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Communication skills play an important role and drive the clinical outcome in general practice. Unfortunately, biomedicine is growing, and communication skill is often overlooked as easy or self-explanatory. Learning these skills in general practice isn’t like procedural skills training. Besides understanding the theory and clinical process of communication skills, we have to know why and how. This article briefly organizes the conceptual model and shows how to learn communication skills in general practice. Self-directed learning drives the learner who takes their own way to learn. A trained teacher also can provide constructive feedback and carry out a needs-assessment of the learner. Through transformative learning, the learner can understand the five key steps of communication skills in general practice and transfer the learned skills into clinical practice by their own process. The five key steps include medical humanities, principles of family medicine/general practice, clinical methods, counseling micro skills, and clinical applications. The aim is to find the personal learning method and clinical consultation style for each physician.
Ocean Gardens Health Centre, Health Bureau, Macau SAR, China
*Address all correspondence to: louistam20150807@gmail.com
1. Introduction
According to the development of general practice, communications skills are considered a key element in consultation, like operation in surgery. The imbalanced expectation between doctors and patients may lead to doctor-patient risk cases. Evidence supports that poor or invalid communication is the origin of medical error [1], while good communication can improve clinical outcomes, reduce medical errors, facilitate self-management, and build preventive behaviors [2, 3, 4]. One study that analyzed patient’s values in communication styles showed that more patients preferred patient-centered physicians over biomedical physicians [5]. However, communication skill deficits in senior medical students [6], doctors in training [7] and early-term general practitioners [8]. there are plenty of methods [9], including role play, group work and videotaping, and teacher use teaching technique aid to enhance these skills. But the frequency of teaching by teachers is not the major element [10]. In fact, motivation of the learner, including self and extrinsic, i as primary focus, which is supported by many adult learning theories [11, 12]. Communication skills in general practice are easy to overlook; each physician is an adult and has their own experience, which is very difficult to change. Except for the motivation, self-directed, immediate, problem-centered, and reflective practices are mentioned in the learning method of adults [13].
Good interpersonal relationship does not mean good communication skills in general practice. Physicians report knowing about the importance of communication skills in practice but have difficulty applying them in the actual workplace [14]. Communication skills in medicine, including theoretical basis or principle, should effectively address all of these issues to help patients become healthier. One article [15] highlights the process of learning communication skills in general practice; they have five steps including medical humanities, principles of family medicine/general practice, clinical methods, counseling micro skills, and clinical application. It mentions that communication skills have a unique position in general practice based on the developmental process, from the origin and framework of general practice into action.
In conclusion, learning consultation skills in general practice isn’t like procedural skills training that may more closely align with informative learning and the goal of knowledge. The former combines with learner centered, that based on the need of learner, and ability of understanding the development of general practice. It has no defined end point. Through continuous learning and modification, the phenomenon of transformative learning is developed. This article briefly organizes this conceptual model and shows how to learn communication skills in general practice (Figure 1).
Figure 1.
The conceptual model of learning communication skills in general practice.
2. Concept of learning communication skills in general practice
2.1 Self-directed and mentorship/partnership
At the heart of self-directed learning is the concept that the learner takes control of their own process by taking responsibility of and deciding what and how something is learned [16]. This concept is supported by adult learning theories and has been shown to improve clinical performance [17], including the domains of clinical skills and attitudes [18]. However, indeed, reflection and extrinsic motivation are insufficiently addressed by this concept. A trained teacher in educational techniques, who can provide suitable reflection and carry out a needs-assessment of the learner, translates to better learning outcome [13]. Peer-feedback has an equally important role to play in enhancing learning [19].
