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DOCTOR – PATIENT

COMMUNICATION
Joshua Immanuel A. Marcos, MD,Msc
Emilio Aguinaldo College of Medicine
Session Objectives
The Medical Student should be able to:
• Define patient-centered interviewing
– Identify the required facilitation, questioning
and relationship-building skills
• Define doctor-centered interviewing
• Discuss the process of patient-
centered and doctor-centered
interviewing
Read
• Chapter 6-
– Doctor- Patient Communication by Fraser’s
book “ The Clinical Method”
• Chapter 5
– The doctor Patient Relationship
• Chapter 2
– The Consultation
Why Doctors Must be Good
Communicators?
• Diagnosis and the
understanding of its effects
on a patient’s life and
experience clearly depend
on the doctor
• Transmission of the exact
message by the patient to
the doctor
• Use of verbal and non-
verbal skills to enable
patient to talk freely
Why Doctors Must be Good
Communicators?
• Correctly interpreting the signals the
patient is sending out and by relaying back
to the patient that his message is received
and understood

I understand..
Got it
doctor?
Why Doctors Must be Good
Communicators?
• Helps to establish a relationship between
the two parties which has a beneficial
effect on the outcome of the consultation
• Patients are more likely to comply if they
are allowed to tell the MD what he feels is
relevant about his problem  interpreted
in the patient’s own language
“Traditional apprenticeship method
of teaching medical students
to take the clinical history often fails
to teach them sufficient interviewing
skills to enable them to obtain an
accurate and full account of their
patient’s problems…”

Maguire and Rutter 1976


In Real Life…
• It is hard for doctors to
get feedback on their
behavior because
dissatisfied patients do
not usually tell the doctor
that they are dissatisfied
• Do not return on follow-
up
Communication Skills Needed in
the Consultation
2 MAIN PARTS OF THE
CONSULTATION
• THE INTERVIEW
– The doctor seeking the reason for
the consultation
• THE EXPOSITION
– Doctor informs the patient of
his conclusions and diagnosis and
what treatment and advice should
be given
Allaying Anxiety During the
Consultation

Korsch and Negrete 1972


Tips in Reducing Patient Anxiety
During Consultation
• Greeting by name
• Giving out a true
smile
• Rising to meet the
patient
• Shaking his hand
• Indicating where he
can sit
• Taking a brief
informal chat
Setting of the Consultation
• Influences strongly the type of communication likely to
take place
• Other variables include:
– Appearance and grooming of the doctor
– Gestures
– Eye contact
– Seating arrangement in the clinic
– Distractions in the room
– Presence of a telephone or beeper, cellular phone
– Number of waiting patients
– Time allotted for each patient seen
Seating Arrangement

CO-OPERATION CONFRONTATION

CONVERSATION
Opening Clinical History
• After welcoming
• Start with non-committal statements
– “Well now?”
– “What can I do for you?”
• Aim to let the patient tell his story as
fully as possible
PATIENT-CENTERED
INTERVIEWING
PATIENT-CENTERED
INTERVIEWING

The interviewer encourages


the patient to express
what is most important to him
of her and facilitates the
narration of the patient’s story
Active Listening
• When we go beyond the physical
complaints of our patient and listen to
him as a person—how our patient feels
about his illness , what his perceptions
about it are and what makes him
believe in the way he does in relation to
his illness
Active Listening
• The whole person approach teaches us
to treat the patient as a person with
feelings and thoughts and a life context

• Not just as disease or as a clinical case


Rationale for Patient-Centered
Interviewing
• Improves patient satisfaction,
compliance, knowledge and recall and
decreases doctor shopping and
lawsuits
• Shown to improve health outcomes
– Better BP control and blood sugar control and
even perinatal outcomes, shortened length of
hospital stay and improved mortality in
critically ill patients, improved cancer
outcomes
Required Facilitating Skills
• The doctor must master the following
core QUESTIONING skills
– Open-Ended Questioning skills
• Silence
• Nonverbal encouragement
• Neutral utterances and continuers
• Reflection and echoing
• Open-ended requests
• Summary and paraphrasing
– Close-Ended Questioning Skills
• Yes and No answers
• Brief answers
Required Facilitating Skills
• The doctor must master the following
core RELATIONSHIP-BUILDING skills
– Emotion-seeking
• Direct inquiry
• Indirect inquiry: self disclosure, impact and belief
about problems
– Emotion handling
• Naming and labeling
• Understanding and validation
• Respect and praise
• Support and partnership
Patient Centered Interviewing:
The Process
STEP 1: SETTING THE STAGE FOR THE
INTERVIEW
(30-60 SECONDS)
AIM: To recognize the identity of the patient,
introducing himself and ensuring patient’s
readiness to proceed with the interview
• Welcome the patient
• Use the patient’s name
• Introduce yourself and identify your specific role
• Ensure patient readiness and privacy
• Remove barriers to communication
• Ensure comfort and put the patient at east
Patient Centered Interviewing:
The Process
STEP 2: Obtaining the agenda including the
Chief Complaint(30-60 SECONDS)
AIM: To orient the patient to the expected
duration and process of the interaction and
elicits the patient’s agenda

