School of Medicine

Graduate Entry 2012/13

Clinical Communication

Student Guide

Course Leaders:

Dr Ged M Murtagh	Dr Athina Belsi

Tel: 020 3312 7761	020 3312 1100

Email: g.murtagh@imperial.ac.uk	a.belsi@imperial.ac.uk

https://education.med.imperial.ac.uk

Graduate entry - Clinical Communication

CONTENTS

Page

SOLE	iii

INTRODUCTION	3

Course structure	3

Learning objectives	5

Assessment details	7

Attendance and lateness	7

Reading list	8

Contact details	9

Timetable	10

BACKGROUND INFORMATION	11

What is a patient-centred interview?	11

Consultation models	16

Patient-centred interviewing skills	21

Becoming an effective communicator – reflection	31

SESSION MATERIALS

Session 1 Consultation skills – the initial approach	37

Session 2 Patient-centred communication	49

Session 3 Interviewing volunteer patients	67

Session 4 Interviewing a simulated patient	78

Session 5 History-taking (i): Content and process	93

Session 6 History-taking (ii) with a simulated patient	113

Session 7 History-taking (iii): Social history	121

Session 8 Revision workshop	137

SOLE FEEDBACK – Clinical Communication

The following pages provide you with templates on which you can record your thoughts as the course proceeds. At the end of the course you can enter your views onto SOLE.

Please answer all questions by selecting the response which best reflects your view.

Very Good	Good	Satisfactory	Poor	No Response
The support materials available for this module (e.g. handouts, web pages, problem sheets and/or notes on the board).
The organisation of the module.
Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
Feedback on my work has been prompt (this refers to your work being commented upon within a specified time).
Feedback on my work has helped me clarify things I did not understand.

Please use this box for constructive feedback and suggestions for improvement.

SOLE FEEDBACK - INDIVIDUAL TUTORS

This template gives you the opportunity to record your comments about your tutor.

On the following section, you have an opportunity to record any comments and constructive feedback you have for each tutor.

The tutorial was well structured	The tutor explains concepts clearly.	The tutor engages well with the students.
Tutor	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree

Please use the space below for additional constructive feedback on each tutor.

Tutor	Comments

SOLE FEEDBACK - INDIVIDUAL LECTURERS

Please note that for SOLE, a Lecturer’s name will only appear once. This template gives you the opportunity to record your comments about each lecture in the order of delivery.

On the following section, you have an opportunity to record any comments and constructive feedback you have for each lecturer.

The structure and delivery of the lectures.	The explanation of concepts given by the lecturer.	The approachability of the lecturer.	The interest and enthusiasm generated by the lecturer.
Lecturer and Lecture Title	Very Good	Good	Satisfactory	Poor	Very Poor	Very Good	Good	Satisfactory	Poor	Very Poor	Very Good	Good	Satisfactory	Poor	Very Poor	Very Good	Good	Satisfactory	Poor	Very Poor

Lecturer and Lecture Title	Please use this box for additional constructive feedback.

VERY IMPORTANT!

I

t is critical that you approach your feedback carefully and seriously. The ultimate purpose of SOLE feedback is to improve the course, so do not waste this feedback opportunity with throw away comments (e.g. ‘the lecture was a waste of time’, ‘I cannot see the relevance of this session’). The course leaders cannot do anything with comments like this as they lack any specificity or explication. If you do decide to comment on the course think about providing a rationale for your evaluation and do so with the view of how to improve the course in a reasonable way. SOLE feedback is taken very seriously by the College, so please treat it with the same level of seriousness.

Introduction

Course structure

The contents of this guide are based on those provided to students and tutors during Years 1 and 2 of the Undergraduate MBBS. Clinical Communication (CC) is designed to span the four years of your MBBS. CC is part of the “Foundations of Clinical Practice” theme, which also includes Problem-Based Learning (PBL), Society and Health, Epidemiology and Public Health and Personal and Professional Development.

In your Graduate Entry (GE) Year we introduce you to the concept of patient-centred interviewing. There is a strong evidence base supporting this approach. Although the focus of the CC is on the interpersonal communication that takes place between doctors and patients in a consultation, we interpret clinical communication in its broadest sense and explore ways in which you can communicate effectively within health care teams, using written communications for health care, and consider the influence of technology on communication.

The first year of “Clinical Communication”

By the end of your GE year, you should be able to describe and demonstrate a range of basic communication skills (verbal and non-verbal) relevant for working with patients, peers and clinicians. You will be able to identify a patient-centred consultation and will have developed basic relevant skills for opening, establishing rapport gathering information and closing interviews that explore patients’ experiences. You will also be aware of your strengths and weaknesses in communicating within some health care contexts and have clear strategies for the maintenance of your effective skills and improvement of your developing skills.

Years 3,5,6

Once you have joined the UG and Direct Entry (DE) courses, CC is increasingly integrated with clinical practice as you progress through medical school. In later years you will participate in communication sessions on a range of topics that include:

Giving information about procedures

Explaining risk information to patients

Dealing with aggressive and violent patients

Communicating with children (and their parents)

Sharing difficult news patients and their relatives

Communicating while conducting procedures

Communicating with other health care professionals

Throughout your curriculum you will have an opportunity to interview patients in different contexts. In psychiatry you'll participate in sessions that use a range of educational methods to support the maintenance of your basic interviewing skills as well as the development of more complex skills for interacting with patients experiencing very strong emotions and psychotic states. A recent initiative in psychiatry at Imperial has been the development of audiovisual resources of consultations that explore communication, diagnostic and other professional skills. You will use these resources to help you work towards meeting the expectations that the GMC has of new graduates.

In general practice you will also participate in sessions that aim to integrate clinical decision-making (e.g. steps to making diagnoses, patient management etc) with communication skills.

In fact in all your clinical attachments there will be opportunities to focus on your clinical communication. Sometimes these are highly structured activities, other times they rely on you to recognise and learn from what you are experiencing.

Structure of sessions

For each session there is:

A summary

An introduction stating aims, learning objectives, methods, activities An activity description with aim/s and prompts

An outline of closure including a review of the learning objectives, summary of issues, instructions for evaluation and a lead into the next session

Recommended reading and other references

Session reflection and evaluation

There are SOLE sheets at the beginning of this guide. Please make sure you record the name of your tutor for each session as CC is taught by a variety of different tutors. In addition, you may also be asked to complete additional “minute papers” after some sessions. The purpose of the minute papers and SOLE is two-fold;

To provide you with the opportunity to reflect on whether you have met the learning objectives set for the session

To provide us with feedback on the content and educational methods that is crucial for the ongoing evaluation and modification of the course

Educational methods

Group sizes vary; Session 1 involves the whole cohort; other interactive sessions are taught in smaller groups. Simulated patient interviews are performed individually or in groups of 3-5. A range of methods are used in the delivery of the programme: brainstorming, student presentations, trigger video-clips and role-play with peers, volunteer patients and professional simulated patients.

VERY IMPORTANT!

T

he clinical communication programme is designed to provide you with sound fundamental skills that will enhance your ability to communicate with patients. The information that is presented here, in addition to the material covered on the course is your blueprint to carry with you throughout your medical education and beyond. Communication skills are not an optional add-on extra, they are the key mechanisms supporting integral features of clinical practice including your knowledge base, and problem solving abilities.

Learning objectives – Graduate entry year 1 Autumn and Spring

These session objectives may include tasks you should be able to carry out after you have completed the relevant activity. They provide you with a way to assess how well you are keeping up with the material. Note that they are also provided to the external examiners as a guide to what you should know at the end of the course.

Based on the Background Information

Define a patient-centred interview

List reasons for adopting the patient-centred approach to interviewing

Describe at least two different models of patient-centred consultations

Identify skills used in patient-centred consultations

Session 1: Consultation skills – the initial approach

Describe the General Medical Council competencies expected of new graduates in relation to communication

Outline the content of the first year of “Clinical Communication”

Describe and understand patient centred communication

Identify key skills that can be used when meeting patients for the first time

Understand the relation between content and process

Session 2: Patient centred communication

Further exploration of patient-centred communication

Describe the sources of non-verbal communication

Describe the role of non-verbal communication in conveying emotion

Describe the importance of non-verbal communication in consultations

Session 3: Interviewing volunteer patients

Outline the skills necessary for approaching patients in a manner that enables you to communicate effectively and sensitively

Identify communication and other professional skills that you used effectively

Provide a rationale for using these skills

Identify patient centred interviewing skills that you need to develop

Make use of the feedback from the simulated patients to identify

ways in which you will maintain your strengths in communicating

ways in which you will improve on your communication weaknesses

Session 4: Interviewing a simulated patient

Identify skills used effectively in simulated patient-centred interviews

Receive feedback on communication skills from a simulated patient

Receive feedback on communication skills from a tutor

Develop awareness of personal strengths in communicating

Develop awareness of personal weaknesses in communicating

Identify ways in which communication strengths will be maintained

Identify ways in which communication weaknesses will be improved

Session 5: History Taking (i): Content and Process

Identify the key content features of a medical history

Identify the skills necessary to establish the patient’s presenting complaint, the history of the presenting complaint and past medical history

Interview and receive feedback from a simulated patient

Practise using and integrating the skills associated with patient-centred interviewing while taking a medical history

Session 6: History taking with a simulated patient

Receive feedback on your communication skills from a simulated patient

Receive feedback on communication integrated with history-taking skills from a tutor and from peers

Identify those history-taking skills that you used effectively in the simulated interviews

Identify those skills that require further development

Identify ways in which your communication and history-taking strengths will be maintained

Identify ways in which your communication and history-taking weaknesses will be improved

Session 7: History Taking (ii): Social History

Give examples of the range of problems to which diet contributes

Discuss some of the problems in establishing a patient’s dietary habits

Give examples of the key screening questions to ask every patient when taking a nutrition history

Identify the skills necessary for an effective assessment of drug, alcohol and tobacco use

Use a range of other questions to explore each area more deeply

Session 8: Revision Workshop

Key learning points from the course will be covered

There will be opportunities to observe and practice communication skills

The exam format will be explained and there will be opportunities to ask questions

Assessment

There are two main types of assessment. The first – formative assessments – are those which provide you with feedback on your progress in reaching the curriculum objectives. This feedback comes in different formats - verbal from tutors, peers and simulated patients or written as comments on an assignment, a graded piece of work or an electronic message to all students on your cohort’s progress. The second type of assessment – summative assessment – are sometimes referred to as high stakes assessments as your performance in these tests influences whether you proceed to the next level of study.

Formative assessments

Throughout the course you will receive feedback both verbally and in writing on various aspects of the course. Although the assessments are formative, they do act as a requirement to sitting the summative exam – in order to satisfy this requirement, you are expected to attend all simulated patient interviews (sessions 3, 4 and 6). If you have authorised absence form any of these sessions, we will attempt to make arrangements for you to join a group from the 6-year or DE programme.

Summative Assessment

As a part of the FOCP summative assessment package you will be assessed on your ability to demonstrate patient centred communication. This assessment will take place in June and you will be asked to conduct a 10 minute interview with a simulated patient. The interview itself will be almost identical in format to your previous in course encounters and therefore the assessment of your performance will be based entirely on what has been covered in the course. You will be graded as satisfactory or unsatisfactory. If your performance is graded as unsatisfactory you will have the opportunity to re-take the assessment in August.

Further details about examinations will be provided in course and on the Intranet later in the year.

Attendance and sickness policy

Good attendance is considered an important professional skill, as outlined in your student agreement. An attendance sheet will be completed at each session. You must sign in for each small group session. Signing in for absent colleagues is unacceptable and is considered cheating. Students who do this will be asked to leave the session. Additional penalties may be applied.

If you are unable to attend a session, please email Michael Strevens prior to the session or within 24 hours.

Lateness

Sessions will start and finish on time. Students who arrive more than 15 minutes late are excluded from that session.

Reading list

Books (Practical insights)

There are many texts on basic medical interviewing skills. Although we do not recommend any particular reference, students have found the following books valuable.

Cole SA & Bird J. The Medical Interview: The Three Function Approach. 2000. 2nd edition. Mosby: Missouri

Lloyd M & Bor R. Communication Skills for Medicine. 2009. 3rd edition. Churchill: London

Silverman J, Kurtz S, Draper J. Skills for Communicating with Patients. 2005. 2nd edition. Radcliffe Medical Press: Oxford

Smith RC. Patient-Centred Interviewing: An Evidence-Based Method. 2002. 2nd edition. Lippincott William and Wilkins: Philadelphia

Washer P. Clinical Communication Skills. 2009. Oxford University Press: Oxford. (also contains useful links and podcasts)

Books (analytical insights)

The following books are really for those of you who want to extend your knowledge of doctor-patient communication. Effectively, they provide useful analytical foundations to support the skills you will be learning. They are by no means required reading but have been included as an extra layer of materials and resources you can utilise to galvanise your communication skills.

Heritage J. and Maynard D. (eds.) Communication in Medical Care: Interaction between primary care physicians and patients 2006. Cambridge University Press: Cambridge. (See Chapters 1, 5, 6, and 8)

Roter D. and Hall J. Doctors Talking with Patients/Patients Talking with Doctors: Improving communication in medical visits 2006. Auburn House, Westport, CT.(See Chapters 1, 2, 5 and 8)

Websites

Foundation Programme http://www.foundationprogramme.nhs.uk/pages/home

Tomorrow’s Doctors http://www.gmc-uk.org/education/undergraduate/undergraduate_policy/tomorrows_doctors.asp

National Patient Safety Agency http://www.npsa.nhs.uk/

Contact Details

The core communication faculty are based in The Clinical Skills Centre, 2nd Floor, Paterson Wing, St Mary’s.

If you have any questions relating to this programme, please contact:

Dr Ged M. Murtagh	g.murtagh@imperial.ac.uk	020 3312 7761

Dr Athina Belsi	a.belsi@imperial.ac.uk	020 3312 1100

Mr Michael Strevens	m.strevens@imperial.ac.uk	020 8383 1078

Dr. Ged M. Murtagh

Dr. Murtagh is a social scientist whose research involves the application of conversation analysis to the medical encounter. He received his Postgraduate Certificate in Learning and Teaching in 2005. He has contributed to clinical communication skills teaching for Undergraduate medical students in his previous position at the University of Leicester. With colleagues at Leicester he has developed a consultation aid for Oncologists and cancer patients soon to be tested in an intervention study at the Leicester Royal Infirmary. With colleagues at Imperial and the University of Bristol he is extending this work into surgical training examining communication skills in surgical practice.

http://www1.imperial.ac.uk/medicine/people/g.murtagh/

Dr Athina Belsi

Dr. Belsi is a social scientist with a background in public health. Her research focuses on the motivation to study and the impact of personality on clinical career pathways. She is currently developing research on communication within healthcare teams. She has previously taught at the Dental Institute and the School of Medicine in her previous position at King’s College London where she worked on developing communication stations for the OSCE. Recently, in the Department of Public Health and Primary Care here at Imperial, Dr Belsi has led work into understanding patient perceptions of integrated care pathways. She has also been involved in the Pilot Registry for the Investigation and Prevention of Alzheimer’s disease (RIPA).

Timetable

Please refer to the intranet for information about venue and start times for sessions 3, 4 and 6.

1: Consultation skills – the initial approach
Tues 16 Oct	9 am – 12 noon	Wolfson: Lecture theatre 2	HM
2: Patient-centred communication
Tues 16 Oct	A	2 – 5 pm	Wolfson: Seminar room 1	HM
Tues 16 Oct	B	2 – 5 pm	Wolfson: Seminar room 2	HM
3: Interviewing volunteer patients (* time tbc)
Thurs 18 Oct	A	11 am – 12 noon	Wolfson: Lecture theatre 3	HM
Thurs 18 Oct	B	12.15 – 1.15 pm	Wolfson: Lecture theatre 3	HM
4: Interviewing a simulated patient
Fri 25 Jan	individual times allocated	StM/CX
5: History Taking (i): Content and Process
Thurs 14 Feb	A	10 am – 1 pm	Wolfson: Seminar room 1	HM
Thurs 14 Feb	B	10 am – 1 pm	Wolfson: Seminar room 2	HM
6: History Taking with simulated patients
Tue 12 Mar	individual times allocated	StM/CX
7: History Taking (ii): Social History
Tues 19 Mar	2 – 5 pm	Wolfson: Lecture theatre 3	HM
8: Revision Workshop
Fri 19 Apr	2 – 5 pm	Wolfson: Seminar room 1	HM
Fri 19 Apr	2 – 5 pm	Wolfson: Seminar room 2	HM

Background information for Clinical Communication

This section contains information that is core to communicating in clinical contexts. It is essential that you have read and thought about this information before you attend each session

Learning objectives

All students are expected to be able to:

Define a patient-centred interview

List reasons for adopting the patient-centred approach to interviewing

Describe at least two different models of patient-centred consultations

Identify skills used in patient-centred consultations

Identify attitudes commensurate with patient-centred interviewing

What is a patient-centred interview (PCI)?

Much of the focus of clinical communication is based around the central concept of a “patient-centred approach”. Over the last 30 years or so, research into what constitutes a patient-centred interview (PCI) has resulted in a number of definitions and general concepts. An early definition by Edith Balint (1969); “understanding the patient as a unique human being” has evolved over the years into more sophisticated measures.

A PCI is one in which the interviewer identifies, acknowledges and responds to the patient in a way that encourages the patient to participate and ensures that their own agenda becomes part of the consultation process. This is in contrast to paternalism, or doctor-centredness, where doctors dominate the agenda setting, goals and decision-making in regard to information and services, where the medical condition is defined in biomedical terms and where the patients’ voice is largely absent (Roter,1977). In learning about patient centred interviewing you will become aware of the importance of not only how you can encourage patient involvement in the consultation, but also the different ways in which patients themselves participate in consultations.

The advantages of PCI for clinicians include:

The advantages of using patient centred consultations have been identified by Stewart, 2001) as;

the basic medical tasks are accomplished

it is informative, (providing both technical information and expertise and recommendations for behaviour in a way that is understandable and motivating)

it is facilitative, (in that all the patient’s concerns are likely to be established)

responsive (to the patient’s emotional needs and concerns);

participatory (so that patients have a responsible and authentic role in the decision making).

Advantages for patients

Stewart (2001) has identified factors that patients consider as signals of the doctor offering patient-centred care. In consultations that demonstrate PCI, the clinician:

Explores the patient’s main reason for the visit, concerns and need for information

Seeks an integrated understanding of the patient’s world – that is, seeing them as a whole person with emotional needs and facing real life issues

Finds common ground on what the problem is and mutually agrees on management

Enhances prevention and health promotion

Enhances the continuing relationship between the patient and the doctor

Outcomes of Patient Centred Interviewing

Patient-centred interviewing has been shown to:

Improve diagnostic efficiency

Increase patient satisfaction

Increase concordance/adherence with treatments

Improve recovery

Reduce the number of symptoms

In primary care (Stewart, 2001) found that patient centred communication was correlated with the patient’ perceptions of finding common ground. Also, positive perceptions were associated with better recovery from their discomfort and concern, better emotional health and fewer diagnostic tests and referrals. They conclude that patient centred communication positively influences patients’ health.

Patients’ experience of being a participating member in the discussion of the problem and the treatment process may translate in to the patients’ reduced need for further investigation or referral – simultaneously reducing the physicians’ need as well. These findings counter a common misconception: that being patient centred means responding to every whim of the patient, thereby increasing expenses to the health care system (Stewart, 2001).

The evidence base for PCI

In a study of patient preferences, Little et al (2001a) found that patients in primary care clearly wanted a patient-centred approach, with the 3 key elements being communication, partnership and health promotion. Without a patient-centred approach, patients are less satisfied, less empowered, and may have greater symptom burden and higher rates of referral (Little et al, 2001b)

Abdel-Tawab & Roter (2002) looked at the usefulness and feasibility of client-centred models cross-culturally. They found that a client-centred approach to the consultation was associated with a three-fold increase in the likelihood of client satisfaction and continuation of treatment at 7 months. It is suggested that in Egypt, just as in the more developed world, client-centred models of communication are likely to produce better outcomes than the more traditional doctor or illness-centred models. Similarly, Saha et al (2008) discuss the broad overlap in the features associated with PCIs and culturally competent healthcare interactions.

Research suggests the PCI can be classified under six broad headings (Putnam & Lipkin, 1995) which are used to outline some of the evidence base that supports the importance of PCI across clinical contexts.

Allow patients to express their major concerns

Seek patients’ specific requests

Elicit patients’ explanations of their illnesses

Facilitate patients’ expressions of feelings

Give patients information

Involve patients in developing a treatment plan

1. Allow patients to express their major concerns

Korsch et al (1968) studied over 600 visits to a paediatric emergency room, and later Tuckett et al (1985) studied visits to general practitioners. Both studies found that patients tend to mention only one-quarter to one-third of their major concerns. Patients who were encouraged to express more of their concerns were more satisfied and more likely to comply with treatment.