Over the past several decades, there have been many conceptual models for helping us understand self-directed learning. The Person Process Context (PPC) model acknowledges [20] that the optimal situation for self-directed learning is when there is a dynamic interrelationship among the three elements, person, process, and context. Person or learner implies characteristics of the individual; process involves the teaching-learning transaction; context considers the environmental and sociopolitical situation. All of them are basically of equal importance. The most effective in self-directed learning is when the person, process, and context are in balance. The PPC model involves the psychological and personal characteristics conducive to self-directedness and also explores what teachers, learners, or facilitators can do to increase or decrease self-directedness in a given situation.
Based on the key factors of PPC model and principle of family medicine, a conceptual model of self-directed learning in learning communication skills in general practice (Figure 2) is proposed. The person or learner includes personality, life and medical experience, self-concept, and attitude in general practice. The process is set up in a way that encourages learners to take control of their own learning and involves learning skills, technological skills, and teachers in an educational technique. The key context to support the learning environment in general practice encompasses medical policy, patient’s consultation behavior, and continued education or training to enhance communication skills.
Figure 2.
PPC model of learning communication skills in general practice.
In other words, motivation, including intrinsic and extrinsic, is the primary focus in learning communication skills in general practice. Self-motivation is original in learning, a suitable teaching-learning process encourages learners to take control of their own learning, and a supportive environment provides the suitable learning climate.
2.2 Transformative learning
Transformative learning is “a deep, structural shift in basic premises of thought, feelings, and actions” [21]. It supports the development of effective medical education [22], including development of non-technique skills [23].
One article [24] mentions three learning processes of transformative learning: learning within meaning schemes, learning new meaning schemes, and learning through meaning transformation. The learner and teacher are interdependent. The following tries to explain this learning processes based on learning communication skills in general practice (Figure 3). The first process involves learners working with what they already know and previous perspective. Learners should know the concept of communication skills by their own way; then they can ask why and how to learn though any methods, including discussing with others or using digital technology. Teachers can review the most efficient manner to show what the learner needs based on their thought. The second process combined the intrinsic and new knowledge within learners’ meaning perspectives. Learners can acquire a new understanding in communication skills to augment their previous perspectives and attempt to create their personal communication style based on the framework of general practice.
Figure 3.
Transformative learning of communication skills in general practice.
The lasting process is learning through meaning transformation that results in perspective transformation. It is no doubt that everyone is unique, including physicians. Understanding these differences and adopting a personal consultation style could enhance the outcome of communication skills [25]. Transformation of learning communication skills in general practice has started since self-reflection of the assumptions that supported the learners’ perspective. Learners felt that rearranging the skill or presentation could result in increasing efficiency in clinical outcome. Through transformation, the learner, who felt anxiety because of past failure, becomes confident in communication skills. But the anxiety is only the previous process. Teachers can provide new constructive reflection in each process without relying on any notes. In short, learners encounter communicative problems in general practice that cannot be resolved through a present or new concept or understanding; the resolution becomes a redefinition of the problem and application in practice continually.
3. How to learn communication skills in practical action: from medical humanities to clinical application
Motivation is the origin of adult learning. Through transformative learning, this section tries to explore how to learn these skills in practical action. One review article [15] clearly organizes five key elements to understand the different levels of communication skills in real practice, which are medical humanities, principles of family medicine/general practice, clinical methods, counseling micro skills, and clinical application (Figure 1). Each learner has a different background and intrinsic perspective; there are no fixed steps to learn communication skills in general practice. An example of that is a medical student may learn the basic concept as an entry point and a senior physician starts from the clinical application.
3.1 Medical humanities
Medical humanities is concerned with “the science of the human” and brings perspectives of disciplines such as history, philosophy, literature, art, and music to understanding health, illness, and medicine [26]. According to the basic principle of family medicine [1], medicine changes are based on health-related events, from major infectious diseases decades ago to chronic diseases, developmental disorders, behavioral disorders, accidents, and a different range of infectious diseases nowadays. Medical humanities is leading the growth of general practice and the origin of communication skills.
