‘In every art there are few principles and many techniques.”       - Dale Carnegie

Introduction
Today I am going to talk on a fundamental subject of communicating with our patients. Our syllabus at undergraduate (BHMS) level or at Post — graduate (M.D.) level doesn’t contain the subject of communication although we get very few points on case taking. Case — taking in homoeopathy is a multi-dimensional complex process, which demands the full exploration of a human being. It is not merely gathering of some symptoms through a certain frame of questions. To be frank with you when I began homoeopathic practice, I was unaware of the depth of case — taking and communication skills; My entire interview was based on questions alone and I was bombarding my patients with innumerable, stereotyped, successive spells like Rawalpindi Express of Shoab Akthar. I was concentrating not on length and accuracy but on speed. This resulted in many fours and sixes as there were many ‘Sachins’ in my patients. I lost many matches and yet I was confused : why I lost? Why were there drop-outs?
I started looking seriously and I found that communicating with patients has a heavy bearing upon physician — patient interaction. Now I realize that communication is a critical component of all medical interaction, it is not “just talking” and that communication is the keystone of the doctor-patient relationship.

Communication: Meaning
Exchange of words only doesn’t constitute ‘communication.’ The word ‘communication’ originates form Latin term “communicare” or “communico” meaning TO SHARE. When a patient communicates his grievances, his complaints, his painful experiences from his life, he actually SHARING with the physician. SHARING involves a deeper process of human interaction, of human relation.
Webster dictionary defines communication as “the interchange of thoughts or opinions.” Interchange: to inform, tell, express, or show in order to get a reaction or a response. It also means to listen, understand, weigh or evaluate.
Charles Estes defines communication “ the reception, digestion, and transmission of meanings, attitudes and feelings through words, gestures and symbols.”
Communication has a basic attribute of enlargement of feelings, facts, attitudes and ideas
So when a physician starts interrogating a patient, a patient is unearthed, unfolded and ears to him as a living vibrating individual whose facts are known, whose inner feelings are brought onto the surface, his attitudes and inclinations are understood and his ideas are
Communication is not a momentary event; in fact it is a momentary intensification of continuing, cumulative process that starts even before actual communication takes place and continues even after it has occurred.
Communication is not merely transmission of meaning from one person to another through symbols. It involves the pathway
Source ---- Sender------Sent------Received------ Receiver------- Result
The success of communication is measured in terms of not only the effective transmission of the message but also the achievement of intended resuIt.” This sentence indeed gives the crux. Only concentrating on sending the message, a physician shouldn’t or relaxed; he must concentrate also on what is the net result of communication. This net result is the feedback which every patient gives to a physician.
Key — Communication Skills
There are two critical skills - Active listening and Feedback.
Listening
I give pivotal importance to listening. A homoeopathic physician who sits on a chair with holistic philosophy in the mind, who has to deal with the patient from totalistic viewpointf who has to keep his awareness fully to focus on emotions, on every body movement gestures, postures, speech modulations etc etc. has to be a good listener. It is said the knowledge - seeker has to be a good listener. The process of case taking is a knowledge seeking process. Ultimately it is the patient who gives knowledge to a homoeopathic physician.
Major difference between ‘hearing’ and ‘listening’ must be understood. Hearing alone is not listening Hearing means merely picking up sound vibrations_ while listening means making sense out of what we hear. Hearing is related with ‘ear’ functioning while listening is related with ‘ears, brain, and mind’.

To be an active listener, following skills with help a homoeopathic physician.
i) Make eye contact
ii) Exhibit affirmative head nods & appropriate facial expressions.
iii) Avoid distracting actions or gestures
iv) Ask questions
v) Paraphrase
vi) Avoid interrupting the patient
vii) Don’t over talk
viii) Make smooth transactions

The Second critical skill is Feedback. The process of interview evokes innumerable responses from a patient. Some responses may not be likened but a physician has to keep mind balanced. A physician must remember “positive feedback is more readily and accurately perceived than negative feedback.”