Korsch et al (1968) found that parent satisfaction was higher in interviews where the doctors demonstrated warmth and friendliness, took patients’ concerns and expectations into account, did not use jargon and provided clear explanations as to the cause and diagnosis.

Orth & Stiles (1987) showed that hypertensive patients who talked about their concerns in their own words (as opposed to answering yes/no questions) were more likely to have lower blood pressure.

Patients are more satisfied when they are permitted to express their concerns (Hall et al, 1988).

Kaplan et al (1989) showed that a high ratio of patient-to-physician talk was related to better overall health ratings, fewer days lost from work, and fewer functional limitations. Further, when doctors asked open-ended questions, patients reported greater satisfaction than the common practice of doctors asking a series of closed-ended questions.

When PCI was first introduced many were concerned about time and workload yet it emerged that doctors trained to obtain a complete list of patients’ concerns and worries at the beginning of a consultation spent no longer than untrained doctors in consultations (Putnam et al, 1988). Similarly assumptions that if you let the patient talk at the outset of the consultation, they’ll go on forever have been challenged by research. Langewitz et al (2002) actually found that if uninterrupted, the average talking time for patients was 92 seconds and 78% of patients had finished their initial statement within 2 minutes. In all cases studied, doctors reported that the information that patients were giving was important and relevant.

Doctors are often quick to redirect patient’s initial descriptions of their concerns and thus miss the opportunity to elicit other concerns or to gather potentially important information. completion. Allowing patients time to express their worries can improve interview efficiency and efficacy.

In a study looking at recovery from upper respiratory tract infections in patients attending a hospital-based walk-in clinic, speed of recovery was linked to the doctors’ attention to the patients’ concerns. The other variables examined were symptom type and severity, initial level of health concern, findings on examination, culture result and therapy (Brody & Miller, 1986).

2. Seek patients’ specific requests

Patients usually have specific requests that are often not apparent from the presenting complaint however, doctors rarely ask patients about their specific requests. (Eisenthal et al, 1990; Eisenthal and Lazare 1976, 1977).

A study where patients with headaches were interviewed found those who reported feeling the doctor had fully discussed their problem with them were 3.4 times more likely to have complete resolution of their headache (Headache Study Group, 1986)

When doctors were trained to elicit patient requests, granting the request was not necessary for patient satisfaction. In a study of 118 patients in primary care practice, 70% of patients hoped for education about their illness, 43% wanted information about non-drug treatments (e.g. diet, exercise), 25% wanted to participate in decision-making about their illnesses, and only 24% wanted stress counselling (Brody et al, 1989). Only 65% desired an examination, 48% wanted tests, and 30% wanted medications.

We know that doctors often fail to elicit all of a patient’s reasons for attending an appointment. Barry et al (2000) found that only 4 of 35 patients voiced all of their agendas in the consultation. In this study, patient agendas were classed as symptoms, diagnosis theories, illness fears, wanted and unwanted actions, self-treatment and emotional and social issues. Some of the poor outcomes in this study were associated with unvoiced agenda items. Patients and their needs must be more fully present in the consultation in order for better healthcare to be conducted.

3. Elicit patients’ explanations of their illnesses

Establishing patients’ own explanations of their illness is explored in depth within the Health Belief Model (Kleinman et al, 1978) within the sociology course. We explore it from a clinical communication perspective because developing this skill is likely to have a significant impact on the quality of medical care you offer. E.g. the ability to really listen.

Patients who were able to get the doctor to listen to their ideas or concerns about the cause of the illness were more likely to recall what the doctor told them and felt more committed to the doctor’s view of the diagnosis and treatment (Tuckett et al, 1985).

Patients often try hard to insert their view on causation but are frequently not heard.

Studies on reduction in blood pressure have shown that improvement was greater in hypertensive patients, who were allowed to express their health concerns in their own words and without interruption, as opposed to answering closed-ended questions (Orth et al,1987; Roter et al, 1995).

McKinley & Middleton, 1999 examined what patients wanted or expected when they consulted with a doctor almost all patients had requests they wished to make, 60% had their own ideas about what was wrong, and 38% had considered explanations about why they were unwell. Failure of doctors to address their agendas is likely to have an adverse affect on the outcome of the consultation.

4. Facilitate patients’ expressions of feelings

The evidence shows that there is little overt discussion of emotions during medical interviews yet illness is often associated with often extreme emotional experiences and expressions.

A study of 50 tape-recorded visits to a clinic were coded for the number of times a doctor attempted to obtain patients’ feelings about their illness. Of 3,500 utterances, only 10 were overt requests for information about feelings. Of 4,500 patient utterances, 174 were overt statements (other than physical pain) of the patient’s feelings while a further 152 added emphasis to their symptoms (Putnam & Young, 1984).

It is best practice to separate fact from opinion which can aid our understanding of another person’s experience. Consider how often we hear expressions such as “I know exactly what you mean” or “I can tell you are upset / angry”. The rule of thumb is to separate out opinion from fact e.g. “I think I understand what you mean” or “I think you look upset at the moment.” Separating fact from opinion in this way helps individuals to express themselves whilst respecting it might be different for others.

Emotional distress among patients in primary care often goes unrecognised during the consultation. Roter et al (1995) explored the effects of communication skills training on the process and outcome of care associated with emotional distress in patients. This randomised control trial found that patients reported a reduction in emotional distress up to six months after a consultation with a physician who had received (the intervention) communication skills training programme to help physicians address patients emotional distress, when compared with patients who consulted with a physician in the control group (no training). Doctors who are able to facilitate patients’ expressions of feelings and address emotional distress can improve the process and outcome of care without lengthening the time of the consultation by using patient-centred skills.

5. Give patients information

In 1964, Egbert et al showed that surgical patients who were given information by anaesthetists were discharged up to 2.7 days earlier than surgical patients who did not receive the information. Such findings have influenced the movement towards PCI.

By 1984, although doctors largely agreed that giving information was important, it seemed they had a tendency to grossly overestimate how much they provide. Waitzkin (1984) showed that in a 25-minute interview, doctors spent less than one minute giving information but they all thought they had spent nine times this amount. The amount of information patients receive is positively correlated with patient satisfaction.

Doctors often find it difficult to assess their patients’ preferences for involvement in decision making. Patients may not always appreciate the implications of involvement in decision-making which may reflect lack of understanding or past experience of health care. Robinson and Thomson (2001) discuss this in light of the research and suggest that there may be differences between patients’ desire for receiving information and the desire to take responsibility for the treatment decision itself. Assumptions cannot be made about how much information a patient wants nor can they be made about how much a patient wants to be involved in treatment decisions. These assumptions can be avoided with a patient-centred approach to interviewing; it would seek to elicit patients’ ideas, concerns, and expectations about information exchange and decision making.

Several studies explore different ways of giving information to patients (e.g. verbally, non-verbally - patient information leaflets, internet etc). Van Zuuren et al (2006) explored patients’ responses to receiving information on gastroscopy. Overall, they found that patients who received the brochure experienced less anxiety before and reported greater satisfaction afterwards.

It is important to broadly think about the ways in which doctors can deliver information to patients – that is, not just in face to face interactions during consultations, although that is a powerful medium and, most valuable for individualising or tailoring information to patient’s needs.

6. Involve patients in developing a treatment plan

There is a definite flow in medicine towards patient-clinician partnership models of care. The journal, Patient Education and Counselling presents many examples of ways to achieve such partnerships in a wide range of contexts and methods for measuring their effectiveness. For example a review article by Haywood et al (2006) evaluated the evidence for promoting patient involvement in care through coaching, sharing educational materials and provision of feedback to health care providers. Many of the most effective strategies and models for patient involvement first emerged over 20 years ago. E.g. Kaplan et al, 1989 established how if patients are coached to request more information, their questions are increased and they become more effective in obtaining information.

Teaching patients how to read their medical records and understand their illnesses resulted in significant improvements in functional capacity (what patients are able to do) and in the physiological parameters of patients with diabetes, hypertension and ulcer disease. The functional capacity of patients with breast cancer was also improved (Kaplan et al, 1989).

Roter (1977) showed that patient involvement was also related to improved adherence to appointments.

The use of a patient-centred model to explore ideas, beliefs and expectations with non-adherent patients was found to improve clinical control and medication use. Dowell et al (2002) offered patients who were using treatments sub-optimally and had poor clinical control of their illness extended consultations with doctors to help explore their situation and expose barriers to change. Of the 22 subjects engaged in the study, 14 had improved clinical control or medication use three months after the intervention ceased.

In a study examining patient-perceived involvement in Parkinson’s disease therapy decisions, Grosset & Grosset (2005) found such involvement to be closely linked to patient satisfaction which is linked to compliance intent and also to quality of life. These results are similar to many studies conducted in primary care.

Disease and Illness

Disease is the biomedical cause of sickness in terms of pathophysiology.

Illness is an individual’s unique experience of sickness including their perception, experience and ways of coping with the “disease.”

When Balint et al (1970) first introduced the term “patient-centred medicine,” they contrasted it with “disease-centred medicine” or “doctor-centred medicine”

Such traditional or “conventional medical model” have been dominant model in medical practice. This model assumes that disease can be fully accounted for by deviations from a norm of measurable biological variables. It does not consider social, psychological and behavioural dimensions of disease and illness.

Introduction to patient-centred consultation models

The research around PCIs has resulted in a number of consultation models which aim to achieve the broad concepts of patient-centredness. Although there are several other models, here, we introduce two models, the Calgary Cambridge model and the Transformed Clinical Method. Epstein et al (1993) compared consultations models and concluded that “on a theoretical level the models are complementary. Different models represent variation in style rather than any difference in the theory that underpins them.”

Many students find “Calgary-Cambridge” a useful starting point as it is a structural model. This means it can be followed in step-by-step manner which helps novice learners. Calgary-Cambridge is also the model of choice in Year 3 “Clinical Methods Teaching” as it is commonly used in general practice.

1. Calgary-Cambridge observation guides (Silverman et al, 2005)

This structural model sets out the medical interview in phases with specific objectives to be achieved at each stage. There is also a set of affective skills that are relevant in all phases. Our Imperial College model is similar to this one, adapted for medical students who are learning medical interviewing and other consultation skills rather than for experienced clinicians who are already in the workplace (Figure 1).

1. Initiating the session

The basic tasks for the doctor (or student) are to establish initial rapport and to identify the reason(s) for the consultation. The skills to achieve these tasks are similar to the skills used to achieve the similar tasks in all of these models: greeting the patient, introducing yourself, demonstrating interest, using open questions, etc.

2. Gathering information

This phase of the interview focuses on exploring the patient’s problems and understanding the patient’s perspective. Again, this is similar to exploring the emotional aspects of the patient’s illness and getting to know the patient as a whole person. The other task in this phase is to provide a structure to the consultation to help both you and the patient to know where the consultation is going and to assist in the management of time.

3. Physical examination

Many interactions with patients will include a physical examination. It is important to keep communicating with the patient during the examination to let them know what you are doing and to pick up verbal and non-verbal cues (e.g. indications of pain).

4. Explanation and planning

The aim of this phase is to give comprehensive and appropriate information responding to what the patient wants. Each patient must be assessed and the appropriate amount and level of information given. You will have options in explanation and planning depending on the context - whether you are discussing opinion and significance of problems or negotiating a mutual plan or discussing investigations and procedures. Doctors are obliged to provide some information to patients (e.g. purpose and risks of proposed surgery) even if patients do not want it.

5. Closing the session

This is a crucial part of any consultation. It can help to maintain the rapport. A summary enables review of what has been learned as well as checking for any other information that you may have missed or that the patient wants to tell you.

6. Building the relationship

This occurs throughout the entire consultation. You are aiming to use specific skills to help build the relationship with the patient and to establish rapport. In order to build an effective relationship, you need to involve the patient and share your thoughts and ideas. This will help to enhance their understanding and you may also want to provide a rationale for the questions you are asking, the physical examination, lab tests, treatment etc. This will also include getting consent from patients as well as discussing confidentiality.

7. Providing structure

This occurs throughout the entire consultation. My making organisation overt, both you and the patient will know where you are in the consultation. This can be achieved by summarising at the end of a line of enquiry, signposting the next section of the interview, structuring the interview in a logical way and attending to timing.

Figure 1: Outline of the Cambridge-Calgary observation guide

2. Transformed clinical method (Stewart et al, 2003)

This model has six components. The first three focus on the process between the doctor and patient and the last three focus on the context within which the doctor and patient interact. All components make up the holistic model that is patient-centred clinical practice (Figure 2).

1. Exploring both the disease and illness experience

Aim: To assess the two conceptualisations of ill health: disease and illness

In addition to assessing the disease process by taking a history and doing a physical examination, the doctor actively seeks to enter in the patient’s world to understand his or her unique experience of illness. Specifically, the doctor explores the patient’s feelings about being ill, their ideas about the illness, how the illness is impacting on their functioning and what they expect from the doctor.

F = feelings

I = ideas

F = function

E = expectations

2. Understanding the whole person

Aim: To integrate the concepts of disease and illness with an understanding of the whole person. This includes an awareness of all the aspects of the patient’s life, such as personality, developmental history, life cycle issues, and the contexts in which they live.

3. Finding common ground

Aims:	To define the problems

To establish the goals of treatment &/or management

To identify the roles to be taken by patient and doctor

Sometimes patients want to play a passive role in their treatment and management but the doctor needs to be able to assess this before assuming the role the patient wants to take in managing their own health.

4. Incorporating prevention and health promotion

Aim: To promote health as well as prevent disease.

This highlights the importance of using each contact with the patient as an opportunity for prevention and health promotion. This may include helping to educate your patients.

5. Enhancing the doctor-patient relationship

Aim: To develop and maintain the patient-doctor relationship

Each contact should build on the relationship by including compassion, trust and a sharing of power. Self-awareness is essential as well as an appreciation of the unconscious aspects of the relationship such as transference and counter transference.

6. Being realistic

Aim: To use all resources effectively to achieve the 5 components above

This requires that the doctor is realistic about time, participates in teambuilding and teamwork (either in the hospital or within their general practice) and recognises the importance of effective use of physical and other resources.

Figure 2: Transformed clinical method

Components	Tasks
1. Exploring both the disease and illness experience	History, physical examination, lab tests Dimensions of illness (feelings, ideas, effects on function and expectations)
2. Understanding the whole person	The person (e.g. life history, personal and developmental issues) The proximal context (e.g. family, employment, social support) The distal context (e.g. culture, community, ecosystem)
3. Finding common ground	Problems and priorities Goals of treatment and/or management Roles of doctor and patient
4. Incorporating prevention and health promotion	Health enhancement Risk avoidance Risk reduction Early identification Complication reduction
5. Enhancing the doctor-patient relationship	Compassion Power Healing Self-awareness Transference and countertransference
6. Being realistic	Time and timing Teambuilding and teamwork Wise allocation of resources

Communication skills for patient-centred interviewing

Having reviewed the concept of patient centred interviewing, some of the supporting evidence and models relating to the patient centred approach to clinical communication, it is worth saying something about the relevant skills. On the clinical communication programme you will learn about one fundamental principle and two types of skill sets. The governing principle is understanding the importance of the sequential organisation and structure of the medical interview. The skill sets include content skills and process skills.

The components of the medical interview

Content skills

Firstly, there are content skills, i.e. the substantive character of questions and responses, information being sought and delivered, discussion of treatment options, management plans etc. Most texts dealing with consultation skills will suggest that the content of a medical history should include:

Presenting complaint

History of the Presenting Complaint

Past Medical History

Social History

Family History

Lifestyle

Functional enquiry/systems review

Whilst these are relevant and important lines of inquiry, this still begs the question, HOW do you cover these topics in a way that will ensure you gathering information effectively and efficiently in a way that does not alienate the patient. This is where process skills come in

Process Skills

Process skills allow you to answer the HOW question. Content and Process CANNOT be viewed as mutually exclusive. The relation between the two will be developed more extensively in Year 2.

The following information sets out a framework which incorporates, structure as well as fundamental process skills to assist you in communicating effectively with patients. It is designed to reflect the needs of medical students learning to communicate in medical interviews for the first time but is also relevant for interacting with patients during physical examination and while conducting procedures.

Commencing the interaction

Greet the patient

A formal greeting should be used (e.g. “Hello” “Good morning” etc). It is usually more helpful to commence formally and then move to informality as the relationship accommodates. The patient’s name should also be used (e.g. “Good morning Mr Wilson”) and you should check the patient’s identity. Shaking hands with patients during your greeting is not essential but is often welcomed by patients.

State your full name and clarify your role

Use your full name and state your role (e.g. “My name is Louis Channing and I am a medical student working with Dr. Abdullah.” “I am Ching Chow Man. I am a student doctor here at the clinic.”)

Obtain patient’s name

Checking the name of the patient is helpful in ensuring that you are speaking to the right patient.

Attend to patient’s comfort

If a patient is uncomfortable they are less likely to be able to spend time with you and unable to concentrate. Look at your patient to see if they are in pain and respond to what you see. It is helpful to share your observation with your patient. (e.g. “You don’t seem very comfortable on that chair…?”) Note physical aspects of the environment that contribute to comfort - the temperature of the room, draughts, noise, furniture, bedding etc. Facial expressions are also often indicative of a patient’s level of comfort. Don’t ignore what you see. Check it out with the patient.

Obtain the patient’s consent

When you are practicing communication, it is important that you explain what you are doing. (e.g. “Good morning Mr. Williams. I am Shavaun Sekkil, a medical student at Imperial College. I am here today to spend time interviewing patients as part of my course. I wondered if you would talk with me for about 10 minutes about why you have come to the hospital/clinic/GP today?”) Leave enough time for the patient to answer your question. Sometimes it is better not to sit down until you have asked this question. Once you have sat down, it can be harder for the patient to decline. This is not always the case. If patients do not want to speak with you then you need to respect their wishes and leave. Think about the reasons patients might not want to speak – already been interviewed by several students, feel poorly, just don’t want to talk to you, waiting for an appointment for a test, just returned from a test, in pain etc… It is important to read the GMC’s guidance on consent, Seeking patient’s consent: the ethical considerations. The Medical Protection Society provide helpful guidelines for students (http://www.mps.org.uk/student). Consent is defined as “the informed choice of a competent patient, freely given.” (MPS, 2003)

Clarify confidentiality

This is a potentially controversial aspect of your relationship with patients and other health care professionals. For more information see General Medical Council (2009) Guidelines on Confidentiality: Protecting and Providing Information.

For many of the interactions with patients, it is probably unnecessary for you to categorically state unprompted at the outset of your interview that the information obtained will be confidential. Use your judgment as to whether you think you need to state that an interaction will be confidential. Be aware of exactly what you are promising - although it is tempting to promise that “everything you say will be absolutely confidential”, it is likely that the information you gather from the patient will be shared with your team. It is important you clarify this with the patient. Sometimes patients may disclose important information to you that they haven’t told anyone. It is helpful if you have already told them you will be passing the information on.

You must maintain confidentiality of all patient information within the health care team caring for the patient. If you are asked to submit information about your experiences of patients for your medical teachers, then the patient must be de-identified. Your medical ethics sessions should provide further information about this.

State purpose of the interaction

It is helpful to state the purpose of the interview. That way, patients know what they are agreeing to. (e.g. “I would like to talk to you for 5 mins to find out more about why you have come into hospital today. I’d also like to ask you questions about your health in the past as well as find out about your family and work life.” “I have been asked to close the wound with stitches.”) Avoid statements such as “I would like to practice my communication skills” Although an honest statement, this can place a question mark over the relevance of the interview for the patient.

Clarify time available

Patients do not always have a lot of time to talk with you. It is polite to state how long you expect to spend with a patient. It can also help them plan their time. Patients might have an appointment with another health care professional or going for tests and it would be unhelpful to encroach on that time. It can also be helpful for you if you find that you have a talkative patient who you would like to focus on your questions. If you have already let them know how long you have then it does not seem rude to remind them that you only have a few minutes. If you want to take longer, then you can always ask the patient if you can extend the interview.

Empower patient to ask questions or seek clarification of anything that is unclear

Patients can be invited to ask questions (even though you may not have the answers) as well as to check with you if there is anything you have said that is unclear. (e.g. “If anything I say is unclear, please let me know and I will explain.” “Please feel free to ask me questions at any time during the interview,” “If you have any questions about what I am doing, please just ask.”)

Gathering information

Use open-ended questions initially

Open-ended questions are designed to enable the patient to provide a more open, elaborate response, other than yes or no. (“Can you tell me what brings you here to the clinic today?”, “Can you describe the symptoms for me? ”Closed-ended questions are designed to produce a more restricted response from the patient (e.g. yes or no). They are useful when you need to narrow the focus of the discussion to more specific topics, or in circumstances where the patient may not be in a fully conscious state. Examples of closed -ended questions include: “Are you in pain now?” ”Is it a sharp pain?”

