05 the Doctor - Patient Communication

8/9/2019 05 the Doctor - Patient Communication

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DOCTORDOCTOR PATIENTPATIENT

COMMUNICATIONCOMMUNICATION

Joshua Immanuel A. Marcos, MD,MscJoshua Immanuel A. Marcos, MD,Msc

Emilio Aguinaldo College of MedicineEmilio Aguinaldo College of Medicine


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Session ObjectivesSession Objectives

The Medical Student should be able to:The Medical Student should be able to:

Define patientDefine patient--centered interviewingcentered interviewing

Identify the required facilitation, questioningand relationship-building skills

Define doctorDefine doctor--centered interviewingcentered interviewing

Discuss the process of patientDiscuss the process of patient--centered and doctorcentered and doctor--centeredcentered

interviewinginterviewing


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ReadRead

Chapter 6Chapter 6--

Doctor- Patient Communication by Frasers

book The Clinical Method

Chapter 5Chapter 5

The doctor Patient Relationship

Chapter 2Chapter 2

The Consultation


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Why Doctors Must be GoodWhy Doctors Must be Good

Communicators?Communicators? Diagnosis and theDiagnosis and the

understanding of its effectsunderstanding of its effectson a patients life andon a patients life and

experience clearly dependexperience clearly dependon the doctoron the doctor

Transmission of the exactTransmission of the exactmessage by the patient tomessage by the patient to

the doctorthe doctor Use of verbal and nonUse of verbal and non--verbal skills to enableverbal skills to enablepatient to talk freelypatient to talk freely


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Communicators?Communicators? Correctly interpreting the signals theCorrectly interpreting the signals the

patient is sending out and by relaying backpatient is sending out and by relaying back

to the patient that his message is receivedto the patient that his message is received

and understoodand understood

I understand..Got it

doctor?


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Helps to establish a relationship betweenHelps to establish a relationship between

the two parties which has a beneficialthe two parties which has a beneficial

effect on the outcome of the consultationeffect on the outcome of the consultation Patients are more likely to comply if theyPatients are more likely to comply if they

are allowed to tell the MD what he feels isare allowed to tell the MD what he feels is

relevant about his problemrelevant about his problem interpreted ininterpreted in

the patients own languagethe patients own language


Communicators?Communicators?


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Traditional apprenticeship methodof teaching medical students

to take the clinical history often fails

to teach them sufficient interviewing

skills to enable them to obtain anaccurate and full account of their

patients problems

Maguire and Rutter 1976


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In Real LifeIn Real Life

It is hard for doctors toIt is hard for doctors to

get feedback on theirget feedback on their

behavior becausebehavior because

dissatisfied patients dodissatisfied patients donot usually tell the doctornot usually tell the doctor

that they are dissatisfiedthat they are dissatisfied

Do not return on followDo not return on follow--

upup


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Communication Skills Needed inCommunication Skills Needed in

the Consultationthe Consultation2 MAIN PARTS OF THE2 MAIN PARTS OF THE

CONSULTATIONCONSULTATION

THE INTERVIEWTHE INTERVIEW

The doctor seeking the reason for

the consultation

THE EXPOSITIONTHE EXPOSITION

Doctor informs the patient ofhis conclusions and diagnosis and

what treatment and advice should

be given


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Allaying Anxiety During theAllaying Anxiety During the

ConsultationConsultation

Korsch and Negrete 1972


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Tips in Reducing Patient AnxietyTips in Reducing Patient Anxiety

During ConsultationDuring Consultation Greeting by nameGreeting by name Giving out a trueGiving out a true

smilesmile

Rising to meet theRising to meet thepatientpatient

Shaking his handShaking his hand

Indicating where heIndicating where he

can sitcan sit Taking a briefTaking a brief

informal chatinformal chat


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Setting of the ConsultationSetting of the Consultation

Influences strongly the type of communication likelyInfluences strongly the type of communication likelyto take placeto take place

Other variables include:Other variables include:

Appearance and grooming of the doctor

Gestures

Eye contact

Seating arrangement in the clinic

Distractions in the room

Presence of a telephone or beeper, cellular phone

Number of waiting patients

Time allotted for each patient seen


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Seating ArrangementSeating Arrangement

CO-OPERATION CONFRONTATION

CONVERSATION


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Opening Clinical HistoryOpening Clinical History

After welcomingAfter welcoming

Start with nonStart with non--committal statementscommittal statements

Well now? What can I do for you?

