Patients with special needs (mentally
unstable patients, aggressive patients,
anxious patients, depressive patients,
socially disadvantaged patients, patients
with permanent damage/disability);
The doctor calls up the patient and says, "I have
some bad news and some worse news. The bad
news is that you have only twenty-four hours left
to live."The patient says, "That is very bad news.
What could be worse?"
The doctor says, "I've been trying to reach you
since yesterday."
Doctor – patient communication
Prefer to expect:
• Patient comes unprepared;
• Patient monitors care, which he/she
(not)receives;
• Patient recognizes (criticizes) treatment, which
he/she got, physician´s and nurses mistakes and
faults;
• Patient talks about these mistakes and faults (it is
usually out of a physician´s office so he/she
creates a favourable or unfavourable reputation).
Doctor – patient communication
The physician must be good:
• Psychologist;
• Sociologist;
• Philosopher;
• Expert (his/her approach must be both
professional (trained) and creative – made to
the patient and his/her problems measure –
individualized).
Doctor – patient communication
Advice to patients in verbal communication:
• Ask about everything you want to know and
what you are unsure;
• Talk to your doctor, what, where and how it
hurts you;
• Tell all the problems at once;
• Tell your doctor about all your doubts and
what you don´t believe.
Doctor – patient communication
Advice to patients in non-verbal communication:
• Patient should look into physician´s eyes;
• Patient should respect physician´s privacy;
• Patient should respect other patient´s privacy;
• Truthfulness.
Tricky question is whether it is possible to order
patients to believe their physicians. TRUST is
something what is created by repeated contacts
with physicians.
What do you think is the most important thing for
patient?
Doctor – patient communication
Questions, which patient wants to usually know:
• Cause of his/her pain or problem;
• How it is possible to change this pain or problem;
• For how long it can be solved;
• What should he/she do if his/her condition
doesn´t change in hour, three days, a week;
• What are the side effects of recommended
treatment;
• What limits does the treatment cause;
Doctor – patient communication
That is why a physician should develop the habit
of repeat these types of sentences:
• Do you want to ask a question?
• Could you repeat what I have said.
• What will (not) you do?
• As I understand it, you say that…
• Could you repeat how you will take the
medicine.
Doctor – patient communication
Patient around the world are the same. Tate´s so
called Rule of one third:
• 1/3 accepts the physician recommendation
and follows it.
• 1/3 follows physician recommendation, but
inconsistently and inefficiently.
• 1/3 ignores physician recommendation.
Doctor – patient communication
Mentally unstable patient:
• Matter of specialized facilities.
• Must be respect of human dignity.
• „You´re crazy. You´re a freak. You belong to a
madhouse. You're paranoid - humiliating
insults.“
• It goes for these patient that they must agree
with treatment and hospitalization.
Doctor – patient communication
In the past these people were chained to the
wall or they were exposed in an iron cage. But
there was one case in the Czech Republic at
the beginning of 90s´. One physician was so
rude to a mentally unstable woman – he
applied an injection so violently she lost the
ability of walk alone and meaningful speech.
After that she was pushed into the emergency
car against her will and she broke fingers on
her hand.
Doctor – patient communication
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To be considerate;
To listen to what they say;
Try to understand what they say;
Verify their information, message.
Emotional health is more fragile and more
tricky.
(Tate, 2005)
Doctor – patient communication
Aggressive patient:
• Aggression is considered to be a natural
behaviour even at the civilized man. We carry
it inside as a remnant of the historical period.
• Aggression means low tolerance to mental
stress.
• It is manifested by affective up to violent and
life-threatening behaviour.
Doctor – patient communication
Who can be aggressor?
• Patient who suffers from persistent conduct disorder;
• Patient who perceives too sensitively unfavourable
diagnosis;
• Patient who is disappointed by the few hopeful
predictions;
• Patient who is disappointed by limited treatment
possibilities;
• Patient who suffers from severe pain;
• Patient who waits for too long (in the morning with
an empty stomach).
Doctor – patient communication
Rarely the patient is aggressor for himself/herself:
• Self-harm;
• Refuses food;
• Prevents nurse to treat him/her (knocks out
syringe, pulls out infusion or probe, attempts
to commit suicide);
Why do you think they do these things?
Doctor – patient communication
Aggressive patient manifests increased unrest:
• Tapping feet;
• Walking nervously;
• Kicking into the space and objects;
• Beating with objects;
• Using strong gestures;
• Breathing loudly and irregularly;
• Increasing excitement on his/her face and increasing
tone of voice;
• Using of profanities, insults and threats.
Doctor – patient communication
How to react from a position of
physician?
What is the best way how to react?
Doctor – patient communication
• A physician should immediately find out what
was the starting torque.
• It is appropriate to react with fast questions to
find out what was the cause of inadequate
emotions (because doctor gets time to think).