Open and closed questions, however, do not work automatically in this way and should not be seen as fool proof devices. They are merely a reflection of some of the patterns of interaction in the medical encounter. How you interact with a patient is always a contingent matter, i.e. patients can produce closed responses to open questions and very open responses to closed questions. IT IS VERY IMPORTANT TO BE AWARE OF THIS CONTINGENCY FROM AN EARLY STAGE . The key to controlling this contingency is to learn to ‘read’ the patient and allow the information the patient gives (verbal) and gives off (non-verbal) to inform the design and of your questioning (See ‘Use of open and closed questions’ below).

Allow patient to complete first sentence/s

Doctors have been found to interrupt patients before they have even finished answering the first open-ended question of the interview. It is really important to discipline yourself to leave the patient to talk at the beginning of an interview. This conveys very powerful messages about your level of interest in the patient and your willingness to listen. This wait time may be as little as a minute but provides the patient with an opportunity to express their views.

Sometimes patients need to be interrupted and this is okay. Interruptions may be necessary because the patient is getting increasingly tense, diverging from the topic, there is a shortage of time, there is urgency associated with a procedure etc. You need to be able to make appropriate judgments as to when to interrupt. Clear statements of the purpose of the interaction and an indication of the time available can be helpful in managing time during an interaction. Non-verbal means of interrupting a patient may include the use of clear hand signals or changing body position, adjusting gaze or making eye contact.

Identify the patient’s ideas, concerns and expectations (ICE)

Although these items (ICE) are content rather than process skills (see above), they tap into what the patient often thinks is the most important aspect of the consultation. Failure to explore and acknowledge ICE can negatively impact on information gathering resulting in inaccurate diagnoses and reduced patient satisfaction (e.g. Ideas - “Is there anything you think might be causing these symptoms?” “Patients often have ideas about possible treatments. Do you have any ideas?” Concerns – “Do you have any concerns about your illness? “Are you worried about your symptoms?” “Patients often have worries about their symptoms. Do you?” Expectations – “What are you hoping the doctor will do?” “What do you think your treatment will be like?”)

It is important that the questions you ask are in context so they contribute to the normal flow of conversation between you and the patient. Think about ideas, concerns and expectations as areas you would like to cover in conversation, not questions on a list. DO NOT SIMPLY ASK A PATIENT. ‘WHAT ARE YOUR IDEAS, CONCERNS AND EXPECTATIONS’. Firslty, this is a multiple question (see Avoid Multiple Questions below). Secondly, it is more effective to phrase questions about ICE in more familiar ways, e.g. ‘Are you worried about your symptoms?’ ‘What are you hoping will be the outcome of your consultation/treatment?’

Remember that you do not have to agree with the patient’s ideas, allay their concerns or meet their expectations. What is important is that you find out what this baseline information is and work from there. Patients may be satisfied with the fact that you cannot meet their expectations. Overt discussion of this is helpful rather than the patient leaving the interview thinking that you don’t really have a clue about what s/he is expecting.

Listen attentively

Lang et al (2000) made a call for Active Listening as a way to ensure that patients ICE provide us with clues about patient illnesses.

“Most patients who experience illness symptoms develop an explanatory model. More frequently than physicians realize, these attributions involve serious and potentially life-threatening medical conditions. Only a minority of patients spontaneously disclose or "offer" their ideas, concerns, and expectations. Often patients suggest or imply their ideas through "clues." Active listening is a skill for recognizing and exploring patients' clues. Without this communication skill, patients' real concerns often go unrecognized by health care professionals. Qualitative techniques including videotape analysis, post-interviewing debriefing, and interpersonal process recall were used to identify types of clues. We propose a taxonomy of clues that includes

(1) expression of feelings (especially concern or worry),

(2) attempts to understand or explain symptoms,

(3) speech clues that underscore particular concerns of the patient,

(4) personal stories that link the patient with medical conditions or risks, and

(5) behaviours suggestive of unresolved concerns or unmet expectations.

This clue taxonomy can help physicians recognize patients' clues more readily and thereby improve their active listening skills. A deeper understanding of the true reasons for the visit should result in increased patient satisfaction and improved outcomes.

James H. Quillen of College of Medicine, East Tennessee State University tells us that,

Active listening needs us to grasp what a speaker is saying from his or her viewpoint. It needs us not just to listen but to convey to the speaker that we are listening and understanding their point of view. Active listening needs us to listen for the bigger picture. Most messages have more than one part the actual content and the feeling or attitude underlying this content. Both are important.

Active listening can be demonstrated verbally (e.g. staying with patient’s topic; using the patient’s words; reflecting statements back to the patient; making summaries etc) and non-verbally (e.g. using eye contact; nodding, body posture, avoiding note taking or using the computer; sitting still). If you are too busy thinking about the next question to ask and not listening to the patient, your next question is less likely to be appropriate.

Use non-verbal behaviours

It is not news to the medical profession that the best doctors listen to the words and the non verbal messages from the patient. It is active listening that allows the doctor to reach the diagnosis and plan the most effective treatment. As long ago as 1935 LJ Henderson offered the following advice.

When you talk with the patient, you should listen, first for what he wants to tell, secondly for what he does not want to tell, thirdly for what he cannot tell

(Billings and Stoeckle 1999:25)

A major aspect of all communication behaviour is non-verbal, Non- verbal communication includes eye contact, body posture, gestures, facial expressions, touch etc. Non-verbal communication is incredibly powerful and can generate a wide range of feelings that in turn impact on the consultation. It can be thought of as the tune that lingers and is remembered long after the specific words are forgotten. As you gather more experience you will begin to recognize the power of non- verbal behaviours and harness them to aid your own communication abilities. In principle, your nonverbal behaviour needs to convey to the patient that he or she is the focus of your attention and needs to be adjusted in relation to the patient’s response to you. Although analysing specific behaviour can be helpful when you are learning about communication, it is usually the overall impact of these behaviours that patients respond to.

Attention to the arrangement of physical space for interviewing can influence the communication (e.g. sitting adjacent rather than opposite to patients, sitting at the same level). Distance to the patient needs to be considered as well – neither too close nor too far. A rule of thumb would be to secure approximately 1 metre distance between you and the patient chest to chest.

Use open to closed-cone questions

Open and closed questions can be used to facilitate information gathering and patient involvement. Try starting with open questions (questions which are designed to introduce a topic without influencing the response) initially and then move to more focused and closed-ended questions (questions which limit the patient’s response to one or two word answers). (e.g. – open “Can you tell me why you have come into hospital?…Can you tell me more about the pain?… e.g. – closed Exactly where is the pain? Have you ever had it before? You said it sometimes moves along your leg, is there anything you do that makes it better?…”) Both types of questions are useful but serve different purposes. However, open and closed questions are only tools and should not be seen as all that is needed to communicate with patients (see ‘Use open-ended questions initially’ above).

Pick up verbal cues

Patients sometimes hint at their concerns and it is important that you pick up these leads. (e.g. “You mentioned that your brother had a similar experience, can you tell me more about that?” “You said that the headaches have been worse since December. Have you any ideas why that might be the case? etc). If patients ask questions, you acknowledge the question and try to answer it if it is within your breadth of knowledge. As students you need to take special care with the information that you provide patients. If you do not know the answer, it is alright to admit this. Sometimes it may be appropriate to follow up questions that patients have asked you with the health care team.

Pick up non-verbal cues

Sometimes patients are less overt in their request for information or their expression of worries and fears. Non-verbal behaviours such as facial expressions, eye contact and body positioning and attention can convey important cues to patient’s needs. Look at patients and respond to what you see. A patient who suddenly winces suggests they have acute pain. Do not ignore it. A patient who is distracted may be irritated because you are not focusing on what they want to talk about etc. Again do not ignore these responses, but acknowledge them, “Are you in any discomfort now?” “Is there anything you’d like to discuss that I haven’t covered yet?”

Probe sensitively

In some interviews it is important to probe topics very sensitively. These may be topics which many people find sensitive – the death of a family member, taking a sexual history etc. However, not all patients will respond this way. Examples of sensitive probing include: “I can see this is difficult for you. Do you want to go on…? “ Patients are often able to continue. It is your acknowledgement of the difficulty that enables them to do so. Another example uses the skill of “normalising.” For example, “Many patients find it difficult to talk about resuming sex after this sort of surgery, is this difficult for you?”

Survey for other problems

Never assume that the patient has just one or two presenting complaints or symptoms. Always explore for more. “So far you have mentioned that you have been experiencing headaches and neck pain, is there anything else?” It is helpful to identify other problems near the beginning of the interview. This avoids the patient bringing up a new issue towards the end of the interview when there may not be time to address it. However, it is important to remember that patients do not always feel comfortable telling everything at once, especially if they do not know you.

Set the agenda

It may not be possible to explore all the patient’s problems in one meeting and so you may have to work with the patient to decide what you should do. “You have mentioned several symptoms. We will not have time to deal with them all today. I have the impression that the headaches are the most important thing for you right now and I would like to focus on that as well. In the next appointment we can start to deal with the muscle pain. At this stage it is hard to tell if they are related. Is that ok with you?”

Clarify patient’s terms

Patients sometimes use terms that are colloquial and may require clarification. Do not assume that you know what is meant. Similarly, patients may use medical terms incorrectly. If you do not know a patient well, then it may be best to check out what they mean. (e.g. depression, diarrhoea etc)

Make interim summaries

Make use of interim summaries in order to check and clarify what you have understood. This also conveys to the patient that you have been listening. “I’d like to summarise what you have told me so far…” “Just so I can check that I have got this clear, the symptoms first started…”. Interim summaries can also be used in this way to give yourself some time to reflect on which direction to move into next particularly if you lose your train of thought.

Signpost or make transition statements

Signposting or transition statements are critical skills which you need to familiarise yourself with very early on. These are statements that link the interview together. They provide direction so you and the patient know where you’ve been and what’s coming next. “We have discussed why you have come into the hospital, what I would like to do now is ask you some questions about your health in the past.” “During the interview, I’d like to ask you questions about why you have come into hospital, what you have experienced since you have been here and what you are expecting will happen next.” Learning how to make transition statements now will stand you in very good stead in the future. Transition statements are very important devices which shape the sequential organisation of the interview as they render the process transparent for the patient and show that you are listening. We will explore the sequencing of your interaction more so in Year 2

Use silence appropriately

Silence can be very helpful in interviews. Already we have outlined the need to avoid interruptions right at the beginning of the interview. Remember that when people are unwell they can be less able to think as quickly as they usually do. Patients often need more time than others to respond to questions. Also, remaining silent, nodding and maintaining eye contact, after the patient has spoken can sometimes be interpreted by the patient as a ‘go-ahead’ signal resulting in them telling you more. Sometimes students also run out of things to say. At these moments, stop and think about what you have learned in the interview can be helpful in triggering a new line of questioning rather than simply thinking about what you need to ask next. Silences can be uncomfortable but they can also be used effectively.

Avoid multiple questions

These are questions that ask for multiple bits of information all bound up in one question. “Do you smoke and drink?” should be broken into two questions. “Do you smoke?” wait for an answer and then follow later with “Do you drink alcohol?” Asking a multiple question increases the possibility of the patient answering only one part of the question which can have a negative impact on your information gathering

Avoid leading questions

These are biased and sometimes judgmental questions that may lead the patient to agree with you rather than eliciting accurate information. “You don’t smoke do you?” “So you’ve never had heart problems?” The last question could be used as a means of checking the information you have already gathered which would be acceptable but should not be used as the opening exploratory question.

Avoid unexplained jargon

Patients vary in their understanding of medical terminology, so it is important that you ensure that your patient understands the language that you use. If you use medical terminology, check whether the patient understands and explain any terms that they are unfamiliar with. Remember that some language you consider to be every-day terminology may be regarded as jargon to some patients (e.g. stools, cannula). On the other hand, patients who read up on their conditions may be familiar with medical terminology and be comfortable using it – remember to check that their understanding of the terms is correct.

Closing the interaction

Provide an end summary

Before finishing the interview it is valuable to make a summary. “I’d like to summarise what we have discussed.” It means that you can check with the patient the accuracy of your information as well as leave the patient with a sense of what they and you thought important. Lasting impressions can be important in the same way that positive first ones are important to make. It also signals to the patient that you are about to finish. If you have just finished a procedure then it is helpful to state precisely what you have done. Patients are sometimes anxious while you are conducting procedures and so are less able to acquire new information (e.g. “Mrs. Renton, I have put 6 stitches in your wound. It is now closed and you can see has a gauze dressing over the top…”). Use the same principles of communication by restating what you have done.

Discuss an action plan

This will probably not be valuable in your early interviews because you will not have an action plan. The most likely response would be: “Thanks for spending time with me. If you wait here, the doctor will be along to see you shortly.” In later years when you are explaining procedures to patients this would include something like: “You will need to do the following things in preparation for your colonoscopy. First … second… etc. Is that clear? It can sound complicated but it is very important that you understand the preparation. Perhaps you can go over it with me again?”

Check for further information

Sometimes patients wait until the last moment to ask key questions, especially if you have not provided them with an opportunity to do so earlier or patients may not feel comfortable asking for or sharing information sooner. Therefore, it is helpful to ask if the patient has any further information immediately before the end of the interview.

Ask for questions

Another offer for the patient to ask you questions. Again, patients are assimilating information throughout the information and your summary might have triggered an area of discussion they would like to pursue.

Check if the patient has any worries or concerns

This is different to asking for questions. It is explicitly checking out the patient’s worries and concerns. New concerns may have emerged during the interview. “When we first started talking you mentioned you were worried about the timing of the operation. Now that we have clarified that, I was wondering if you had any other concerns.”

Display Empathy

Empathy is a fairly accurate understanding and sense of what the patient is feeling. It is sometimes referred to walking in the other person’s shoes. It differs from sympathy because you do not need to feel their pain, empathy has an “as if” quality. So to be empathetic you need to imagine what it is like to be the other person and demonstrate this to the patient through your behaviour. We can experience empathy when we watch a film but then we don’t need to give the character feedback or demonstrate that we do understand what they are experiencing. When we empathise accurately with patients we are more likely to develop rapport. Our ability to empathise and build rapport relies on our communications skills.

Cole and Bird (2000;15) define empathy as

Indicating one person’s appreciation, understanding and acceptance of someone else’s emotional situation…. A physician can best build rapport and respond to patients’ emotions by communicating empathy”

To make an empathic statement, you need to recognise what the patient is feeling and communicate this to the patient. After the patient has expressed a feeling, an empathic statement can make a personal connection with the patient. “Yes, I can see you are in pain.” “That must have been very difficult managing all those years” “I can tell from what you are saying that it was a distressing time for you.” “I hear what you are saying about your depression. It can be extremely difficult.” Alternatively, patients can show their emotions non-verbally and it is helpful for you to note this and let the patient know too. “You still seem worried.” “I can see that is hurting.” “It is ok to be upset.”

Avoid being judgmental

Although you will almost certainly hold many very strong views about a whole range of subjects, in clinical care it is important that those views are only shared appropriately if at all. You will be confronted by patients who may trigger various feelings in you that in non-clinical life, you might make judgments about. People who hold strong religious beliefs (or none at all), who smoke, gamble, who are obese (or have other eating disorders), who drink and drive, have alcohol or drugs problems etc. As a professional you are expected to recognise your responses to patients’ lifestyles and behaviours and not to let such personal judgments get in the way of the care you provide. During your medical training, especially on the clinical communications and patient contact courses we will explore strategies to manage personal views in less judgemental ways than you might express them in your private life.

Summary

To summarise, not all the skills listed above must be evident in every patient encounter. They are a guide to best practice offering you a framework to develop your consultation skills in line with the principle of patient centred interviewing.

Assessing your own patient-centred interactions

The following questions have been developed to help practitioners reflect on their patient-centred behaviours. Although designed for practicing clinicians, they can be useful to help you in your observations of doctors in practice.

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 treatments?

Did I share in decision-making?

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

Did we agree?

Affective and instrumental skills

Another way of looking at skills is to consider them as being either affective or instrumental. Affective skills are the skills that encourage and maintain a relationship. Instrumental skills are those that relate to task-oriented behaviours. Think about skills in the way that you personally find most helpful. Howe (1997) characterises communication skills in the following way:

Affective skills (that help the patient to talk) include:

Using non-verbal behaviours (eye contact, body posture, attentive listening,
show warmth)

Social verbal cues (greeting, giving the patient time to speak, not interrupting)

Facilitating behaviours (nodding, showing interest)

Expressing empathy

Acknowledging feelings shown or expressed verbally

Instrumental skills relate to:

(Type and content of questions)

Asking open-ended questions, especially early in the consultation

Directing the consultation into psychosocial issues

Specific enquiry after emotional/mental health symptoms (focused/closed
questions)

(Making sure you have understood)

Clarifying what the patient means

Feeding back to the patient what you think they mean (internal summary)

Asking for specific examples

(Structuring the consultation)

Keeping the consultation focused

Summarising what has been said

Allowing the patient opportunities to express further concerns or questions

Signposting when changing or introducing new topics

(Exploring the patient’s point of view)

Asking open questions to elicit the patient’s story

Asking about the patient’s ideas (presenting complaint, treatment options,
causation, etc)

Asking about the patient’s concerns

Asking about the patient’s expectations (diagnosis, prognosis, treatment, etc)

Becoming an effective communicator

Reflection

The term ‘reflection’ is applied to relatively complex or ill-structured ideas for which there is not an obvious solution and it largely refers to amending knowledge and understanding that we already possess

Learning to reflect is an essential skill in a fast changing world where facts and truth can change and you will constantly encounter novel situations. Reflection / reflective learning is likely to involve a conscious and stated purpose for the reflection, usually with a specified learning outcomes, or the aim of taking specific action towards a learning goal or clarification. It is common in education for students to be asked to reflect on an experience and present their reflection to others for assessment (in written or verbal form).

On the communications skills course you will be expected to develop and demonstrate that ability to reflect. One way of considering reflection is as a triangle around an event and you will be asked to reflect on your learning from some of the sessions.

Other people’s thoughts and ideas e.g. Comments from tutors and peers or classroom debates. Reflection on experience My own thoughts, feelings, current beliefs and ideas. The professional or disciplinary thoughts and ideas – often found in policy documents, academic readings research and teaching materials

Experts often reflect-in-practice and adjust their behavior or identify gaps in their knowledge very quickly. One of the challenges as we move from novice towards expert from learner to teacher is we forget the earlier stages of our own development. Perhaps you have experience of a parent or partner trying to teach you to drive or cook? When we have been driving for years it is easy to say to the L driver “ok change gear, forgetting” how automatic that procedure has become for us. The novice driver may need different information broken down into stages “can you hear the change in the revs? That means it is time to change up into second gear”. Or to make most sauces or soups most cooks would suggest you should make a roux. Would you be able to follow that instruction? (Gently melt butter and add flour).

A reflective model

Boud, Cohen and Walker (1993) provided a simple model to guide us towards the art of reflection using of seven headings. They assume you will take theory and practical experiences into account.

Cast your mind back to the experience.

Notice and attend to your feelings about the experience.

Re-evaluate - think about it with the benefit of hindsight

Ask - how does this experience fit in with my current understanding? (Association)

Ask- how can I include it in my practice, attitudes or understanding? (Integration)

Consider how you can check it out in practice, try new version on for size? (Validation)

Include new understanding or skill in my day-to-day practice with a clear rationale until it is challenged or confirmed by further knowledge or changes (Appropriation)

On the CC course, and several others you will be asked to reflect in different ways. Sometimes you will be expected to “evaluate” your own learning or to provide feedback on someone else’s performance. Certainly in examinations if you are asked to provide a rationale the best answers are reflective, taking account of theory and practice and demonstrating that learning.

References

ABDEL-TAWAB, N. & ROTER, D. (2002) The relevance of client-centered communication to family planning settings in developing countries: lessons from the Egyptian experience. Soc Sci Med, 54, 1357-68.

BALINT, M., HUNT, J., JOYCE, D., MARINKER, M. & WOODCOCK, J. (1970) Treatment or Diagnosis: a study of repeat prescriptions in general practice., Philadelphia PA, JB Lippincott:.

BARRY, C. A., BRADLEY, C. P., BRITTEN, N., STEVENSON, F. A. & BARBER, N. (2000) Patients' unvoiced agendas in general practice consultations: qualitative study. BMJ, 320, 1246-50.

BRODY, D. S. & MILLER, S. M. (1986) Illness concerns and recovery from a URI. Med Care, 24, (8) 742-748.

