By Jonathan Silverman , Suzanne Kurtz and Juliet Draper . Radcliffe Publishing Ltd , 2004 , PB £27.95 , 262 pp Difficult Conversations in Medicine . ISBN 1-85775-640-1 Skills for Communicating with Patients was first published in 1998, and has been extensively revised for the 2005 edition. There is a companion book, Teaching and Learning Communication Skills in Medicine, also first written in 1998, which is not addressed in this review. The book is unique among communication skills books in two important ways. The first is that it integrates the traditional medical interview approach with the patient-centred approach, thus not throwing diagnostic reasoning out with paternalistic approaches to the clinical encounter. The authors effectively integrate the two traditions to make a comprehensive, but practical guide to teaching communication skills in medicine. The second critical element that runs throughout the book is a comprehensive, but focused, review of the literature on effectiveness of communication skills. They join that with evidence that effective communication is rarely practiced in routine clinical encounters. This provides a powerful statement of need that was undertaken in the first edition, and is still relevant. In the intervening years, the evidence for effectiveness has mounted, and the literature is now much more convincing. In addition, the chapter on ‘Explanation and Planning’ has been expanded to include shared decision-making. This section explicitly includes shared decision-making as a necessary skill. As with the rest of the book, both effectiveness evidence and the rationale for the curriculum are provided. This allows the authors to present theoretical and research evidence to guide the choice of specific communication skills to include in the curriculum. They have answered both the ‘so what’ question and the ‘how to’ question. The book should prove useful to its intended audience, medical educators and programme directors in medicine, nursing, allied health and counselling. However, it is also useful to decision aid developers and others who design and implement enhancements to the clinical encounter. The book is organized into 8 chapters. The five follow their curricular outline, and the chronological flow of a clinical encounter. Chapter 1 provides an overview of the rationale and elements of the communication skills curriculum. The synthesis of the biomedical perspective disease-orientation (sequence of events, symptom analysis, relevant systems review), and the patient's perspective illness-orientation (ideas and beliefs, concerns, expectations, effects on life, feelings) is clearly laid out. The Calgary-Cambridge Guide is included. This short list of the 70 skills the authors believe to be necessary is justified in terms of the structure, skills identification, validity from research and articulation of the proper breadth of the communication skills curriculum. The authors identify the post-1998 research by others that both validates and strengthens the approach described. The final chapter is devoted to special issues, including breaking bad news, cultural and social diversity, age-related issues, depression and others. A short (10 page) middle chapter is called, ‘providing structure to the interview’. It shows how providing structure and building the relationship should happen throughout the interview. Here, as elsewhere, they cite the broad consensus on which their approach is based, citing the work of Pendleton, Neighbour, Cohen-Cole, van Theil and van Dalen, Kalet, Stewart, and others who have participated in consensus processes in Europe and the UK, North America and Australia. The core of the book is the discussion of the major sections of the medical encounter: initiating the session, gathering information, physical examination, explanation and planning, and closing the session. In each of these sections, the problems in communication that require explicit teaching, the objectives, and the skills are identified. Examples of questions and patient responses are provided that make it clear why these skills are needed. References to research literature consistently identify what improvements may be expected if the relevant skills are used. Of particular interest to readers of Health Expectations is the shared decision-making section of the chapter on explanation and planning. The authors review the literature that shows large deficits in young doctors’ information-giving skills, and the evidence that better communication process skills will both engage patients more effectively, and support reaching concordance. The literature review shows that patients want more information than they typically receive, and that patient recall and understanding can be improved if better communication skills are employed. The relationship between shared understanding, and shared decision-making is made explicit, and the reasons patients give for non-participation in clinical encounters reviewed. Overall, the synthesis of theoretical, empirical and practical perspectives make this book an important reference for educators and researchers interested in improving the quality of the clinical encounter, and enhancing the patient's role.
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Nov 29, 2023
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