects did you have? yes/no questions are used to probe more explicit information:
So can you say whether overall you feel that it helped==or didn't in this appendix, a summary analysis of the communication between a client and a doctor in one consultation is presented. the transcript So are you on it again at the moment? of the consultation is available in appendix 2 in a format that presents And did you get the same range of side effects you got the first the interactions as moves and turns. the transcript and analysis presented here provide the opportunity to see and better understand what goes on in a consultation from Assumptive questions close off client response choices.
STATEMENTS the beginning to the end. further, the commentary makes visible and And you've had a fairly erratic life pattern, haven't you?
available the analytic approach to the language and discourses used You have a mini manic period?
ANSWERS by clients and doctors. each of the consultations was analysed in a complex questions ask the listener to provide
what the bar graph below shows us is that the doctor asked more than one piece of information in reply
QUESTIONS relatively few questions (15 in all), and made considerably fewer Are you happy to con
EXAMINA tinue TION taking it like this on for the time statements compared with the client (19 versus 36). twenty seven that you're premenstrual for a few months to see how you go? percent of the doctor's questions were open and 73 percent were Or would you prefer to take it consistently, because (both), you
ACKNOWLEDGEMENTS closed. what is significant in this consultation is the large contributory know, I think there's evidence tha
t you could do it either way? QUestions And stAtements
type oF consUltAtion: mAnAgement
QUestions And stAtements
Developing effective communication Between Doctors anD clients next page
the doctor gave the client agency in this consultation largely by interestingly, depression was not mentioned again explicitly in the eliciting and incorporating the stories that the client brought to the medical encounter. one of the key ways the doctor achieved this another way to build up the shared knowledge was by eliciting was by allowing the space for the client to tell her own narratives and validating the client's ‘ own views about what she thought was about her health – both physical and psychological. the consultation the appropriate treatment for her own health (this follows the above contained a series of narratives, which were facilitated by the doctor's questioning strategies: the doctor asked a number of open, discretionary questions (see above) which allowed space for the Client: I think I [sighs], well, I suppose post-traumatic stress client to open out, and more probing closed questions (see above) disorder is something that I had identified by a counsellor. which were used to build up specific information around the client's Doctor: Yeah. health. the strategies used by the doctor included actively listening Client: I wouldn't begin to know what to do about it apart from with supportive, collaborative feedback, and not asserting her medical trying to manage it by keeping my stress levels down. expertise early in the consultation or stating her opinion definitively.
Doctor: Yeah, which is good. That's a really important thing
the doctor reduced her professional distance from the client in a number of ways, such as use of the inclusive pronoun we to construct solidarity: what follows is the doctor validating the client's way of dealing with the problem: Doctor: I suggested that we try the anti-depressants.
Client: And that's what I try and do. But it's really difficult in this the doctor allowed space for the client to be part of the decision- sort of day and age, you know, it's like.==you know, making process by modalising and modulating recommendations there's always something. which allowed the client to question or disagree: Doctor: ==I'm starting to wonder whether you might be, you
might find it a benefit to actual y take this for a period of
Doctor: I am actually wondering.
Doctor: I am starting to wonder whether you might be, you
And I'd like to know how you would feel about that.
might find it a benefit to actually.
Client: Well.I wouldn't necessarily be in agreement with taking a Doctor: I think we talked about it.
full dose. Doctor: No, I don't think so== health care practitioners need to learn complex rhetorical strategies Client: ==Cause I think it's too strong. that enable them to work with clients in building the shared Doctor: because you actually had a few side effects, I agree with
knowledge that is vital for an objective and accurate diagnosis and an effective treatment plan. one way that the doctor began the process of building up the shared knowledge in the consultation was the doctor even modulates the recommendation to take the by introducing the idea that the client was suffering from depression. medication for a period of time I'm starting to wonder whether you this was the key moment in this interaction: might be, you might., which al ows the space for the client to disagree. the doctor hands over even more control to the client by the Doctor: ==Now. I'm just wondering. I'm going to put an idea, I'm
comment And I'd like to know how you would feel about that which just going to talk about an idea.I've been treat, I suggested
explicitly al ows for shared decision making. another example of that we try the anti-depressants because of its properties shared decision-making from the consultation is as follows: for managing premenstrual symptoms and of course you
just take it for a short period of time when that's happening.