CLACK, G. B., ALLEN, J., COOPER, D. & HEAD, J. O. (2004) Personality differences between doctors and their patients: implications for the teaching of communication skills. Med Educ, 38, 177-86.

COLE, S. A. & BIRD, J. (2000) The Medical Interview: The Three Function Approach., Missouri, Mosby.

DOHERTY, E., MCGEE, H. M., O'BOYLE, C. A., SHANNON, W., BURY, G. & WILLIAMS, A. (1992) Communication skills training in undergraduate medicine: attitudes and attitude change. Ir Med J, 85, 104-7.

DOWELL, J., JONES, A. & SNADDEN, D. (2002) Exploring medication use to seek concordance with 'non-adherent' patients: a qualitative study. Br J Gen Pract, 52, 24-32.

EGBERT, L. D., BATTIT, G. E., WELCH, C. E. & BARTLETT, M. K. (1964) Reduction of Postoperative Pain by Encouragement and Instruction of Patients. A Study of Doctor-Patient Rapport. N Engl J Med, 270, 825-7.

EISENTHAL, S., KOOPMAN, C. & STOECKLE, J. D. (1990) The nature of patients' requests for physicians' help. Acad Med, 65, 401-5.

EISENTHAL, S. & LAZARE, A. (1976) Evaluation of the initial interview in a walk-in clinic. The patient's perspective on a "customer approach". J Nerv Ment Dis, 162, 169-76.

EISENTHAL, S. & LAZARE, A. (1977) Evaluation of the initial interview in a walk-in clinic. The clinician's perspective on a "negotiated approach". J Nerv Ment Dis, 164, 30-5.

EPSTEIN, R. M., CAMPBELL, T. L., COHEN-COLE, S. A., MCWHINNEY, I. R. & SMILKSTEIN, G. (1993) Perspectives on patient-doctor communication. J Fam Pract, 37, (4) 377-88.

GMC (1998) Seeking patient's consent: The ethical considerations. http://www.gmc-uk.org/guidance/current/library/consent.asp

GMC guidelines on confidentiality: Protecting and providing information. http://www.gmc-uk.org/guidance/current/library/confidentiality.asp

GMC (2003) GMC Tomorrow's Doctors. Recommendations for undergraduate medical education. http://www.gmc-uk.org/education/undergraduate/undergraduate_policy/tomorrows_doctors.asp

GROSSET, K. A. & GROSSET, D. G. (2005) Patient-perceived involvement and satisfaction in Parkinson's disease: effect on therapy decisions and quality of life. Mov Disord, 20, (5) 616-619.

HALL, S. S. (1988) The doctor. Hippocrates (Sausalito), 2, 74-83.

HAYWOOD, K., MARSHALL, S. & FITZPATRICK, R. (2006) Patient participation in the consultation process: a structured review of intervention strategies. Patient Educ Couns, 63, 12-23.

The Headache Study Group of The University of Western Ontario. (1986) Predictors of outcome in headache patients presenting to family physicians--a one year prospective study. Headache, 26, 285-94.

HOWE, A. (1997) Notes from Videotape: talking with patient. University of Sheffield.

KAPLAN, S. H., GREENFIELD, S. & WARE, J. E., JR. (1989) Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care, 27, S110-27.

KLEINMAN, A., EISENBERG, L. & GOOD, B. (1978) Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med, 88, 251-8.

KORSCH, B. M., GOZZI, E. K. & FRANCIS, V. (1968) Gaps in doctor-patient communication. 1. Doctor-patient interaction and patient satisfaction. Pediatrics, 42, (5) 855-871.

LANGEWITZ, W., DENZ, M., KELLER, A., KISS, A., RUTTIMANN, S. & WOSSMER, B. (2002) Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ, 325, 682-3.

Lazare, A. eds. (1995) The Medical Interview: Clinical Care, Education and Research (pp32-49), Ann-Arbour, New York, Springer-Verlag.

LIN, E. H., SIMON, G. E., KATON, W. J., RUSSO, J. E., VON KORFF, M., BUSH, T. M., LUDMAN, E. J. & WALKER, E. A. (1999) Can enhanced acute-phase treatment of depression improve long-term outcomes? A report of randomized trials in primary care. Am J Psychiatry, 156, (4) 643-645.

LANG, F., FLOYD, M. R. & BEINE, K. L. (2000) Clues to Patients' Explanations and Concerns About Their Illnesses: A Call for Active Listening. Arch Fam Med (Am Med Assoc), 9, 222-227

LITTLE, P., EVERITT, H., WILLIAMSON, I., WARNER, G., MOORE, M., GOULD, C., FERRIER, K. & PAYNE, S. (2001) Preferences of patients for patient-centred approach to consultation in primary care: observational study. BMJ, 322, 468-72.

LITTLE, P., EVERITT, H., WILLIAMSON, I., WARNER, G., MOORE, M., GOULD, C., FERRIER, K. & PAYNE, S. (2001) Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations. BMJ, 323, 908-11.

LLOYD, M. & BOR, R. (2004) Communication Skills for Medicine (2nd ed), London, Churchill.

MCKINLEY, R. K. & MIDDLETON, J. F. (1999) What do patients want from doctors? Content analysis of written patient agendas for the consultation. Br J Gen Pract, 49, (447) 796-800.

MCMANUS, I. C., KIDD, J. M. & ALDOUS, I. R. (1997) Self-perception of communication ability: Evaluation of a questionaire completed by medical students and general practitioners. British Journal of Health Psychology, 2, 301-15.

MPS guide to medical records. http://www.medicalprotection.org/uk/booklets/records

NEIGHBOUR, R. (2005) The Inner Consultation (2nd ed), Oxford, Radcliffe Publishing.

NORTON, R. W. (1978) Foundation of a communicator style construct. Human Communication Research, 4, 99-112.

NOVACK (1995) Therapeutic aspects of the clinical encounter. (pp 32-49). IN LIPKIN, M., PUTNAM, S. M. & LAZARE, A. (Eds.) The Medical Interview. New York, Springer-Verlag.

ORTH, J. E., STILES, W. B. & AL, E. (1987) Patient exposition and provider explanation in routine interviews and hypertensive patients' blood pressure control. 1: Health Psychol., 6, (1) 29-42.

Patient Education and Counselling. www.elsevier.com/locate/pec

PARLOW, J. & ROTHMAN, A. I. (1974) ATSIM: a scale to measure attitudes toward psychosocial factors in health care. J Med Educ, 49, 385-7.

PENDLETON, D. (1984) The Consultation: an approach to learning and teaching., Oxford, Oxford University Press.

PETERSON, M. C., HOLBROOK, J. H., VON HALES, D., SMITH, N. L. & STAKER, L. V. (1992) Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med, 156, (2) 163-165.

PUTNAM, S. M., STILES, W. B., JACOB, M. C. & JAMES, S. A. (1988) Teaching the medical interview: an intervention study. J Gen Intern Med, 3, (1) 38-47.

PUTNAM, S. M. & LIPKIN, M. (1995) The patient-centred interview: research support (530-537). IN LIPKIN, M., PUTNAM, S. M. & LAZARE, A. (Eds.) The Medical Interview: Clinical Care, Education and Research. New York, Springer-Verlag.

ROBINSON, A. & THOMSON, R. (2001) Variability in patient preferences for participating in medical decision making: implication for the use of decision support tools. Qual Health Care, 10 Suppl I, i34-8.

ROTER, D. L., HALL, J. A., KERN, D. E., BARKER, L. R., COLE, K. A. & ROCA, R. P. (1995) Improving physicians' interviewing skills and reducing patients' emotional distress. A randomized clinical trial. Arch Intern Med, 155, 1877-84.

ROTER, D. L. (1977) Patient participation in the patient-provider interaction: the effects of patient question asking on the quality of interaction, satisfaction and compliance. Health Educ Monogr, 5, 281-315.

SILVERMAN, J., KURTZ, S. & DRAPER, J. (2004) Skills for Communicating with Patients (2nd ed), Oxford, Radcliffe Medical Press.

SMITH, R. C. (2002) Patient-Centred Interviewing: An Evidence-Based Method (2nd ed), Philadelphia, Lippincott William and Wilkins.

STEWART, M. (2001) Towards a global definition of patient centred care. BMJ, 322, 444-5.

STEWART, M., BROWN, J. B., WESTON, W. W., MCWHINNEY, I. R., MCWILLIAM, C. L. & FREEMAN, T. R. (2003) Patient-Centred Medicine: Transforming the Clinical Method, Oxford, Radcliffe Medical Press.

SZASZ, T. S. & HOLLENDER, M. H. (1956) A contribution to the philosophy of medicine; the basic models of the doctor-patient relationship. AMA Arch Intern Med, 97, 585-92.

TUCKETT, D., BOULTON, M., OLSON, C. & WILLIAMS, A. (1985) Meetings Between Experts: An Approach to Sharing Ideas in Medical Consultations, London and New York, Tavistock Publications.

VAN ZUUREN, F. J., GRYPDONCK, M., CREVITS, E., VANDE WALLE, C. & DEFLOOR, T. (2006) The effect of an information brochure on patients undergoing gastrointestinal endoscopy: a randomized controlled study. Patient Educ Couns, 64, (1-3) 173-82.

WAITZKIN, H. (1984) Doctor-patient communication. Clinical implications of social scientific research. JAMA, 252, (17) 2441-2446.

WOLOSCHUK, W., HARASYM, P. H. & TEMPLE, W. (2004) Attitude change during medical school: a cohort study. Med Educ, 38, 522-34

Session 1

Consultation skills – the initial approach

Learning objectives

After this session, you are expected to be able to:

Describe the General Medical Council competencies expected of new graduates in relation to communication

Outline the content of the first year of “Clinical Communication”

Assess your current level of communication skills and identify areas for development

Identify skills that can be used when meeting patients for the first time

Aims

To contextualise the clinical communication theme as a new sub-discipline within medical education.

To provide an opportunity for you to consider ways of dealing with the challenges of communication and medical ethics you may face during medical education and practice

To help you identify the difference between professional communications skills and “just talking”

Methods

The entire cohort of students will be present in a lecture theatre for this large group session which includes didactic teaching, role-play demonstrations and discussion. You are encouraged to contribute to the session during discussion activities.

Activities

Introduction to “Clinical Communication”

Consultation demonstrations and discussion

Break

Consultation demonstrations and discussion

Summary

Activity 1: Introduction to “Clinical Communication” (CC)

Aim:	To introduce clinical communication at Imperial College

Communication is the core clinical skill.

It is estimated that doctors may conduct as many as 200,000 consultations in their professional lives.

Eighty percent (80%) of diagnoses are made through history-taking alone.

During the 70’s and 80’s, there was evidence that the patient-centred communication skills of medical students declined as they “progressed” through medical school. As a consequence communication courses were developed, implemented and evaluated. New graduates are now expected to be competent in a range of communication behaviours.

Numerous studies show that patient satisfaction or dissatisfaction with their doctors is related to the doctor’s communication skills rather than their clinical competence.

However good your general communication skills are, you will need to learn clinical communication skills in order to practise medicine – this is more than ‘just talking’

As Peter Washer explains in his opening chapter Why learn communication skills?

To be a doctor you need to learn about clinical sciences (anatomy, pharmacology and so on) as well as clinical skills, such as examination skills. You might think: What’s the point of learning communication skills when it’s just talking, and you can do that already? The reason that you need to formally learn communication skills as part of a medical degree is because as good as your general communication skills may be, to be an effective doctor you need to learn effective clinical communication skills.

He sets his readers the task of asking people they know what their doctor, or a hospital experience was like for them.

Often patients will say that hospitals are noisy and that the food was awful. But generally the memories that people keep of their experiences of accessing health care are about the doctors and nurses they encountered…Analyse anyone enthusing about their doctor, and most of the time you will find the patient is talking about how good their doctor’s communication skills are. Patients rarely say: ‘Her knowledge of pharmacology was the best’ or ‘His examination of my chest was amazing’. Patients generally are not in a position to know whether doctors are competent in these areas; they just assume, rightly, that doctors are experts and know what they are doing. However, the ‘interface’ between that expertise and the patients’ experience is the doctor’s communication skills. From the patient’s perspective, communication skills are what distinguish an excellent doctor from a competent one. Doctors’ poor communication skills are often at the root of patient discontent with health care, and are one of their principal motivations for complaints and litigation.

General Medical Council (2009) Tomorrow’s Doctors: Recommendations on Undergraduate Medical Education contains several references to communication. 13. The graduate will be able to carry out a consultation with a patient: (a) Take and record a patient's medical history, including family and social history, talking to relatives or other carers where appropriate. (b) Elicit patients' questions, their understanding of their condition and treatment options, and their views, concerns, values and preferences. (c) Perform a full physical examination. (d) Perform a mental-state examination. (e) Assess a patient's capacity to make a particular decision in accordance with legal requirements and the GMC's guidance (in Consent: Patients and doctors making decisions together). (f) Determine the extent to which patients want to be involved in decision-making about their care and treatment. (g) Provide explanation, advice, reassurance and support. 15. Communicate effectively with patients and colleagues in a medical context. (a) Communicate clearly, sensitively and effectively with patients, their relatives or other carers, and colleagues from the medical and other professions, by listening, sharing and responding. (b) Communicate clearly, sensitively and effectively with individuals and groups regardless of their age, social, cultural or ethnic backgrounds or their disabilities, including when English is not the patient's first language. (c) Communicate by spoken, written and electronic methods (including medical records), and be aware of other methods of communication used by patients. Appreciate the significance of non-verbal communication in the medical consultation. (d) Communicate appropriately in difficult circumstances, such as breaking bad news, and when discussing sensitive issues, such as alcohol consumption, smoking or obesity. (e) Communicate appropriately with difficult or violent patients. (f) Communicate appropriately with people with mental illness. (g) Communicate appropriately with vulnerable patients. (h) Communicate effectively in various roles, for example as patient advocate, teacher, manager or improvement leader. 19. Use information effectively in a medical context. (a) Keep accurate, legible and complete clinical records. (b) Make effective use of computers and other information systems, including storing and retrieving information. (c) Keep to the requirements of confidentiality and data protection legislation and codes of practice in all dealings with information. (d) Access information sources and use the information in relation to patient care, health promotion, advice and information to patients, and research and education. (e) Apply the principles, method and knowledge of health informatics to medical practice.

It is now commonly accepted that students can learn to be more effective communicators. Although some people seem to be effective communicators by virtue of their personalities, others require support. Even the most able and experienced communicators benefit from opportunities to practise, reflect and receive feedback on their communication skills.

The British Medical Association (2004) has published a guide to communication skills for clinical practice and training. It is worth reading this document to familiarise yourself with what communication abilities medical professional organisations expect of you; to recognise the relevance of the clinical communications theme at Imperial and understand how it has been structured to help you acquire and improve these skills. What do you think the key communication skills might be?

Maguire and Pitceathly (2002) summarise key communication skills of doctors and describe teaching and learning approaches that are effective in achieving these skills. Although the paper focuses on doctors, the content is relevant to undergraduate medical students. The paper also discusses blocking behaviours used by medical and other health care professionals.

Our attitudes both personal and professional tend to underpin all our communication. Developing professionally appropriate attitudes is a crucial component of clinical communication. Our attitudes are signalled and conveyed in verbal and non-verbal communication. Attitudes can be slower to change than knowledge and skills and whilst we do explore these aspects in this theme many of your professional attitudes will be formed across all the themes and your clinical experiences. Many professional attitudes are shaped through “role modelling” careful choice of your role models. Careful choice of your role models may help you develop a mix of attitudes, skills and knowledge that will ensure you become effective as a patient centred communicator – a requirement for “tomorrow’s doctors”.

Expertise, in any domain, requires years of deliberate practice and learning from experience. In the first year of clinical communications you will develop your ability as a reflective practitioner. It is this deliberate process of reflection that will help you learn from experience and develop expertise. Ericsson (2004) draws on the development of expertise and mastery in different domains (sports, music, chess) and makes parallels with medicine to highlight the importance of deliberate practice. This has particular bearing on the development of communication skills. Although you might already be a very effective communicator, achieving mastery in communication relevant for health care practice involves subtle yet significant modifications to how we ordinarily communicate.

For example, in ordinary conversation questions and answers are the basic units we use to open and structure our communication with others.

E.g.	Student 1: ‘Hi, how’s it going?’

Student 2: ‘Fine, how’s things with you?’

Student 1; ‘Terrible, I just came out of clinical communication lecture and I didn’t understand a thing’

Student 2: ‘I know what you mean the other day I was in an anatomy lecture

and.....’

In this fairly typical example of how ordinary interaction works we can see that questions and answers are used to open and introduce the first topic of talk. There afterwards, full blown conversation commences.

In doctor patient interaction questions and answers take a much more prominent role and are used much more by doctors and patients to structure their interaction.

E.g.	Dr: ‘Hello Mrs Parker, what can I do for you today?’

Pat: ‘Hello Doctor, well I have been having trouble with my back’

Dr: ‘What kind of trouble?’

Pat: ‘I have been having a lot of pain in the lower back’

Dr: ‘Can you describe the pain?’

Pat: ‘How do you mean?’

Dr: ‘Well is it a sharp pain?’

Pat: ‘Yes’

Dr: ‘Does it keep you awake at night?’

Pat: ‘Yes sometimes’

Dr: ‘Is it worse at particular times of the day?’

Pat: ‘It’s definitely worse in the morning when I get out of bed?’

The prominence of questions and answers in doctor patient interaction is one of the subtle yet significant modifications of our ordinary interaction. Modifications like this require closer scrutiny to ensure that this form of communication achieves the dual objectives of effective information gathering alongside patient involvement. This is a key skill you will explore on the clinical communication programme.

It is sometimes difficult for learners to continually review their communication skills as they become increasingly focussed on acquiring technical aspects of history-taking or other clinical skills. This might explain how in the past students’ communication skills have been found to deteriorate during their journey through medical school. However we aim to integrate these core communication skills with clinical practice in a way that allows you to remain focussed and continually develop. Clinical communications skills and patient centred behaviours are highly transferable and will serve you well throughout your career.

You will learn about communication in other aspects of your curriculum. In the Foundation of Clinical Practice Course you will also explore doctor-patient communication, professional development. However, this is from a sociological perspective and by the end of the year you will be able to recognise the differences and overlaps between perspectives.

As communication is a generic skill and you will need to develop your ability to work with colleagues from other disciplines Clinical communications tutors are drawn from a variety of disciplines.

Session structure

Each session has a structure which is intended to be flexible and allow tutors and students adapt approaches to optimise teaching and learning opportunities. The next section outlines the structure in the CC Guides.

The “Introduction” section

Places the session in context within the CC making links to what has gone before and what comes next

Outlines the teaching and learning methods we will use in the session: trigger videotapes, instructional videotapes, demonstrations, brainstorming, discussions, role-play, readings and interviews with simulated patients

The “Aims” section

Broad outline of what we intend to achieve in the session

Learning objectives

State specifically what we aim to help you to know, understand or be able to do at the end of a session

The “Activities” outline

What we plan to do in the session

How each activity is designed to help you meet the learning objectives

The “Summary” section

Reviews what we have done in the session including what we set out to do and how we did it.

Asks you to evaluate or reflect on whether or not we / you achieved the learning objectives

Provides an opportunity for questions

Recommended readings and references are available from the medical libraries at each campus or online

Evaluation and reflection

Why do we ask you to evaluate after each session?

It provides feedback for us to identify what works and what can be improved in the clinical communications theme

It offers you an opportunity to review what you have been learning – this can help with your recall at a later date

It encourages reflection and self- evaluation - skills required by all professionals

Ground rules for group work

Attendance registers are kept. Please refrain from ever signing for anyone other than yourself. Doing so is not permitted and might result in your not being permitted to complete the course

Confidentiality. Whilst you may discuss your own experiences or learning from CC you are expected to behave professionally and ensure you never disclose the identities of your colleagues who participated in the session

You are expected to be an active participant in each session. Learning from and with others helps develop self-awareness, an important component of effective communication and the development of expertise.

Tutors and students are expected to be punctual. The structure of the sessions requires we start and finish on time. If you are more than 15 minutes late you may be refused entry to session

Guidelines for effective giving and receiving feedback about skills, knowledge and attitudes are included in the CC Guide. You are expected to be familiar with them and to use them. You will also be given support to identify your own strengths and areas for further development. Self appraisal is a professional skill required of the modern health care professional.

Assessment

See above

Activity 2: Consultation demonstrations and images

Aims: To portray different approaches to meeting patients

To identify effective and ineffective features in terms of behaviour, attitudes, feelings and ethics

To focus on verbal and non-verbal communication as indicators of patient-centeredness

You will see a variety of role-play demonstrations illustrating different approaches to meeting patients.

