Developing rapport

Acceptance

Acceptance is a concept that enables us to respond supportively to our patients’ beliefs and feelings while enhancing our relationship with our patients. The concept of acceptance as proposed by Briggs and Banahan (1979) suggests that our initial response to patients’ contributions should be:

Acceptance

  • to accept non-judgmentally what the patient says
  • to respect what the patient thinks is true.

It is very important to differentiate acceptance from agreement or confirmation. It is not the same and this needs to be apparent to both you and your patient.

Their theory suggests that we should accept patients’ ideas and emotions without initially attempting to dissuade the patient that they might be unfounded. The key concept here is to accept and acknowledge the patient’s legitimacy to hold views and to own feelings.

Empathy

The work of Poole and Sanson-Fisher (1978) has clearly shown that empathy is a construct that can be learnt by medical students. They utilised a 9 point evaluation scale developed by Truss and Carkhuff (1 967) which ranges from stage I:

“completely unaware of even the most conspicuous of the client’s statements; responses not appropriate to the mood and content of the client’s statements” to stage 9: “unerringly responds to the client’s full range of feelings in their exact intensity; recognises each emotional nuance and reflects them in his words and voice; expands the client’s hints into a full-blown but tentative elaboration of feeling or experience with unerring sensitive accuracy”! Truax has shown that psychotherapists who score highly on this scale achieve change.

Poole and Sanson-Fisher showed that medical students’ ability to empathise did not improve over their medical school training without specific training: both first and final year students scored poorly on the evaluation scale (av. 2.1). However; after participating in eight 2 hour workshops based on audiotapes, students scale ratings significantly improved to an average level of 4.5 (stage 5; accurately responds to all the patient’s’ discernible feelings, any misunderstandings are not disruptive due to their tentative nature.

After training students also:

  • used less jargon
  • made clear attempts to understand the unique meaning of events words and symptoms to patients
  • less often blocked off emotional-laden areas
  • obtained descriptions of more of their patient’s’ problem areas
  • appropriately matched their voice tone to their patients’ more often
  • did less of the talking
  • responded more in an understanding mode
  • offered less advice
  • were reported by patients to be understanding and caring

Use of notes

One of the most important of all non-verbal skills is eye contact. It is so easy to be distracted from providing this by the notes or the computer as we grapple to comprehend our patient’s problem: yet, poor eye contact can be readily misinterpreted by the patient as lack of interest and can inhibit open communication. Heath (1984) in a qualitative study in British general practice has examined in detail the consequences of physicians attempting to increase their efficiency in the consultation by reading the patients records and listening to the patient at the same time. She demonstrated how instead of increased efficiency, quite the opposite occurs:

  • patients withhold their initial reply to the doctor’s solicitation until eye-contact has been given
  • patients pause in mid-utterance when the doctor looks at the notes and resume when eye-contact is regained
  • patients use body movement to catch the doctor’s gaze if he is reading the notes while the patient is talking
  • patients’ fluency deteriorates as the doctor looks away and recovers on re-establishment of gaze
  • information given to the doctor while he is reading the notes is frequently missed or forgotten

The conclusion of this is that using the records while the patient is speaking is not an efficient way of conducting the consultation for either patient or doctor. The patient will give their information more slowly and less completely and the doctor may well not “hear” the information provided. Heath suggests various strategies to overcome the problem the doctor faces when needing to both bear the patient’s story and examine their records:

  • deliberately postpone using the records until the patient has completed their opening statement
  • wait for opportune moments before looking at the notes
  • signpost both your intention to look at the records and when you have finished thereby separating listening and note reading so that the patient understands and is comfortable with the process.
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