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Communication skills

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Communication skills

  1. 1. COMMUNICATION SKILLS IN THE MEDICAL INTERVIEW Philip D Welsby Consultant in Infectious Diseases Head of Communication Studies for Third Year Edinburgh medical students 1
  2. 2. INTRODUCTION Communication skills often are taught as though communication occurs independently of a context. This account is rooted in the context of medical interviews and I have provided various (mostly verbal) gambits that doctors, could, using their judgement, adapt for use in various situations. There have been many papers and articles written on communication with patients. Almost all are based on a mixture of experimentally proven techniques and personal opinion. What follows is no exception. Diagnoses are usually made from the history (1) and a good history almost always means that communication between doctor and patient have to be effective. We cannot define what makes a good doctor (2) and this makes good teaching difficult to define. In retrospect most physicians before about 1940 were valued almost exclusively for their communication skills (a role strangely, but very relevantly, now seems to have been taken over by alternative medicine practitioners). The satisfaction that both doctor and patient feel after an interview is often a reflection of the interpersonal interaction and on occasion the interpersonal interaction is the treatment. PROBLEMS IN COMMUNICATION There are five major difficulties with doctor-patient communications. 1. In clinical medicine the interview situation is complex, dynamic, often unpredictable, and no one can keep in mind all the qualities he or she should be utilising (Figure 1). People often avoid confronting such complexity by using reductionistic techniques (3). Notably they try to impose models which often utilize overlapping circles or multibranching flowcharts (now rechristened algorithms) that ignore the facts that A) people think sequentially, B) people can only think one thought at a time. Diagrams analysing multiple factors that operate simultaneously are useless in prospect because this is equivalent to wearing green spectacles and finding that the world is green. Such models are however useful for analysing what happens in interviews in retrospect. Furthermore analysis using at least two models is appropriate when attempting to comprehend of complex systems. C) there is a reductionist assumption that, if the ingredients are well chosen then the final meal will be successful and that, if you learn the “communication cookbook “guidelines you don’t need experience. 4) if you are consciously using a model whilst conducting an interview you are almost certainly not listening to the patient!. 2
  3. 3. 2. There are no standard doctors and patients. Personality attributes of doctors and patients vary. There are said to be five personality dimensions ranging from curious to incurious, conscientious to non-conscientious, extroverted to introverted, agreeable to antagonistic, and neurotic to stable, and even the possessors of extremes of each attribute have to communicate (Figure 2). Some communication cook-books treat all interviews as essentially similar. 3
  4. 4. 3. Personalities and their attributes usually cannot be changed significantly, but use of simple techniques can still assist communication. 4. Patients will want to know a diagnosis but may not appreciate its significance and may be reluctant to ask. Their perception of what you say may differ from what you said, or what you thought you were saying. Medical truths may not be absolute. In real life Mark Twain’s injunction “When in doubt tell the truth” is perhaps too simple. Some patients may not want to know “the truth.” Denial is sometimes an effective coping mechanism. Remaining in ignorance, especially about things that cannot be changed, may allow people to continue to function. It is sensible to be open with the patient “I will answer any questions you ask to the best of my ability, but be careful only to ask questions if you will find the answers useful” (this makes it obliquely obvious that there is potentially distressing or worrying information). Depending on your judgement of the situation it may be appropriate to help the patient take ”One step at a time” at his or her own 4
