Considerations for effective communication in a clinic setting

As the role of the pharmacist in primary and secondary care continues to evolve, more and more pharmacists are leading their own specialist services and running their own clinics. It is therefore imperative to upskill pharmacists to meet the needs of the service. One of the most essential skills needed for clinic-based pharmacists is good communication. Good communication skills can have a huge impact on patient care; they can influence how patients and healthcare professionals feel about the clinician conducting the clinic, whether they trust the clinician’s judgment and, ultimately, whether they choose to follow their advice.

Running a clinic for the first time can be a daunting experience, particularly if there are few or no other pharmacists running clinics in the same trust to look to for advice or ideas. Additionally, communication skills in the clinic setting are not a primary area of focus in pharmacy undergraduate or postgraduate (general pharmacy practice diploma) training.

With more pharmacists now running their own clinics, whether face-to-face or virtually, it is important that support is available to them. This article provides tips and advice on how to communicate effectively with patients and other healthcare professionals in a clinic setting.

Communicating with the patient

Be on time

If the clinic is virtual or over the phone, make sure to call the patient at the allocated time. The patient may have made special arrangements to be free for this appointment. For example, they may have taken time off work or asked a family member to join them for the call at that particular time. If you are calling them early, ask them if that is convenient for them. If you are calling late, remember to apologise. If the patient does not answer the call, try to reach them again later.

Do not rush. Patients can easily pick up when a healthcare professional is rushing a consultation. Going into clinic an hour before the first patient appointment can allow time to prepare effectively and lessen pressure to rush consultations.

Explain the purpose of the consultation

Remember that the patient may have expected to see a doctor and having a consultation with an independent prescriber or advanced practitioner may be a new concept for them. It is therefore important to introduce yourself and explain your role within the team. Be confident and put the patient at ease.

At the start of the consultation, confirm the patient’s identity, whether you are conducting the consultation face-to-face or over the phone.

Tell them what the consultation is about. A reality of practice is that some patients come to a clinic without any prior explanation of the appointment’s purpose. They may not be aware that they were referred to you or they may have thought the appointment was for something else.

Listen to your patient and try not to interrupt. Time for each patient is limited, but when a patient feels listened to, they develop a sense that their clinician cares, and that builds rapport and trust. However, do keep the consultation ‘on track’ and be able to regain control when needed.

Verbal and non-verbal communication

Tone can make all the difference. The same words spoken with a different emphasis can relay completely different messages. Also, remember that a calm and empathetic tone can help de-escalate a distressed or angry patient.

If you are conducting a face-to-face consultation, pay attention to your body language and maintain eye contact. Non-verbal communication can sometimes be more powerful than verbal.

Look to use open questions rather than closed ones to encourage patients to give plenty of information, so that you can understand their perspective. However, closed questions can be useful when you need a simple, direct answer (e.g. have you had any bleeding since starting the edoxaban tablets?) or to clarify information.

Put the patient first

Make the patient feel empowered and at the centre of the consultation. Make them feel it is all about them and encourage shared decision-making, where they are involved in designing their management plan.

Put yourself in the patient’s shoes and think about what, based on their lifestyle, might help improve treatment adherence and offer different options. For example, offering a once-daily tablet to a patient who takes all their other medicines once daily, rather than a twice-daily tablet where the second dose could be inconvenient or difficult for them to remember to take.

Respect the patient’s wishes, ideas and beliefs. There may be times when your patient chooses the option that you may not prefer. For example, patients may decide to continue warfarin rather that switch to a direct oral anticoagulant, despite being a suitable candidate for switching. Explore their reasons for not switching — these may surprise you. Patients have been known to continue with warfarin as the regular international normalised ratio appointments at their anticoagulation clinic had become part of their regular routine and were the only human contact they had.

Beware of and guard against discrimination (e.g. on the basis of age or disability). If a patient presents with a carer, be careful not to talk only to the carer or ignore the patient. This is surprisingly common and demoralising for the patient (see Box 1).

Consider communication barriers

If there is a language/other communication barrier, you must think of ways to overcome them, perhaps with the help of a patient’s next of kin or family member. For more confidential/sensitive consultations, or when you require an impartial interpretation, try using your trust accredited interpretation service. If the consultation is face-to-face, find out if you can book an interpreter to attend at the time of the appointment. If via telephone, find out if you have a telephone interpretation service in your trust. Telephone interpreting allows three-way conversations between you, the patient and the interpreter. Patients with a language barrier have a higher rate of non-adherence to medication and so it is particularly important to try to arrange for an interpreter​[1]​.

Be prepared to have a consultation with more than one person. Some patients present with multiple family members who may also have their own questions. If your consultations are via phone, there may be other family members listening to you. Document the names of all those who were present at the time of the consultation.

Reinforce important information

To assess how well you counselled your patient, ask them to repeat some of the main points you mentioned to them, to gauge their understanding. This may be difficult to ask, but perhaps say: ‘Just so I can make sure I did a good job explaining things to you, can you please repeat some of the key points we discussed in this consultation?’. That way, you are not questioning their ability to understand, but simply making sure that you have done your job effectively.

