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Gathering informationGathering information
Learning outcomesLearning outcomes
To understand the core objectives of gathering dataTo understand the core objectives of gathering data To be aware of the traditional model of history takingTo be aware of the traditional model of history taking To understand the strengths and weaknesses of the traditional historyTo understand the strengths and weaknesses of the traditional history To understand the disease - illness modelTo understand the disease - illness model To be able to define diseaseTo be able to define disease To list examples of diseases without illnessTo list examples of diseases without illness To be able to define illnessTo be able to define illness To list examples of illnesses without diseaseTo list examples of illnesses without disease To understand why it is important to explore both the disease and illness in the consultationTo understand why it is important to explore both the disease and illness in the consultation To be able to list the skills utilised during gathering data and understand what they each To be able to list the skills utilised during gathering data and understand what they each
meanmean To construct phrases to explore ideas, concerns, expectation and feelingsTo construct phrases to explore ideas, concerns, expectation and feelings To understand why it is important to discover the patient’s perspective of their illnessTo understand why it is important to discover the patient’s perspective of their illness To understand how patient centred consulting may improve the consultationTo understand how patient centred consulting may improve the consultation To apply some of the skills learned to practical role-playing exercisesTo apply some of the skills learned to practical role-playing exercises
What are the core objectives of data gathering?What are the core objectives of data gathering?
To take an accurate medical history in order to recognise the To take an accurate medical history in order to recognise the patterns associated with certain diseasespatterns associated with certain diseases
To explore and understand the patient’s perspective of their To explore and understand the patient’s perspective of their symptoms and illnesssymptoms and illness
To structure the consultationTo structure the consultation To improves the process of diagnostic reasoningTo improves the process of diagnostic reasoning To ensure effective and efficient use of timeTo ensure effective and efficient use of time
To involve the patient in an interactive process that promotes To involve the patient in an interactive process that promotes their participation and rapporttheir participation and rapport
What is the format of a traditional historyWhat is the format of a traditional history??
Presenting problem(s)Presenting problem(s) PMH PMH DHDH SHSH FHFH AllergiesAllergies Systems enquirySystems enquiry
What are the strengths and weaknesses of What are the strengths and weaknesses of the traditional medical history model?the traditional medical history model?
StrengthsStrengths
It is a scientific approach. The development of a method of It is a scientific approach. The development of a method of classification of the underlying causes of disease paved the way classification of the underlying causes of disease paved the way for advances in medical sciencefor advances in medical science
Pathologists could give clinicians feedback of the accuracy of their Pathologists could give clinicians feedback of the accuracy of their diagnostic skillsdiagnostic skills
Provides a clear method of taking and recording the clinical history Provides a clear method of taking and recording the clinical history on a carefully structured templateon a carefully structured template
Prevents omission of key points and data extracted from the Prevents omission of key points and data extracted from the patient appears in a standard assimilatable formpatient appears in a standard assimilatable form
WeaknessesWeaknesses
The scientific method does not aim to understand the meaning of The scientific method does not aim to understand the meaning of illness for the patient or to place it in the context of their life or illness for the patient or to place it in the context of their life or familyfamily
The closed questioning method encourages an inefficient and The closed questioning method encourages an inefficient and inaccurate method of history takinginaccurate method of history taking
The premature search for scientific facts prevents us from The premature search for scientific facts prevents us from listening and therefore taking an accurate history and picking up listening and therefore taking an accurate history and picking up cues to the patient’s problems and concernscues to the patient’s problems and concerns
Fundamentally it is doctor-centredFundamentally it is doctor-centred
Disease-Illness Model (1989)Disease-Illness Model (1989)
McWhinney (1989) University of Western OntarioMcWhinney (1989) University of Western Ontario
Also know as:Also know as: The transformed clinical methodThe transformed clinical method Patient-centred clinical interviewingPatient-centred clinical interviewing
Considers both the doctor’s and patient’s agendaConsiders both the doctor’s and patient’s agenda
What defines a disease?What defines a disease?
