Communication skills

Communication Skills in Patient Interview

Dr Nesif Al-Hemiary
MBChB – FIBMS(Psych.)
International Associate of the Royal College of Psychiatrists(UK.)

Bio-psycho-social Model of disease

In 1977, George Engel at the University of Rochester, published a seminal paper that described the bio-psycho-social model of disease, which stressed an integrated systems approach to human behavior and disease.
The bio-psycho-social model is derived from general systems theory. The biological system emphasizes the anatomical, structural, and molecular substrate of disease and its effects on the patient's biological functioning;
the psychological system emphasizes the effects of psychodynamic factors, motivation, and personality on the experience of illness and the reaction to it;
and the social system emphasizes cultural, environmental, and familial influences on the expression and the experience of illness.
Engel postulated that each system affects, and is affected by, every other system.

The Medical Interview

Initiation of the interview
Gathering of information
Physical examination
Explanation and planning
Closing of the interview


Old versus New Approaches
2 Fs (Find it & Fix it).

4 Es (Engagement, Empathy, Education, Enlistment).

Initiation of the interview
Greet the patient
Introduce yourself
Show respect and care: make sure that the patient is sitting comfortable.
Ask about the reasons of the consultation
Make a list of the problems that need to be discussed.

Gathering of information

Encouragement
Open versus closed-ended questions
The biomedical perspective
The patient perspective
Listen carefully
Pay attention to emotional cues
Pay attention to non-verbal cues
Clarify unclear information
Summarize
Avoid medical jargon( language)


Providing a structure for the interview
Make a logical order of the different parts of the interview
At the end of each part ; summarize and clarify before moving to the next.
Make short pauses between different parts and use appropriate opening sentences.
Keep time limits so that you can finish the interview within 45-60 minutes.

Building of a relationship

Show a proper non-verbal cues: eye to eye contact, facial expression , attention to patient’s gestures , movements, and tone of voice
Don’t remain busy with recording notes
Show trust
Accept patient views
Be empathic
Be supportive
Be sensitive and delicate during emotional upsets.
Make a mutual relationship with the patient(share the patient in decision making).

Physical examination

Explain before each step.

Ask for permission before each step.

Explanation
Give enough information( like etiology, management, and prognosis of the illness)
See what kind of information the patient have , give information that can be understandable by the patient and that can be satisfactory.
Avoid difficult language and medical terms.
Use pictures and drawings
Avoid premature advice and reassurance.
Integrate the patient perspective

Planning

Participation in decision making ( let the patient understanding the process of decision making, make him a partner in decision making and increase his commitment to the decision).
Explain the available options for management.
Consider what the patient prefers.
See if the patient has any concerns before making a decision.

Closing the interview

Agree with the patient to review the next steps.
Safety network : explain expected and unexpected complications and explore how the patient can get help.
Agree on the next visit.
Provide a suitable closing remarks.


Breaking bad news
Bad news can be :
• Diagnosis of a dangerous illness like cancer or disability
• Death of a patient
• Having abnormal baby
• Developing a complication of treatment
• Minor things like postponement of an operation or unavailability of a bed

How to give bad news

Personal preparation
The physical setting
Talking to the patient and responding to concerns
Arranging follow up or referral
Feedback and handover to colleagues

Personal preparation

Is the patient expect bad news?
Should any one else be present( such as a nurse or a relative)?
What does the patient already knows about the illness ,or what has happened?
What personal resources does the patient have?
Have I got sufficient time to spend with the patient?
Are there any” what if ….” questions I should prepare my self for?(e.g. what if he discharges himself? What if she became angry with me?)


The physical setting
The ideal setting : private room that is reasonably comfortable, free from interruptions ,and has calm ambience.
This might not always be available
You might offer the best that you can like the curtains to separate patient from others , talking in low voice , etc …

Things you should not do

Don’t give bad news at the end of a physical examination while the patient is still undressed
Don’t give bad news in corridors and over the telephone ( if this can be avoided)
Don’t pace around, keep looking out of the window, or become distracted by activities nearby

Talking to the patient and responding to concerns

Talk slowly
Monosyllabic replies are avoided
Use the minimum jargon
Be empathetic to the patient’s needs and concerns

Breaking bad news requires :

Empathy
Starting with what the patient and relatives already knows or understands
Finding out what the patient wants to know
Active listening, giving information, inviting feedback and addressing concerns
Eliciting the patient’s own resources for coping
Instilling realistic hope


Giving information
In order to give information effectively you must:
Understand the information and be able to convey it
Use ideas and language that the patient can understand
Be prepared to respond to the patient’s questions

Guidelines of giving information

Describe what information you plan to give :
Results of physical examination
Results of test
Diagnosis or provisional diagnosis
Cause of the problem
Necessary further investigations
Treatment plan
Prognosis

Summarize your understanding of the patient’s problem.

Find out the patient’s understanding of the condition
Use appropriate language:
Use short words and short sentences
Avoid medical jargon
Avoid vagueness
Give specific information


THANK
YOU