General Practice

Question 1

what is general practice essentiall

Answer 1

General Practice is about caring for the whole person as well as their illnesses, the promotion of healthy life styles, and providing the first point of contact and out of hospital care for patients.
Doctors working in General Practice enjoy problem-solving with their patients, combining evidence-based medicine, wide ranging clinical skills and compassion to care for the individual.
They provide a holistic approach aimed at managing risk, and dealing with (rather than resolving) uncertainty and complexity. The added value is delivered by allowing a story to evolve and develop rather than applying a protocol to every presentation in an attempt to resolve it.

Question 2

personal qualities required to be a good GP

Answer 2

Ability to care about patients and their relatives
A commitment to providing high quality care
An awareness of one’s own limitations
An ability to seek help when appropriate
Commitment to keeping up to date and improving quality of one’s own performance
Appreciation of the value of team work
Good interpersonal and communication skills
Clinical competence
Organisational ability
Ability to manage oneself
Ability to work with others
Maintaining good practice
Relating to the public
Ability to deal with uncertainty

Question 3

GPs as business owners

Answer 3

most GPs are independent contractors, either owning and running the business on their own or in partnership with others.GPs are responsible for running the business affairs of the practice, providing adequate premises and infrastructure to provide safe patient services and employ and train practice staff.

Question 4

use of practice IT systems

Answer 4

Store appointments
Book appointments
Assist in consultations (patient records)
Support prescribing
Electronic management of hospital letters
Electronic management of blood/other results
Use in audit
E-consultations
Chronic disease management and recall
Patient leaflets/resources
Public health information
Identify patients for screening programmes

Question 5

the practice team

Answer 5

manager
IT/admin 
secreterial
reception
nurses - junior/senior
ANPs/PAs
phlebotomists/HCAs

Question 6

3 broad types of skills needed or successful medical interviewing

Answer 6

content skills
perceptual skills
process skills

Question 7

what are content skills?

Answer 7

What doctors communicate - the substance of their questions and responses, the information they gather and give; the treatments

Question 8

what are perceptual skills?

Answer 8

What they are thinking and feeling - their internal decision making, clinical reasoning; their awareness of their own biases, attitudes and distractions.

Question 9

what are process skills?

Answer 9

How they do it - the ways doctors communicate with patients; how they go about discovering the history or providing information; the verbal and non-verbal skills they use; the way they structure and organise communication.

Question 10

factors influencing the consultation

Answer 10

physical factors

personal factors - doctor and patient

Question 11

physical factors affecting the consultation: site and environment

Answer 11

Attendance at a roadside accident in the dark, cold and pouring rain, with bystanders milling around and sometimes offering advice is obviously a different scenario to the doctor managing this same problem in the emergency department of a major hospital

Question 12

physical factors affecting the consultation: adequacy of medical records

Answer 12

Many patients have continuing health problems. An adequate record of the history of the illness, patient background, drugs in current use, etc. will avoid the need to waste time in reviewing such matters whenever the patient attends.

Question 13

physical factors affecting the consultation: time constraints

Answer 13

A time is usually allocated to each appointment which in itself is determined by many factors. There is usually an upper limit of time available and in certain cases this will significantly influence the consultation.

Question 14

physical factors affecting the consultation: patient status

Answer 14

New patient or known patient (known patient vs unknown) new problem or old problem (whether patient is new or known to you).

Question 15

personal factors affecting the consultation: age

Answer 15

As a general rule younger doctors are sought after by younger patients and older doctors by older patients, with of course considerable overlap.

Question 16

personal factors affecting the consultation: sex

Answer 16

Similar attitudes exist as with age differences. A barrier may exist to effective communication if a patient is forced to
consult a doctor of the opposite sex when the reverse is preferred.

Question 17

personal factors affecting the consultation: backgrounds and origins

Answer 17

In particular social class and ethnic factors. There may be considerable language difficulties in both these instances which could adversely affect outcome.

Question 18

personal factors affecting the consultation: knowledge and skills

Answer 18

This is an important factor to the doctor but to a lesser extent with the patient. Consider the position of the doctor when he or she is a patient!