  5. 5. pace or to say “We perhaps should discuss this further” and leave it to the patient to take up the offer. 5. Few people (and this includes doctors) understand the nature of risk. Almost everything a doctor advises or actually does depends on an assessment of benefits compared to risks and, inevitably such assessments vary with the circumstances of individual patients. In contrast patients (like the media) want absolutes: not “What is the mortality rate?” but “Will I survive?” Often the best that doctors can do is to quantify the risk. Patients may well find this vagueness difficult to deal with and may well be helped if you say what you would do in their circumstances, but stress that you are not the patient and that they have to make the decision. This “If I were in your situation” approach is particularly helpful when dealing with relatives who may have to make decision on behalf of their elderly parents - relatives may not wish the burden or potential guilt of suggesting that active interventions should cease and the chances of this occurring can be minimised if they can agree with, rather than themselves initiating such suggestions. Conducting a medical interview is somewhat like playing jazz: you have to be prepared to improvise on top of a structured sequence. WHAT DO PATIENTS WANT? Patients’ priorities have been summarised by the European Task Force on Patient Evaluations of General Practice (4). The most highly rated attributes in order were humaneness, competency/accuracy, patients’ involvement in decisions and time for care. Patients want a doctor who listens and who does not hurry them (5) and provision of information and opportunities for participation are rated highly (6). Patient satisfaction is increased by a patient-centred approach to consultations (6). Patients want to have confidence in their doctor. A survey (8) reported that certain terms or actions diminished a patient’s confidence in their doctor. • “Let’s see what happens.” • “I Don’t know.” • Asking a nurse for advice • “I think this might be…” • “I haven’t come across this before” • “I’m not sure about this.” • “I need time to find out more.” • Used a book to find out about a condition. • Used a computer to find out about a condition. • Asked another GP for advice. The problem is that every good doctor should have realised or ought to have done all of the above. Perhaps we ought to do this covertly? Social banter may help put the patient at ease, but possibly more helpfully, can disguise the fact that you have forgotten the patient’s name (it does happen) and/or help you to remember the patient’s other details. Doctors with good communication skills have greater job satisfaction, less work related stress, identify patient’s problems more accurately, and their patients adjust better psychologically and are more satisfied with their care (9). 5
  6. 6. Patients may want to change their minds. Try to avoid this by over pressurising patients into decisions that they do not wish to make. Additionally patients may not give relevant feedback if they feel that they have been party to irreversible decisions “I (was made to) say I would take the tablets but quite frankly I can’t be bothered. But I can’t tell the doctor this.” Patients usually have between one to four concerns (10). Most patients express a clear desire to be well informed about their health, in order of priority, diagnosis, prognosis, aetiology and prevention, treatment, and social effects. Some patients will not so wish. People who get given what they want almost invariably claim that they are satisfied, but sometimes what people want (satisfaction) is not necessarily what they need and the problem for different doctors is that different patients want or need different things. Some patients wish to be fully informed whilst others are content to let life happen to them (the Benidorm syndrome1 ). The former will wish in-depth information and discussions whereas the latter will often say “Whatever you think best doctor.” Great care is required with the latter group to strike the right balance of information and advice without assuming responsibility for decisions that should be made by the patient. Patient may be reluctant or fail to mention problems if they believe: • that nothing can be done • the doctor will be burdened • the doctor will not want to be burdened • they will appear ungrateful • that it is not the doctor’s job to deal with their problems • that their worst fears may be confirmed • the doctor is unsympathetic 1 I have observed that many patients returning from a holiday in Benidorm have seemingly, despite having been conscious, been well asleep in that they do not know whether they had stayed on an island! 6
  7. 7. PROMOTING COMMUNICATION Ensure privacy. Although this should be obvious, doctors often forget that open ward areas often allows patients in adjacent beds to hear other patients’ histories. When interviewing patients it is necessary for both parties to develop confidence and rapport quickly so that mutual trust can be established (Figure 3) Respect confidentiality. Under most circumstances one to one conversations in private pose no problems. Problems arise when people wish to discuss problems involving others, usually relatives “ I have distinct worries about my sister so I thought I would come to see you.” You have to decide where reasonable discussion strays over the border into disclosure. And then you have to state the boundary politely but firmly. “Obviously I cannot discuss this any further without X’s permission.” Use words the patient will understand. Avoid medical jargon. Patients may not understand medical jargon and, worse, this may encourage patients to use medical terms, possibly incorrectly. Be aware that words may have different meanings in different contexts. Term Medical meaning Non-medical meaning Acute Rapid onset Severe Numb Lack of cutaneous sensation Any abnormal sensation Chronic Long duration Severe Migraine A specific headache syndrome Any severe headache Sick Vomiting or nausea Unwellness, dispirited Cancer Histologically malignant Universally fatal Be aware of, and beware of, local terms (I once suggested that the wife of a County Durham market gardener should try pouring on cold tea when she complained that her husband’s twig 7