Doctor – patient communication
1) We express our participation verbally:
• I understand you well.
• I share your outrage.
• I'm sorry…
• Unfortunately, it sometimes happens.
• Please, sit down. We can talk about it right now.
• Don´t give up. We can advise on how to proceed.
• What do you think I should do now?
• Do you think we can solve this situation? - using
questions we for patient to answer, to rational
thinking which can calm the patient).
Doctor – patient communication
Voice:
• calm, gentle, lower-pitched and quieter voice.
Postures, gestures:
• slow movements, slow gestures, friendly
hand, use of touch (grasping arm).
Doctor – patient communication
2) We should be o the same wavelength:
• Energy are not passing;
• Communication is on two different levels;
• Patient's anger may increase;
• It´s necessary to demonstrate authority;
• To act/behave directively mirroring his/her
gestures.
Doctor – patient communication
„Well, Mr. Novák, could you sit down on a
chair, please…“ (in doing that we either touch
him/her to show the direction or denote the
direction) and we encourage the patient –
„just calm down slowly, take a deep breath
and we try to relax - otherwise we can not
continue and I couldn't help you. You came to
my office and you want me to help you“.
Doctor – patient communication
Anxious patient:
• Anxiety can be „in born“;
• Based on exaggerated fears about their health;
• Disappointed expectations of himself/herself or
others – the patient failed;
• For these patients is typical: anxiety and stress to get
through an illness…
• Doctor plays the role of parents in this relationship.
Doctor – patient communication
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Gentle but persuasive voice;
Slow and clear speech without an admonition;
Attentive listening ;
Kind but not reproving look;
Eye contact;
Mild gestures;
Detailed explanation of the problem;
Expressing of hope that they will try to find
solution together.
Doctor – patient communication
Examples for the beginning of the interview:
• If I listen to you well, you suffer from…
• Sit down and we are going to talk about…
• I will help you if you tell me everything calmly.
• I suggest first to do this and after…
• Together we will solve your problem.
• Perhaps we can find a solution.
Doctor – patient communication
Depressive patient:
• Depression deprives man of joy, especially
from life.
• sadness, indifference, helplessness,
indecisiveness, delayed speech and voice,
talking about suicide, suicide attempt;
• these patients are very touchy.
Doctor – patient communication
• Physician should avoid these types of
sentences:
„Look, this man is blind and deaf, this man
doesn´t have leg and both of them have the
joy of life…“
• „You just make things up.“
• „It won´t be better, only worse.“
• „Do not focus on youself.“
• It hurts pacient because he/she perceives it as
a criticism against himself/herself.
Doctor – patient communication
• Depressive patient records each unknown
manifestation of the body as the disease (incurable);
• If you solve one problem they will come with another
- endless string of problems;
• Vicious circle which heightens patient´s individual
suffering.
• One recommendation: Make an agreement with the
patient that he/she doesn´t attempt to commit
suicide
Doctor – patient communication
Socially disadvantaged patient:
• Homeless people;
• Drunks;
• Addicts;
• Prostitutes;
• Abused by another person;
Doctor – patient communication
• Special categories of social workers should
take care of them.
• Specific problem is a long-term
unemployment.
• Loss of the possibility of self-realization.
• Absence of any ID.
Doctor – patient communication
Entrance interview:
• Find out the current situation;
• In the case of the woman in productive age
we ask about her family;
• But there can be a problem that the patient is
unable to speak.
• Orient on the basis of ID.
• Act as in case of crisis and assume
responsibility for the patient.
Doctor – patient communication
Patient with permanent damage/disease:
• Mental (anxiety, aggression, depression);
• Sensory (blind, deaf, deaf blind);
• Physical (wheelchair);
• With reduced intelligence (mentally
handicapped);
• Combination of these defects.
Doctor – patient communication
Professional approach:
• Without bias;
• Without prejudice;
• Without aversion.
• UN – 20. 12. 1971 – Resolution of right of the
physically and mentally handicapped.
Doctor – patient communication
Our society has decided to integrate disabled
and handicapped people:
• barrier-free access to schools, public
institutions, to shops, to public sanitation;
• installation of audio signal devices at
crossings, guide strips on sidewalks.
Doctor – patient communication
Guidelines for communication with
handicapped patients:
• Choose a communication which is adequate to
form and patient´s individual disability;
• Always keep eye contact;
• Speak to the patient (even if she/he is
accompanied, even if we are sure he/she can´t
perceive us);
Doctor – patient communication
• Speak clearly, always use literary language without
foreign or slangy medical terminology;
• Do not feel sorry about patient´s handicap, it
decreases his/her psychological comfort;
• Talk with a patient appropriately to his/her age, not
according to her/his mentality;
• Move tolerantly their moodiness, indiscretion, grain.
• Talk with gentle, calm voice.
Doctor – patient communication
Have a nice day 