F a m i l y M e d i c i n e
Consultation
o It is the central act of medicine.
o Parts:
The interview.
The exposition.
Interview Skills Exposition Skills
❖ Put patient at ease. ❖ Use appropriate exposition style,
❖ Establish reason for directive or sharing.
consultation. ❖ Use clear & understanding
❖ Allow patient to elaborate language.
presenting problem fully. ❖ Give critical information 1st.
❖ Use silence appropriately. ❖ Give aids to patient
❖ Listen attentively understanding.
❖ Search for specific & relevant ❖ Check patient's understanding
information. ❖ Obtain patient's consent to
❖ Phrase questions simply & management .
clearly
❖ Aware of patient's verbal cues.
❖ Aware of patient's non-verbal
cues.
o Consultation Style:
Doctor centered.
Patient centered.
o Required Communication Skills:
Questioning.
Listening.
Responding.
Explaining.
o Methods of Monitoring Communications Skills in Consultation:
One-way mirror.
Audio-recording.
Video-recording method of choice.
3rd party observation.
Communication Skills
o Physical Setting:
Chair 1.5 meter apart.
Set in an angle direct face-to-face avoided.
No one else present.
o Mode of Address:
Address patient by his name.
Observe patient closely as enters.
Guide the patient to chair.
Put patient at ease.
R a w a n K h a n d a q j i
o Type of the Questions: o Causes of Resistance (obstacle for open communication):
Open. Presence of 3rd party.
Closed specific answer. Family doctor.
Leading best avoided. Fear of Dx of serious disease, admission to hospital, operation.
o Establishing Relationship with Patient: Reluctance to take up the doctor time.
Opening of the consultation is the key to put the patient in ease. Embarrassment.
Factors enhance the relationship: Cultural barriers.
Accessibility, waiting time, eating position. o Incongruous Elements within the Interview:
Doctor appearance.
Facilitate communication. Control the interview.
Greeting patient by name, raising to meet, shaking
Listen in unhurried way. Cover all inquiries in limited time.
hands. Avoid inhibiting the patient. Keep the patient to the point.
Demonstrate interest. Seek accurate information. Tolerate vagueness.
Encourage open communication. Endeavoring to follow a diagnostic Being ready to divert & respond to
Show warmth, sympathy, empathy, support, interest. pathway. patients disclosure & cues.
Explore patient’s ideas, concerns, expectations. Keep a full accurate record for the Not allowing pen & notes to inhibit free
interview. communication.
Volunteer information.
Involve patient in his own management.
Use time effectively.
o Methods of Understanding Meaning of Patient’s Symptoms: Communication
Symptoms are form of communication.
Attentive listening.
o It is a multi-level information exchange.
Dialogue to clarify meaning.
o It is a 2-way process both are active.
Selection bias avoidance.
o Health care = physical care + cognitive care + behavioral care +
o Facilitating Communications:
psychological care.
Comfortable setting.
o Communication skills are absolute requirement in obtaining Hx.
Warm introduction.
o Most complaint about doctors (90%) are due to failure of
Open initial inquiry.
communication.
Specific invitation.
o Good communication improves health care symptoms resolution.
Sequence of selective questions. o Failure of communication errors in medical practice.
Systematic questions later.
Further open questions. o Aims of Communication:
Non-verbal: To be heard.
Speech. To be accepted.
Reflecting. To be understood.
Clarifying. To get action.
Summarizing. o Elements of Communication:
Appropriate use of silence. Speaking.
Writing.
Listening.
Body language.
o Elements of Interpersonal Communication: o Listening Skills:
Verbal. Be prepared.
Intonational voice modulation. Be interested.
Paralinguistic non-verbal sound. Keep an open mind.
Kinetic. Listen critically.
o Non-Verbal Communication: Resist distraction.
Any type of communication except speech. Take notes.
Body language is transmitted subconsciously. Encourage speaker with sounds & nodes.
Mismatch between verbal & non-verbal signals problem. Clarify points.
Different cultures use different gestures: Lean forward.
Eye contact in Britain respectful. Eye contact.
Eye contact in India non-respectful. o Causes of Poor Writing:
o Body Language: Lack of instructions.
Eye contact interest, sincerity. Not knowing the reader wants.
Facial expression. Lack of importance placed on writing.
Holding gaze for long time interest, hostile. Lack of confidence.
Holding gaze for short time nervous, untrustworthy. Inexperience.
Head position: Dyslexia.
Up neutral attitude. o Producing a Written Document:
Tilted interest. Plan.
Down disappointed, -ve attitude. Research collect data.
Hands & Arms: Organize mind maps.
Folded aggressive. Draft 1st draft put as skeleton then expand it.
Clutching one’s body nervousness, uncertainty. Uncover don’t obscure your purpose (grammar, spelling are
Hands behind back superiority. important).
Legs & Feet: Clarity when you choose your writing style (choose passive or
Crossed legs normal. active voice).
Crossed legs + Crossed arms lack of interest. Edit.
Twisting one’s leg around unease. o Telephones Communication:
Swinging foot annoyance. Verbal only misunderstanding could happen.
Foot-tapping impatience. Golden Rules:
Body Gesture: Be brief.
Leaning forward. Speak clearly.
Touch & physical contact (hand shaking) help Be courteous.
sharing feeling in consultation. Speak slowly.
Intonation. o Deceptive Communication:
Appearance. Patients lies or half lies.
o CARE Skills: Even initial complaint may be falsified.
Holistic concern with all aspects of patient situation. Sometimes the patient motive may be to please as much as to
C comfort. deceive the doctor.
o Barriers of Communication: Wiser approach is to emphasize that the symptoms are very
Perception. familiar, that serious illness has been excluded and that
Jumping to conclusion. significant improvement can be expected.
Stereotyping.
Education & background.
Personality.
o Obstacles to Communication:
Problem of time 98% of primary care patients & 70% in
hospital take < 2 min to describe their complaint.
Problem of pain, suffering, death.
Problem of sexuality.
Problem of doctor’s anxieties:
Anxiety about inadequacy or failure.
Anxiety to patient’s emotional reactions to sensitive
topics, breaking bad news.
Anxiety related to unresolved personal problems.
o Polys Doctors Use to Distance themselves from Patient Feelings:
Restrict focusing on non-emotional topics.
Diverting focus away from emotive topics.
Playing down the feeling as normal.
Blanketing patient with over-reassurance.
Using leading questions.
Jollying the patient along with platitudes and clichés.
o Communication when Things go Wrong:
Being less than honest has very different implications when
things have gone wrong.
He may try to lie his way of treatment.
Unwise to adopt defensive posture.
Be prepared to say sorry.
Openness is the wisest policy.
Objective factual information with appropriate clinical
reassurance is provided.
At least 1/3rd of all patients presenting to primary care medical
clinics has no evidence of underlying disease to account for
their symptoms.
Every effort should be made to establish the diagnosis of a
functional disorder in a +ve way rather than merely by a process
of exclusion.
Some somatic complaints are amplification of normal
physiological sensation.