Doctor: Alright. Well, look, I think we'll agree that you do it the way
Now, I'm actually wondering whether we've actually
that you've outlined to me. And maybe do it over another, uncovered that you've got a bit of real depression==
say, three months. And then let's review it. Client: ==Mm. Client: See how it goes. Doctor: that is there all the time.
Client: I think I [sighs], well, I suppose post-traumatic stress what is also interesting here is the use of the personal pronoun we disorder is something that I had identified by a counsellor. which this doctor uses throughout the consultation creating a feeling Doctor: Yeah. of solidarity and joint decision-making. / sexual anD reproDuctive health consultations next page
empAthy And rApport
post-consUltAtion intervieWs
there are various ways that the doctor showed empathy and Both client and doctor felt that this had been a successful rapport in the consultation. one way was by introducing herself and consultation. the client said that she got what she required from the immediately putting the client at ease: consultation and that her and the doctor were in agreement about the appropriate treatment for her pre-menstrual symptoms. the Doctor: So, nice to see you again, I think I saw you on the 1st client says, she basically mirrored back . much of what I thought . February. I felt that she was quite . received my information quite positively, she gave me positive feedback and agreed with me on a number of another way was to offer supportive and reassuring feedback. the doctor used high frequency continuatives and acknowledgements During the consultation the client referred to a number of including Mmm, Yeah, Good, OK, All right throughout the consultation. struggles in personal life as wel as number of physical and mental these encouraged the client to continue tel ing her narrative. yet medical issues. this is indicative of the doctor's concern with the another way was to mirror the client's point of view by agreeing whole person rather than just one presenting issue. at the end with many of the client's statements, by repeating or reinstating the of the consultation the doctor was emotional and explained to client's propositions: the researcher that she is often moved by clients, I may feel very sympathetic to the patient. the doctor said that she hoped the client Client: .But, like, it goes over the top. took away a sense of being heard . and of being in control herself of Doctor: Yeah, ==it's almost like
what's happening. the doctor made a further interpersonal comment, Client: ==And goes bang again. I like her . I like people who are outside the square.
Doctor: You have a mini manic period.
Client: Yeah. It's like a manic sort of up and down. I mean, I
wouldn't be prepared to sort of label myself but it really does seem to coincide with the cyclical==things. Doctor: =='Yes, it sounds like it does.'
Below is a restatement of the client's proposition: Client: As I said, I work shift work.
Doctor: Yeah. And you've had a fairly erratic life pattern, haven't you?Client: Well, basically, yeah. That whole carer sort of thing. another way that empathy and rapport were established with the client was by the doctor chatting to the client about aspects of her own life which were unrelated to the client's health: Doctor: I think that's very true. No, I've been interested to see how my mother's been dealt with in hospital too and== and then a little later, by or by sharing her personal views: Doctor: Yeah, we're a bit guilty of doing that in the medical profession, giving that impression. Developing effective communication Between Doctors anD clients next page
presenting concern: follow up on use of antidepressant for premenstrual tension
length:
15 mins 20 seconds words and phrases in bold in the transcript are examples of expression of attitude and emotion.
appenDix 2.
transcript of
a management
so, nice to see you again.
i think i saw you on the 1st of february.
statement
==trialling the () to see if we could help your
of concern
management consultations are where doctor and client explore options for managing issues such as fertility control or menopause.
so, how, how've you found it? of condition
the structure of the following management consultation is: wel , i took it as suggested and the first half tablet it was Opening Statement of concern Exploration of conditionn like i got hit by a bus. But that's okay because i felt like
Diagnosisn Treatmentn Digression Closing throwing myself under one anyway==
n = recurring stage so i guess, yeah. [laughs] very apt. [laughter] very
in language analysis, a move is a speaker's utterance. the analysis below describes the function of each utterance: We'd better get onto sydney transport eh?
