Person Centred Communication in Primary Care

Question 1

Why is effective communication essential to high quality medicine?

Answer 1

Complaints about communication skills feature heavily in a large percentage of claims against doctors (“my doctor won’t listen”, “my doctor never explains anything to me”)

Research shows that in improves patient satisfaction, recall, understanding, concordance and outcomes of care

Question 2

What are the 4 essential components of clinical competence?

Answer 2

Knowledge,
Communication skills,
Physical examination
Problem solving

Question 3

What 3 broad types of skills are needed for successful medical interviewing?

Answer 3

Content skills
Perceptual skills
Process skills

Question 4

What are content skills?

Answer 4

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

Question 5

What are perceptual skills?

Answer 5

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

Question 6

What are process skills?

Answer 6

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

Question 7

What physical factors influence a consulatation?

Answer 7

Site and environment

Adequacy of medical records

Time constraints

Patient status

Question 8

How can site and environment influence a consultation?

Answer 8

Attendence 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 9

How can the adequacy of medical records influence a consultation?

Answer 9

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 10

How can time constraints influence a consultation?

Answer 10

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 11

How may patient status influence a consultation?

Answer 11

New patient or known patient, new problem or old problem

Question 12

What personal factors can influence a consultation?

Answer 12

Age
Sex
Backgrounds and origins
Knowledge and skills
Beliefs
The illness

Question 13

How may age influence a consultation?

Answer 13

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

Question 14

How may sex influence a consultation?

Answer 14

Similar attitude with age differences.

A barrier may exist to effective communicatoin if a patient is forced to consult a doctor of the opposite sex when the reverse is preferred

Question 15

how may backgrounds and origins influence a consultation?

Answer 15

in particular social class and ethnic factors.

There may be considerable language difficulties in both these instances which could adversely affect outcome

Question 16

How may knowledge and skills influence a consultation?

Answer 16

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 17

How may beliefs influence a consultation?

Answer 17

Everyone has thier own health beliefs about all sorts of aspects affecting illness and disease (e.g. vitamin taking, ideas about weather affecting illness, bizarre theories about cause of disease, etc)

Beliefs may be influences 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 18

How may the illness influence a consultation?

Answer 18

A consultation in which is 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 19

What are the 3 styles of doctor/patient relationships in medical interviewing have been described by Szasz and Hollender?

Answer 19

Authoritarian or paternalistic relationship

Guidance/ co-operation

Mutual participation relationship

Question 20

What is a authoritarian or paternalistic doctor/patient relationship?

Answer 20

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 21

What is a guidance/co-operation doctor/patient relationship?

Answer 21

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 22

What is a mutual participation doctor/patient relationship?

Answer 22

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 involes 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 23

The medical consultation typically involves up to 3 separate activities.

What are they?

Answer 23

Talking together
- always

Doctor examing the patient
- often

Performing procedures
- sometimes

Question 24

What is the open ended question?

Answer 24

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 25

What do we mean by listening in a consultation?

Answer 25

Vital to the quality of communication are active listening skills.

This means asking questions thta 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 patients body language (i.e. nervousness, eye filling with tears)

Question 26

What so we mean by silence in a consultation?

Answer 26

While the patient is communicating freely the doctors 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 petient 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 27

What is facilitation in a consultation?

Answer 27

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 facilitation

Question 28

What are the different types of questions?

Answer 28

Open-ended question
Direct question
Closed question
Leading question
Reflected question

Question 29

What are the advantages and disadvantages of questions in a consultation?

Answer 29

When the doctor asks a question of the patient s/he tends to take control of the interview and so directs it along the lines of his/her own thinking or hypothesis generation.

Although this is quite valid, the use of questions too early in an interview still confines the amount of information the patient may give.

More importantly it may completely disrupt the true priorities of the patients concern and prevent the doctor from finding out other reasons for the patient’s attendence than those contained within the patient’s opening statement

Question 30

What is an open ended question?