Question 19

personal factors affecting the consultation: beliefs

Answer 19

Everyone has their own health beliefs about all sorts of aspects of illness and disease (eg, vitamin taking, ideas about weather affecting illness, bizarre theories about cause of disease, etc). Beliefs may be influenced by your medical training: most patients do not have that luxury. Health beliefs are often influenced by the media, other people, past experiences, and are often not medically accurate

Question 20

personal factors affecting the consultation: the illness

Answer 20

A consultation in which a patient is to be told that he has a terminal illness will be much more difficult to conduct than one where only a minor illness is present.

Question 21

3 styles of doctor/patient relationship

Answer 21

authoritarian or paternalistic
guidance/co-operation
mutual participation

Question 22

describe an authoritarian relationship

Answer 22

The physician uses all of the authority inherent in his status and the patient feels no autonomy. He tries hard to please the doctor and does not actively participate in his own treatment.

Question 23

describe a mutual participation relationship

Answer 23

This is the most desirable for the more complex diagnostic interview, as it is for the management of patients suffering from a chronic illness. Here the patient feels some responsibility for a successful outcome which involves both active participation and a feeling of relatively greater personal autonomy. This is created by appropriate moderation of the doctor’s use of his authority. In such a relationship, the widest range of relevant diagnostic information tends to emerge and the most successful outcome of treatment is likely to occur.

Question 24

describe a guidance/co-operative relationship

Answer 24

The physician still exercises much authority and the patient is obedient, but has a greater feeling of autonomy and participates somewhat more actively in the relationship

Question 25

name 3 interviewing techniques

Answer 25

the open-ended question
listening and silence
facillitation

Question 26

interviewing techniques: the open ended question

Answer 26

The open-ended question is essential in initiating the interview. A question such as, “what kind of troubles have you been having?” may start to elicit an account of the problems and worries that a patient has.

Question 27

interviewing techniques: listening and silence

Answer 27

Vital to the quality of communication are active listening skills. This means asking questions that follow on logically from what
the patient has told you, encouraging them to talk by nodding, making eye contact, etc, plus picking up on the patient’s body
language (ie, nervousness, eyes filling with tears).
Silence is a means of encouraging communication. While the patient is communicating freely, the doctor’s behaviour of choice
is an interested attentive and relaxed silence. An attentive facial expression and posture tells the patient non-verbally that s/he
has an interested listener.
Silence can also encourage communication. If the patient falls silent the interviewer should consider being silent him- or herself
for at least a brief time (a few seconds - not a long uncomfortable gap!). If one senses that the patient is holding back and that
his/her non-verbal behaviour reflects tension or discomfort, one’s silence is likely to be appropriate.

Question 28

interviewing techniques: facilitation

Answer 28

Facilitation encourages communication by using manner, gesture or words that do not specify the kind of information that is
sought. It suggests that the doctor is interested, and encourages the patient to continue. Silence and facilitation tend to go hand
in hand
- an interested, attentive manner is of course facilitating. Change of facial expression or posture displaying greater interest or
attention is a facilitation.

Question 29

types of questions

Answer 29

open 
direct
closed
leading 
reflecting

Question 30

types of questions: open

Answer 30

is not deeking any particular answer but simply signals to the patient to tell his story

Question 31

types of questions: direct

Answer 31

asks about a specific item

Question 32

types of questions: losed

Answer 32

can only be answered by a yes or not

Question 33

types of questions: leading

Answer 33

presumes the answer

Question 34

types of questions: reflected

Answer 34

allows the doctor to avoid answering a direct question

Question 35

non-verbal communication

Answer 35

instinctive
learned
clinical oversvation

Question 36

how do we classify non-verbal communication

Answer 36

Our communication with others is a complex process of words, tone of voice and body movements. We often place great
importance on what is said, but in fact, a researcher (Albert Mehrabian) found that the total impact of a message depended on:
Verbal communication (7%) • Tone of voice (38%) • Non-verbal behaviour (55%)
This indicates that non-verbal aspects are of great importance in the communication process. The verbal channel conveys
information, the non-verbal however, conveys interpersonal attitudes and can be a substitute for verbal messages.
A number of non-verbal communications (body language) can be identified.