  8. 8. ‘n’ berries were not working on the basis that my wife had found her plants to grow better with this remedy!)2 Ensure that patients can hear what you are saying. Patients who appear unintelligent or demented may appear so because they are deaf or dyphasic. In any event do not speak too fast, and leave pauses for the patient to interrupt gracefully. Introducing yourself to the patient. The greeting may be different depending on circumstances. Names. With a patient you know well it may be appropriate to use their first name. With patients not previously known to you a formal approach is probably best. With a young patient or with children use of the first name may also be appropriate. With new patients above, say, 14 years of age it may be best to start out more formally and use the family name. This raises the problem of the title of women of marriageable age. It is presumptive and risky to say either Miss or Mrs but Ms seems a bit too formal. When in doubt use a formal approach as this could be modified later in the interview, but a change from informal to formal may be seen as abrasive. Opening the conversation. The best opening gambit to an interview will obviously depend on circumstances. “What can I do for you today?” shows goodwill and willingness to be helpful. Should you shake hands? This introduces an aura of formality which may or may not be appropriate. Should you stand up to greet the patient? Again a matter of judgement. Discover the agenda. The agenda needs to be established early in interviews and in practice is often defined by the interviewer’s initial approach. Should you wait for the patient to start talking or should you “fish for the agenda.” “What can I do for you?” or “What is the matter?” rather than a simple “Hello” followed by an expectant pause. Communicate rapidly if necessary. Strangely enough few pundits in communication teaching have addressed the need for more rapid communication, despite the fact that the average consultation time in UK General Practice is now (2002) about seven minutes and has been continuously decreasing. Try to appear unhurried! Within a few minutes of an interview you should have assessed: • Whether the patient is in input or output mode • What the upfront complaints are • Whether there is any hidden agenda • What further questions you need to have answered • When and how you should ask these If a patient’s problem is obviously complicated it many be sensible, as soon as this is apparent, to say “We need more time than is available just now to discuss this. We need to arrange a longer meeting.” Define your role. 2 A confusion between horticultural and medical advice. At least I recommended cold tea! 8
  9. 9. There is a widespread assumption that doctors are more influential than we are (perhaps this is partially our fault). Whilst doctors may have indirect access to some services in the community or in the hospital, but no direct access, it is important to state clearly when problems, be they social, financial or personal is outwith your influence. “ Although I can unfortunately do nothing myself I am willing to write a letter” or “This problem would be best taken to …….” Strive to remember the patient’s name. Babies are a particular problem. Every parent will react adversely if their darling is referred to as “it” but babies have little identifying characteristics with which to associate their name. What can you do if you never knew the name or have forgotten it? “How is the young man/lady today?” may help conceal your ignorance but if the clothing does not clearly identify the sex of the baby this ploy cannot be used. In the absence of any better suggestions my advice is to use a nonsense name. “How is young Hieronymous today?” “How is the little one?” almost seems to confess that the name has been forgotten. Help patients focus on their problems. If patients are garrulous or hopelessly polysymptomatic you could say “Could you help me by summarising the main points in one minute?” or “It would be helpful if you could write out the complaints on this sheet of paper?” – and you decide the size of paper that you give to the patient! Sometimes it is better to defer discussions until a longer appointment can be arranged. 9
