Patient Centred Communication Flashcards
How many consultations will a doctor do in a professional lifetime?
200,000
Communications problems lead to
complaints and claims
Communication improves
Patient satisfaction Recall Understanding Concordance Outcomes of care
Factors affecting clinical competence
Knowledge
Examination
Problem solving
Communication
Interviewing skills
Content skills
Perceptual skills
Process skills
Factors of content skills
What doctors communicate
Substance to their questions and responses
Information gathered and given
Responses
Factors of perceptual skills
What they are thinking and feeling
Internal decision making
Clinical reasoning
Awareness of own biases, attitudes and distractions
Factors of process skills
How they communicate
Way they communicate with the patients
How they discover the history or provide information
Verbal and non-verbal skills
How they structure and organise communication
Factors influencing consultation
Physical factors
Personal factors
Physical factors affecting consultation
Site and environment
Adequacy of medical records
Time constraints
Patient status
Personal factors affecting consultation
Age Sex Background and origins Knowledge and skills Beliefs Illness
Beliefs can be influenced by
Medical training (doctors only)
Media
Other people
Past experience
Styles of doctor-patient relationships
Authoritarian/paternalistic
Guidance/co-operation
Mutual partnership
Authoritarian/paternalistic doctor-patient relationship
Doctor uses all authority inherent in status
Resides in expertise and skills
Patient feels no autonomy, tries hard to please doctor and does not actively participate in treatment
Guidance/co-operation doctor-patient relationship
Doctor still exercises authority
Patient is obedient, has a greater feeling of autonomy and participates more actively in the relationship
Mutual partnership doctor-patient relationship
Appropriate moderation of use of doctors authority
Widest range of relevant diagnostic information emerges
Most successful treatment outcomes
Patient has some responsibility for successful outcome, involved in active participation and has greater feeling of autonomy
Interviewing techniques
Open-ended questions Listening and silence Facilitation Different question types Confrontation Support and reassurance
Different types of question
Open-ended Direct Closed Leading Reflected
When might confrontation be used?
When the doctor senses the patient is not speaking clearly or freely
What percentage of communication is verbal, tone of voice and non-verbal?
7% verbal
38% tone of voice
55% non-verbal
Types of non-verbal communication
Instinctive
Learned from life experiences
Learned from training
Clinical observation
Factors to be considered when interpreting body language
Culture
Context
Gesture clusters
Congruence
What is congruence?
The word used to describe when a patients body language matches their verbal language
Examples of body language
Gaze behaviour
Posture
Specific gestures
Behaviour is influenced by
Attitudes - positive or negative
Subjective norm
Perceptions of control over behaviour
A person is more likely to make a behavioural change if
Positive attitudes towards it
The change brings about consequences important to the patient
They believe others think it is important that they do it
They feel they have the necessary resources, skills or opportunities to overcome barriers
Stages of change
Pre-contemplation Contemplation Preparation Action Maintenance Relapse
Important factors in treating and communicating with patients with a disability
Etiquette
Patient-centred approach
Think what can be done to achieve the best possible function
Diagnosis and assessment of disability
Work with multidisciplinary team, voluntary services and social work
Factors of etiquette to consider
Don’t give assistance before first asking if the patient wants it
Don’t be upset if assistance is refused
Don’t be afraid to use figures of speech which refer to the impairment
Don’t use disabled as a noun
Don’t use nouns ending in ‘ic’ e.g. epileptic, diabetic
What principles of the Hippocratic Oath still apply?
Duty to respect autonomy of individuals
Duty to do no harm and to do good towards the patient
Duty to ensure your expertise is justly distributed amongst all patients in your care
What is the regulating body of doctor’s behaviour?
GMC
What is autonomy?
Cornerstone of free society
People have the same rights to actions and choices as we ourselves would wish to have
When are individuals not autonomous?
Children
Individuals with severe learning disabilities
Limitations to autonomy
Acceptability of effects of individual actions on other people
Applied through social pressure and the law of the land
Main features of professional relationship
Mutual respect and trust - based on empathy
What is empathy?
