Year 2 Tutorial 1 Patient Centred Communication Flashcards
Good communication improves
Patient satisfaction Recall Understanding Concordance There will be better outcomes of care
Clinical competence
Knowledge
Examination
Problem Solving
Communication (this bridges the gap between examination and actually working with patients)
Content of interviewing skills
What doctors communicate
Substance to ques and responses
Information both gathered and given
Responses
Perceptual Skills
The ability to understand what the patient and the doctor is both thinking and feeling
Internal decision making
Clinical Reasoning
Awareness of own biases, attitudes and distractions
Process skills
How they communicate
Way they communicate with patients
How they explore the patient history and provide information and explanations
Verbal and non-verbal skills
How structure and organise the communication
Physical factors that can influence a consultation
Site and environment
Adequacy of medical records (continuing health problems, adequate history of illness, patient background and drug history all prevents time wasting in reviewing these when a patient comes for a consultation)
Time constraints
Patient status (are they known or unknown to you)
Personal factors that can influence a consultation
Age (younger doctors can be saught by younger patients etc)
Sex (female doctors may be sought by female patients)
Social class and ethnicity (language difficulties)
Knowledge and skills (important to doctor but less ot patient except when doctor becomes patient)
Beliefs (doctors influenced by medical training whereas the publics are often not medically accurate)
Illness (the type of illness can effect how the consultation will go)
Ethnicity can affect consultations at three levels
Patient level (mastery of local language)
Provider level (provider skills and attitudes)
System level (organisation of referral and appointment systems)
Publics health beliefs are influenced by
Media
Other people
Past experiences
Variables that determine type of doctor patient relationship
Degree of participation
Patients feeling of autonomy
Degree of domination by the doctor
Authoritarian/paternalistic relationship
This is promoted by the medical model. The doctor uses all authority inherent in their status and resides in expertise and skills. The patient feels no autonomy and tries hard to please the doctor. Their views are excluded and as a result they will not actively participate in treatment.
Guidance/cooperation relationship
The doctor still exercises authority but the patient is obedient, has a greater feeling of autonomy and participates more actively in relationship.
Mutual partnership
Appropriate moderation of use of authority by the doctor. The patient is given some responsibility for the successful outcome.
Gives the greatest range of information and the most successful treatment outcome.
Open interview
o Doctor listens and facilitates
o Discusses possible ways forward (treatment, referral)
o Patient acts in partnership
♣ Should be aspired to but at the least ask preferences e.g. tablets or capsules, antidepressants or counselling
Listening and Silence
Asking the patient questions logically from what they have told you
Encouraging them to talk via nodding and eye contact
Picking up on body language
Silence
Encourages communication
Attentive facial expression and posture tells the patient non-verbally that you are an interested listener
Facilitation
Communication using manner, gestures or words that don’t specify the type of information being sought.
Changing facial expression or posture to display greater interest
Open ended question
Not seeking any particular answer but signals to patient to tell story
Tell me about the pain
Direct question
Asks about specific question
Where is the pain
Closed question
Can be answered with a yes or no
Is the pain severe
Leading question
Presumes answer
The pain is severe
Reflected question
Allows the doctor to avoid answering direct question from the patient
You want to know the cause of the pain
Confrontation
When the doctor sense the patient is not speaking clearly or freely.
“you seem frightened, tell me more about that”
Break down of communication
• 7% verbal, 38% tone of voice and 55% non-verbal
Instinctive non-verbal communication
Crying, expressions of pain or laughter
Learned from life experiences non-verbal communication
These are acquired at an early age and dependent on the culture and family experience
Learned from training non-verbal communication
Communication training courses provide greater insight into communication with others and understanding ourselves
Clinical observation non-verbal communication
Recognising clinical syndromes
Gesture clusters
Single gesture easily misinterpreted. Need to base interpretation on gesture clusters.
Congruence of non-verbal communication
Incongruence between verbal and non-verbal communication requires attention.
Lack of congruence implies omission, inaccuracy, suppression of info
Gaze behaviour
Eye contact indicates interest. If there is no eye contact it can indicate a person being dishonest or holiday back information.