  10. 10. Ensure that time sequences are made clear. Near the start of the interview you could remark “This is obviously complex. To help me get an overall view could you list the main points in, say, a minute?” Some patients cannot tell a simple story in a correct time sequence. Identify the treatments that have been or are being given. “What drugs are you actually taking?” (notice the inclusion, almost accidentally, of “actually” may help patients to reveal that they are not taking all the drugs you think they are). Occasionally you may also be told about drugs of abuse! Learn how to say “Yes” or “No” tactfully. In the past a straightforward reply “Yes” was unequivocal, but now “Yes” often seems to be a little less than absolute, almost inviting patients to say “Yes, but……” which may be perfectly legitimate way for them to request further information. If you want to convey an unequivocal “Yes” say “Absolutely.” If you wish to say “No” but wish to emphasise that you are not responsible for the negativity a useful ploy is to say “I’m afraid the answer has to be no because…..” Try to exhibit a neutral approach. It may be difficult to remain neutral when you have distinct thoughts about a particular individual3 . Whatever you may feel about various groups of patients, your job is to look after individuals to the best of your ability and this demands a wide repertoire of communicational skills and tolerance. Some patients exasperate but never forget there may be understandable medical or situational reasons why some patients irritate or annoy. Assess how problems are affecting the patient. “Tell me how this affects you?” or “This must cause you problems in day-to-day living: could you tell me about these problems?” Try to see problems from the patient’s point of view. What to you is trivial may be much more important to the patient. Acknowledge this. “I can appreciate that this is a major worry.” Do not dominate. In particular when dealing with patients who are in bed it helps to get down to the patient’s level. Having someone towering over you, literally talking down to you when you are vulnerable, may be very uncomfortable. Similarly do not patronise - it has been observed that male doctors ask men “What is the matter?” but tend to ask women “What seems to be the matter?” Admit areas of ignorance. It is a matter of judgement whether you take the risk of destroying a patient’s confidence. If you are less than knowledgeable about a certain topic it may be appropriate to be straightforward and say “There are people who know more about this than I” but qualify “I will take advice from…” Communicate slowly. 3 A surgeon once remarked to me “One thing that working in A and E taught me was that I had to tolerate things that should not be tolerated.” 10
  11. 11. If there is a lot of information to impart do it slowly and allow pauses for the patient to reflect. Speaking slowly is helpful but speaking more deliberately even at full speed is more easy to understand than normal speech. Listen more. The average patient in the USA is only allowed 22 seconds for his or her initial statement then the doctor takes the lead (11). A Swiss study revealed that, in a tertiary referral centre nearly 80 percent of patients were satisfied with two minutes of listening by the doctor (12). Doctors invariably speak faster than patients and interrupt more. Interrupt with care. Patients will talk on average for about 90 seconds if uninterrupted but on average GPs interrupt after 18 seconds (13) and this might convey the impression that doctors are abrupt and a bit rude. The technique of interruption is crucial when the interviewer needs instant clarification of crucial points as the story unfolds. Polite interruption only occurs when the talker takes a breath and preferably the interruption should be a short closed question. “That was the first time ever then?” Never interrupt people in mid-sentence, as this is very rude. Encourage the patient from time to time. Minor comments such as “Yes,” “Right” or a nodding of the head can reassure the patient that you are listening and that your attention is not elsewhere. Sometimes patients may say something that demands a more substantial but non-committal acknowledgement of what has been disclosed. A useful ploy is to say “Amazing, do carry on.” Amazing is a totally non- committal expression. A flexible voice intonation also suggests interest. Reward positive thinking without being patronising. “I’ve never had your problem but if I had I hope that I could cope as well as you have been.” Continuation messages are also useful to reassure patients that you are interested and need to know more: • “How did that affect you....?” • “That must have been very worrying....” • “Do tell me more about this” • “Please tell me more” • “This is important” Develop your own techniques putting your personality to best use. Accentuate the positive. Whenever possible try to accentuate the positive. Not “the risks of smoking are” but rather “the benefits of not smoking are reduced incidence of.......” Accentuate the positive even when there are distinct negative messages. “Well, that’s all the bad news. The good news is that …..” Remember that even trivial diagnoses can be perceived as serious, especially if medical terms are used. For example the last word of the following will dominate the communication “The wart on your hand is a benign tumour.” Better to say “The results show that the wart is totally benign.” Direct questions. Closed-ended questions are valuable for defining purposes. But always make sure that a “Yes” or “No” response is sensible. Such questions are valuable for establishing definite events “Was that in June” or the presence of specific symptoms “Was it painful?” or 11