Consultation demonstration (next page in student guide)

In this role-play, a first year medical student has been asked to interview a patient who has come to the GP practice today. This role-play will run more than once, with different approaches by the student. Think about the following questions each time. (use the space on the next page to record your thoughts).

What do you think worked well (from the student’s/surgeons’ perspective)?

Why do you think the student is behaving this way?

What impact does this have on the patient?

In order to improve the interview, what could have been done differently?

What ethical issues does this consultation involve?

Why is awareness of feelings important when meeting patients?

Now that you have identified different types of behaviour in medical students meeting patients, you need to be aware of how the way that you feel when approaching patients will influence how the interview goes

Feelings can influence behaviour and in the experiential activities in CC we routinely identify your feelings before exploring your observed behaviour. We are aiming to support you in making links between your feelings and behaviour.

A second reason for developing awareness of own and others’ feelings is to ensure that thoughts are differentiated from feelings. Thoughts can be right or wrong. feelings are subjective and belong to the owner. Therefore, when patient’s health beliefs are elicited in consultations (thoughts), these are open to “correction” in terms of understanding health, illness and disease from a Western scientific medical perspective. When patients express worries (feelings), doctors (and medical students) are in no position to tell patients how the patient should feel. A frequent response is to say, “Don’t worry.” It is inappropriate to tell patients what to feel until you know exactly what the patient is worrying about (not what you think s/he is worrying about) and that you know the patient’s worries are no longer warranted. Instead, it is more helpful to acknowledge the patient’s worry, “I can see you’re worried. Is there anything in particular that’s worrying you?”

Empathy is recognising what the patient is feeling and communicating this to the patient.

Therefore, in order to show empathy, doctors need to be able to distinguish thoughts and feelings. Empathy, in our context is essential in conveying care and understanding, leading to therapeutic doctor-patient relationships (Larson & Yao, 2005).

Sometimes we are unaware of the impact of our feelings on others. In health care it is especially important we are aware of our feelings since the impressions that we make on patients, their families and other health care professionals can influence the quality of care.

Spiro (1992) reports on the problem of medical students losing some of their empathy as they learn science and detachment, and makes the point that students and doctors need to value empathy and try to retain their passion. “Physicians need rhetoric as much as they need knowledge, and they need stories as much as journals if they are to be more empathic than computers.”

Patients seldom verbalise their emotions directly or spontaneously and instead offer clues to how they are feeling. Therefore it is important for clinicians to use basic empathy skills such as recognising when emotions may be present in patients but not directly expressed, inviting an exploration of the unexpressed feelings in order to clarify, and effectively acknowledging these feelings so that the patient feels understood. These are the skills that will help make the students empathic clinicians (Suchman et al, 1997).

Bylund and Makoul (2002) found no difference in the verbal expression of empathy (naming of an emotion) between male and female patients. Consistent with other literature, female physicians tend to communicate higher degrees of empathy within the consultation in response to empathic opportunities created by patients.

Examples of Empathic statements

After the patient has expressed a feeling, an empathic statement can make a personal connection with the patient. “I can see you’re in pain.” “That must have been very difficult managing all those years” “I can tell from what you are saying that it was a distressing time for you.” “I hear what you’re saying about your depression. It can be extremely difficult.” Alternatively, patients can show their emotions non-verbally and it is helpful for you to note this and let the patient know too. “You still seem worried.” “I can see that is hurting.” “It’s ok to be upset.”

E-Learning Package

The UK Council of Clinical Communication in Undergraduate Medical Education is an organisation made up of the Clinical Communication course leaders from all 33 UK Medical Schools, including Imperial. The UK Council have created an e-learning package which has been made available to you to support the development of your clinical communication skills.

The package is made up of 7 modules, each of which focuses on a key task defined in the Calgary-Cambridge consultation model;

Initiating the consultation

Information gathering and history taking

Communicating during the physical examination

Explaining and planning

Closing the consultation

Structuring the consultation

Building the relationship

In addition, there is an introductory module which outlines the purpose of the package and gives some background on how it was made and why as well as ideas about how to best use it;

Essential Clinical

These modules are available for you to access at any time, but we will be signposting in Clinical Communication teaching sessions and in the guide when they may be most appropriate. There is also benefit to revisiting a module at different time points in the course as you will benefit at different levels depending on your level of experience (for instance you may focus on the basic information gathering skills in Year 1, but may bemore interested in the clinical reasoning elements of history taking in Year 3, both of which are covered in “Information gathering and history taking”.

E-Learning task

We recommend that you complete the “initiating the session” module at this point. This will allow you to consolidate what you have observed today in relation to how to open a consultation or student/patient encounter.

Summary

Describe the General Medical Council competencies expected of new graduates in relation to communication

A range of competencies are expected that include clinician-patient communication as well as communication with other health care professionals.

Outline the content of the first year communication programme

Five sessions that aim to meet basic competencies as set out in the GMC document. There is an emphasis on developing reflective skills that will be beneficial throughout your careers in relation to developing communication and other clinical skills. Other educational methods use experiential exercises to develop self-awareness and observational skills.

Identify skills that can be used when meeting patients for the first time

We have had an opportunity to observe different ways students interact with patients and considered the reasons why students might behave as they do and the messages this behaviour conveys to patients.

Recommended reading and references

BMA (2004) Communication skills education for doctors: an update. London.

ERICSSON, K. A. (2004) Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med, 79, (10 Suppl) S70-81.

Foundation Programme. http://www.foundationprogramme.nhs.uk/pages/home

LARSON, E. B. & YAO, X. (2005) Clinical empathy as emotional labor in the patient-physician relationship. JAMA, 293, 1100-6.

MAGUIRE, P. & PITCEATHLY, C. (2002) Key communication skills and how to acquire them. British Medical Journal, 325, 697-700. http://bmj.bmjjournals.com/cgi/content/full/325/7366/697

SILVERMAN, J., KURTZ, S. & DRAPER, J. (2004) Building the Relationship (ch 5, pp 117-140). Skills for Communicating with Patients. Oxford, Radcliffe Medical Press.

SPIRO, H. (1992) What is empathy and can it be taught? Ann Intern Med, 116, (10) 843-846.

SUCHMAN, A. L., MARKAKIS, K., BECKMAN, H. B. & FRANKEL, R. A. (1997) A model of empathic communication in the medical interview. Journal of American Medical Association, 277, (8) 678-82.

Tomorrow's Doctors. http://www.gmc-uk.org/education/undergraduate/tomdoc.pdf

WASHER, P. (2009) Why learn communication skills? (Ch 1, pp4-10). In WASHER, P. Clinical Communication skills. Oxford, OUP.

WASHER, P. (2009) The structure and process of a medical interview (Ch 2, pp11-17). In WASHER, P. Clinical Communication skills. Oxford, OUP.

Please complete your SOLE pages before leaving the session and make sure that you read the background information section before session 2

Session 2

Patient-centred communication

Introduction

This session assumes you have read the section on Background Information for CC which provides a theoretical foundation for the practice of communication skills within consultations.

This session offers an opportunity to discuss and link the theoretical foundations of patient centred communication and how it applies to interviewing and consultation to effective communication with patients. The underlying skills and frameworks are identified and applied through role-play.

Aims

To identify skills associated with patient-centred interview approaches

To raise awareness that there are models for use in consultations

To practise the skills of a patient-centred interview

Learning objectives

At the end of this session, you are expected to be able to:

Describe the role of reflective practice in professional development

Identify skills effectively used in simulated patient-centred interviews

Identify skills that require development

Methods

You will work in groups of approximately 25. Activities include discussing the theoretical basis of patient-centred interviewing and role-play.

What is a patient-centred interview (PCI)?

Much of the focus of clinical communication is based around the central concept of a “patient-centred approach”. Over the last 30 years or so, research into what constitutes a patient-centred interview (PCI) has resulted in a number of definitions and general concepts. An early definition by Edith Balint (1969); “understanding the patient as a unique human being” has evolved over the years into more sophisticated measures.

A PCI is one in which the interviewer identifies, acknowledges and responds to the patient in a way that encourages the patient to participate and ensures that their own agenda becomes part of the consultation process. This is in contrast to paternalism, or doctor-centredness, where doctors dominate the agenda setting, goals and decision-making in regard to information and services, where the medical condition is defined in biomedical terms and where the patients’ voice is largely absent. (Roter,1977).

Testing your knowledge of the patient centred approach

List 3 advantages of the patient centred approach for clinicians

List 3 advantages of the patient centred approach for patients

Studies suggest that a patient centred approach can in some cases improve patient outcomes. List 3 some of the outcomes that can be improved following a patient centred approach.

Why is it important to elicit the patient’s explanations of their illness as part of a patient centred approach?

Why is it important to allow patients to express the major concerns as part of a patient centred approach?

Activity 2: Making impressions

Aim:	To explore the concept of making impressions, especially first, often non verbal ones.

You will be shown an interview on DVD between a simulated patient and a medical student without sound. You should observe and note what is being communicated and how.

How would you describe the patient?

How would you describe the medical student?

Eye Contact

What does this aspect of non-verbal communication tell you about a person?

How powerful is it?

If you use this communication, what does it tell the patient about you?

In what ways can this aspect of communication be used most effectively?

What features of this aspect of communication are especially important in health care?

How might gender or cultural differences impact on non verbal communication?

2.	Body positioning and spatial distance

What does this aspect of non-verbal communication tell you about a person?

How powerful is it?

If you use this communication, what does it tell the patient about you?

In what ways can this aspect of communication be used most effectively?

What features of this aspect of communication are especially important in health care?

How might gender or cultural differences impact on non verbal communication?

3.	Paralanguage

“Paralanguage: is everything but the content of language.

What does this aspect of non-verbal communication tell you about a person?

How powerful is it?

If you use this communication, what does it tell the patient about you?

In what ways can this aspect of communication be used most effectively?

What features of this aspect of communication are especially important in health care?

How might gender or cultural differences impact on non-verbal communication?

4. Touch

What does this aspect of non-verbal communication tell you about a person?

How powerful is it?

If you use this communication, what does it tell the patient about you?

In what ways can this aspect of communication be used most effectively?

What features of this aspect of communication are especially important in health care?

How might gender or cultural differences impact on non verbal communication?

Feedback skills

Aim:	Students should be aware of these guidelines for giving and receiving feedback

Giving and receiving feedback are equally important skills and have relevance to the development of effective professional practice. As a professional you will give and receive feedback in different forms. For students and junior doctors, feedback is essential for the development of skills, knowledge and attitudes in clinical medicine. Increasingly, you will be involved in giving feedback so this activity provides some guidelines to get you thinking about helpful approaches.

Feedback is important for learning because it:

Provides acknowledgement of trainees’ acquisition of professional knowledge, appropriate attitudes and mastery of skills

Provides guidelines for areas that need to be developed

Provides motivation to undertake that development

Provides insight into personal style

Can lead to improved clinical practice

Preparation for giving feedback

What is the purpose of feedback in this situation?

Is your colleague ready for feedback?

Does your colleague want feedback?

What does your colleague want feedback on?

What does your colleague think s/he has done well?

What does your colleague think s/he needs to improve?

What do you want to say?

How do you want to say it?

Giving feedback

Consider giving feedback on what has been done well and areas that need developing

Give feedback immediately after the role-play

Consider what has been done well first but be flexible too – respond to your colleague’s needs

Describe specific knowledge, attitudes and skills and give examples to illustrate what you mean.

Describe your experience of the behaviour

When identifying weaknesses or deficits, work with your colleague to develop alternatives (e.g. “Can you think of different ways of…?” “Sometimes I find it helpful…” “When you did… I was wondering what would have happened if you’d done…”)

Confine feedback on areas that need developing to things that can be changed

Be honest

Be accurate

Show empathy

Use silence effectively

Respond to your colleague’s verbal and non-verbal cues

Do not overload with too much information

Limit the use of generalisations

Preparation for receiving feedback

Do you want feedback? If not consider your reasons.

What is the purpose of feedback in this situation?

Are you ready to receive feedback?

What do you want feedback on?

What do you think you have done well?

What do you think you need to improve?

Receiving feedback

Listen carefully

Ask for feedback to be repeated if you did not hear it clearly

Clarify feedback that is unclear or unsupported

Assume the feedback is constructive until proven otherwise

Use the elements of feedback that are helpful

Pause and think before responding ( You might choose to say “I want to take that away and think about it” This may be an appropriate response)

Consider the value of defending/arguing (return to the purpose)

Ask for ways you might improve

Separate your feelings from the content of feedback

These guidelines are given for today’s session and they are broadly transferable to many of the situations you may encounter during your medical training and career. For instance, PBL sessions, clinical skills teaching, SOLE feedback reports.

Support Challenge Model

This model can help you think about the way you give feedback. Statements given as feedback can be graded in terms of support and challenge. The most effective feedback falls in the high support/high challenge quadrant.

Support	“That was obviously great – you are trying very hard”	“A good effort. I could see how you were drawing the feelings out. I wonder if you got to the crux of the matter?”
“Good, carry on, seems to be working”	“Well that could have been done better. Why didn’t you focus more earlier on?”
Challenge

Activity 3: Role-play

Aims:	To provide an opportunity to practise the interviewing skills

To practise giving and receiving feedback

To introduce the reflective assignment

The success of role-play depends in large part on the quality of preparation for the experience together with the enthusiasm from all participants.

Students divide into groups of three. There will be three role-plays each of five minutes’ duration. Each student plays the role of medical student (interviewer), patient and observer.

Preparation for roles should take a few minutes and then feedback within the small groups takes a few minutes. Preparation and feedback are as important as conducting the interview.

Immediately following the role-play, each student should take a moment to write a few notes about the experience for the interviewer. The interviewer reflects on how s/he felt during the interview, the patient on how s/he felt and the skills that were used effectively.

After the first role-play, the group should stop and join together as a larger discussion group to identify any difficulties. The remaining two role-plays can be completed without the large group rejoining.

Task for interviewer (for each role-play)

You are a medical student attached to a general practice.

The GP is running a little late and has asked you to go and talk to the next patient.

As well as finding out why the patient has come to the clinic today (and what the patient expects from the consultation), ask some questions about background information such as the patient’s family (and personal) relationships and his/her occupation.

It can also be helpful to identify the patient’s worries or concerns about the visit.

Take care to explore all the patient’s difficulties early in the interview.

Task for observer (for each role-play)

Use the checklist on the next page to identify which skills the interviewer uses in the consultation.

Facilitate the feedback remembering the principles outlined in Activity 2.

The following questions may be helpful in staying focused on your task and ensuring a balance.

Observer asks the interviewer:

Can you briefly state how you felt during the interview? [Students should be encouraged to simply name the emotion/s they experienced and not the rationale or thoughts for those feelings. The purpose of this question is to raise the student’s awareness of the link between feelings and behaviour]

Can you describe two aspects of the interview that worked well?

Observer asks the role-play patient:

Can you identify two communication skills that the interviewer used that were effective?

Observer provides specific feedback on two skills that s/he observed worked well

Observer asks the interviewer:

Can you identify two aspects of the interview that you would do differently if you could repeat the interview?

Observer asks the role-play patient:

Can you identify two communication skills that the student could have used to improve the interview?

Observer provides feedback on two skills that could have improved the interview including both verbal and non-verbal

Observer summarises the feedback on things that worked well and things to improve

Interviewer receives written feedback from observer and role-play patient

Patient centred interviewing skills

Preparing for interaction Attend to self-comfort Minimise distraction Focus attention on next interaction	Giving information Skills to be covered later in CC
Commencing the interaction Greet the patient State your full name Clarify your role Obtain patient’s name Attend to patient’s comfort Obtain the patient’s consent State purpose of the interaction Mention note taking Clarify time available Assess patient’s ability to communicate Demonstrate interest and respect Empower patient to ask questions or seek clarification of anything that is unclear	Closing the interaction Provide an end summary Discuss an action plan Check for further information Ask for questions Check if the patient has any worries or concerns
Gathering information Use open questions initially Allow patient to complete first sentence/s Identify the patient’s ideas, concerns and expectations Use active listening verbal (staying with patient’s topic; using patient’s words; reflection) non-verbal (eye contact; nodding) Use other non-verbal behaviours (body posture; gestures; facial expressions, nodding) Use open to closed-cone questions Pick up verbal cues Pick up non-verbal cues Probe sensitively Survey for other problems Set agenda Clarify patient’s terms Make interim summaries Signpost or transition statements Use silence appropriately Avoid multiple questions Avoid leading questions Avoid unexplained jargon	Relationship building skills Throughout each stage, it is important to use relationship-building skills in order to establish and maintain your relationship with the patient Use active listening Make empathic statements Show warmth Pick up verbal and non-verbal cues Use non-verbal behaviours (posture, gestures, facial expressions) Identify patient’s ideas, concerns and expectations Avoid being judgmental Not all the skills listed here will be used in every interaction. The skills are not necessarily in a specific order although some skills obviously precede others.

This page has been left deliberately blank for student notes

Simulated patient rating form

Rate your satisfaction with the student for each of the following:

Not at all satisfied	Completely satisfied	Unable to rate
1	Beginning the interview	1	2	3	4	5	6	U
2	Asking questions	1	2	3	4	5	6	U
3	Listening to you	1	2	3	4	5	6	U
4	Warmth towards you	1	2	3	4	5	6	U
5	Asking about your feelings	1	2	3	4	5	6	U
6	Choice of words	1	2	3	4	5	6	U
7	Topics covered	1	2	3	4	5	6	U
8	Ending the interview	1	2	3	4	5	6	U
9	Student’s appearance	1	2	3	4	5	6	U
10	Overall satisfaction	1	2	3	4	5	6	U
Highly anxious	Not at all anxious
11	How anxious do you think student was?	1	2	3	4	5	6	U

Please add any other comments that you would like to make below:

This page has been left deliberately blank for student notes

Reform these Discussion questions

In a large group discussion, each role-play group should identify one skill used effectively by their interviewer.

The following questions might also be helpful to promote discussion and reflection:

How many groups consistently asked about the patient’s ideas, concerns and expectations?

Did your group encounter difficulties with the introduction? The information gathering? The closure?

Did you follow guidelines for feedback? If so, were they helpful?

Did you experience any difficulties in role-play?

Reflective practice

Reflection can be considered as a set of interrelated questions and responses.

What do I think / feel / believe

What do others think/ feel / believe

What does the literature and evidence base tell me about my thoughts, feeling and actions.

Developing the skill of reflection is essential to professional development throughout your career.

Reflective practice has been described as the “essence of professionalism” and so has obvious relevance to medical practice (Schon 1983). Schon’s work was based on observations of different professional groups.

When professionals are faced with unexpected events or problems, they respond by reflecting-in-action or later by reflecting-on-action. Reflection-in-action or “thinking on your feet” is a process by which you draw on your current repertoire of experiences – images, ideas, actions, patterns in order to make sense of the problem confronting you. Reflection on action (as you are asked to do throughout the clinical communications curriculum) helps you extend your repertoire and be better prepared for the next challenge or unexpected event. Reflective practitioners aim to place the problem within their own and the professions’ frame of reference in order to seek out the best solution and anticipate its’ consequences.

Reflecting-on-action or “retrospective thinking” occurs after the unexpected event or problem and has particular relevance for feedback since discussion of what has taken place can help the practitioner broaden their base of experience and so extend their repertoire. Reflective practice has been widely embraced as an educational approach to support practitioners in dealing with the broad range of problems they may face in clinical practice.

Using this theoretical approach to professional practice, we have created the following questions in relation to this role-play activity to support the development of your reflective practice skills.

How did you feel during the interview?

What skills did use during the opening phase of the interview? What skills were not used or used ineffectively?

What skills did you use while gathering information? What skills were not used or used ineffectively?

What skills did you use during the closing phase of the interview? What skills were not used or used ineffectively?

Why do you think you are stronger in some skills?

Why do you think you are weaker in other skills?

What will you do to maintain your strengths?

What will you do to improve areas of weakness?

Summary and review of learning objectives

Discuss characteristics of patient-centred communication

List reasons for adopting a patient-centred approach to interviewing

Outline guidelines for giving feedback

Outline guidelines for receiving feedback

Identify skills effectively used in simulated patient-centred interviews (student role-play)

Identify skills that require development

Summary

A patient centred interview PCI is one in which the interviewer identifies, acknowledges and responds to the patient in a way that encourages the patient to participate and ensures that their own agenda becomes part of the consultation process. This is in contrast to paternalism, or doctor-centredness, where doctors dominate the agenda setting, goals and decision-making in regard to information and services, where the medical condition is defined in biomedical terms and where the patients’ voice is largely absent. (Roter,1977).

The difference between the two approaches is define through the style of communication, both verbal and non-verbal.

Doctors need to be able to recognise patients’ non-verbal cues in speech patterns, facial expressions, affect and body postures. They also need to be aware of how their own non-verbal behaviour can influence patients.