Biomedicine can do harm when overlooked and has limits and dangers that are now more clearly understood [27]. Understanding medical humanities can reduce the gap between biomedicine and the human sciences [28], promote a patient-centered approach in practice [29], and reduce biomedical hubris [30]. In general practice, each patient has their own perspective and presents different illness behaviors. Communication skills in general practice can connect and balance “cure (biomedical)” and “care (communication)”.
Terms of “reflective practice” and “narrative medicine” sound vague, but they are an important element in learning medical humanities. Reflective practice is the basis for self-directed lifelong learning. Narrative medicine [31] promotes narrative competence, that is, the capacity for empathic understanding and being able to adopt multiple perspectives. It matches the concept of transformative learning. In short, medical humanities is the reason why we need to learn clinical communication skills. The more understanding we have of the origin or development of family medicine/general practice, the more flexible we are to apply the communication skills.
3.2 Principle of family medicine/general practice
Based on the historical evolution of medical humanities, principle of family medication/general practice, that is the framework of communication skills, was developed. This principle guides the task and attitude in clinical practice.
An article in 2016 presented the five principles of family medicine/general practice as follows: compassionate care, a generalist approach, continuity of a relationship, reflective mindfulness, and lifelong learning [32]. Compassionate care is an attitude expressing as patient-centered communication and empathy. It is difficult to measure. A family physician focuses on the person rather than on a particular body of knowledge, group of disease, or special technique. The continuity of relationship means that an interpersonal relationship has not a defined end point. These relationships enable them to develop deep knowledge of their patient through a sense of connection, trust, enhanced professional competence, and respect. Reflective mindfulness refers to the ability of awareness of personal thoughts and emotions, which leads to greater depth and contextual relevance. Lifelong learning is the process of personal and professional development. Through transformative learning, positive personal and professional skills are developed [33]. Each principle is an essential attribute of family medicine that governs our actions. The application and attitude of communication skills in general practice are based on these principles.
3.3 Clinical method
Clinical method is the model that operationalizes the idea of principle. In the principle of family medicine, family physicians are available for all types of problems, and there is no predetermined other in consultation [1]. This task is time consuming, broad, and cumbersome. Suitable clinical methods help us to make a reasonable decision.
The patient-centered clinical method is not only a search for disease but also an attempt understand sickness from the patient’s perspective [34]. This method is appropriate for broad-based disciplines such as family medicine. By focusing on this method, spiritual history may help reveal the patient’s value, be it a clinical resource for comprehensive care or to improve adherence to the treatment and personal resistance of the patient [35]. In fact, good communication skills in general practice can be powerful for exploring spiritual history. Because a diagnostic process is usually a statement of probability rather than certainty in family physicians, a hypothetico-deductive approach to problem solving is integral to the patient-centered method [1].
There is the revised patient-centered clinical method with integral hypothetico-deductive approach (Figure 4) based on one review article [15]. We use communication skills to connect each step. The key to a patient-centered approach is sensitivity to two kinds of cues: cues to differential diagnosis and patient’s cues [35]. The former is based on medical knowledge. The latter is the patient’s cue about what they consider important, then formulate patient’s R.I.C.E. (Reason, Idea, Concern and Expectation). However, cues can express themselves in verbal and nonverbal forms, including what we see, smell, hear, and feel about patients and their story. Hypotheses are generated and rank ordered on the basis of the cues acquired and knowledge. Then test the hypotheses that based on the science of probability. While the value between patient and physician reaches balance tending to patient’s health, the nature of above hypotheses was established that including major clinical problem, minor problem, need for reassurance and problem of living presenting. Finally, we get the idea of what course the consultation is likely taking and search for common ground. This approach assists the physician to narrow the heart of the problem in consultation, whether it is biological, psychological, social, or all three.
Figure 4.
Patient-centered clinical method with integral hypothetico-deductive approach in clinical decision making.