Question 37

non-verbal communication: instictive

Answer 37

(eg, crying, expressions of pain, laughter).

Question 38

non-verbal communication: learned, life experience

Answer 38

The body language learnt from life experience is acquired at an early age, and is dependent on culture and family experience

Question 39

non-verbal communication: learned, from training

Answer 39

Training courses in communication are increasing. These provide a greater insight into our communication with others, as well as an understanding of ourselves

Question 40

non-verbal communication: clinical observation

Answer 40

In the medical interview certain non-verbal messages are observed (eg, pain or abnormal movement, distress, degree of sickness, etc). The doctor also learns to recognize certain clinical syndromes (eg, Hypo-thyroidism, acromegaly, Parkinsons disease, side effects of steroids). As with any communication, both verbal and non-verbal cues occur within the medical interview. The doctor, by becoming more sensitive and aware of the non-verbal communication will acquire a further dimension in the doctor-patient relationship - recognition of what the patient is really saying and his/her concerns. The temptation is to deal with facts, but if 55% of our communication is non-verbal, then perceiving and understanding body language is essential. The doctor may also use this skill to modify his/her own interview behaviour.

Question 41

4 important points to consider about interpreting body language:

Answer 41

culture
context
gesture clusters
congruence

Question 42

body language interpretation: culture

Answer 42

Body language differs between cultures, and care must be taken not to misinterpret it.

Question 43

body language interpretation: context

Answer 43

Body language interpretation depends on the context (eg, the posture the patient adopts may be because of the discomfort of back pain or because of poor vision or hearing and not because of the non-verbal message).

Question 44

body language interpretation: gesture clusters

Answer 44

single gesture may easily be misinterpreted by the body language reader. It is therefore important that the interpretation is based on gesture clusters. The cluster of gestures re-inforces the message.

Question 45

body language interpretation: congruence

Answer 45

Non-verbal messages are more reliable than words, and any incongruence between the two requires attention. It has been said that the further we move from the mouth, where we can choose our words the more honest the body becomes. A lack of congruence can imply omission, inaccuracy or even suppression of information. Research has shown that when there is a lack of congruence, non-verbal gestures carry five times more impact than the verbal channel.

Question 46

body language: gaze behaviour

Answer 46

Eye contact is important in communication, and indicates interest. During communication a speaker holds eye
contact 30% of the time, the listener holds eye contact the majority of the time. Inadequate eye contact makes the listener ill at
ease (eg, with a timid or nervous person) and can indicate when a person is being dishonest or holding back information.
Communication can be cut off by looking away or the stammering/stuttering eyes.

Question 47

body language: posture

Answer 47

Posture provides further information. A depressed person often looks literally depressed - head bowed, slumped
posture; the anxious person is often restless and fidgety. Hands placed behind the head can suggest a confident or superior
attitude. Fidgitting and moving around in the seat can indicate anxiety (or extrapyramidal symptoms).

Question 48

body language: specific gestures

Answer 48

Body language can tell you if the patient is comfortable about the topic or not. Common barrier positions
include folded arms, legs or feet crossed and ankle lock gestures. Holding a handbag or fiddling with a cufflink may indicate
unease.
Hand-to-face actions form the basis of human deceit gestures. These gestures can indicate doubt, uncertainty, lying or
exaggeration. Hand to face gestures include the mouth guard (the hand covers the mouth), the nose touch, the eye rub, the ear
rub and the neck scratch. Cheek and chin gestures indicate interest and evaluation. The head support indicates boredom. The
hand on the cheek indicates interested evaluation, while the index finger pointing indicates negative or critical thoughts.
The hands clenched position is a frustration gesture, indicating that the person is holding back a negative attitude. There seems
to be a correlation between the height at which the hands are held and the degree of the person’s negative mood.