Aim to let the patient tell his story asAim to let the patient tell his story as

fully as possiblefully as possible


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PATIENTPATIENT--CENTEREDCENTERED

INTERVIEWINGINTERVIEWING


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The interviewer encouragesThe interviewer encourages

the patient to expressthe patient to express

what is most important to himwhat is most important to him

of her and facilitates theof her and facilitates the

narration of the patients storynarration of the patients story

PATIENTPATIENT--CENTEREDCENTERED



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Active ListeningActive Listening

When we go beyond the physicalWhen we go beyond the physical

complaints of our patient and listen tocomplaints of our patient and listen to

him as a personhim as a personhow our patient feelshow our patient feels

about his illness , what his perceptionsabout his illness , what his perceptions

about it are and what makes himabout it are and what makes him

believe in the way he does in relation tobelieve in the way he does in relation to

his illnesshis illness


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Active ListeningActive Listening

The whole person approach teaches usThe whole person approach teaches us

to treat the patient as a person withto treat the patient as a person with

feelings and thoughts and a life contextfeelings and thoughts and a life context

Not just as disease or as a clinical caseNot just as disease or as a clinical case


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Rationale for PatientRationale for Patient--CenteredCentered

InterviewingInterviewing Improves patient satisfaction,Improves patient satisfaction,compliance, knowledge and recall andcompliance, knowledge and recall anddecreases doctor shopping anddecreases doctor shopping and

lawsuitslawsuits Shown to improve health outcomesShown to improve health outcomes

Better BP control and blood sugar control andeven perinatal outcomes, shortened length ofhospital stay and improved mortality incritically ill patients, improved canceroutcomes


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Required Facilitating SkillsRequired Facilitating Skills

The doctor must master the followingThe doctor must master the followingcore QUESTIONING skillscore QUESTIONING skills

Open-Ended Questioning skills

Silence Nonverbal encouragement

Neutral utterances and continuers

Reflection and echoing

Open-ended requests

Summary and paraphrasing

Close-Ended Questioning Skills Yes and No answers

Brief answers


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The doctor must master the followingThe doctor must master the followingcore RELATIONSHIPcore RELATIONSHIP--BUILDING skillsBUILDING skills

Emotion-seeking

Direct inquiry

Indirect inquiry: self disclosure, impact and beliefabout problems

Emotion handling

Naming and labeling Understanding and validation

Respect and praise

Support and partnership

Required Facilitating SkillsRequired Facilitating Skills


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Patient Centered Interviewing:Patient Centered Interviewing:

The ProcessThe ProcessSTEP 1: SETTING THE STAGE FOR THESTEP 1: SETTING THE STAGE FOR THE

INTERVIEWINTERVIEW

(30(30--60 SECONDS)60 SECONDS)

AIM: To recognize the identity of the patient,AIM: To recognize the identity of the patient,introducing himself and ensuring patientsintroducing himself and ensuring patientsreadiness to proceed with the interviewreadiness to proceed with the interview

Welcome the patientWelcome the patient

Use the patients nameUse the patients name

Introduce yourself and identify your specific roleIntroduce yourself and identify your specific role Ensure patient readiness and privacyEnsure patient readiness and privacy

Remove barriers to communicationRemove barriers to communication

Ensure comfort and put the patient at eastEnsure comfort and put the patient at east


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STEP 2:STEP 2: Obtaining the agenda includingObtaining the agenda including thetheChief ComplaintChief Complaint(30(30--60 SECONDS)60 SECONDS)

AIM: To orient the patient to the expectedAIM: To orient the patient to the expected

duration and process of the interaction andduration and process of the interaction andelicits the patients agendaelicits the patients agenda

1.1. Indicate the time availableIndicate the time available

2.2. Indicate the interviewers needsIndicate the interviewers needs3.3. Obtain a list of all issues the patient wants toObtain a list of all issues the patient wants to

discussdiscuss

4.4. Summarize and finalize the agendaSummarize and finalize the agenda


The ProcessThe Process


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STEP 3: Opening the history of presentSTEP 3: Opening the history of present

illnessillness (30(30--60 seconds)60 seconds)

AIM: Use of focusing openAIM: Use of focusing open--ended skills to openended skills to open

the history of present illness (HPI)the history of present illness (HPI)

1.1. Use an openUse an open--ended beginning question orended beginning question or

statementstatement

2.

2.

Use nonUse non--focusing openfocusing open--ended skillsended skills3.3. Obtain additional data from nonObtain additional data from non--verbal sourcesverbal sources




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STEP 4: Continuing the PatientSTEP 4: Continuing the Patient--Centered HPICentered HPI

(5(5--10 minutes of 40 minute visit)10 minutes of 40 minute visit)

AIM: To facilitate the patients description ofAIM: To facilitate the patients description ofher physical symptoms and their personalher physical symptoms and their personaland emotional contextand emotional context

1.1. Use focusing openUse focusing open--ended skills to obtain aended skills to obtain adescription of the patients physical symptomsdescription of the patients physical symptoms

2.2. Use focusing openUse focusing open--ended skills to develop theended skills to develop thepersonal or psychopersonal or psycho--social context of thesocial context of thepatients storypatients story




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STEP 4 (continued)STEP 4 (continued)

3.3. Use of emotionUse of emotion--seeking skills t develop anseeking skills t develop an

emotional contextemotional context4. Use emotion handling skills to address4. Use emotion handling skills to address

elicited emotionselicited emotions

5.Use focused open5

.Use focused open--ended skills, emotionended skills, emotion--seeking skills and emotion handling skillsseeking skills and emotion handling skills

to expand the storyto expand the story




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STEP 5: Transition to the DoctorSTEP 5: Transition to the Doctor--centeredcentered

