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Clinical Communications Revision Notes Dr Tanya Tieney (t.tierney@imperial.ac.uk) & Dr Ged Murtagh (g.murtagh@imperial.ac.uk)

Patient centred interview (PCI) –the interviewer identifies, acknowledges and responds to patient’s thoughts and

feelings throughout an entire episode of illness. The interviewer focuses on the patient’s needs as perceived by the

patient as well as incorporating a medical perspective

General advantages (identified by Stewart 2001):

o Basic tasks accomplished

o Informative

o Facilitative – with regards to patients ICE

o Participatory

Patient-specific advantages:

o Explores reason, concern and needs

o Dr sees patient as whole person, leading to integrated understanding of the patient’s world

o Finds common ground; mutually agrees on management

o Enhances prevention and health promotion

o Enhances dr-patient relationship

Outcomes

o Improve diagnostic efficiency

o Increase patient satisfaction

o Increase concordance/adherence with treatments

o Improve recover

Classification of PCI (Punam & Lipkin 1995)

o Allow patients to express their major concerns

o Seek patients’ specific requests

o Elicit patients’ explanations of their illness

o Facilitate patients’ expression of feelings

o Give patients information

o Involve patients in developing a treatment plan

Disease and illness – disease is the biomedical cause of sickness in terms of pathophysiology, whereas illness is an

individual’s uniqueexperience of sickness including their perception, experience and ways of coping.

When “patient-centred medicine” is contrasted with “disease/doctor-centred medicine” (which was

dominant in past medical practice), it shows that the latter assumes that disease can be fully accounted for

by deviations from a norm or measurable biological variables. It does not consider social, psychological and

bevaioural dimensions of disease and illness.

Patient-centred consultation models – used to develop and sustain effective patient centred communication. Each

model aims to broaden the conventional disease-centred approach to include psychological issues, the family and

the doctor. Models are either structural, functional or a combination. Structural models organise the consultation

around stages, whereas functional models organise generic ways of working to achieve specific goals.

Calgary-Cambridge: structural model which sets out the medical interview in phases with specific objectives

to be achieved and relevant required skills.

1. Initiating the session

2. Gathering information

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3. Physical examination

4. exploration + planning

5. closing the session

6. building the relationship

7. providing structure

Transformed clinical method: 6 component model; first 3 focussing on the process between dr and patient,

last 3 focussing on the context within which the dr and patient interact

1. exploring both the disease and illness experience:

F=feelings, I=ideas, F=function, E=expectations

2. understanding the whole person

3. finding common ground – defining the problem, establish goals and identify roles taken by dr and patient

4. incorporating prevention and health promotion

5. enhancing the dr-patient relationship

6. being realistic – about time, teambuilding, allocation of resources

three function approach (Cohen-Cole & Bird 2000) – addressing essentials doctors need to develop before

interview, each function associated with specific set of interview behaviours

1. building the relationship

2. assessing the patient’s problems – obtaining information

3. managing the patients problems – ensuring compliance and concordance with treatment, and patient

understanding

The inner consultation (Neighbour, 2005) – highlights 5 stages (checkpoints) in consultations:

1. connecting – establishing rapport

2. summarising – patient information

3. handover – management plan + passing responsibility to patient

4. safety netting – ensure understanding if things do not go as expected

5. housekeeping – complete any tasks necessary

The consultation: an approach to learning and teaching (Pendleton et al 1984) – highlights 7 tasks, 5 of which

the doctor needs to achieve, and the last 2 addressing time, resource management and establishing a

relationship with the patient

1. define the reason for the patient’s attendance

2. consider other problems

3. with the patient, choose an appropriate action for each problem

4. to achieve a shared understanding of the problems with the patient

5. to involve the patient in the management and encourage him to accept appropriate responsibility

6. to use time and resources appropriately

7. to establish and maintain a relationship

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Communication skills for PCI

Self-assessment of PCI:

Do I know significantly more about the patient now than I did before I spoke to them?

Was I curious?

Did I listen?

Did I find out what mattered to them?

Did I make an acceptable working diagnosis?

Did I use their language and ideas when I started explaining?

Did I share options for investigations or treatment?

Did I share in decision-making?

Did I make some attempt to see that they are really understood?

Did we agree?

Thoughts: theories that may be right or wrong and are open for correction Feelings: are subjective and belong to the owner, therefore are not open for correction Empathy: recognising what the patient is feeling and communicating this to the patient

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Non-verbal communication: doctors need to be able to recognise patients’ non-verbal cues, as well as being aware of how their own non-verbal behaviour can influence patients. Non verbal communication is continuous, is the main attitude for conveying attitudes, emotions and needs to be congruent with verbal communication if to be effective. There are 4 aspects of non-verbal communication:

Facial expressions and eye behaviour

Body positioning and spatial distance

Paralanguage

Touch

Feedback: is important because it provides guidelines for areas that need to be developed, motivation to undertake

that development, provides insight into personal style and can lead to improved clinical practice.

Preparation for giving feedback

o Purpose?

o Is your colleague ready?

o Do they want it? What do they want it on?

o What have they done well?

o Areas of improvement?

o What do you want to say? How do you want to say it?

Giving feedback – be considerate, highlight both positive and negative areas, be honest, be accurate, show

empathy, use silence effectively, respond to your colleagues verbal and non-verbal cues, do not overload, be

specific

Preparation for receiving feedback

o Do you want feedback? What do you want it on?

o Purpose?

o Are you ready?

o Self-analysis

Receiving feedback – listen carefully, ask for explanations, assume feedback is supportive, consider the

feedback, ask for ways to improve, separate your feelings