General Practice Flashcards
what is general practice essentiall
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.
personal qualities required to be a good GP
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
GPs as business owners
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.
use of practice IT systems
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
the practice team
manager IT/admin secreterial reception nurses - junior/senior ANPs/PAs phlebotomists/HCAs
3 broad types of skills needed or successful medical interviewing
content skills
perceptual skills
process skills
what are content skills?
What doctors communicate - the substance of their questions and responses, the information they gather and give; the treatments
what are perceptual skills?
What they are thinking and feeling - their internal decision making, clinical reasoning; their awareness of their own biases, attitudes and distractions.
what are process skills?
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.
factors influencing the consultation
physical factors
personal factors - doctor and patient
physical factors affecting the consultation: site and environment
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
physical factors affecting the consultation: adequacy of medical records
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.
physical factors affecting the consultation: time constraints
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.
physical factors affecting the consultation: patient status
New patient or known patient (known patient vs unknown) new problem or old problem (whether patient is new or known to you).
personal factors affecting the consultation: age
As a general rule younger doctors are sought after by younger patients and older doctors by older patients, with of course considerable overlap.
personal factors affecting the consultation: sex
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.
personal factors affecting the consultation: backgrounds and origins
In particular social class and ethnic factors. There may be considerable language difficulties in both these instances which could adversely affect outcome.
personal factors affecting the consultation: knowledge and skills
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!
personal factors affecting the consultation: beliefs
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
personal factors affecting the consultation: the illness
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.
3 styles of doctor/patient relationship
authoritarian or paternalistic
guidance/co-operation
mutual participation
describe an authoritarian relationship
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.
describe a mutual participation relationship
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.
describe a guidance/co-operative relationship
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
name 3 interviewing techniques
the open-ended question
listening and silence
facillitation
interviewing techniques: the open ended question
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.
interviewing techniques: listening and silence
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.
interviewing techniques: facilitation
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.
types of questions
open direct closed leading reflecting
types of questions: open
is not deeking any particular answer but simply signals to the patient to tell his story
types of questions: direct
asks about a specific item
types of questions: losed
can only be answered by a yes or not
types of questions: leading
presumes the answer
types of questions: reflected
allows the doctor to avoid answering a direct question
non-verbal communication
instinctive
learned
clinical oversvation
how do we classify non-verbal communication
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.
non-verbal communication: instictive
(eg, crying, expressions of pain, laughter).
non-verbal communication: learned, life experience
The body language learnt from life experience is acquired at an early age, and is dependent on culture and family experience
non-verbal communication: learned, from training
Training courses in communication are increasing. These provide a greater insight into our communication with others, as well as an understanding of ourselves
non-verbal communication: clinical observation
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.
4 important points to consider about interpreting body language:
culture
context
gesture clusters
congruence
body language interpretation: culture
Body language differs between cultures, and care must be taken not to misinterpret it.
body language interpretation: context
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).
body language interpretation: gesture clusters
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.
body language interpretation: congruence
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.
body language: gaze behaviour
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.
body language: posture
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).
body language: specific gestures
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.