well, side effects actually wear off.
what side effects did you have? well, initially, headaches.
move code
also sleepiness. and morning fogginess, basically.
i'm one of those people, i open my peepers and i'm all, ah, [laughs]
==i might be grumpy but i'm there.
whereas, yeah, it took me a while to wake up, which wasn't a bad thing because my biggest problem is
actually insomnia, which really impacts quite a lot on
my health and which just worsens as the pmt sets in,
which is, like i said, very prolonged. um…the problems i
had was actually coming off it and when i actually got
Appraisal (in bold)
‘hit by a bus' ‘nice'
==and stopping.
/ sexual anD reproDuctive health consultations next page
transcript cont. again, i stopped taking it as soon as i got my period but and that thought will predominate above everything else. when i have my period i felt like i've been hit by a bus
[doctor finishes writing notes and resumes eye contact
with client] okay, so you start to== so there's not a lot of dif erence between how i feel
==start to==visualise [doctor and client mirror each
when i have my period and when i took the first half of other's hand gestures]
the tablet, it was almost identical.
==think negative.
well, visualise some trauma or something==
and… then i, when, when i stopped taking it after a few days i actually had a bit of a backlash of mood swings.
you know. it can be any time of the day but then everything else just, is like being sucked into a worm
and i actually had a friend point out to me how erratic
hole. and that tended to stop that.
i was being and … i don't know, maybe it's bet er
either to actually halve the dose again and then come
off it really slowly or whether i shouldn't take it as a
so that i was actually able to stop==
fulltime thing.
==now. i'm just wondering. i'm going to put an idea,
okay. just== ()
i'm just going to talk about an idea…i've been treat, i
suggested that we try the anti-depressants because of
its properties for managing premenstrual symptoms and video footage starts here. comments on non-verbal communication in [].
of course you just take it for a short period of time when
[Doctor and client facing each other across corner of
that's happening. desk and making eye contact] it's like you're a film
now, i'm actually wondering whether we've actually
star. you're nicole kidman today. [shared laughter]
uncovered that you've got a bit of real depression==
can you just push that door? [Client reaches back behind her to close door] thanks.
so, you wondered, you actually felt better taking it and
that is there all the time.
you felt worse when you tried to come off it==
i think i [sighs], well, i suppose post-traumatic stress
disorder is something that i had identified by a counsellor. [doctor and client mirror each other's hand gestures,
and you had a bit of a rebound from coming off it?
doctor nodding as client talks]
A bit of a rebound.
yeah. [nodding head]
i wouldn't begin to know what to do about it apart from apart from that, i felt that some days it made me drowsy, trying to manage it by keeping my stress levels down.
other days it didn't. yeah, which is good. that's a really important thing
and i think that might have something to do with my
and that's what i try and do. But it's really difficult in
health status on that particular day, like whether i'm this sort of day and age, you know, it's like…==you
tired and stressed. [doctor nods head continually
know, there's always something.
as client talks] ==i'm starting to wonder whether you might be, you
might find it a benefit to actually take this for a period
as i said, i work shift work.
yeah. and you've had a fairly erratic life pat ern, haven't
and i'd like to know how you would feel about that.
well, basically, yeah. that whole carer sort of thing.
well…i wouldn't necessarily be in agreement with
taking a full dose.
yeah. so can you say whether overal you feel that it
helped==or didn't help? no, i don't think so==
==yeah, i feel it helped. ==cause i think it's too strong.
because you actually had a few side effects, i agree
Because certainly one of the things that i felt it did was that when i get…[doctor starts to write notes on file] it's quite strong. and i have to say, it's effects are quite
when i get sort of upset or anxious about something,
it's almost like being sucked into a worm hole and i
==to say the least.