The biomedical cause of sickness in terms of pathophysiologyThe biomedical cause of sickness in terms of pathophysiology
It is the doctor’s role to search for symptoms and signs of It is the doctor’s role to search for symptoms and signs of underlying diseaseunderlying disease
Discovering a diagnosis for the patient’s ‘disease’ is the Discovering a diagnosis for the patient’s ‘disease’ is the doctor’s traditional and central agendadoctor’s traditional and central agenda
Think of examples of diseases without illness?Think of examples of diseases without illness?
Ovarian cancerOvarian cancer
HypertensionHypertension
HypothyroidismHypothyroidism
What are the components that constitute What are the components that constitute illness?illness?
Illness is the individual patient’s unique experienceIllness is the individual patient’s unique experience
The patient’s perspectives include feelings, thoughts, The patient’s perspectives include feelings, thoughts, concerns and effects on life that any period of illness inducesconcerns and effects on life that any period of illness induces
It represents the patient’s response to events around them, It represents the patient’s response to events around them, their understanding of what is happening to them, and their their understanding of what is happening to them, and their expectations of helpexpectations of help
Think of examples of illness without diseaseThink of examples of illness without disease
Bereavement reactions and grief symptomsBereavement reactions and grief symptoms
Tension headachesTension headaches
Child with school problems and abdominal painChild with school problems and abdominal pain
Why explore both perspectives?Why explore both perspectives?
To support, understand and build a relationshipTo support, understand and build a relationship
The traditional disease model does not explain everythingThe traditional disease model does not explain everything
Discovering the patient’s perspective may aid diagnosis and Discovering the patient’s perspective may aid diagnosis and make for more effective and efficient interviewsmake for more effective and efficient interviews
Groundwork for explanation and planningGroundwork for explanation and planning
What are the skills used in data gathering?What are the skills used in data gathering?
PatPatient’s narrativeient’s narrative
Questioning techniquesQuestioning techniques
Attentive listeningAttentive listening
Facilitative responseFacilitative response
CuesCues
ClarificationClarification
Time framingTime framing
Internal summaryInternal summary
LanguageLanguage
IdeasIdeas
ConcernsConcerns
ExpectationsExpectations
EffectsEffects
FeelingsFeelings
Patient’s narrativePatient’s narrative
Encourages the patient to tell the story of the problem(s) Encourages the patient to tell the story of the problem(s) from when first started to the present in own words from when first started to the present in own words (clarifying the reason for presenting now)(clarifying the reason for presenting now)
““Tell me all about it from the beginningTell me all about it from the beginning””
Questioning techniquesQuestioning techniques
How we ask questions plays a central role in the quality and quantity of How we ask questions plays a central role in the quality and quantity of information obtainedinformation obtained OpenOpen
““Tell me about your headaches?”Tell me about your headaches?” More specific but openMore specific but open
What makes your headaches better or worse?”What makes your headaches better or worse?” ClosedClosed
““Do you ever wake up with the headache?”Do you ever wake up with the headache?”
Use open and closed questioning techniques appropriately moving from Use open and closed questioning techniques appropriately moving from open to closedopen to closed
The open to closed coneThe open to closed cone
Attentive listeningAttentive listening
Requires a combination of focus, facilitation skills, wait time Requires a combination of focus, facilitation skills, wait time and picking up cuesand picking up cues
Facilitative responseFacilitative response
Facilitates the patient’s responses verbally and non-verbally by Facilitates the patient’s responses verbally and non-verbally by use of:use of:
EncouragementEncouragement SilenceSilence Repetition (echoing)Repetition (echoing) ParaphrasingParaphrasing
Restating in your words the content or feelings behind Restating in your words the content or feelings behind the patient’s messagethe patient’s message
Sharing your thoughtsSharing your thoughts
CuesCues
Picks up the patient’s verbal and non-verbal cues (body Picks up the patient’s verbal and non-verbal cues (body language, vocal cues, facial expression); checks them out and language, vocal cues, facial expression); checks them out and acknowledges them as appropriateacknowledges them as appropriate
ClarificationClarification
Checks out statements which are vague or need amplification Checks out statements which are vague or need amplification (eg (eg “Could you explain what you mean by light-headed?”)“Could you explain what you mean by light-headed?”)