3.4 Counseling micro skills
Physicians find the suitable clinical method for general practice appealing but difficult to implement. Counseling micro skills not only began the field’s shift away from ineffective to innovative training methods, but they undertook the enormous challenge of closing the gap between theory and practice [36]. There are five basic counseling micro skills: attentive ehavior, questioning, confrontation, focusing, and reflection of meaning (Table 1). Each micro skill has an intrinsic meaning.
Counseling micro skills
Explanation
Attending behavior
It is the aspect of building rapport. Physicians encourage patients to talk and open up their concern through non-verbal behavior [37], including matching non-verbal behavior, physical closeness, the use of movement, facial expression, eye contact, and sometimes silence. This skill can take a little time to learn effectively.
Questioning
Effective questioning helps patients put their own thoughts into words and to clarify their problems [38]. There are two main types of questioning: open and closed.
Confrontation
This skill assists to increase the patient’s self-awareness that the patient may have overlooked or avoided. The physician can identify a discrepancy that highlights this to the patient.
Focusing
This skill brings the patient’s conversation into certain areas.
Reflection of meaning
It reflects back to the person the important content of what the patient has said more clearly and by using the physician’s own words [37].
Table 1.
The summary of five basic counseling micro skills.
Cumulative micro-training has shown positive impacts on communication skills in previous studies [39]. This training method consists of six steps [38], and each training session focuses on one or two new skills and then gradually increases in complexity. First, learners receive a theoretical instruction and its function in counseling communication skills. Second, learners observe examples, such as video, showing an inadequate application of the skill, followed by showing the adequate application. Third, learners try to practice the skill separately, like dry swimming. Fourth, learners practice this skill among each other via role-plays. Fifth, learners receive feedback from fellow learners and tutors. Finally, learners note down the points based on the feedback. In the same way, learners build their skills by progressing through these steps. Learners find the use of micro skills difficult initially, then use the skills effectively but feel a little unnatural or awkward. And learners apply the skills thoroughly without being immediately aware.
3.5 Clinical application
Each micro skill is dependent and has to be combined in clinical consultation. For example, swimming can be described in terms of rules for correcting imbalance, breathing, and adjustments made by the body floating on water. However, focusing on special components may actually cause sinking. Similarly, each consultation is different, and one cannot conduct a consultation while trying to keep in mind the subsidiary rules and components [1].
Different counseling approaches have been developed after the flexible application and combination of each micro skill; the examples are motivation interview, BATHE technique, supportive counseling, cognitive behavioral therapy, and stages of the change model. All of these counseling approaches are commonly used in general practice or family medicine and applied in different clinical encounters. For example, the BATHE technique has been developed for time-limited consultation, that is, an initial screening for mood condition and for the condition of psychosocial conflict (such as chronic pain) [40].
However, physicians do not transfer these learned skills to clinical practice as comprehensively as they should [41]. The actual situation is different from training methods. Practicing in real patients has been shown to be valuable for learning communication skills and understanding patient illnesses [42]. Observation of consultations, through video or live, combined with self-directed learning and constructive feedback seems like an effective method to learn communication skills [43]. Videotaping is an important learning tool. Through reviewing videotapes, learners can view their consultation process from patients’ perspectives. Based on the concept of learning: self-directed and mentorship, videotaping can be used as a form of self-assessment to identify communication strengths and weakness [44]. Teachers also can give their feedback after watching a recorded interview. In short, videotaping is very useful in recognizing actual learner interactions with patients, particularly awareness of nonverbal cues. It can be used for study alone, comparison with peers, and checking communication improvement over time [45]. Through recurrent practice, feedback, and self-awareness from clinical consultation, physicians can reach the personal style communication skill in practice finally.
Learning communication skills in general practice has no end point and no fixed format. Learners should know the theoretical basis, through actual needs, internal, and external drive, then understand the clinical communication skills step by step by their own process. Finally, the personal right and comfortable communication style is transformed.
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Written By
Kwong Ho Tam
Submitted: 02 July 2023Reviewed: 14 July 2023Published: 09 August 2023
Open access peer-reviewed chapter