  12. 12. landmarks for subjective symptoms “When did the fatigue start?” or for obtaining specific information. “Was there weakness of your left arm?” “Have you ever thought about suicide?” Open-ended questions are useful when symptoms may have psychodynamic implications “Could you tell me more about your life situation when the symptoms first started?” On the other hand if you are short of time questions should be more specific in nature. Escalating questions can be useful to pursue historical points of importance: • “Is there anything else you want to tell me?” • “Is there anything else you ought to tell me?” • “What else is there that I ought to know?” • “But I suspect that there is more to this than what you have told me….” Followed by an expectant silence. Leading questions. Try to avoid too many “When did you last beat your wife?” leading questions. Leading questions make presumptions (however “multiple choice” leading questions can be helpful when the patient has difficulty in providing a description “Was the pain, sharp, dull, stabbing, like a tight band, or affected by breathing?” - offering a few choices in each menu to avoid overloading the patient). Leading questions can be used to help patients “confess” historical points that might not be volunteered. “This infection you had, was it something you caught from someone else?” Sometimes “When did you last beat your wife?” questions are helpful when a “never” reply is elicited. A reply “Never” to “When did you last vomit blood” more reliably excludes vomiting blood whereas a reply “No” to “Have you vomited blood?” in practice might mean “Not recently.” Leading questions sometimes can be used to help patient to confess to poor compliance. Non- compliance with advice or with drug treatment may be as high as 40-50%. Non-compliance is financially costly and jeopardises your professional standing with the patient: “If the doctor can’t tell I am not taking the drugs then he/she obviously thought that they wouldn’t have been very helpful”. Useful questions to help patients admit poor compliance include: • “Do you find it difficult to take the tablets?” • “Do you ever forget to take the tablets?” • “What proportion of tablets do you miss?” • “When you feel better do you sometimes stop taking the tablets?” • “If you feel worse do you sometimes stop taking the tablets?” Asking potentially offensive questions. Always explain why you need to ask and sometimes this is best coupled with a pseudo- apology. “I’m sorry to have to ask about this, but it is relevant because…..” Pick up verbal clues. Pay attention to use of words. “This pain……” suggests that there has been another, perhaps similar, pain. Hesitancy in giving replies can provide clues. A diffuse rambling history may suggest that there is a hidden agenda for requesting to see you. Clues that physical symptoms may be presentation of underlying non-physical problems may include: • Your unsureness why the patient has presented. In such situations you have to fish for the reasons. “I see, but what was it actually that caused you to come today?” The 12
  13. 13. “actually” is an important word as it can communicate that you are open to a disclosure of what might have remained a hidden agenda. • Emergency consultations that are not emergencies • The patient’s mood seems inappropriate for the complaint Be realistic. Be realistic about what you and the medical services can provide. Some patients believe that doctors have infinite influence upon social problems and political grievances. It may not be possible or appropriate to attempt to deal with some problems in a single session. It may be impracticable to set targets that the patient has no chance of attaining. Pay attention to factors that encourage or inhibit disclosures. Within reason try to respond to the patient’s mood: do not be jocular when the patient is depressed. Engineering abrupt topic changes. This requires a tactful, but forceful, clear intervention (when the patient is taking a breath). “That was helpful. But could you tell me about ……” On the other hand to prevent abrupt topic changes by the patient again requires forceful, clear interventions, also when the patient is taking a breath. “Hold on, tell me more about the …..” Listing of problems. Asking the patient to return with a list of the stresses they are under might well be revealing for you and for the patient. Many patients, like many doctors, have no conception about what normal behaviour is. Perfectionist or workaholic patients may have no idea that people take time off work with a head cold or just because they feel off colour. Ignore potential provocations. Some patients’ inappropriate use of certain adjectives is annoying if not actually offensive. Ideally try to ignore the adjectives and concentrate on the nouns unle3ss they too are offensive. Non-verbal communication. Eye contact, gestures, and our posture are all relevant. Although not strictly non-verbal the mood of voice is also relevant – there are said to be eight moods – affection, anger, boredom, cheerfulness, impatience, joy, sadness and satisfaction (14). Try to incorporate these into your repertoire. A deep voice conveys authority, whereas speech errors or hesitations suggest nervousness. Try to avoid “You know,” or “Kind of” or “ers” at the beginning of a sentence. Use of body language. Doctors, like anyone else, will vary in their abilities to usefully modify their inherent body language. In my experience students are most fearful of seeing themselves rather than hearing their verbal performance on videos of interviews (this suggests that most of us will learn new and important things about ourselves by welcoming the stress of such exercises). The way we use hand movements to emphasize points, the (appropriate) touching of patients, and the doctor’s facial expression can convey their attitudes emotional responses. Dress plays a part in non-verbal communication. In a time of changing fashions it is difficult to give specific advice, other than that neatness is very important. 13
  14. 14. Be self-aware. Viewing videos of your interviews can often provide unexpected (and sometimes unwelcome) realisations. Do I really wave my arms around that much? Do I really interrupt that much?4 Be aware that you might not be the best person to give advice. “You perhaps ought to see …. who knows far more about this than I.” Communicating with patients who are somatising. Somatisation is the projection of primarily psychological problems onto bodily parts. Often patients resist the suggestion that psychodynamic factors are relevant to their complaints. Of course somatising patients may well have something wrong with their soma and not their psyche (no one is infallible and no doctor can should be 100 percent sure of anything, especially when excluding pathology). In such circumstances it is important not to alienate patients who may be thinking “You think it’s all in my mind.” Often it is good policy to be straightforward. “I think I have done all that is necessary to exclude serious illness. This is not necessarily the same as saying that there is nothing wrong but rather that there is no simple explanation or cure for your symptoms. In the absence of a medical quick fix treatment we have to consider options that will help you to deal with your symptoms and these include….” or “The good news is that there is no major reason (no ulcers, no growths) for your symptoms but your …….may be overactive or irritable.” IMPARTING INFORMATION. The amount of information that should be communicated at one sitting will vary, and depends on whether information is just spoken or whether written information will also be provided. In any event people tend to forget about two thirds of what they are told so it helps if you tell patients what you are about to tell them, tell them, and then tell them what you have just told them! This takes skill so that you do not bore or patronise the patient. Be aware that patients with significant levels of distress may not be on “input mode.” Ascertain what the patient knows already and what they think about it. Try to confirm the patient’s understanding. Ask them if they can remember. “I think we agreed three major things” perhaps using a facial expression inviting the patient to tell you what these were. Try to make items of information simple. If at all possible tell patients that you are about to tell them a specific number of important things. This will help them remember. In addition most people cannot remember more than about a third of what they have been told. The more complex the information, the less will be the proportion that will be remembered. Therefore make specific efforts to help the patient increase recall: • Simplify complex information • Categorise “I am going to tell you three things: these are 1……” • Prioritise. State important facts first. • Repeat important information. • Ensure comprehension. ”Are you following this so far?” 4 Afraid so! 14
  15. 15. Check that the patient has understood and remembered your advice. Towards the end of the interview always ask questions, the answers to which hopefully will confirm that the patient has understood. It may be useful to give the patient relevant leaflets or write up a prioritised personal list of concerns. Four techniques may be useful. • Set ideas in a familiar context • Make ideas more accessible • Link ideas with an individual • Use an image or a metaphor Encourage patient involvement. “There is a lot that you can do to assist the medicine in doing its job” (in practice this often involves either reducing smoking, reducing alcohol intake or losing weight). Invite feedback. “Is there anything else we need to reassess?” or “Is all this Okay?” Explain what tests you want to do and what these entail. Doctors hardly ever explain what tests entail. With a flourish of our pen (using a barium enema as an example) we send patients off to a room where they will meet someone whom they have never met before, who will push a tube up their bottom, pour in chalk, and tilt them up, down, and around! Neutralise incorrect information. Most patients obtain sensible advice from sensible sources in the