Answer 30

Not seeking any particular answer but simply signals to the patient to tell his story

“Tell me about the pain”

Question 31

What is a direct question?

Answer 31

Asks about a specific item

“Where is the pain?”

Question 32

What is a closed question?

Answer 32

Can only answer yes or no

“Is the pain severe?”

Question 33

What is a leading question?

Answer 33

Presumes the answer and is best avoided

“The pain is severe?”

Question 34

What is a Reflected question

Answer 34

Allows the doctor to avoid answering a direct question from the patient

“You want to know the cause of the pain?”

Question 35

What is confrontation?

Answer 35

When the doctor senses that the patient is not speaking freely and clearly, the technique of confrontation may be used. In confrontation the interviewer describes to the patient something striking about his verbal or non-verbal behaviour. Here the clinician directs the patient’s attention to something that s/he may not be aware of or at best be dimly aware of. As a result it very often has the effect of introducing a new topic. Examples of confrontation are: “You look sad”, “You seem frightened”, “You sound angry”, “I notice that you have been rubbing the back of your neck”.

A particularly appropriate time to confront a patient is when his/her verbal and non-verbal behaviour are clearly incongruous. For example a patient may speak about very sad things in an indifferent manner, about insults or gross injustice without displaying anger, or about comfortable circumstances and happy events in a mood of dejection. A comment on these discrepancies may lead to valuable information about the patient’s difficulties and especially about any conflicts.

Question 36

What do we mean by support and reassurance?

Answer 36

The clinician’s ability to be appropriately supportive and reassuring helps create an atmosphere in which the patient is encouraged to communicate. It also helps to promote the continuity of the relationship.

Question 37

What non-verbal communications can be identified?

Answer 37

Instinctive

Learned

• From life experiences
• From training

Clinical observation

Question 38

How much impact does non-verbal communication have on what we say?

Answer 38

Verbal communication (7%)

Tone of voice (38%)

Non-verbal behaviour (55%)

Question 39

What are instinctive non-verbal behaviours?

Answer 39

Crying
Expressions of pain
Laughter

Question 40

What are learned non-verbal behaviours?

Answer 40

From life experiences:
-The body language learnt from life experience is acquired at an early age, and is dependent on culture and family experience.

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

Question 41

What is clinical observation non verbal communication?

Answer 41

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).

Question 42

What four points are important to consider in terms of body language?

Answer 42

Culture
Context
Gesture clusters
Congruence

Question 43

Why is culture important to body language?

Answer 43

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

Question 44

Why is context important to body language?

Answer 44

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 45

Why are gesture clusters important to body language?

Answer 45

A 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 46

Why is congruence important to body language?

Answer 46

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 47

How is gaze behaviour important for body language?

Answer 47

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 48

How is posture important for body language?

Answer 48

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 49

How do specific gestures effect body language?

Answer 49

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.

Question 50

What is health?

Answer 50

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity

Question 51

What is the iceberg of illness?

Answer 51

3% of people are under hospital care

19% are attending GP

55% have symptoms and taking action

18% have symptoms and taking no action

3% have no symptoms

Question 52

What is the difference between disease and illness?

Answer 52

Disease = symptoms, signs etc

Illness is the patients perspective -> ideas concerns, expectations

Question 53

What factors make people present?

Answer 53

Medical factors:

• New symptoms
• Visible symptoms
• Increasing severity
• Duration

Non-medical factors:

• Crisis
• Peer pressure
• Patient beliefs
• Expectations
• Social class
• Economic
• Psycholgical
• Environment
• Culture
• Ethnic
• Age
• Gender
• Media

Question 54

What are the differences between primary and secondary care?

Answer 54

The general practitioner deals comprehensively with all medical presentations, whereas the hospital practitioner deals with selected patients relating only to his particular specialty.

Where the hospital practitioner must specialise in depth the general practitioner must specialise in breadth.