Non-verbal communication

is continuous – it goes on for as long as the communicators are in each other’s presence.

is the main channel for conveying attitudes, emotions and affect.

Needs to be congruent - If there is discordance between the verbal and the non-verbal messages, the non-verbal communication will be more powerful and more likely to be believed.

skills can assist in demonstrating attentiveness to the patient and facilitate the formation of a helping relationship. Ineffective attending behaviour closes off the interaction and prohibits relationship building.

Disparity in power and control between patient and doctor can lead patients to be particularly attentive to NV cues to doctor’s attitudes and meanings.

In the next session, you will have an opportunity to interview simulated patients. Based on your experience today, think carefully about the skills you will try and use in your next interview. Please ensure you complete the learning goals form before coming to the session. Make sure you have read the session guide and arrive on time.

Recommended readings

BOWER, D. J., DIEHR, S., MORZINSKI, J. A. & SIMPSON, D. E. (1998) Support-challenge-vision: a model for faculty mentoring. Medical Teacher, 20, (6) 595-597.

COLE, S. A. & BIRD, J. (2000) Learning how to interview (Appendix 1, pp 272-280). The Medical Interview: The Three Function Approach., Mosby: Missouri

MOULTON, L. (2007) The Naked Consultation: A Practical Guide to Primary Care Consultation Skills, Oxford, Radcliffe Publishing.

LLOYD, M. & BOR, R. (2004) Basic communication skills (ch 2, pp 9-22). Communication Skills for Medicine. 2nd ed. London, Churchill.

LIPKIN, M., FRANKEL, R., BECKMAN, H., CHARON, R. & FEIN, O. (1995) Performing the interview (ch 5, pp 65-82). IN LIPKIN, M., PUTNAM, S. M. & LAZARE, A. (Eds.) The Medical Interview: Clinical Care, Education and Research. Ann-Arbour, New York, Springer-Verlag.

NEIGHBOUR, R. (2005) The Inner Consultation, Oxford, Radcliffe Publishing.

NESTEL, D. & TIERNEY, T. (2007) Role-play for medical students learning about communication: guidelines for maximising benefits. BMC Med Educ, 7, 3.

SILVERMAN, J., KURTZ, S. & DRAPER, J. (2004) pp 35-55 (patient-centred communication using role-play). Communicating with Patients. 2nd ed. Oxford, Radcliffe Medical Press.

SMITH, R. C. (2002) Facilitating skills (ch 2, pp 17-33) (patient-centred comm). Patient-Centred Interviewing: An Evidence-Based Method. 2nd ed. Philadelphia, Lippincott William and Wilkins.

SCHON, D. A. (1983) The Reflective Practitioner, San Francisco, Jossey-Bass.

SUMMERTON, N. (2007) Patient-centred Diagnosis, Oxford, Radcliffe Publishing.

THISTHLETHWAITE, J. & MORRIS, P. (2006) The Patient-Doctor Consultation in Primary Care, London, RCGP.

WASHER, P. (2009) The structure and process of a medical interview (Ch 2, pp11-17). In WASHER, P. Clinical Communication skills. Oxford, OUP.

Facial expressions and eye behaviour

EKMAN, P., FRIESEN, W. V. & O'SULLIVAN, M. (1988) Smiles when lying. Journal of Personality and Social Psychology, 54, (3) 414-420.

PRKACHIN, K. M. & CRAIG, K. D. (1995) Expressing pain: The communication and interpretation of facial pain signals. Journal of Nonverbal Behaviour, 19, (4) 191-205.

RUUSUVUORI, J. (2001) Looking means listening: Coordinating displays of engagement in doctor-patient interaction. Social Science and Medicine, 52, 1093-1108.

Touch

HELME, D. W. (2002) Gaining patient satisfaction through empathic comforting: an examination of the nonverbal communication context of touch in the patient/provider relationship. Communication and Cognition, 35, (1-2) 123-135.

LEWIS, R. J., DERLEGA, V., NICHOLS, B., SHANKAR, A., DRURY, K. & HAWKINS, L. (1995) Sex differences in observers' reactions to a nurse's use of touch. Journal of Non-verbal Behaviour, 19, (2) 101-113.

LORENSEN, M. (1983) Effects of touch in patients during a crisis situation in hospital. IN WILSON-BARNETT, J. (Ed.) Nursing research, ten studies in patient care, development in nursing research (Vol 2). Wiley, U.K.

VORTHERMS, R. C. (1991) Clinically improving communication through touch. Journal of Gerontological Nursing, 17, (5) 6-10

WHITCHER, S. J. & FISHER, J. D. (1979) Multidimensional reaction to therapeutic touch in a hospital setting. J Pers Soc Psychol, 37, (1) 87-96.

Paralanguage

ALPERT, M., POUGET, E. R. & SILVA, R. R. (2001) Reflections of depression in acoustic measures of the patient's speech. J Affect Disord, 66, 59-69.

CAPORAEL, L. (1981) The paralanguage of care giving: baby talk to the institutionalised aged. Journal of Personality and Social Psychology, 40, (5) 876-884.

CHRISTENFELD, N. (1995) Does it hurt to say um? Journal of Non-verbal Behaviour, 19, 171-186.

EIDE, H., QUERA, V., GRAUGAARD, P. & FINSET, A. (2004) Physician-patient dialogue surrounding patients' expression of concern: applying sequence analysis to RIAS. Soc Sci Med, 59, 145-55.

SKELTON, J. R. & HOBBS, F. D. (1999) Descriptive study of cooperative language in primary care consultations by male and female doctors. BMJ, 318, 576-9.

Body positioning and spatial distance

HARRIGAN, J. A. & ROSENTHAL, R. (1983) Physicians' head and body positions as determinants of perceived rapport. Journal of Applied Social Psychology, 13, (6) 496-509.

GORAWARA-BHAT, R., COOK, M. A. & SACHS, G. A. (2007) Non-verbal communication in doctor elderly patient transactions (NDEPT): Development of a tool. Patient Education and Counselling, 66, (2) 223-234.

E-learning task

We recommend that you complete the “building the relationship” module at this point. This module explores in detail the skills used to develop rapport with patients and focuses in particular on non-verbal skills

We also recommend that you complete the “information gathering and history taking” module at this stage. This is the longest module. Concentrate on the sections discussing the process skills to reinforce the content of session 1 and 2. Aspects on the content of the history and clinical reasoning are more appropriate at a Year 2 or even a Year 3 level.

It would also be useful to look at the module on “structuring the consultation” before your next session in December. This is because these are skills students often report difficulty with when interviewing the volunteer patients.

Please complete your SOLE pages before leaving the session

Session 3

Interviewing volunteer patients

Introduction

This session provides you with an opportunity to have three interview experiences with different patients who present with different conditions.

The interviews are formative assessments (formative assessments can be thought of as assessments for learning); you will get feedback to help you identify how well you are performing and how you can improve. You will be able to build your role-play experiences from Session 2 and plan to maintain the skills identified in that interview as well as incorporate additional skills. The exercises in this session will also familiarise you to the way in which objective structured clinical examinations (OSCEs) will be used as summative assessments – assessments of your learning.

In this session you will be interviewing volunteers from the community who have agreed to participate in the session.

In order to get the most out of this session please complete the learning goals form before you arrive.

Please remember to bring your Student Guide and supplement to the session and note that you will be required to record your reflections based on your interview with the simulated patients.

Learning objectives

After participating in this session, you should be able to:

Outline the skills necessary for approaching patients enabling you to communicate effectively and sensitively

Identify communication and other professional skills that you used that were effective

Provide a rationale for using these skills

Identify skills relevant to patient-centred interviewing that you need to develop

Make use of the feedback from the simulated patients

Identify ways in which you will maintain your strengths in communicating

Identify ways in which you will improve on your communication weaknesses

Activities

You attend a pre scheduled one-hour session

You complete interviews with 3 volunteer simulated patients

You will receive written feedback from each simulated patient and get support to complete a reflective assignment based on your experiences in the session.

Preparation

Before you meet the volunteer simulated patients the session coordinator will discuss with you

The learning objectives

Your task and the structure of the session

Your completed learning goals form

Written reflective assignment

It is common for students to feel nervous and or excited about these interviews and this is part of the learning experience. You will have an opportunity to consider and explore your feelings and how they might influence your interview behaviour.

The task

Interview the patient and find out why they have come to the clinic (general practice). You should state that you are a medical student and that you spending time at the GP practice talking with patients.

To ensure your interview is patient-centred you need to explore the patient’s ideas about their illness (or treatment), their concerns and expectations of the meeting with the doctor. You are not expected to make a diagnosis or recommend treatment.

You will probably get most out of the session if you review the communication skills list before the session and ask for clarification of anything about which you are uncertain. This session is an opportunity to practice many of the interviewing skills that are already familiar

Note-taking is not necessary because these are brief interviews and it is valuable to try and work without notes. Our previous experience suggests that for some students taking notes interrupts the flow. You may find note-taking at this stage of your development may have an impact on how well you establish rapport with the patients and their feedback on your performance.

Interviewing simulated patients

The session will run as follows:

Meet the session co-ordinator

Review your completed learning goals form and retain a copy.

Conduct your interviews as directed by session co-ordinator

After each interview, complete the brief reflection form. Use this form, together with your learning goals and simulated patient rating forms, to complete your eportfolio task

After you have finished your interviews, you will be debriefed by the session co-ordinator

Patient centred interviewing skills

Preparing for interaction Attend to self-comfort Minimise distraction Focus attention on next interaction	Giving information Skills to be covered later in the CC
Commencing the interaction Greet the patient State your full name Clarify your role Obtain patient’s name Attend to patient’s comfort Obtain the patient’s consent State purpose of the interaction Mention note taking Clarify time available Assess patient’s ability to communicate Demonstrate interest and respect Empower patient to ask questions or seek clarification of anything that is unclear	Closing the interaction Provide an end summary Discuss an action plan Check for further information Ask for questions Check if the patient has any worries or concerns
Gathering information Use open questions initially Allow patient to complete first sentence/s Identify the patient’s ideas, concerns and expectations Use active listening verbal (staying with patient’s topic; using patient’s words; reflection) non-verbal (eye contact; nodding) Use other non-verbal behaviours (body posture; gestures; facial expressions, nodding) Use open to closed-cone questions Pick up verbal cues Pick up non-verbal cues Probe sensitively Survey for other problems Set agenda Clarify patient’s terms Make interim summaries Signpost or transition statements Use silence appropriately Avoid multiple questions Avoid leading questions Avoid unexplained jargon	Relationship building skills Throughout each stage, it is important to use relationship-building skills in order to establish and maintain your relationship with the patient Use active listening Make empathic statements Show warmth Pick up verbal and non-verbal cues Use non-verbal behaviours (posture, gestures, facial expressions) Identify patient’s ideas, concerns and expectations Avoid being judgmental Not all the skills listed here will be used in every interaction. The skills are not necessarily in a specific order although some skills obviously precede others.

Learning goals

Students name:

How do you feel about your interviews with the simulated patients?

What skills do you want to focus on in your interviews?

1.

2.

3.

What aspects of the literature and previous clinical communications sessions do you hope to explore during the sessions? E.g. non-verbal communication

Brief and immediate self assessments

Interview 1

What worked well?	What could I improve?

Interview 2

What worked well?	What could I improve?

Interview 3

What worked well?	What could I improve?

This is an opportunity to review what you have done and to ask questions and seek clarification about patient-centred interviewing skills.

To develop your capacity as a reflective medical practitioner consider the following;

How closely did

your feelings about the interview and

your self-assessment

match

the feedback from each volunteer simulated patient

the literature and points raised in the clinical communications skills sessions and guides?

It is important that you recognise which communications skills you are using well at present and which need improvement, Think about what you do that works well and how you might maintain that particular skill Also identify the skills you need to improve and how you will go about that. We know from studies on expertise that experience alone is insufficient for developing new skills. What plans do you have to develop expertise?

The patients you have interviewed are volunteers from the community talking about health problems they have person experience with. Although they receive written information about the session and briefing, they are not trained professionals in medical education and very occasionally some may act inappropriately due to lack of understanding of the session aims (e.g. expecting students to diagnose, providing challenging consultations or role-playing unrealistic scenarios). If you have experienced any such behaviours, please bring it to the attention of the session coordinator.

Written reflections on interview

Skill	Feelings	Rationale	Patient Response
Opening Describe a skill you used to open the consultation	Identify feelings not thoughts ”I felt the patient was withholding information” is a thought not a feeling. “I felt nervous at the beginning” is a feeling.	You should include your own reasoning backed up by evidence from the literature	Patient’s responses could include verbal or non-verbal behaviours in response to the skills used by the student
Establish Rapport Describe a skill you used to establish rapport
Information Gathering Describe a skill you used to gather information
Closure Describe a skill you used to close the consultaiton
Maintain Strengths Say how you will maintain strengths	Improve Weaknesses Say how you will improve weaknesses

Depth of reflection can be assessed using the criteria below.

You should be performing to at least level 3 (Developing reflection).

No evidence of reflection

Answered some questions descriptively (e.g. stated skills that were used but omitted feelings, rationale and patient’s reactions)

No suggestions for maintaining strengths and improving weaknesses

No reference to the literature or course materials.

Surface approach to reflection

Answered some questions from each category (e.g. skills, feelings, rationale, patient’s reactions)

No, or only general suggestions for maintaining strengths and improving weaknesses

Limited reference to the literature or course materials

Developing reflection

Answered most questions across each category (e.g. skills, feelings, rationale, patient’s reactions) some evidence of analysis rather than mere description.

General suggestions for maintaining strengths and improving weaknesses

Incorporated up to two of the following – patient feedback, past experience, evidence for patient-centred interviewing etc

Some clear links with the literature and course materials

Deep reflection

Answered all questions

Specific and targeted suggestions for maintaining strengths and improving weaknesses

Incorporated at least two of the following - patient feedback, past experience, evidence for patient-centred interviewing etc

Integrated use of literature and course materials.

ePortfolio Task

Portfolios have become commonplace in the NHS. The Royal College of General Practitioners describes the purpose of an ePortfolio;

“Above all else the ePortfolio is where the [trainee] records their learning in all its forms and settings. Its prime function is to be an educational tool that will record and facilitate the management of the journey of clinical and personal development through learning. It is the system used to record the evidence collected through the application of the workplace based assessment tools. It might be described as the “glue” which holds the curriculum learning and assessment together.”

As Imperial Medical Students, you also have your own ePortfolio. This is a place where you can collect evidence of your learning and map your progress. There are some ePortfolio tasks that are compulsory and form part of your assessment, but it is essentially yours to record and reflect as much as you want.

The aim of this eportfolio exercise is for you to integrate your own reflections with the feedback received from the patient and from that consider your progress with developing your communication skills with patients.

You are required to gateway this form, but you will not receive feedback on its content. The process of reflecting on the session is critical as it will galvanise your preparation for the exam in June which will rely heavily on your ability to reflect on a doctor-patient interview. It also allows you to construct a plan for development based on your thoughts before, during and after the session and incorporate your patients’ feedback. If you would like to discuss anything about the session, please email Dr Murtagh or Dr. Belsi.

Please refer to the following materials from the session to help complete your eportfolio task:

learning goals form

brief and immediate self assessments

Volunteer patients’ feedback forms

Use the form entitled: “GE-CC-Session 3: Interviewing Volunteer Patients”

E-learning task

We recommend that you complete the “information gathering and history taking” module at this stage. This is the longest module, but at the moment, the most relevant content is related to the skills involved in information gathering. Other aspects are more relevant later on (content of the history- after session 5 and clinical reasoning next academic year).

Often students find it hard to bring their interviews to an effective close during this session. Please also complete the module on “closing the consultation” before your next session in January when you will be working with professional simulated patients.

Recommended reading

COLE, S. A. & BIRD, J. (2000) Ten Common Concerns (ch 6, pp 51-59). The Medical Interview: The Three Function Approach., Mosby: Missouri

COLE, S. A. & BIRD, J. (2000 ) Opening (ch 7, pp 63-67). The Medical Interview: The Three Function Approach. 2nd ed. Missouri, Mosby.

Foundation Programme. http://www.foundationprogramme.nhs.uk/pages/home

KIDD, J. & NESTEL, D. (2004) Facilitating reflection in an undergraduate medical curriculum. Med Teach, 26, (5) 481-483

LIPKIN, M., FRANKEL, R., BECKMAN, H., CHARON, R. & FEIN, O. (1995) Performing the interview (ch 5, pp 65-82 : see pp 73). IN LIPKIN, M., PUTNAM, S. M. & LAZARE, A. (Eds.) The Medical Interview: Clinical Care, Education and Research. Ann-Arbour, New York, Springer-Verlag.

MAGUIRE, P. & PITCEATHLY, C. (2002) Key communication skills and how to acquire them. British Medical Journal, 325, 697-700.
PM:12351365

SILVERMAN, J., KURTZ, S. & DRAPER, J. (2004) Skills for Communicating with Patients (2nd ed) (pp 57-105), Oxford, Radcliffe Medical Press.

SMITH, R. C. (2004) Patient-Centred Interviewing (ch 3, pp 35-69). Patient-Centred Interviewing: An Evidence-Based Method. 2nd ed. Philadelphia, Lippincott William and Wilkins.

Tomorrow's Doctors.
http://www.gmc-uk.org/education/undergraduate/tomdoc.pdf

WASHER, P. (2009) The structure and process of a medical interview (Ch 2, pp11-17). In WASHER, P. Clinical Communication skills. Oxford, OUP

Session 4

Interviewing a simulated patient - II

Introduction

You need to arrive 15 minutes before your scheduled interview time. Times and venue information will be on the Year 1 intranet.

Learning objectives

After participating in this session, you should be able to:

Identify skills used effectively in simulated patient-centred interviews (simulated patients)

Receive feedback on communication skills from a simulated patient

Receive feedback on communication skills from a tutor

Develop awareness of personal strengths in communicating

Develop awareness of personal weaknesses in communicating

Identify ways in which communication strengths will be maintained

Identify ways in which communication weaknesses will be improved

Methods

Students work individually with a tutor (or a pair of peer tutors) and a professional simulated patient

Activities

You will attend for a scheduled 40-minute session

You will meet with a session coordinator

For the 20 minutes in-between, you will work individually with a tutor (or peer tutors) and a professional simulated patient

A recording of your interview is made and you will keep this as a log of your progress

You will reflect on your experience and receive verbal and written feedback from the simulated patient and the tutor

Some of you will work with peer tutors and others with faculty tutors

Preparation

Aim: To provide you with information about your interview with a simulated patient

The activity will be introduced by the tutor. This includes:

Review of the learning objectives

Your task

Learning goals form

In this session you will learn as much from things you do less well as well as getting feedback on the strengths you demonstrate as a communicator. You will have the option of taking “time-out” if you get stuck for words or for any other reasons during your interview with the simulated patient. Please remember the purpose of this session is for you to learn and develop rather than you giving a wonderful performance.

Tutors are asked to model the skills associated with patient-centred interviewing when dealing with students. For example, tutors begin by introducing themselves and their role in the session, finding out and using the student’s name, checking out what the student thinks is the purpose of the session and how it will run, asking the student how s/he feels, checking if s/he has any questions, eye contact, a handshake etc

Your tutor will brief you on the patient you will interview in this session. Your task in the interview is to find out as much as possible about the reason why the patient has attended the hospital.

It is more important that you focus on trying out some of the skills we have discussed in order to establish and develop a relationship with the patient. This will help you learn about the patient’s experience of illness – their ideas, concerns and expectations. You will benefit most from the session if you review the communication skills list before the session and ask for clarification of any about which you are uncertain. Most of the skills will already be familiar to you.

Also try to remember

* You should obtain consent from patients to practise your interviewing skills.

* To try out some of the techniques for closing the interview.

Interviewing a simulated patient: Session protocol

Although we encourage flexibility, most sessions will run according to the following protocol.

You will be

Met by the tutor

provided with task for role-play

Asked to produce (or complete) a brief learning goals form

You’ll be invited to briefly discuss learning goals in relation to your task ( what aspect of the interaction would you particularly value feedback on?)

Asked to conduct the interview

Tutor records and observes student interview

Provided with feedback on your patient-centred interviewing skills in line with the sheet provided as a to guide observations and feedback

To ensure you get the most out of the session it will most often follow the following structure,

Tutor asks the student:

Can you briefly state how you felt during the interview? [You will be encouraged to simply name the emotion/s they experienced and not the rationale or thoughts for those feelings. The purpose of this question is to raise the your awareness of the link between feelings and behaviour]

Please describe two aspects of the interview that you consider to have worked well?

Tutor asks the simulated patient:

Please identify two communication skills the student used effectively?

Tutor provides specific feedback on two skills that s/he observed worked well

Tutor asks the student:

Please identify two aspects of the interview that you would do differently if you could repeat the interview?