yep. [doctor continues to write notes] Developing effective communication Between Doctors anD clients next page
so the effect of being, feel like being hit by a bus==plus
where it's like this roller coaster ride. and along come
the hot flushes as well and everything== ==initially. ==initially ==and other, and== associated with that. and i suppose, you know, lifestyle
==and then, like, the thing, the thing that it did, when that, issues do come into it.
of condition
those sort of side ef ects set led down was that it al owed
me to concentrate more on the here and now rather than wel , specifical y in terms of taking this is alcohol and sort of, i mean, my mind often just, like, the whole
other drugs that can affect the brain so that's important
premenstrual thing, when that kicks in, what happens is that we don't, you know.
my mind starts to speed up and up and up. and at the
wel , i'm not taking any other drugs. and the alcohol's end of that period, it's almost like, it's, i can't sleep, you
been quite minimal.
know, i'm sort of, start pacing, i'm doing several things
at once and i seem to achieve quite a lot during those
excellent. well, that's fine.
times but then when i get menstrual it's again like being hit by a bus, suddenly i'm so groggy. and that's why, it's
But that doesn't seem to [laughs] really…you know,
like this cycle and riding a wave. and then after about a
i still realise at this point, i started keeping a diary and
week, when my period's finished, i level out. [client uses a after, i actually wrote down when i started taking the
lot of hand gestures to emphasise what she's saying] tablets [doctor nodding head] and when i started feeling
off, except i forgot to bring it this morning as i'm actually
mm. [doctor listening to client very intently, sitting
premenstrual at the moment and i'm quite stupid.
so are you on it again at the moment? and then very slowly it goes on the up and up and up
and up and up and up. then i get really restless and
yes, i started um…about four days ago.
agitated and, you know, running around doing 101
and did you get the same range of side ef ects you got things at once. But, like, it goes over the top.
yeah, ==it's almost like ==and goes bang again.
good, okay. so, are==
you have a mini manic period.
==it was just that first one.
yeah. it's like a manic sort of up and down. i mean,
are you happy to continue taking it like this on for the
i wouldn't be prepared to sort of label myself [doctor
time that you're premenstrual for a few months to see
shakes head] but it really does seem to coincide with
how you go? or would you prefer to take it consistently.
Because (both), you know, i think there's evidence that
==yes, it sounds like it does.
you could do it either way.
But it's so extreme. and that's what i wasn't coping
there is. i think i'd like to…just fine tune it a bit more
and instead of this time abruptly ceasing it, what i'd like
to do, like, for instance, when i started it again this time, i did still get the drowsiness so i decided not to take
one the next day because i wanted to see how long that well, there's certainly are, i think we talked about it
drowsiness would last. and al into the next day i felt the
last time, you can go from having it so severely that it's
ef ects. so that then i took it the fol owing night and then actually classified as a mental disorder.
i took it, i didn't have a problem. [doctor nodding head
while client talks] that's about 4 to 6% of women. But 96% of women okay. [doctor nodding]
do experience some premenstrual changes. so you're
and then when i, instead of abruptly ceasing taking
probably not at the extreme end but you're probably
it, what i'd like to actually do is either cut it down to a
closer to that end that you are up to the, you know, ==end that doesn't have symptoms. ==wel . it was like, when i was younger, it wasn't that and then do that over a few days and then stop it, rather
than just abruptly stopping it.
yeah, i'm okay with that. [doctor nodding]
it's as i'm getting older.
cause, like, when i stopped it, i didn't get any rebound yeah, well, it==does worsen.
right away, it was a few days later and then i got al ==
==and it's exacerbating.
a bit wobbly.
==i think your system's obviously quite sensitive to it
because you're on a fairly small dose. But i'm happy
and the periods where i'm actually level are getting
for you to do that.
i'm fairly sensitive to actually just about anything.
