Figure 4-1 outlines the basic model of communication. A sender sends a message to a receiver. The message can be verbal, meaning that spoken or written words are used to send the message. It can also be nonverbal, meaning the message is expressed without words through body language, facial expression, and other means. Most messages are sent using a combination of verbal and nonverbal communication. The feedback from the receiver to the sender, also verbal or nonverbal, helps the sender decide whether to initiate a new message, expand on the original message, or clarify the message.

Nonverbal Measures to Facilitate Communication

In the United States, eye contact is important (Figure 4-3). Maintaining eye contact is a sign of interest and involvement. However, being aware that in many cultures it is not respectful to look directly at older people is important. This is especially true in Asian and Native American cultures. Many Latinos also do not look directly at a person they respect, such as a teacher or a physician.

Figure 4-3 Photograph showing a comfortable talking distance and eye contact that is typical for the United States.

If the patient looks away and the medical assistant continues to seek eye contact, the patient may perceive this as aggression. Maintaining eye contact with someone who is culturally uncomfortable with that nonverbal communication creates a barrier between the two individuals.

For the most part, control of body language is unconscious. Therefore it is important for the medical assistant to be aware of the patient’s nonverbal messages. Being alert to the patient’s body language allows the medical assistant to notice when a patient feels uncomfortable or anxious. When a patient’s words and body language do not match, the body language is usually a more genuine reflection of the patient’s feelings.

Touching a person, even gently, can also be interpreted in many different ways. Moving closer can indicate interest, but it may also be viewed as aggressive. Many adults do not like to be touched by people they do not know well.

Cultural sensitivity is extremely important. For example, some Asians do not like to have their heads or their children’s heads touched. This may present a problem when the medical assistant must measure the head circumference of an Asian infant. If this occurs, the medical assistant should stress to the infant’s parent in a reassuring tone of voice that measuring head circumference is an important health assessment procedure and that there is no disrespect intended in the action.

A gentle pat on the shoulder can be reassuring to a patient, but it is important to notice if the patient becomes tense or appears uncomfortable when touched. If the medical assistant steps back, the patient will usually relax. In the United States, people normally maintain a distance of about 3 to 4 feet for conversation with others, but in other cultures this comfort zone varies.

If the medical assistant must penetrate the patient’s personal comfort zone for a procedure, it may help to make a statement that prepares the patient for movement into the patient’s personal space. For example, when applying a sterile dressing to a wound, the medical assistant might say, “I’m going to have to move in now so I have a better view of the area.”

What Would You Do? What Would You Not Do?

Case Study 1

Nancy Walker, CMA (AAMA), has called Jennifer Boland, a 32-year-old married mother of three, from the waiting room. Nancy notices that Jennifer is not looking at her, but the patient cooperates with getting her weight and vital signs. When Nancy asks the reason for today’s visit, it seems to take Jennifer a long time to answer. She picks at the sleeve of her jersey and finally says in a low voice that she is afraid she might be pregnant. Her voice cracks a little, and then she wipes one of her eyes.

Interviewing Techniques

Closed Questions

Two types of questions can be used when conducting a patient interview. These include closed questions and open questions. Closed questions are questions that can be answered with one word (e.g., yes or no) or a short answer (e.g., I was born on January 16, 1985). Closed questions are especially effective when the medical assistant needs to obtain specific information.

Examples of closed questions include the following:

• What is your date of birth?

• Who referred you to our office?

• Have you taken any medication for your pain?

• What medications are you currently taking?

Open Questions

Open questions consist of questions that encourage the patient to open up and talk. Examples of open questions include the following:

• What brings you to see the doctor today?

• What is your pain like?

• What has been going on with you since you were last here?

• How has your appetite changed over the past few months?

Open questions help the patient do the following:

• Identify what is important

• Express feelings

• Relay perceptions

Open questions are particularly effective in allowing the patient to describe a problem in his or her own words and explain how the patient feels about the problem. Because of this, open questions should be used to obtain a patient’s chief complaint and conduct a patient interview. When using open questions, it is important for the medical assistant to employ active listening techniques.

If the medical assistant asks primarily closed questions, the patient may fail to give important details or mention other problems. If the medical assistant asks directly if the patient has been following a special diet or taking prescribed medication, the patient may feel pressure to agree, even if this has not always been the case. When a patient is encouraged to talk freely, a more realistic picture may emerge.

Keeping the Conversation Going

On occasion the medical assistant will need to employ techniques to keep a conversation going with a patient. For example, the medical assistant may need additional information from a patient, but the patient stops talking. When this occurs, the medical assistant should employ techniques that encourage the patient to continue speaking without steering the conversation in a particular direction. A useful technique in such a situation is to ask the patient an open question; however, “why” questions should not be used. Examples of “why” questions include the following:

• Why aren’t you taking your medication?

• Why aren’t you following your diet?

“Why” questions tend to make people defensive. Rather than having the patient justify his or her actions, it is important to identify the underlying reasons as to why the patient did not take the medication or stay on the diet. Effective questions that keep the conversation flowing without making a patient defensive include the following:

• How do you set up your meals and snacks?

• What problems are you having taking your medication?

• What do you think about having to take medication at school?