Do not rely on verbal communication only. Think of other ways to reinforce the message, such as written communication in the form of letters, information leaflets or booklets.

Summarise and emphasise the essential information discussed at the end of the consultation. Explain to the patient what to do and who to contact if any issues arise in future.

Avoid rushing clinical decisions

Do not feel under pressure to make a clinical decision during the clinic appointment if the matter is not urgent. It is good practice to seek specialist advice from colleagues to help reinforce the decision-making process. You may opt to end a consultation by explaining to the patient that you will discuss their case with the consultant and get back to them on the final decision, either via phone or a letter sent in the post at a later date. Patients understand this and appreciate the multidisciplinary approach.

After the consultation

Document the communication between you and the patient via a letter to the GP. Remember to send a copy of the letter to the patient as well. As the patient will receive a copy, ensure abbreviations, acronyms and jargon are avoided. When documenting past medical history in the letter, think about the patient’s level of knowledge: do they know their kidney disease is chronic? How much do they know about their cancer? It is best to try to establish how much they know during the consultation so that your letter does not contain information that will surprise them.

Think of ways to get feedback on your service — for example, via patient surveys. It could be a good way of providing insight into your communication skills.

Communicating with other healthcare professionals

Remember to make full use of the wider team and build relationships with colleagues, whether it is the medical team, service managers or support staff; make sure that you understand their roles and think about how they could help you in your clinic journey.

If you are an independent prescriber, find out if you have a prescribing group in your trust. Check what policies and guidelines are in place for independent prescribing in your trust and ensure any documentation is completed prior to starting your prescribing role. It is always a good idea to have a medical practitioner as a mentor or supervisor to support you in your prescribing role. Consider asking a specialist in your area of practice to adopt this role.

Documentation

To ensure safe transfer of care, communicate the outcome of your consultation clearly to the patient’s GP via a letter (as outlined above). Ensure this letter is saved electronically on to the patient’s records. Often patients bring up other concerns they may have in conversation, which may not be related to your speciality. Ensure you communicate those concerns to the GP.

Document all verbal conversations you have had with other healthcare professionals​[2]​. You may have sought advice regarding how to manage the patient or even just called the local pharmacy to inform them a patient is starting a new medication that will need to be included in their dosette box. Ensure the name and role of who you speak to is also documented. If you have communicated with another healthcare professional in writing, ensure you attach the correspondence to the patient records. In complex patient cases, do not be afraid to ask other healthcare professionals for a written response detailing their advice.

Write brief notes or use a proforma during the consultation, and then type up the letter once the consultation ends. Some clinicians may see all their patients and then verbally dictate or type up all the letters. Others may prefer to type each letter immediately after a patient has been seen while the conversation is fresh in their mind.

Creating a template for letters can save time and help to remind you to obtain all the essential information, but do not be afraid to adapt the template for each patient if needed.

Add your contact details to the letter so that the GP can contact you. Including an email address on letters sent to local GPs can be a good way to open a line of communication and encourage them to email you for non-urgent advice. This can help build relationships and rapport.

Once completed, send letters to the GP promptly but be aware that they may not read your letter immediately. Urgent matters that need immediate action should be communicated via phone call and documented appropriately.

Accuracy and professionalism of communication

If you are new to the clinic setting and articulating letters is not something you are used to, ask an experienced member of staff to read the letter before sending it off. Does it read well? Is it clear to the reader? Are all options discussed and risks documented clearly in the letter? Even highly experienced clinicians can benefit from the input of specialists when dealing with complex patient cases, and it can be good practice to ask for a consultant or senior colleague to proofread your letters in these circumstances. This extra check provides reassurance that nothing has been missed and that documentation is clear and accurate.

If you spot a prescribing error in the clinic setting, it is important to provide constructive feedback to the prescriber and report the error appropriately​[3]​. Be mindful of how you provide the feedback and how to document the error in the clinic letter. Consider it from the prescriber’s perspective and remember the patient also gets a copy of the letter. The error needs to be communicated in a professional, non-judgemental way to the prescriber, without undermining the patient’s trust in that prescriber.

Check your letter before sending, particularly if it was dictated. Dictated letters are typed by non-clinical staff. Look out for spelling and grammatical errors. Remember your letters will be on record for several years​[4]​.

Follow-up

Once you decide to discharge the patient from your clinic, ensure you transfer the care appropriately to the GP, including communicating via a letter any recommendations on monitoring requirements and the frequency of monitoring. Remember, non-medical GP surgery staff may be allocated the task of monitoring therapy. Do not assume that all GP staff know how to monitor patients. As the patient receives a copy of the letter, it is useful for them to know the future monitoring requirements.

Communicate clearly, via writing, any issues you require the GP to follow up with other healthcare professionals (see Box 2).

If you have asked a healthcare professional for advice and are awaiting their reply, communicate this via writing for the GP and others to make them aware that you are following this issue up.

Useful resources

• Standards for the education and training of pharmacist independent prescribers
• Consultation skills assessment
• Investigating the prevalence and causes of prescribing errors in general practice: The PRACtICe Study