/ sexual anD reproDuctive health consultations next page
transcript cont. my, i mean, i don't use any other, i use painkil ers for the
i think you've got good insight, yeah. [doctor stops
duration of my period but apart from wine and cigaret es writing to look at client]
and coffee, and i don't drink a lot of coffee, real y
i mean, i deal with people every day who…you know,
take a, have a pharmacy sit ing in their house. and one of Alright.
the biggest problems now is that there's an expectation
there that, you know, even with in services, you know,
well, look, i think we'll agree that you do it the way that
that we don't deal with things from, you know, like a
you've outlined to me. and maybe do it over another,
holistic approach.
say, three months. and then let's review it.
i know, i know, that's true.
see how it goes.
i guess that's the word for it.
i think that's very true. [doctor leans back and
have you got enough in your prescription? relaxes into her chair]
well, you have given me some repeats.
no, i've been interested to see how my mother's been yeah, so there should be enough there.
dealt with in hospital too and== you'l get one person saying this and one person saying that and you need to match them up.
and you're only taking a small amount anyway.
[client leans down to put something in her bag, packing up to go] and being a doctor, you know what goes on. [looks up at doctor and they smile at each other]
well, i think that, look, i, i think i did explain to you last
time that this is all trial and error, there's no absolute
so then you have to unpack it for your mother answer and there's never one size fits al with this. But i think==
scary stuff. scary stuff, yeah.
==i wasn't looking for a magic cure. [doctor leans in
more towards client] i think if we've overal , if you overal think that you've
i'll give you that to take back to the receptionist. [doctor got some improvement and you've got some, you
hands client her file] know, something to work with, i hope that we'll get
some results in the end. it's about learning to manage it.
and say, you know, about four months.
it's about learning to manage it, you're right there, because, you know, there are other factors that come About four months, yeah. okay. alright.
into it as well. and i think we live in a society where we
think, you know, some tablet's going to create magic
cure alls for everything and they're just really tools.
and if i run out in the meantime, i can i suppose just
yeah, [doctor picks up client file, holds it, looks back at client as she starts to speak] we're a bit guilty of doing that in the medical profession,
and have that.
giving that impression.
they may not understand quite what i'm doing but you
well, the rest of the community is too, so it's not just a
one way street.
i understand what i'm doing.
people expect that.
and if the quarter doesn't work i'll try it full time. it's about, this sort of thing is very much about you
alright then.
working out what is happening to you and what works for you and then us helping you to kind of fine tune it. But
okay. see you later.
if it gives you a bet er sense of control over your life, then and thanks very much for doing this.
you can often make some changes in other areas that
will allow you to have a more == consistently smooth
take care.
[doctor starts to write on client file] there is a relationship between lots of dif erent things when talking about stuff
like that, so. i think i'm very aware, working in the
Bye. [recordings end] health services myself.
Developing effective communication Between Doctors anD clients next page
appenDix 3.
appenDix 4.
interview
interview
questions –
can you tell us a little about your professional background? can you now tell us about what your roles and responsibilities are and what a typical day or week may look like? regarding communication – can you discuss how communication works operationally at fp and are communication processes and networks effective? are there problems in communication at fp here at ashfield? 1. Describe briefly in your own words what happened in the how are grievances dealt with? can you discuss communication training in your education 2. what were the main points that you think you communicated to programs? (either as a participant or as a trainer) focussing on the consultation, can you outline what you 3. what were the main points that you think the client believe are effective communications strategies you use in communicated to you? 4. from your experience was this a successful consultation? what kinds of communication detract from the development of 5. Do you think you successfully pinpointed the main issue for the shared understandings? can you give some examples of where you thought there may 6. Do you think the client left anything unsaid in the consultation? have been misunderstandings or breakdowns in communication 7. what did you find challenging or difficult about the consultation? 8. what do you think the client took away? can you give a specific example of where you think there has 9. Do you have any additional comments? been a mismatch or misunderstanding that has been taken away from the consultation? how do social and cultural factors influence what occurs for both clients and practitioners in the consultation? how can this research contribute to improving the effectiveness of the consultation? would you like to add any further comments? / sexual anD reproDuctive health consultations next page
appenDix 5.
appenDix 6.
consultation anD type of
interview
questions –
the question types identified in the recorded family planning consultations are outlined below: closed yes/no questions take the form of interrogative clauses.