ProcessProcess (30 SECONDS)(30 SECONDS)

Aim: To close the patient centered portion andAim: To close the patient centered portion and

open the doctoropen the doctor--centered processcentered process

1.1. Summarize brieflySummarize briefly

2.2. Check accuracyCheck accuracy

3.3. Indicate that both content and style ofIndicate that both content and style ofinquiry will change if the patient is readyinquiry will change if the patient is ready




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DOCTORDOCTOR--CENTEREDCENTERED



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DoctorDoctor--Centered InterviewingCentered Interviewing

The doctor takes charge of the interactionThe doctor takes charge of the interaction

to acquire specific details not providedto acquire specific details not provided

already by the patient, usually to diagnosealready by the patient, usually to diagnose

disease or to fill in the routine data basedisease or to fill in the routine data base


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FILLING THE HISTORY OFFILLING THE HISTORY OF

PRESENT ILLNESSPRESENT ILLNESS1.1. Define the cardinal features of the patientsDefine the cardinal features of the patients

chief complaintchief complaint

2.2. Define the cardinal features of otherDefine the cardinal features of othersymptoms (those already mentioned by thesymptoms (those already mentioned by thepatient and those not yet introduced) in thepatient and those not yet introduced) in theorgan system of the patients chieforgan system of the patients chiefcomplaintcomplaint

3.3. Inquire about relevant symptoms outsideInquire about relevant symptoms outside

the involved systemthe involved system4.4. Inquire about relevant nonInquire about relevant non--symptomsymptom(secondary) data(secondary) data


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Seven Cardinal Features ofSeven Cardinal Features of

SymptomsSymptoms

1.1. Location and radiationLocation and radiation

a. Precise location

b. Deep or superficial

c. Localized or diffuse

2.2. QualityQuality

a. Usual descriptors

b. Unusual descriptors


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3. Quantification3. Quantification

a. Type of onset

b. Intensity or severity

c. Impairment or disability

d. Numeric description

-number of events

-size and volume


SymptomsSymptoms


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4. Chronology4. Chronology Time of onset of symptoms and intervals between

recurrences

Duration of symptom

Periodicity and frequency of symptoms Course of symptom (short-term or long-term)

5. Setting5. Setting

6. Modifying factors6. Modifying factors

Precipitating and aggravating factors Palliating and relieving factors

7. Associated symptoms7. Associated symptoms


SymptomsSymptoms


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DoctorDoctor--Centered InterviewingCentered Interviewing

Inquiring about symptoms in the same bodyInquiring about symptoms in the same bodysystemsystem

Asking about other relevant symptomsAsking about other relevant symptoms

Inquiring about relevant nonInquiring about relevant non--symptom datasymptom data

Scanning without interpretation versusScanning without interpretation versushypothesis testinghypothesis testing

Becoming patient centered when necessaryBecoming patient centered when necessary


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The Rest of the HistoryThe Rest of the History

Past Medical HistoryPast Medical History Medications

Allergies

Previous hospitalizations

Personal and Social HistoryPersonal and Social History Habits Occupation

Home life

Sexuality

Lifestyle

Family Medical and Social HistoryFamily Medical and Social History Heredo-familial diseass

Family composition and relationships

Level of function


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Reasons Why Interviews FailReasons Why Interviews Fail

1.1. Failure to prepare the patientsFailure to prepare the patients

2.2. Failure to control the interviewFailure to control the interview

3.3. The influence of a premature or restricted focus onThe influence of a premature or restricted focus onstudents (e.g. students assuming that there is onlystudents (e.g. students assuming that there is only

1 problem)1 problem)4.4. A lack of systematic interview procedureA lack of systematic interview procedure

5.5. Lack of clarification of the information in order toLack of clarification of the information in order toestablish the accuracy of the dataestablish the accuracy of the data

6.6. Unresponsiveness to verbal and nonUnresponsiveness to verbal and non--verbal cuesverbal cues

7.7. Lack of self Lack of self--awarenessawareness8.8. Difficulty with taking notes and maintaining eyeDifficulty with taking notes and maintaining eye

contactcontact


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During the Exposition PhaseDuring the Exposition Phase

Create the appropriate balance ofCreate the appropriate balance of

priorities between the person andpriorities between the person and

illnessillness

Convey to the patient sympathy,Convey to the patient sympathy,

empathy and honestyempathy and honesty

Remain aware of the patients right toRemain aware of the patients right to

share in the decisionshare in the decision--making processmaking process


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Read also:Read also:

Breaking bad newsBreaking bad news

Ending the consultationEnding the consultation

Reasons why expositions failReasons why expositions fail Monitoring your own communicationMonitoring your own communication

skillsskills


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Documents

05 the Doctor - Patient Communication