In answering these questions, the patient may provide clues as to the underlying reasons for not staying with the prescribed treatment plan.

Drawing Patients Out

Active listening includes techniques to draw a patient out and/or clarify what a patient is saying. This is especially important when the patient is trying to cope with strong feelings about his or her medical problems. Refer to Table 4-1 for a full listing of communication techniques that demonstrate active listening.

Table 4-1

Communication Techniques That Demonstrate Active Listening

Technique	Description	Example
Using open questions	Asking questions that do not expect a particular answer, especially a yes or no answer.	“What’s been going on lately?”
Using open questions		“How would you describe your stomach pain?”
Repeating or rephrasing	Saying the same thing as the patient either as a statement or a question to encourage agreement, disagreement, or clarification.	Patient: “ It feels like someone is stabbing me in the side.”
Repeating or rephrasing		Medical assistant: “Like a knife in your side…”
Translating a nonverbal message into words	Translating the patient’s nonverbal expression of emotion into a verbal expression.	Patient: “All the doctor visits, the medication, the pain—it’s really too much.”
Translating a nonverbal message into words		Medical assistant: “You sound like you feel overwhelmed.”
Reflecting	Reflecting is turning a question or statement around to reflect back to the patient; this gives the patient confidence to continue.	Patient: “Would you have this surgery if you were me?”
Reflecting		Medical assistant: “What do you think about having the surgery?”
Paraphrasing and summarizing	Paraphrasing puts the patient’s statement into the medical assistant’s own words; summarizing restates the meaning but may leave out some of the details. The purposes are to validate that the medical assistant has understood and to encourage clarification.	Medical assistant: “So for the past week the pain has been getting steadily more intense and more frequent, and since this morning it hasn’t let up at all.”
Providing silence	Simply waiting for the patient to continue; allows the patient to choose whether to continue or choose a new topic.	(Silence)
Verbalizing the implied	Saying what the patient seems to mean but has not expressed.	Patient: “Usually I don’t mind coming to see Dr. Hughes.”
Verbalizing the implied		Medical assistant: “But you didn’t want to come today…”
Asking for clarification	Asking for more detail or a clearer statement; lets the patient know that the medical assistant has not understood and may show the patient how to make the message clearer.	Medical assistant: “It’s not clear to me how often you have been taking this medication. Do you take it before every meal, or just when you are at home?”

Avoiding Responses That Inhibit Communication

The medical assistant should avoid communication techniques that exhibit disapproval or blame as well as statements that are challenging or not genuine. If a patient feels that the medical assistant is not really listening, does not understand his or her point of view, or does not validate emotions, the patient may become defensive or stop speaking altogether. The medical assistant’s ability to demonstrate acceptance of strong emotions experienced by the patient is especially important.

When a patient expresses concerns, it is tempting to try to reassure the patient. For example, a patient might express anxiety about the results of a diagnostic test. If the medical assistant reassures the patient that the results will probably be normal, the fact that the patient is worried is not validated and the reassurance implies that the patient’s worry is unreasonable or unacceptable. If the medical assistant confirms that it is difficult to wait for test results, the patient is more likely to feel that his or her feelings have been accepted.

Because the medical assistant’s job is to make the person feel comfortable, it is important to avoid being too casual or familiar with a patient. If a subject is sensitive, but it is important to ask about it, the medical assistant can do so in a somewhat tentative way to make it easier for the patient to reply. The medical assistant can identify what the patient might be feeling, but the patient will not always agree. Many people are not always aware of their feelings and may deny feelings that they are communicating nonverbally. This should be respected. Others are only too glad to have their feelings recognized.

Medical assistants should express themselves honestly, without being judgmental, which means critical or negative. They can disagree with what a patient is saying, especially if that disagreement will get the patient to elaborate on what is being said. But they should not argue because arguing sets up a competitive situation. Because the medical assistant represents medical authority, the patient can easily feel threatened and unworthy.

The responses that should be avoided are summarized in Table 4-2.

Table 4-2

Responses That Inhibit Communication

Technique	Description	Example
Offering false reassurance	Telling the patient that everything will be all right; implies that the patient should not feel anxiety or concern. Especially inappropriate when the medical assistant does not know what will happen.	“Don’t worry; your husband will come through this with flying colors.”
Disapproving, blaming	Making a negative value judgment about the patient’s thinking or behavior; by implying or stating that a patient is responsible for his or her health problem, the medical assistant encourages the patient to defend against attack rather than establishing trust.	“You shouldn’t be smoking, you know. No wonder you have trouble breathing.”
Challenging	Insisting that the patient prove a statement or belief.	“Just show me something in writing that says people should never take a bath.”
Defending	Protecting oneself or someone else from criticism, which implies that the patient does not have a right to have a different opinion.	“Dr. Lawler’s patients never have to wait very long.”
Asking for explanations of feelings or behavior	Because patients often don’t know why they feel or act as they do, asking why may be frustrating and cause them to become defensive.	“Why don’t you stick to your diet?”
Asking for explanations of feelings or behavior		“Why are you angry?”
Belittling or negating feelings	Acting as if feelings are less intense than they are or not even present; this implies that the patient’s feelings are not real or not justified	“You are really making a big deal out of a little cut.”