public domain. Obviously a good thing. However some patients can become enmeshed in websites which spin opinions into pseudofacts. Even well respected newspapers contain dangerous incorrect information (from the Sunday Times, “My two-year old grandson has just spent his second three night stay in hospital with a severe asthma attack. He now has an inhaler. Are there alternative treatments you can recommend? Yes there are! Apparently a ryegrass remedy!). It is important that such nonsense is contradicted without alienating the patient – which of us likes to be contradicted and told that their attempts at self-help have been a waste of time? It may be sensible to abstract items of sense from the nonsense and concentrate on and modify these. “Goodness me, some of this is surprising but the advice (to loose weight, or whatever) is good.” If patients present with sheaths of paper it is useful to ask them to return with a brief written assessment. “I would like to know what you make of all this.” Some patients come armed with reams of website printouts authored by a confusion of “single issue fanatics” which, after even a cursory glance, often contain contradictory opinions. Once this is pointed out the patient is reassured that you are knowledgeable. “The number of treatments suggested in practice means that not one is likely to be dramatically effective” and, as almost invariably is the case, “This seems rather expensive for an unproven treatment.” CLOSING DOWN DISCUSSIONS. When an interview does not end naturally or have an obvious conclusion, yet must be concluded, always be polite, friendly, yet firm and do not let the patient think he/she is being rejected. Different individuals will have to evolve their own techniques so that a positive atmosphere is retained whilst the interview is being (negatively) brought to a close. One useful technique is to smile in a friendly fashion whilst asking a question “Is that all right?,” or “I think that’s as far as we need go today,” or “That seems to be the best that we can do 15
  16. 16. whilst intimating with body language (perhaps an open gesture with the hands) that you are about to rise to open the door for the patient. If, at the end of the interview, you feel that something is still being held back, confess that you have not been able to get to grips with the problem and ask if the interview could be resumed later. This may usefully be combined with a request for the patient to write out his/her own story for your records. Finally all the above is useful advice. But experience is important. The quintessential problem is that useful feedback regarding your communication skills is hardly ever forthcoming from the patients. Role-play, especially with retrospective analysis and discussion of video recordings with colleagues enables valuable feedback without the need to learn (often by mistakes) whilst dealing with actual patients. Philip D Welsby REFERENCES 1. Relative Contributions of History-taking, Physical Examination, and Laboratory Investigation to Diagnosis and Management of Medical Outpatients. Hampton JR, Harrison MJG, Mitchell JRA, Prichard JS. Seymour C. BMJ 1975:2:486-489. 2. What’s a Good Doctor and How do you Make One? Editor’s Choice.. The BMJ’s Wild Goose Chase. BMJ 2002;325. 3. Welsby PD. Reductionism in Medicine: Some Thoughts from the Clinical Front line. Journal of Evaluation in Clinical Practice 1999;5:125-131. 4. Wensing M, Jung HP, Mainz J, Olesen F, Grol RA. A Systematic Review of the Literature on Patient Priorities for General Practice Care. Part 1:Description of the Research Domain. Soc Sci Med 1998;47:1573-88. 5. Carroll I, Sullivan FM, College M. Good Health Care; Patient and Professional Perspectives. Br J Gen Pract 1998;48:1507-8. 6. Coulter A, Fitzpatrick R. The Patient’s Perspective Regarding Appropriate Health Care. I: Albrecht GL, Fitzpatrick R, Scrimshaw RC eds. The Handbook of Social Studies in Health and Medicine. London:Sage 2000;454-64. 7. Lewin SA, Skea ZC, Entwistle V, Zwarenstein M, Dick J. Interventions for Providers to Promote a Patient Centred Approach in Clinical Consultations. Cochrane Database Syst Rev 2201;(4)CD003267. 8. Doctors Expressions of Uncertainty and Patient Confidence. Ogden J, Fuks K, Gardner M, Johnson S, McLean M, Martin P, Shah R. Patient Education and Counselling 2002;48:171- 176. 9. Maguire P, Pitceathy C. Key Communication Skills and How to Acquire Them. BMJ 2002;325:697-700. 16
  17. 17. 17 10. Silverman J, Draper J. Identifying the Agenda in the Consultation. Br J Gen Pract 1995;45:52-3. 11. Marvel MK, Epstein RM, Flowers K, Beckman. Soliciting the Patient’s Agenda; Have we Improved? JAMA 1999;281:283-7. 12. Langewitz W, Denz M, Keller A, Kiss A, Rüttimann S, Wössmer B. Spontaneous Talking Time at Start of Consultation in Outpatient Clinic: Cohort Study. BMJ 2002;325:682-2. 13. Simpson M, Buchman R, Stewart M et al. Doctor-patient Communication: the Toronto Consensus Statement. Br Med J 1991;303:1385-7. 14. Davitz J, Davitz L. Correlates of Accuracy in the Communication of Feelings. J Communication 1959;9:110-17.

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