they are used to seek unknown information:
1. can you briefly describe what happened in the consultation? Doctor: Have you got enough in your prescription? 2. what were the main points you think you successfully Client: Well, you have given me some repeats (consultation c15).
communicated to the doctor? 3. what were the main points you think you think the doctor Assumptive questions take the form of statements with rising
communicated to you? intonation. they are typically used to check a doctor's understanding 4. was this a successful consultation for you? of what the client said. they tend to close off the range of possible 5. what did you find challenging or difficult about the consultation? 6. what did you take away from the consultation?7. Do you have any additional comments? Doctor: Last year. So you had it removed in September?Client: May have been towards the end of the year before, I'm really bad with my timing ==[ ] (consultation c01).
extended assumptive questions take the form of a statement
fol owed by a question. they also check a doctor's understanding of
what the client has said:
Doctor: So, it says identify present contraception, so can I write abstinence, is that okay? Client: Abstinence [LAUGHS], it's right (consultation c01).
Developing effective communication Between Doctors anD clients next page
command questions take the form of a command demanding
the eFFective Use oF QUestions
a verbal service. these questions can open up the opportunity for questions can either extend or limit the exchanges between doctors clients to tell narratives about their symptoms, concerns or lifestyles: and clients. when wanting to explore the concerns of clients and to pinpoint the medical or psychological issues that are concerning the Doctor: And tell me what symptoms you get. clients, open-ended questions and command questions allow space Client: General y it's always come, the thing is as wel , this is the for clients to provide detailed responses. other thing is that I teach group fitness classes so I wear a in the following exchange, the command question leads to a full lot of lycra leggings== (consultation c02).
explanation from the client, enabling the doctor to suggest a diagnosis: cohesive sequences of questions often occur when the doctor is
Doctor: Yeah. So can you say whether overall you feel that it fol owing through on symptoms and trying to gain a detailed or more helped==or didn't help? accurate description: Client: ==Yeah, I feel it helped. Doctor: Okay. Doctor: Yeah, yeah. So tell me the symptoms, so you get sore? Client: Because certainly one of the things that I felt it did was that when Client: Just sore. I get . when I get sort of upset or anxious about something, it's Doctor: Sore where? almost like being sucked into a worm hole and I can't get out. Client: Ah.well, mainly on the outer side not inside. Doctor: Yep. Doctor: So is it on the labia, the lips of your ==vulva as well? Client: And that thought will predominate above everything else. Client: ==Yeah, I guess so. Yeah, yeah, yeah. Doctor: Okay, so you start to== Doctor: And the vaginal opening there? Client: ==Start to==visualise. Client: Yes (consultation c02).
Doctor: ==think negative. Client: Well, visualise some trauma or something== Alternative questions take the form of two or three questions
Doctor: ==Okay. connected through the word or. they most often occur when the client Client: you know. It can be any time of the day but then everything is being offered two choices: else just, is like being sucked into a worm hole. And that tended to stop that. Doctor: So, are== are you happy to continue taking it like this on Doctor: Okay. for the time that you're premenstrual for a few months to Client: So that I was actually able to stop== see how you go? Or would you prefer to take it consistently? Doctor: ==Now. I'm just wondering. I'm going to put an idea, Because (both), you know, I think there's evidence that you I'm just going to talk about an idea . I've been treat, I could do it either way. suggested that we try the anti-depressants because of Client: There is. I think I'd like to.just fine-tune it a bit more and its properties for managing premenstrual symptoms and instead of this time abruptly ceasing it . (consultation c15).
of course you just take it for a short period of time when that's happening. Now, I'm actually wondering whether we've actually uncovered that you've got a bit of real depression== (consultation c15).
/ sexual anD reproDuctive health consultations next page
Developing effective communication Between Doctors anD clients

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Developing ffective
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Source: http://www.chec.meu.medicine.unimelb.edu.au/publications/links/resources/famplan_FINAL_digi_revised.pdf