Ability to understand predicament of another and respect their autonomy without necessarily sympathising for them
Key components of the ethical code
Hippocratic oath
Declaration of Geneva Physician’s oath
Constitution of the WHO
WHO definition of health
State of complete physical, mental and social well-being and not merely the absence of disease or infirmity
What percentage of people at any one time are attending their GP?
19%
What percentage of people at any one time are under hospital care?
3%
What percentage of people at any one time have symptoms and are taking action?
55%
What percentage of people at any one time have symptoms and are taking no action?
18%
What percentage of people at any one time have no symptoms?
3%
What is disease?
Symptoms, signs and diagnosis from a biomedical perspective
What is illness?
Ideas, concerns and expectation from a patient’s perspective
Patient sources of referral information
Peers and family TV Health pages of newspapers and magazines "What should I do?" booklets SHOW website Practice leaflet or website
Examples of increasing role of community pharmacists
OTC contraception Statins Health checks Smoking cessation Minor ailments service
Factors affecting uptake of medical care
Medical
Non-medical
Medical factors affecting uptake of medical care
New symptoms
Visible symptoms
Increasing severity
Duration
Non-medical factors affecting uptake of medical care
Crisis Peer pressure Patient beliefs Expectation Social class Economic Psychological Environmental Cultural Ethnic Age Gender
Definitions of illness
Acute
Chronic
Self-limiting
Factors affecting sick role
Social Familial Psychological Financial Medications Responsibilites
Features of sick role for the patient
Patient is exempt from daily responsibilities, not responsible for being ill and unable to get better without help of a health care practitioner. Patient must seek help from HCP. Patient is under social obligation to get better as soon as possible to be able to take up social responsibilities again.
Features of the sick role for the health care practitioner
Must be objective and not judge the patient morally. Must not act out of self-interest or greed but put patient’s best interest first. Must obey professional role of practice. Have to maintain necessary knowledge and skills to treat patients
Have the right to examine patient intimately, prescribe treatment and has wide autonomy in practice
Examples of people held responsible for illness
HIV
Lung cancer
Secondary gains from being classed as sick
Care and sympathy
Concern from family and friends
Financial allowances associated with disability
Using apparently disabling illness as explanation for failures
Avoiding work
Restoring status or domination in family
Achieving revenge for bad treatment or pay from employer or insurance company
Age and gender contact rates
Females attend GP and practice nurse appointments more than males
Consultations increase as age increases
Advantages of house calls
Useful information on patient’s ability to cope with chronic condition or disability
Useful information obtained from relative or carer
Provides social contact for the socially isolated
Disadvantages of house calls
Lack of proper examination facilities
No chaperone
Time consuming
Presence of relative may lead to lack of confidentiality
Doctors working in community
GPs
Community child health specialists
Community geriatric specialists
Community family planning services
Ways to obtain direct access to services while bypassing GPs and NHS gatekeepers
NHS 24 and G-Med Family planning and GUM clinics Pharmacy minor ailment services Physiotherapy A&E Some parts of private sector
Illness presentations
Acute and severe illness
Minor illness
Doctor-patient relationship in hospital
Hospital doctor deals with the individual patient for short periods of time for a specific purpose, decide if the specialty can offer the patient anything and matches patients needs to expertise and does whatever possible
GP doctor-patient relationship
Patient’s medical advisor until patient death or GP retirement. Complex role, continuing and personal. Deal with many patients whose illness is difficult to diagnose in diagnostic/medical science terms.
Issues in having done majority of undergraduate training in hospital specialties
Hospital is tip of the iceberg of care
Narrow spectrum of presentations seen in hospital and may gain distorted view of presentation of illnesses
GP responsibilities
All individuals must register with GP practice to obtain benefits of NHS
GP is responsible for arranging provision of necessary healthcare for an individual
GP acts as patients representative/advocate
GP has responsibility for care of individuals and for general health and well-being of defined population of registered individuals, most of whom at any given point are healthy
Conditions rare in GP
Appendicitis
Cancer
Acute MI
Conditions common in GP
Acute infections Skin disorders Psycho-emotional complaints Minor accidents Intestinal complaints Rheumatic complaints Symptomatic illnesses of uncertain origin Established chronic complaints