Time framingTime framing
Establishes dates and sequences of eventsEstablishes dates and sequences of events
Internal summaryInternal summary
Periodically summarises to verify own understanding of what Periodically summarises to verify own understanding of what the patient has said; invites the patient to correct the patient has said; invites the patient to correct interpretation and provide further informationinterpretation and provide further information
LanguageLanguage
Uses concise, easily understood questions and comments; Uses concise, easily understood questions and comments; avoids or adequately explains jargonavoids or adequately explains jargon
Think of how you might phrase questions that Think of how you might phrase questions that ask patients directly for their:ask patients directly for their:
IdeasIdeasConcernsConcerns
ExpectationsExpectationsFeelingsFeelings
IdeasIdeas
““What do you think is causing it?”What do you think is causing it?”
““What do you think that might be happening?”What do you think that might be happening?”
““Have you any ideas about this yourself?”Have you any ideas about this yourself?”
““Do you have any clues?”Do you have any clues?”
““Do you have any theories?”Do you have any theories?”
““You’ve obviously given this some thought. It would help me to know what You’ve obviously given this some thought. It would help me to know what you were thinking it might be?”you were thinking it might be?”
ConcernsConcerns
““What are you concerned it might be?”What are you concerned it might be?”
““Is there anything particular or specific that you were worried Is there anything particular or specific that you were worried about?”about?”
““What was the worst fear or thought about this?”What was the worst fear or thought about this?”
““In your darkest moments…..what had been going through In your darkest moments…..what had been going through your mind?”your mind?”
ExpectationsExpectations
““How were you hoping I might help you with this?”How were you hoping I might help you with this?”
““What do you hoping I might be able to do for this?”What do you hoping I might be able to do for this?”
““What do you think might be the best plan of action?”What do you think might be the best plan of action?”
““How might I best help you with this?”How might I best help you with this?”
““You’ve obviously given this some thought. What were you You’ve obviously given this some thought. What were you thinking would be the best way of tackling this?”thinking would be the best way of tackling this?”
FeelingsFeelings
““How has all of this made you feel?”How has all of this made you feel?”
““How has this left you feeling?”How has this left you feeling?”
““How have things seemed to you?”How have things seemed to you?”
EffectsEffects
An open question about how the symptoms are affecting the An open question about how the symptoms are affecting the patient’s life is an excellent entry into the patient’s patient’s life is an excellent entry into the patient’s perspective of the problem and often leads to the patient perspective of the problem and often leads to the patient talking openly about their thoughts and feelingstalking openly about their thoughts and feelings
““How has this affected your life?”How has this affected your life?”
Why is it important to discover the patient’s Why is it important to discover the patient’s perspective?perspective?
We make a diagnosis of disease in <50% of patient’s problemsWe make a diagnosis of disease in <50% of patient’s problems
There is much evidence that we never reach a diagnosis event There is much evidence that we never reach a diagnosis event after many consultationsafter many consultations
Exploring the illness perspective early will uncover a number Exploring the illness perspective early will uncover a number of problems where the root is an emotional or personal issueof problems where the root is an emotional or personal issue
Even where there is disease exploring why they have Even where there is disease exploring why they have presented at this time is usefulpresented at this time is useful
The underlying fear of the patient may mask other issuesThe underlying fear of the patient may mask other issues
What are the effects of patient centred What are the effects of patient centred consulting?consulting?