Tutor asks the simulated patient to:

Identify two communication skills that the student could have used to improve the interview?

Tutor provides feedback on two skills that could have improved the interview

Tutor, student and simulated patient review a segment of the videotape

Tutor summarises the feedback on things that worked well and things to improve

Student receives written feedback from tutor and simulated patient

Giving and receiving feedback

These are the guidelines we use in our tutor training for Clinical communication. We will be encouraging you to adopt similar principles when you offer feedback to your colleagues on this or other course within the Foundations of Clinical Practice or later in professional development.

Remind yourself of the purpose of feedback in this situation – e.g for the tutors it is to support student learning in patient-centred communication

Think about what you want to say and how you want to say it

Try to address the learning needs/goals the student identifies - Time will preclude much further discussion

You might like to use a structural approach to interviewing – that is, the interview has a beginning, middle and end. Then think about something from each phase that you observed as working well or something to do differently

It is important to stick with the following sequence for giving feedback

Student interviewer, Patient, Tutor

Focus FIRST on what the student interviewer did well and then proceed to things that can be done differently

Always identify strengths that the student has demonstrated

Give your own experience of the communication

“ I thought it was very helpful when you entered the room and made eye contact whilst introducing yourself with your name, role and a clear statement of the purpose of the interview. I think you said that you would like to spend about 5 minutes talking with the patient about why they had come to hospital. This was clear, honest and focused. Well done.”

“When you said that you wanted to have a little chat, I thought you were trivialising your task and perhaps inadvertently being dishonest. What you are doing is asking several questions about why the patient has come into hospital. That is quite different to a little chat.”

“When you smiled at the patient right at the beginning of the interview, I thought you conveyed a sincere interest in her.”

“When you asked the patient about her smoking, alcohol and other drug use, I wondered whether your tone might have seemed judgmental. You also used multiple questions which are not very helpful for getting specific information.”

“I could not easily hear your name at the beginning of the interview. Even though you have a long name, it is important that you use your whole name right at the beginning. It is also important that you say this when the patient can hear you – not when you are in the process of sitting down and closing the door.”

You might consider that when identifying weaknesses or areas for development, you can ask questions to help the student develop alternatives

“Can you think of different ways of…?”

“Sometimes I find it helpful…What do you think about that?”

“When you did… I was wondering what would have happened if you’d done…Do you have any thoughts on this”

“I was interested in your questions about the impact of the symptoms on the patient’s work. It seemed to me that you really wanted to know about this but your patient was reluctant to share anything further. How else might you have managed this?”

“Do you know why the patient was so anxious? … How might you have explored the reasons for his anxiety? It seemed to me that you assumed why he was anxious.”

Always confine “negative” feedback to things that can be changed.

Be honest – If you did not think that the student was patient-centred, try to specify what it was they did that led you to think this way.

“I did not think it was helpful when you spoke over the patient. Were you aware of doing this?”

“I thought you distanced yourself from the patient when you used terms that the patient did not understand. I worried that your tone of voice might have been perceived as pompous and I noticed you did not make much eye contact.”

“I think you need to think about the way you present yourself – even in this simulated environment. Baseball hats inside are completely inappropriate and the body position you adopted suggested you had little respect for the patient. Let’s have a look at the videotape and let me know what you think.”

Be accurate

Limit the use of generalisations and loose terms like “good” or excellent.

“That was good.” (State why it was “good” – You looked at the patient, you sat up, your tone of voice and the pace of your speech was friendly and engaging. You didn’t fidget and it seemed to me like you really listened…”

Support Challenge Model of Feedback

This model can help you think about the way you give feedback. Statements given as feedback can be graded in terms of support and challenge. The most effective feedback falls in the high support/high challenge quadrant.

Support	“That was obviously great – you are trying very hard”	“A good effort. I could see how you were drawing the feelings out. I wonder if you got to the crux of the matter?”
“Good, carry on, seems to be working”	“Well that could have been done better. Why didn’t you focus more earlier on?”
Challenge

Learning goals – To be completed before your session

How do you feel about your interview with the simulated patient?

What skills do you want to focus on in your interview?

1.

2.

3.

Is there anything specific you would like the tutor to observe and give you feedback on?

Briefly outline.

This page has been left blank for notes

Patient-centred interviewing skills

Preparing for interaction Attend to self-comfort Minimise distraction Focus attention on next interaction	Giving information Skills to be covered later in CC
Commencing the interaction Greet the patient State your full name Clarify your role Obtain patient’s name Attend to patient’s comfort Obtain the patient’s consent State purpose of the interaction Mention note taking Clarify time available Assess patient’s ability to communicate Demonstrate interest and respect Empower patient to ask questions or seek clarification of anything that is unclear	Closing the interaction Provide an end summary Discuss an action plan Check for further information Ask for questions Check if the patient has any worries or concerns
Gathering information Use open questions initially Allow patient to complete first sentence/s Identify the patient’s ideas, concerns and expectations Use active listening verbal (staying with patient’s topic; using patient’s words; reflection) non-verbal (eye contact; nodding) Use other non-verbal behaviours (body posture; gestures; facial expressions, nodding) Use open to closed-cone questions Pick up verbal cues Pick up non-verbal cues Probe sensitively Survey for other problems Set agenda Clarify patient’s terms Make interim summaries Signpost or transition statements Use silence appropriately Avoid multiple questions Avoid leading questions Avoid unexplained jargon	Relationship building skills Throughout each stage, it is important to use relationship-building skills in order to establish and maintain your relationship with the patient Use active listening Make empathic statements Show warmth Pick up verbal and non-verbal cues Use non-verbal behaviours (posture, gestures, facial expressions) Identify patient’s ideas, concerns and expectations Avoid being judgmental Not all the skills listed here will be used in every interaction. The skills are not necessarily in a specific order although some skills obviously precede others.

This page has been left blank for notes

Written reflections on interview

Skill	Feelings	Rationale	Patient Response
Opening Describe a skill you used to open the consultation	Identify feelings not thoughts ”I felt the patient was withholding information” is a thought not a feeling. “I felt nervous at the beginning” is a feeling.	You should include your own reasoning backed up by evidence from the literature	Patient’s responses could include verbal or non-verbal behaviours in response to the skills used by the student
Establish Rapport Describe a skill you used to establish rapport
Information Gathering Describe a skill you used to gather information
Closure Describe a skill you used to close the consultaiton
Maintain Strengths Say how you will maintain strengths e.g.	Improve Weaknesses Say how you will improve weaknesses

Depth of reflection can be assessed using the criteria below.

You should be performing to at least level 3 (Developing reflection).

No evidence of reflection

Answered some questions descriptively (e.g. stated skills that were used but omitted feelings, rationale and patient’s reactions)

No suggestions for maintaining strengths and improving weaknesses

No reference to the literature or course materials.

Surface approach to reflection

Answered some questions from each category (e.g. skills, feelings, rationale, patient’s reactions)

No, or only general suggestions for maintaining strengths and improving weaknesses

Limited reference to the literature or course materials

Developing reflection

Answered most questions across each category (e.g. skills, feelings, rationale, patient’s reactions) some evidence of analysis rather than mere description.

General suggestions for maintaining strengths and improving weaknesses

Incorporated up to two of the following – patient feedback, past experience, evidence for patient-centred interviewing etc

Some clear links with the literature and course materials

Deep reflection

Answered all questions

Specific and targeted suggestions for maintaining strengths and improving weaknesses

Incorporated at least two of the following - patient feedback, past experience, evidence for patient-centred interviewing etc

Integrated use of literature and course materials.

ePortfolio Task

Portfolios have become commonplace in the NHS. The Royal College of General Practitioners describes the purpose of an ePortfolio;

“Above all else the ePortfolio is where the [trainee] records their learning in all its forms and settings. Its prime function is to be an educational tool that will record and facilitate the management of the journey of clinical and personal development through learning. It is the system used to record the evidence collected through the application of the workplace based assessment tools. It might be described as the “glue” which holds the curriculum learning and assessment together.”

As Imperial Medical Students, you also have your own ePortfolio. This is a place where you can collect evidence of your learning and map your progress. There are some ePortfolio tasks that are compulsory and form part of your assessment, but it is essentially yours to record and reflect as much as you want.

The aim of this eportfolio exercise is for you to integrate your own reflections with the feedback received from the patient and from that consider your progress with developing your communication skills with patients.

You are required to gateway this form, but you will not receive feedback on its content. The process of reflecting on the session is critical as it will galvanise your preparation for the exam in March which will rely heavily on your ability to reflect on a doctor-patient interview. It also allows you to construct a plan for development based on your thoughts before, during and after the session and incorporate your patients’ feedback. If you would like to discuss anything about the session, please email Dr Murtagh or Dr. Belsi.

Please refer to the following materials from the session to help complete your eportfolio task:

learning goals form

brief and immediate self assessments

Feedback from the session

Use the form entitled: “GE-CC-Session 4: Interviewing Simulated Patients”

Recommended readings

COLE, S. A. & BIRD, J. (2000) Chief complaint and survey of problems (ch 8, pp 68-77). The Medical Interview: Three Function Approach. 2nd ed. Missouri, Mosby.

COLE, S. A. & BIRD, J. (2000) Chief complaint and survey of problems (ch 8, pp 68-77). The Medical Interview: Three Function Approach. 2nd ed. Missouri, Mosby.

KIDD, J. & NESTEL, D. (2004) Facilitating reflection in an undergraduate medical curriculum. Med Teach, 26, (5) 481-483

LLOYD, M. & BOR, R. (2004) Introduction (ch 1, pp 1-8). Communication Skills for Medicine. 2nd ed. London, Churchill.

LLOYD, M. & BOR, R. (2004) Basic communication skills (ch 2, pp 9-22). Communication Skills for Medicine. 2nd ed. London, Churchill.

PENDLETON, D., SCHOFIELD, T., TATE, P. & HAVELOCK, P. (1984) An approach to learning and teaching (ch 6, pp 61-72). The Consultation: An Approach to Learning and Teaching. Oxford, Oxford University Press.

SILVERMAN, J., KURTZ, S. & DRAPER, J. (2004) pp 57-105 (interviewing SP). Communicating with Patients. 2nd ed. Oxford, Radcliffe Medical Press.

SILVERMAN, J., KURTZ, S. & DRAPER, J. (2004) Skills for Communicating with Patients 2nd ed (pp 107-116 SP session), Oxford, Radcliffe Medical Press.

SMITH, R. C. (2002) Interviewing [ch1, 1-6]. Patient-Centred Interviewing: An Evidence-Based Method. 2nd ed. Philadelphia, Lippincott William and Wilkins.

SMITH, R. C. (2002) Facilitating skills (ch 2, pp 17-33) (patient-centred comm). Patient-Centred Interviewing: An Evidence-Based Method. 2nd ed. Philadelphia, Lippincott William and Wilkins.

SMITH, R. C. (2004) Patient-Centred Interviewing (ch 3, pp 35-69). Patient-Centred Interviewing: An Evidence-Based Method. 2nd ed. Philadelphia, Lippincott William and Wilkins.

WASHER, P. (2009) The structure and process of a medical interview (Ch 2, pp11-17). In WASHER, P. Clinical Communication skills. Oxford, OUP.

Please complete your SOLE pages before leaving the session

Session 5

History Taking (i) Content and Process

Introduction

This is the first session for the second year of the “Clinical Communication” course (CC) and it builds on your experiences from last year. By the end of first-year you were expected to be able to describe and demonstrate a range of basic communication skills (verbal and non-verbal) relevant for working with patients, peers and clinicians. You should be able to identify the central features of a patient-centred consultation and will have developed basic relevant skills for opening, gathering information and closing interviews that explore patients’ experiences. You will have developed awareness of your strengths and weaknesses in communicating within some health care contexts and have clear strategies to maintain your more effective skills and to improve those that are less developed. The introductory section of this manual provides detailed information on aims of the second year of CC.

This session aims to prepare you for establishing a patient’s chief complaint and past medical history. It is the first part of history taking skills with part 2 covering useful skills for taking a social history.

Learning objectives

After this session, you should be able to:

Identify the key content features of a medical history

Identify the skills necessary for an effective assessment of the patient’s chief complaint and past medical history

Discuss the reasons why if doctors and patients have different or unshared expectations or agendas within a consultation the consultation may be unsatisfactory for both

Have practised using and integrating the skills associated with patient-centred interviewing while taking a medical history

Activities

What information do I need from patients?

Role-play

Content and process

In year 1 you have learned the process of taking a medical history using consultation models (e.g. Calgary-Cambridge). This gives you a framework in which to put the content. In your forthcoming clinical attachments, you will soon be inundated with questions you need to ask patients while taking their medical history. The challenge today is to help you integrate the content (information you need from the patient) with the process (effective patient-centred communication). i.e. history taking and patient-centred communication are not two different things!

Content skills

Firstly, there are content skills, i.e. the substantive character of questions and responses, information being sought and delivered, discussion of treatment options, management plans etc. Most texts dealing with consultation skills will suggest that the content of a medical history should include:

Presenting complaint

History of the Presenting Complaint

Past Medical History

Social History

Family History

Lifestyle

Functional enquiry/systems review

Whilst these are relevant and important lines of inquiry, this still begs the question, HOW do you cover these topics in a way that will ensure you gathering information effectively and efficiently in a way that does not alienate the patient. This is where process skills come in

Process Skills

Process skills allow you to answer the HOW question. Content and Process CANNOT be viewed as mutually exclusive. The relation between the two will be developed more extensively in Year 2.

The following information sets out a framework which incorporates, structure as well as fundamental process skills to assist you in communicating effectively with patients. It is designed to reflect the needs of medical students learning to communicate in medical interviews for the first time but is also relevant for interacting with patients during physical examination and while conducting procedures.

You will gain different experiences in history-taking depending on the firms to which you are assigned. Consultants have slightly different emphasis and style regarding the content of a medical history which reflects their personal preferences. We aim to help you understand the broad aims and provide a general checklist of types of information and questions that can contribute to the effectiveness of information gathering.

Remember that checklists of questions can interfere with the flow of communication in medical interviews. Following a checklist can steer the exchange into a doctor-centred interrogation which is unhelpful, not only to the patient but also, to the doctor as important information can be missed. Unless there is a medical emergency, early questions in the medical interview should focus on the patient’s experience of illness. This conveys a powerful message to the patient that you as doctor/ medical student respect and care about what is happening for this patient. Listening to the patient’s experience and subtly guiding them to address the issues you want explored is a very effective way to establish a supportive relationship with your patient while still obtaining more detailed information. It is likely that the patient will feel heard and your own information needs will have been met.

Once the patient has been encouraged to provide their own narrative it can be more appropriate to formulate closed questions that enable you to complete your ‘doctor-centred’ questions which can be formulated in relation to your mental checklist. Robert Smith, in his book “patient-centred interviewing” describes this process as “integrated medical interviewing”. He stresses the importance of returning to patient-centred skills in response to verbal and non-verbal cues from the patient (Smith, 2002).

Sequential Organisation

The key is to ensuring effective integration of content and process is to pay close attention to the sequential organization of the interaction. The following example is only suggestive and is designed to give you a feel of how to think about how to sequence and structure your interview. The different subtle ways in which you ask a question can influence how the patient responds. Sometimes the distinction between ‘open’ and ‘closed’ questions is not sufficient to capture these differences. On occasion patients can provide very ‘closed’ answers to ‘open’ questions. To ensure this doesn’t impact negatively on your information gathering - always

READ THE PATIENT!

Listen carefully to the information the patient provides. Observe carefully how the patient responds to each question. For example, minimal responses or sudden changes in body language provide you with important clues as to how to shape the form and content of the questions you want to ask and how you should ask them. Observing the sequence of the interaction in this way will also enable you to effectively conduct the sequential tasks of the consultation itself.

Use of language

In sociology you will have learned that different social groups can use language differently and that meanings are often bound up with the activities and practices of different social groups. Doctors and patients are two social groups whose use of language (in referring to a particular problem) may be quite different. Consequently, communication difficulties can easily arise. Therefore, you will need to be able to carefully clarify what patients mean when they use certain terms. On the other hand, patients are becoming increasingly more health literate and more assertive in their encounters with health care professionals. Different categories of patients will present their problems in different ways and to handle this effectively you will have to learn how to adjust your communication style accordingly. In this respect clinical communication presents you with an opportunity to critically engage with different theories of the doctor-patient relationship you have learned about in sociology.

Activity 1: What information do I need from patients?

Aim:	To encourage you to explore the range of topics relevant to history-taking

Discuss in 2s or 3s for 2 minutes:

a) What do I need to know about “all” my patients?

Your tutor will then collect the thoughts of the group to create a template of a medical history

b. What do I need to know about patients presenting with…?

Discuss in groups of about 5 for 5 minutes (one patient per group). Each group will then present their thoughts to the room.

b) What topics you might explore with the following patients? How would you word your questions? Remember to consider the language you use and the use of open/closed questions. Refer to the “patient-centred interviewing skills” summary on the next page when considering how you may phrase your questions.

Mr. Dale Gallagher, aged 48, an abattoir worker, has gone to the Emergency Department with acute abdominal pain.

Mr. Stephen Bowers, aged 63, recently retired from taxi driving, has been experiencing acute chest pain and has been brought to the GP clinic by his wife.

Ms. Sara Lieberman, aged 78, an author has made an appointment to see her GP because she has been having episodes of dizziness.

Mr. Jean-Paul Sarkozy, aged 37, has made an appointment to see his GP because he is concerned about the stiffness in his hip joint.

Miss Valerie Pecresse, aged 26, a buyer for a large retail store, is in the outpatient department for investigation of haematuria (blood in urine).

Activity 2: How do I establish the presenting complaint, the history of the presenting complaint and past medical history?

Establishing the patient’s presenting complaint is a standard in medical history taking. This is not always as straightforward as it seems. Patients can respond in vague or general terms or may focus too specifically on particular symptoms. Try to focus on information the patient provides about episodes which caused a change in the patient’s health status to determine the diagnosis given to those episodes. The key is to try to discern which ‘news items’ are relevant to the presenting problem. This will come with repeated opportunities to practice history taking.

How do you establish the patient’s PC, HPC and PMH?

What kinds of questions might you use to establish the patient’s PC?

What kinds of questions might you use to establish the HPC?

What kinds of questions might you use to establish the patient’s PMH?

Activity 3: Role-play

Aims:

To practise taking a medical history using a patient-centred approach to interviewing

To practise meeting the agenda of patients and of interviewers

6 students will be randomly selected to conduct an 8 min interview with a patient exactly as you did in the simulated patient sessions in Y1. The students will work in groups of 2 (an interviewer and an observer). The purpose of this exercise is to provide an opportunity to practice your skills in establishing the PC, HPC and PMH. Those not selected for this exercise will be asked (using the course guidelines) to give and feedback in a way that promotes learning and professional development.

Factors important for successful role-play include:

Clear aims and objectives about task and roles

Roles that reflect real experiences and appropriate level challenges

Acknowledging potential difficulties in role-play

Opportunities to try out different strategies

“Safety” for participants because it is simulated

Following feedback guidelines

Relating role-play to the broader contexts in which you are learning and working

Writing reflections on the experience

Opportunities for debriefing for some students

Summarising experiences

Review the communication skills list before you get started. Do any skills require clarification? The background information section in your Year 1 guide might be a useful reference.

Before the first role-play

Think about how to meet both the patient’s and interviewer’s agendas in a consultation. The following tips might be helpful.

Clearly state your intentions at the commencement of the interview

Try to identify the patient’s presenting complaint as well as their, worries and concerns at the beginning of the interview

Work with your patient to prioritise these symptoms, worries and concerns

Check you understand what your patient is saying

Summarise

Invite your patient to ask questions or clarify anything you say

Consider the strategies that can be used to help patients express their emotions and then deal with the patient’s response. That is, identify the feeling you think the patient is experiencing and let the patient know your thoughts on this. If the interviewer is correct, patients will usually tell you so. Rapport can be established as the interview proceeds.

Many students report the value of using SOCRATES to assess pain. Although we would not recommend that you use it directly – translating the terms into lay language may help ensure that you make an accurate assessment of pain. Remember to ask what patients have done about their pain. This might include taking medicine or resting etc

Site	where exactly is the pain?

Onset	when did the pain start, did it start suddenly or gradually?

Character	describe the pain- sharp? knife-like? gripping? vice-like? burning? crushing?

Radiation	does the pain spread anywhere? To the arm, jaw, groin, etc?

Associations	is the pain accompanied by any other features?

Timing	does the pain vary in intensity during the day?

Exacerbating or relieving factors - does anything make the pain better or worse?

Severity	does the pain interfere with daily activities or with sleep?