Skills for feedback
I) Focus on specific behavior
ii) Keep feedback impersonal
iii) Keep feedback goal-oriented
iv) Make feedback well-timed
v) Ensure feedback positive
vi) Direct forward behavior

Communication skills are not innate or fixed. They can be learned or improved and  consequently the physician can improve the health outcomes
Adherence.Every physician has insecurity in his mind. Whether my patient will stick up to me or will he leave? Insecurity hovers. Anxiety state develops. And the reaction develops “today’s patients do not adhere.” Remember that “poor adherence can be attributed to patient characteristics” is a myth. In fact no consistent relationship has been shown between adherence and
Age
Gender
Social / economic status
Marital status
Personality traits (introverted, gregarious etc.)

Then what does affect adherence?
The patients’ perception of the seriousness of the disease
The patients perception of the efficacy of the treatment
The duration of the treatment and illness
The complexity of the regimen
The relationship with a physician

Skills For Improving Adherence
Demonstrate compassion
Communicate:
Personal concern for the patient
Personal interest with patient’s well being
Activate patient’s motivation
Share responsibility with the patient
Discuss the patient’s beliefs

Barriers to communication
When I started practice I was not aware of ‘barriers’ to communication. I found that there are some patients to whom I was unable to communicate. In some patients I was right at selection of remedy or at repetition, but not knowing how to handle the patients through communication. Subsequently I understood that good communication skills are required not only in the first interview but also in follow-ups. The dropouts in my practice taught me to see the barriers, which are collectively termed, as NOISE. These are as follow

Absence of common frame of reference.
Badly encoded messages.
Disturbance in transmission channel.
Poor retention (esp. in face to face communication).
Inattention by the receiver.
Premature evaluation of the message.
Unclarified assumptions.
Mistrust between sender and receiver.
Different perceptions of reality.
Semantic difficulties.
Vagueness about the objectives to be achieved.
Misinterpretation of the message.
Clash of attitudinal nuances of the sender and receiver.
Psycho - physical factors.
Selection of wrong variety of language.
Now I focus on the factors, which produce the NOISE, and I see that the communication barrier-free and smooth.
I briefly outline some of the qualities needed on the part of a physician f homoeopathic interview.

Homoeopathic interview: qualities desired
Well-defined ego and not to be over involved
Healthy attitude towards patient
Empathy, sensitivity and sensibility
Sufficient intelligence to understand and co-ordinate in a coherent way
Interview skills for warm and effective communication both verbal and non-verbal
Maintaining professionalism, open and trusting way
Ability to create supportive climate in interview to be able to make patients experience their true feelings and honest opinions without fear of rejection or censure
Knowledge of related subjects: clinical, para-clinical, homoeopathic, social, psychoI etc.
A calm, quiet, balanced mind and yet alert
Jovial, charming, cheerful communication
Awareness and observational eye
Precision of mind
Asking the right question(s) at right time
Appropriate use of memory box
Now if you think that you know the basics of communication, you know k communication skills and now you are in a position to take an interview, you may face a lot of difficulties; for, you must know communication techniques.

These are as follows-
1. Facilitation - Verbal or non-verbal communication that encourages, the patient to elaborate.
2. Open-ended Questions - Requests stated in general terms for non-specific information.
3. Direct Questions - Are those that ask patient for specific information.There should not be leading questions; they should give a graded response than yes or no.
4. Support - Indicates physician’s interest and concern and his willingness to help the patient.
5. Empathy - Communication that expresses understanding of and sympathy for the patient’s feelings.
6. Silence — Expresses a range of responses from total disinterest to active concern. It gives the patient a chance to explore and express deeper.
7. Reflection — A response from the physician that repeats, mirrors or echoes a portion of what the patient has just said; useful in eliciting both facts and feelings.
8. Clarification — A response that asks the patient for further information and explanation for the sake of clarity.
9. Confrontation — A technique that brings the patient face to face with the patient should be used with caution.
10. Hypothetical — If patient is not coming out with hard facts, this technique may help in selected cases.
11.Summation — Reviews the information that has been given by the patient.
12.Interpretation — Formulation by the physician of data, events or thoughts in terms that make the patient aware of their inter-relationship.

I have applied all these techniques in my interview chamber and I have found them extremely beneficial. I request you, the readers, to apply these techniques and send me your feedback.

My friends, remember that to explore the human being is not an easy task. One has to change the personality, look within us, banish our prejudices, wrong notions or beliefs and go ahead with vigor. Amen!