Fewer follow upsFewer follow ups
Fewer investigationsFewer investigations
Less referralsLess referrals
Improves diagnostic accuracyImproves diagnostic accuracy
Helps with managementHelps with management
ExercisesExercises
List five common terms or descriptions used List five common terms or descriptions used by patients for each organ system that need by patients for each organ system that need
clarifying in order to be understoodclarifying in order to be understood
List six common causes of headache that need List six common causes of headache that need to be considered in a fifty year old man. to be considered in a fifty year old man. Characterise each in terms of their timing. Use Characterise each in terms of their timing. Use variables such as mode of onset, pattern, variables such as mode of onset, pattern, variation over timevariation over time
List the areas of information or data you need to cover List the areas of information or data you need to cover medically – to make an accurate assessment of the medically – to make an accurate assessment of the
following common presentations met in primary carefollowing common presentations met in primary care
Exacerbation of asthmaExacerbation of asthma DepressionDepression HeadacheHeadache Tiredness and lethargyTiredness and lethargy Low back painLow back pain ProstatismProstatism Skin rashSkin rash Rectal bleedingRectal bleeding DyspepsiaDyspepsia
Discuss the difficulties of patients who somatise. Think of Discuss the difficulties of patients who somatise. Think of how you might phrase questions that explore the link how you might phrase questions that explore the link
between symptoms and emotions or feelingsbetween symptoms and emotions or feelings
eg chronic fatigue, IBS, non-cardiac chest paineg chronic fatigue, IBS, non-cardiac chest pain
Consider how you might respond to the Consider how you might respond to the following patient concernsfollowing patient concerns
““I’ve been getting a stiff neck at work this week and now I’m I’ve been getting a stiff neck at work this week and now I’m frightened I might be getting meningitis”frightened I might be getting meningitis”
““I think my child is dyslexic – and I would like her allergy I think my child is dyslexic – and I would like her allergy tested doctor”tested doctor”
““I don’t have any sex drive anymore and I don’t feel I can cope I don’t have any sex drive anymore and I don’t feel I can cope with the children either – do you think it is caused by my with the children either – do you think it is caused by my hormones?”hormones?”
““I think I’ve got dementia – my memory’s so poor these days I think I’ve got dementia – my memory’s so poor these days and now I’ve started leaking urine – I’m sure this means I’m and now I’ve started leaking urine – I’m sure this means I’m not going to live much longer now”not going to live much longer now”
““Everything I do seems to go wrong, I’m a hopeless mother, Everything I do seems to go wrong, I’m a hopeless mother, I’ve fallen out with my best friend and I can’t even find a part I’ve fallen out with my best friend and I can’t even find a part time job – don’t you think that makes me sound useless?”time job – don’t you think that makes me sound useless?”
““I wonder if you could prescribe antibiotics for Harry – he has I wonder if you could prescribe antibiotics for Harry – he has such a bad cough!”such a bad cough!”
““I wonder if you could give me a full check up doctor – being 40 I wonder if you could give me a full check up doctor – being 40 and all that”and all that”
““I find it very difficult to walk these days – do you think I’ll need I find it very difficult to walk these days – do you think I’ll need a wheelchair soon?”a wheelchair soon?”
““I don’t want to take any medicine for my diabetes or else it will I don’t want to take any medicine for my diabetes or else it will stop me driving my lorry”stop me driving my lorry”
““I think Dr Smith was awful to me on the telephone last night – I think Dr Smith was awful to me on the telephone last night – he didn’t seem to care at all that I’d just brought John back from he didn’t seem to care at all that I’d just brought John back from having a serious operation – I feel like making a complainthaving a serious operation – I feel like making a complaint””
DVD tasksDVD tasks
CuesCues Stop the tape each time there is a significant verbal / non-verbal cueStop the tape each time there is a significant verbal / non-verbal cue Why stop there?Why stop there? What might they have been trying to say?What might they have been trying to say? How would you check your interpretation with the patient?How would you check your interpretation with the patient?
Disease vs illnessDisease vs illness Are both covered?Are both covered? What have you discovered about each area?What have you discovered about each area?
Open to closed coneOpen to closed cone Stop after each question asked?Stop after each question asked? Open or closed?Open or closed?
Stop every minute or so. Discuss the reasoning behind the Stop every minute or so. Discuss the reasoning behind the line of questioning. What do you know at that point and what line of questioning. What do you know at that point and what do you still need to discover? Consider alternative questions if do you still need to discover? Consider alternative questions if relevantrelevant
Has there been clarity between patient and doctor. What Has there been clarity between patient and doctor. What terms or phrases were ambiguous eg dizziness as well as any terms or phrases were ambiguous eg dizziness as well as any jargon used. Were these clarified or explained?jargon used. Were these clarified or explained?