1. Indicate the time available


2. Indicate the interviewer’s needs
3. Obtain a list of all issues the patient wants to
discuss
4. Summarize and finalize the agenda
Patient Centered Interviewing:
The Process
• STEP 3: Opening the history of present
illness (30-60 seconds)
AIM: Use of focusing open-ended skills to open
the history of present illness (HPI)
1. Use an open-ended beginning question or
statement
2. Use non-focusing open-ended skills
3. Obtain additional data from non-verbal sources
Patient Centered Interviewing:
The Process
• STEP 4: Continuing the Patient-
Centered HPI
(5-10 minutes of 40 minute visit)
AIM: To facilitate the patient’s description of
her physical symptoms and their personal
and emotional context
1. Use focusing open-ended skills to obtain a
description of the patient’s physical symptoms
2. Use focusing open-ended skills to develop the
personal or psycho-social context of the
patient’s story
Patient Centered Interviewing:
The Process
STEP 4 (continued)
3. Use of emotion-seeking skills t develop an
emotional context
4. Use emotion handling skills to address
elicited emotions
5. Use focused open-ended skills, emotion-
seeking skills and emotion handling skills
to expand the story
Patient Centered Interviewing:
The Process
STEP 5: Transition to the Doctor-centered
Process (30 SECONDS)
Aim: To close the patient centered portion and
open the doctor-centered process
1. Summarize briefly
2. Check accuracy
3. Indicate that both content and style of
inquiry will change if the patient is ready
DOCTOR-CENTERED
INTERVIEWING
Doctor-Centered Interviewing
• The doctor takes charge of the interaction
to acquire specific details not provided
already by the patient, usually to diagnose
disease or to fill in the routine data base
FILLING THE HISTORY OF
PRESENT ILLNESS
1. Define the cardinal features of the patient’s
chief complaint
2. Define the cardinal features of other
symptoms (those already mentioned by the
patient and those not yet introduced) in the
organ system of the patient’s chief
complaint
3. Inquire about relevant symptoms outside
the involved system
4. Inquire about relevant non-symptom
(secondary) data
Seven Cardinal Features of
Symptoms
1. Location and radiation
a. Precise location
b. Deep or superficial
c. Localized or diffuse
2. Quality
a. Usual descriptors
b. Unusual descriptors
Seven Cardinal Features of
Symptoms
3. Quantification
a. Type of onset
b. Intensity or severity
c. Impairment or disability
d. Numeric description
-number of events
-size and volume
Seven Cardinal Features of
Symptoms
4. Chronology
– Time of onset of symptoms and intervals between
recurrences
– Duration of symptom
– Periodicity and frequency of symptoms
– Course of symptom (short-term or long-term)
5. Setting
6. Modifying factors
– Precipitating and aggravating factors
– Palliating and relieving factors
7. Associated symptoms
Doctor-Centered Interviewing
• Inquiring about symptoms in the same body
system
• Asking about other relevant symptoms
• Inquiring about relevant non-symptom data
• Scanning without interpretation versus
hypothesis testing
• Becoming patient centered when necessary
The Rest of the History
• Past Medical History
– Medications
– Allergies
– Previous hospitalizations
• Personal and Social History
– Habits
– Occupation
– Home life
– Sexuality
– Lifestyle
• Family Medical and Social History
– Heredo-familial diseass
– Family composition and relationships
– Level of function
Reasons Why Interviews Fail
1. Failure to prepare the patients
2. Failure to control the interview
3. The influence of a premature or restricted focus on
students (e.g. students assuming that there is only
1 problem)
4. A lack of systematic interview procedure
5. Lack of clarification of the information in order to
establish the accuracy of the data
6. Unresponsiveness to verbal and non-verbal cues
7. Lack of self-awareness
8. Difficulty with taking notes and maintaining eye
contact
During the Exposition Phase
• Create the appropriate balance of
priorities between the person and
illness
• Convey to the patient sympathy,
empathy and honesty
• Remain aware of the patient’s right to
share in the decision-making process
Read also:

• Breaking bad news


• Ending the consultation
• Reasons why expositions fail
• Monitoring your own communication
skills

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