Posture
Depressed person looks literally depressed
Anxious person may have folded arms, lefs or feet crossed, also fidgeting or moving around
Unease
Holding handbag or fiddling
Deceit
hand to face gestures e.g. mouth guard, nose touch, eye rub, ear rub, neck scratch
Interest and evaluation
cheek and chin gestures; boredom = head support, hand on cheek = interested evaluation, index finger pointing = negative or critical thoughts
Frustration
hands clenched. Correlation between hand height and degree of negative mood
Theory of planned behaviour states that behaviour is influenced by
Attitude: positive or negative evaluation of behaviour
Subjective norm: beliefs about significant others behaviour and how important it is to comply with this
Perceptions of control over behaviour: beliefs about internal and external factors which make behaviour easier or harder to perform and change
Person more likely to make positive behaviour change ifL
o ositive attitude towards it
o Brings about consequences important to them
o Believe others think its important they do it
o Feel have necessary resources, skills or opportunities to overcome barriers and lose weight
Also dependent on self-efficacy (the belief of how well one can perform a difficult task or cope with adversity)
Stages of change
o Precontemplation o Contemplation o Preparation o Action o Maintenance o Relapse
Communicating with patients with disability
o Don’t give assistance before first asking if pt wants it
o Don’t be upset if assistance refused
o Don’t be afraid to use figures of speech which refer to the impairment
o Don’t use disabled as a noun (i.e. the disabled)
o Don’t use negative language e.g. handicapped, crippled, retarded, deformed
Dont use nouns ending in ic
Autonomy
Cornerstone of free society
♣ People free agents with same right to actions and choices as we ourselves would wish to have in a free society
♣ Accepting people for what they are; different attitudes and beliefs and may choose to live in ways different from us
♣ Not making value judgements about differences and not acting superiorly or inferiorly
♣ Position of superior knowledge and strength in medical and legal professions can arise but this doesn’t mean we are superior – need to avoid medical paternalism
Limitations to autonomy
♣ Acceptability of effects of individual actions on other people
♣ Applied through social pressure and the law of the land
Empathy
ability to understand predicament of another and respect their autonomy without necessarily sympathising (feeling sorry) for them
Autonomy of health WHO
♣ The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition
♣ The health of all people is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and States.
Patients under hospital care
3%
Patients attending GP
19%
Patients who have symptoms and take action
55%
Patients who have symptoms and take no action
18%
Patients with no symptoms
3%
Disease
Symptoms, signs and diagnosis from biomedical model
Illness
ideas, concerns and expectations from a patient’s perspective
Percentage of GP appointments with no disease
50%
Patients sources of referral information
o Peers and family o TV o Health pages of newspapers and magazines o “What should I do?” booklet o SHOW website o Practice leaflet or website
Increasing role of community pharmacists in
o OTC contraception o Statins o Heath checks o Smoking cessation o Minor ailments service
Medical factors affecting the uptake of medical care
♣ New symptoms
♣ Visible symptoms
♣ Increasing severity
♣ Duration
Non-medical factors affecting the uptake of medical care
♣ Crisis ♣ Peer pressure – “wife sent me” ♣ Patient beliefs ♣ Expectations ♣ Social class ♣ Economic ♣ Psychological ♣ Environmental ♣ Cultural ♣ Ethnic ♣ Age ♣ Gender ♣ Medical
Sick role
Exempt from daily responsibiliteis
Not responsible for being ill and unable to get better without help from the healthcare professional
Must seek help
Under social obligation to get better ASAP to be able to take social responsibilities again
Health care professional role
Must be objective and not judge pt morally
Must not act out of self-interest or greed but put pt’s interests first
Must obey to professional role of practice
Have and maintain necessary knowledge and skills to treat pts
Right to examine pt intimately, prescribe treatment and has wide autonomy in practice
Adopting the sick role when it’s not necessary may lead to
Lack of sympathy from others
Secondary gains from adopting the sick role
♣ Care and sympathy
♣ Concern from family and friends
♣ Financial allowances associated w/ 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
Advantages of house calls
Useful info on pt’s ability to cope w/ chronic condition or disability
Useful info obtained from relative or carer
Provides social contact for socially isolated
Disadvantages of house calls
Lack of proper examination facilities -> delay in diagnosis
No chaperone
Time consuming
Presence of relative may lead to lack of confidentiality
Other doctors that work in the community
o Community child health specialists
o Community geriatric specialists
o Community family planning services
Bypassing GP’s
o NHS 24 and G-Med o Family Planning and GUM clinics o Pharmacy minor ailment services o Physiotherapy o A&E o Some parts of private sector
Illness presentation of trivial disease
Trivial disease may present w/ acute and severe illness e.g. viral enteritis with pain and violent diarrhoea
Illness presentation of serious illness
bowel cancer with gradual change in bowel habit
Differences between GP’s and hospital doctors
Hospital doctor deals w/ individual pt for short periods of time for specific purpose (to investigate and treat episode of melena or perform a surgical procedure). Decide if specialty can offer pt anything. Matches pt’s needs to expertise and does whatever possible (may be nothing)
The GP is pt’s personal medical adviser until pt death or retirement of dr parts relationship. Role is complex, continuing and personal and difficult for either party to define limits. Apart from terminally ill (many dealt w/ in hospital) deal w/ many unfortunate pts whose illness is difficult to diagnose in diagnostic/medical science terms. Because “buck stops” w/ GP may have to operate outwith boundaries of medical science and give practical help and support
Common conditions seen in GP
o Acute infections (usually upper respiratory) o Skin disorders o Psycho-emotional complaints o Minor accidents o Intestinal complaints o Rheumatic complaints o Symptomatic illnesses of uncertain origin o Established chronic complaints