Before the second role-play

Again

Clearly state your intentions at the commencement of the interview

Try to identify the patient’s presenting complaint as well as their, worries and concerns at the beginning of the interview

Work with your patient to prioritise these symptoms, worries and concerns

Check you understand what your patient is saying

Summarise

Invite your patient to ask questions or clarify anything you say

You may want to refer to your systems review in this role play

1)	Cardiorespiratory symptoms

chest pain

exertional dyspnoea (quantify exercise tolerance: how many stairs)

paroxysmal nocturnal dyspnoea

orthopnoea (i.e. Breathless on lying flat – a symptom of left ventricular failure)

oedema

palpitations (awareness of heart beats)

cough

sputum

haemoptysis (coughing up blood)

wheeze

Take time after the session to reflect on your experience of the role-play. There will also be forms available in the session for observers and patients to record their experiences. These should be given to the interviewer when s/he has finished.

Remember although you may be thinking of a structure to your interview, this may not be the same structure the patient has in mind. For example, when asking about the presenting complaint, patients may respond by giving you information that relates to the history of the presenting complaint.

Before the third role-play

Again

Clearly state your intentions at the commencement of the interview

Try to identify the patient’s presenting complaint as well as their, worries and concerns at the beginning of the interview

Work with your patient to establish the problem and how it relates to the past medical history

Work with your patient to establish the details of the pain

Summarise

Invite your patient to ask questions or clarify anything you say

Again you may want to refer to SOCRATES

Site	where exactly is the pain?

Onset	when did the pain start, did it start suddenly or gradually?

Character	describe the pain- sharp? knife-like? gripping? vice-like? burning? crushing?

Radiation	does the pain spread anywhere? To the arm, jaw, groin, etc?

Associations	is the pain accompanied by any other features?

Timing	does the pain vary in intensity during the day?

Exacerbating or relieving factors - does anything make the pain better or worse?

Severity	does the pain interfere with daily activities or with sleep?

Take time after the session to reflect on your experience of the role-play. There will also be forms available in the session for observers and patients to record their experiences. These should be given to the interviewer when s/he has finished.

Remember although you may be thinking of a structure to your interview, this may not be the same structure the patient has in mind. For example, when asking about the presenting complaint, patients may respond by giving you information that relates to the history of the presenting complaint.

Process of reflection and feedback

Each of you will be the observer once. Your role is to guide the interviewer through reflection and to give them some feedback on their performance.

Use the checklist to identify which skills the interviewer used

For providing feedback remember the guidelines from last year (see below)

The following questions may be helpful in staying focused on your task and ensuring a balance

“What emotions were you feeling during the interview?” [The purpose of this question is to raise your awareness of the link between feelings and behaviour]

“And now describe two aspects of the interview that worked well?”

Observer asks the role-play patient:

“Can you please identify two communication skills that the interviewer used that were effective?”

Observer provides specific feedback on two skills that s/he observed worked well

Observer asks the interviewer:

“Now outline two aspects of the interview that you would do differently if you could repeat the interview?”

Observer asks the role-play patient:

“Can you identify two communication skills that the student could have used to improve the interview?”

Observer provides feedback on two skills that could have improved the interview

Observer summarises the feedback on things that worked well and things to improve

The interviewing student will also receive written feedback

The patient should complete the “simulated patient rating form”

The observer should identify skills used well and those requiring development on the “patient-centred interviewing skills” list

Role-play 1

Medical student

You are working with a general practitioner (GP) who has asked you to practise taking a medical history. One of the patients in the surgery has come to see a doctor because s/he has been feeling unwell for several months. You have a private interview room in which to talk with your patient. Remember to look at the patient and respond to how you think they are feeling.

Observer

Use the checklist to think about the skills the interviewer uses, particularly in the opening and setting the agenda. Consider the content issues in relation to checklist. Use the guidelines on giving feedback to help you give constructive support to your colleague with respect to his/her patient-centred interviewing skills and content aspects of the history. Specifically, does the interviewer note the emotional state of the patient? If so, how does s/he deal with this? What is the patient’s response?

Role-play 2

Medical student

You are working with a general practitioner (GP) who has asked you to practise taking a medical history. One of the patients in the surgery has come to see a doctor about chest pain. The GP has asked you to practice your history taking and to report back before he sees the patient. You have 8 mins to talk to the patient. Try to focus on establishing the specifics of the presenting complaint try also to elicit the patient’s concerns about the complaint (chest pain)

Observer

Use the checklist to think about the skills the interviewer uses, particularly in the opening and setting the agenda. Consider the content issues in relation to checklist. Use the guidelines on giving feedback to help you give constructive support to your colleague with respect to his/her patient-centred interviewing skills and content aspects of the history.

Role-play 3

Medical student

You are a medical student in a vascular surgery clinic. You have been asked to take practice your history taking with a patient who has been referred to the clinic with a pain in the left leg on walking. Please elicit a focused history on the presenting complaints. You are not required to present your findings.

Observer

Concentrate on how well Use the guidelines on giving feedback to help you give constructive support to your colleague with respect to his/her patient-centred interviewing skills and content aspects of the history.

Patient-centred interviewing skills

Preparing for interaction Attend to self-comfort Minimise distraction Focus attention on next interaction	Giving information Skills to be covered later in CC
Commencing the interaction Greet the patient State your full name Clarify your role Obtain patient’s name Attend to patient’s comfort Obtain the patient’s consent State purpose of the interaction Mention note taking Clarify time available Assess patient’s ability to communicate Demonstrate interest and respect Empower patient to ask questions or seek clarification of anything that is unclear	Closing the interaction Provide an end summary Discuss an action plan Check for further information Ask for questions Check if the patient has any worries or concerns
Gathering information Use open questions initially Allow patient to complete first sentence/s Identify the patient’s ideas, concerns and expectations Use active listening verbal (staying with patient’s topic; using patient’s words; reflection) non-verbal (eye contact; nodding) Use other non-verbal behaviours (body posture; gestures; facial expressions; nodding) Use open to closed-cone questions Pick up verbal cues Pick up non-verbal cues Probe sensitively Survey for other problems Set agenda Clarify patient’s terms Make interim summaries Signpost or transition statements Use silence appropriately Avoid multiple questions Avoid leading questions Avoid unexplained jargon	Relationship building skills Throughout each stage, it is important to use relationship-building skills in order to establish and maintain your relationship with the patient Use active listening Make empathic statements Show warmth Pick up verbal and non-verbal cues Use non-verbal behaviours (posture, gestures, facial expressions) Identify patient’s ideas, concerns and expectations Avoid being judgmental Not all the skills listed here will be used in every interaction. The skills are not necessarily in a specific order although some skills obviously precede others.

This page has been left blank for student notes

Simulated patient rating form

Student’s name: ___________________________________

Rate your satisfaction with the student for each of the following:

Not at all satisfied	Completely satisfied	Unable to rate
1	Beginning the interview	1	2	3	4	5	6	7
2	Asking questions	1	2	3	4	5	6	7
3	Listening to you	1	2	3	4	5	6	7
4	Warmth towards you	1	2	3	4	5	6	7
5	Asking about your feelings	1	2	3	4	5	6	7
6	Choice of words	1	2	3	4	5	6	7
7	Topics covered	1	2	3	4	5	6	7
8	Ending the interview	1	2	3	4	5	6	7
9	Student’s appearance	1	2	3	4	5	6	7
10	Overall satisfaction	1	2	3	4	5	6	7
Highly anxious	Not at all anxious
11	How anxious do you think student was?	1	2	3	4	5	6	7

Please add any other comments that you would like to make below:

This page has been left blank for student notes

Summary

By the end of this session, you should be able to

Identify the key content features of a medical history

Identify the skills necessary for an effective assessment of the patient’s, presenting complaint, the history of the presenting complaint and their past medical history

Have practised using and integrating the skills associated with patient-centred interviewing while taking a medical history

E-learning

The most relevant module for the material we have covered in this session is “information gathering and history taking”. This module is the longest of the 7 (about 2 hours if you complete it fully) so we would advise that you either leave plenty of time or complete it in two sittings. Some of the more complex concepts (such as clinical reasoning in history taking) may be more appropriate in Year 3, so please try to re-visit the module next year as well.

You may want to spend some time looking at “initiating the session”, Structuring the session”, “building the relationship” and “closing the session” prior to your simulated patient interview or during your clinical attachment when you will be focusing on history taking in a clinical setting.

References and recommended reading

CLARK, W. (1995) Effective interviewing and intervention for alcohol problems (pp 284-293). IN LIPKIN, M., PUTNAM, S. M. & LAZARE, A. (Eds.) The Medical Interview: Clinical Care, Education and Research. Ann-Arbour, New York, Springer-Verlag.

FISHMAN, J. & FISHMAN, L. (2005) History Taking in Medicine and Surgery, Cheshire, PasTest Ltd.

- a useful source of relevant questions, but many will need adapting to more patient-centred style of interviewing

HEARNE, R., CONNOLLY, A. & SHEEHAN, J. (2002-Feb) Alcohol abuse: prevalence and detection in a general hospital. J R Soc Med, 95, 84-87.

HOCKING, G., KALYANARAMAN, R. & DEMELLO, W. F. (1998) Better drug history taking: an assessment of the DRUGS mnemonic. J R Soc Med, 91, 305-6.

KNEEBONE, R. L. & NESTEL, D. (2005) Learning clinical skills - the place of simulation. The Clinical Teacher, 2, (2) 86-90.

LEWIS, T. (2004) Using the NO TEARS tool for medication review. BMJ 329, 434.

LIPKIN, M., FRANKEL, R., BECKMAN, H., CHARON, R. & FEIN, O. (1995) Performing the interview (ch 5, pp 65-82 : see pp 73). In LIPKIN, M., PUTNAM, S. M. & LAZARE, A. (Eds.) The Medical Interview: Clinical Care, Education and Research. Ann-Arbour, New York, Springer-Verlag.

LLOYD, M. & BOR, R. (2004) Communication Skills for Medicine (2nd ed), London, Churchill.

LONGMORE, M. WILKINSON, I. TURMEZEI, T. CHEUNG, C.K. (ed). (2007) Oxford Handbook of Clinical Medicine (7th ed), Oxford, UK, OUP.

SILVERMAN, J., KURTZ, S. & DRAPER, J. (2004) Skills for Communicating with Patients (2nd ed) (pp 57-105), Oxford, Radcliffe Medical Press.

SMITH, R. C. (2002) Patient-Centred Interviewing: An Evidence-Based Method (2nd ed), Philadelphia, Lippincott William and Wilkins.

SNADDON, D., LAING, R., MASTERTON, G. & COLEDGE, N. (2005) History taking (pp 1-37). IN DOUGLAS, G., NICOL, F. & ROBERTSON, C. (Eds.) MacLeod's Clinical Examination. 11th ed. London, UK, Elseiver Churchill Livingstone.

WASHER, P. (2009) How to take a medical history (Ch 3, pp18-25). In WASHER, P. Clinical Communication skills. Oxford, OUP.

Complete your SOLE pages before you leave the session

In your next session you will be interviewing a simulated patient.

Please check the intranet to find out the time and place of your simulated patient interview session.

Appendix: Content of a medical history (Longmore et al, 2007)

Presenting complaint (PC)

“What has been the trouble recently?”

ICE – Ideas, concerns, expectations about presenting complaint and/or the patients health in general

How is the PC impacting their life? How has it affected their daily living?

History of presenting complaint (HPC)

When did it start? What was the first thing you noticed? Progression since then. Ever had it before?

Assess the patient’s knowledge of investigations (have they had previous investigations? Do they have an expectation regarding investigations?)

Assess the patient’s knowledge of treatment (have they received treatment? Do they have an expectation regarding treatment?)

Try to characterise pain and symptoms roughly as:

Site; radiation; intensity; duration; onset (gradual or sudden)

Character (sharp, dull, knife-like, colicky)

Associated features (nausea, vomiting etc)

Exacerbating and alleviating factors (What, if anything, makes it worse? What, if anything, takes it away or makes it better?)

Direct questioning

Specific questions about the diagnosis you have in mind (and risk factors e.g. travel) and a review of the relevant system

Past medical history (PMH)

Serious illnesses beginning in childhood

Hospitalisations

Surgical Procedures

Accidents or Injuries

Current Medications

Immunisations

Screening Procedures

Medications/allergies

Any tablets, injections?

Any ‘off the shelf’ drugs?

Herbal remedies?

Ask the features of allergies; it may not have been one.

Social and family history (SH/FH)

Probe without prying.

“Who else is at home with you?”

Job

Marital status

Spouse/partner’s job and health

Housing

Who visits? – relatives, neighbours, GP, nurse

Who does the cooking and shopping?

What can the patient not do because of the illness?

Age, health, and cause of death, if known, of parents, siblings, children; ask about TB, diabetes mellitus, and other relevant disease.

Areas of the family history may need detailed questioning e.g. to determine if there is a significant family history of heart disease you need to ask about grandfathers’ and male siblings’ health, smoking, and tendency to hypertension, hyperlipaedemia, and claudication before they were 60 years old, as well as ascertaining the cause of death.

Lifestyle

General questions regarding:

Diet (what types of food do they typically eat?)

Exercise

Sexual history

Recent travel

Any significant life events

Alcohol, ‘recreational’ drugs, tobacco

How much? How long?

Functional enquiry/Systems review

To uncover undeclared symptoms. Some of this may already have been incorporated into the history.

General questions may be the most significant, e.g. in TB or cancer:

weight loss

night sweats

any lumps

fatigue

appetite

fevers

itch

recent trauma

Cardiorespiratory symptoms

chest pain

exertional dyspnoea (quantify exercise tolerance: how many stairs)

paroxysmal nocturnal dyspnoea

orthopnoea (i.e. Breathless on lying flat – a symptom of left ventricular failure)

oedema

palpitations (awareness of heart beats)

cough

sputum

haemoptysis (coughing up blood)

wheeze

Gut symptoms

abdominal pain (constant or colicky, sharp or dull; site; radiation; duration; onset; severity; relationship to eating and bowel action; alleviating/exacerbating or associated features)

indigestion; nausea/vomiting

stool – colour, consistency, blood, colour of blood, slime, difficulty flushing away

tenesmus (feeling that there is something in the rectum that cannot be passed e.g. due to a tumour)

maleana is altered (black) blood passed PR

haematemesis (vomiting blood)

3)	Genitourinary symptoms

incontinence (stress or urge)

dysuria (painful micturition)

haematuria (blood in urine)

nocturia (needing to pass urine at night)

frequency

polyuria

hesitancy

terminal dribbling

vaginal discharge

menses: frequency, regularity, heavy or light, duration, painful, first day of last menstrual period (LMP)

number of pregnancies

menarche

menopause

chance of current pregnancy?

4)	Neurological symptoms

Sight

Hearing

Smell / taste

Seizures, faints, funny turns

Headache

Pins and needles (paraesthesiae)

Weakness “Do your arms and legs work?” poor balance

Speech problems

Sphincter disturbance

Higher mental function and psychiatric symptoms

Differences between right and left

The important thing is to assess function: what the patient can and cannot do at home, work etc.

5)	Musculoskeletal symptoms

Pain, stiffness, swelling of joints

Diurnal variation in symptoms (i.e. With time of day)

Functional deficit

Muscle wasting

Trauma

6)	Thyroid symptoms

Hyperthyropidism: Prefers cold weather, sweaty, diarrhoea, oligomenorrhoea, weight loss, tremor, visual problems

Hypothyroidism: depressed, slow, tired, thin hair, croaky voice, heavy periods, constipation, and dry skin

Session 6

History taking (ii) with a simulated patient - III

Introduction

In this session you will have an opportunity to practise the interviewing skills you were developing so far and blending in the core skill of history taking. Effective use of your communications skills will enable you to obtain clinical information important for making a diagnosis.

Instructions

Please arrive 5 minutes before you are scheduled to start. You are expected to participate throughout the entire session (up to 3 hours).

Please complete the learning goals form before the session and bring it with you.

You will need your CC supplement pages in addition to this guide for this session.

Aim

To give you the opportunity to practise integrating history taking with the patient-centred communication skills you have developed in year 1. There is an opportunity to for you to give and receive feedback on the use of your skills in the context of history taking. Please revisit the principles of and models of feedback outlined in year 1 handbook.

Learning objectives

By the end of this session, you should be able to:

Receive feedback on your communication skills from a simulated patient

Receive feedback on communication integrated with history-taking skills from a tutor and from peers

Identify those history-taking skills that you used effectively in the simulated interviews

Identify those skills that require further development

Identify ways in which your communication and history-taking strengths will be maintained

Identify ways in which your communication and history-taking weaknesses will be improved

After the session, you will be expected to:

Continue the development of self-awareness in relation to your strengths and weaknesses in communicating with patients.

Think about how you might improve your communication skills

Link your learning experiences to other courses in year 2 Foundations of Clinical practice.

Methods

You will work in groups with a tutor and simulated patients.

Learning goals

Complete this form BEFORE coming to the session.

Name: ____________________________

How do you feel about interviewing a simulated patient?

What skills do you want to focus on in your interview?

1.

2.

3.

Is there anything specific you would like the tutor to observe and give you feedback on?

Briefly outline.

This page is blank for notes

Activity 1: Interviewing a simulated patient

Aim: To provide you with an opportunity to practise your interviewing skills while obtaining information important for making a diagnosis

Patient-Centred interviewing skills

Different approaches to interviewing are needed for different patients. A gentle approach may suit one patient, while another might prefer a more assertive manner. It is important to recognise that doctors also differ in their personalities and abilities. There is no one correct approach. You will find your own style and manner of practising in patient centred ways.

Student task in the interview

Your task is to gather information relevant to a medical history in a way that is efficient and orderly, and demonstrate sensitivity to the patient’s needs and concerns. You will aim to achieve some understanding of the simulated patient’s emotional state, and their view of the illness. The patient’s perception of their illness may or may not be accurate from a biomedical perspective, but it is always important – the patient is the expert about the way they are feeling. Also you might find it possible to cover the following areas: obtaining consent, setting the agenda, and assessing alcohol, tobacco and other drug use.

When asking questions consider:

Will the words you are using be understood by the patient?

Does the question contain abbreviations, unconventional phrases or jargon?

Is it vague?

Is it too precise?

Is it biased?

Is it threatening?

Does it contain more than one concept?

Does it contain a double negative?

Are the answers mutually exclusive?

Does it assume too much about the patient’s behaviour?

Is an unambiguous time reference provided?

Is the question cryptic? (Summerton, 2007)

When you are not the interviewing student, you may be allocated a specific task as an observer. This will focus your attention on the interview. For example, you might be asked to make notes on communication skills or on content of the history or the specific skills that the student requested feedback on.

Patient-centred interviewing, history taking content lists will be available in the session. These can guide your observations and feedback. You will also receive the simulated patient rating form completed by the actor.

Working within the allocated times can be difficult so the group and the tutor need to stay focused on the goals of the session and the learning opportunities that arise

Summary

When you have all conducted an interview and received feedback the session will be brought to a close.

Review the learning objectives:

By the end of this session, you should be able to:

Receive feedback on your communication skills from a simulated patient

Receive feedback on communication and history-taking skills from a tutor and from peers

Identify those history-taking skills that you used effectively in the simulated interviews

Identify those skills that require development

Identify ways in which your communication and history-taking strengths will be maintained

Identify ways in which your communication and history-taking weaknesses will be improved

After the session, you should:

Continue the development of self-awareness in relation to your strengths and weaknesses in communicating

Think about how you might improve your communication skills

Link your learning experiences to other courses in FOCP.

ePortfolio Task

This eportfolio task asks you to reflect on your communication skills and history taking. In addition it encourages team-work and feedback skills as you will be gatewaying the forms to peers and giving/receiving feedback.

Please complete the form entitled: GE-CC-Session 6: Simulated Patient History

Remember to incorporate your feelings, feelings of other (tutors, patients, peers) and viewpoint of experts (e.g. literature) in your reflections.

Please gateway/email this form to two other students who were in your session (try to ensure you spread the work load evenly – e.g. select the two students on either side of you as you sit in the room). You should receive completed forms form the other students as well.

When you receive a completed form, please give feedback and return it to the author. The guidelines for grading reflective writing are on the next page.

This task is entirely student-focused and the forms are not gatewayed to staff. If you do not receive a completed form from a colleague in your group or do not receive feedback on your own reflections, we encourage you to ask for it. Ensuring that others support you within a team is an important part of professional behaviour.

Assessment criteria for written reflections

No evidence of reflection

Answered some questions descriptively (e.g. stated skills that were used but omitted feelings, rationale and patient’s reactions)

No suggestions for maintaining strengths and improving weaknesses

No reference to the literature or course materials.

Surface approach to reflection

Answered some questions from each category (e.g. skills, feelings, rationale, patient’s reactions)

No, or only general suggestions for maintaining strengths and improving weaknesses

Limited reference to the literature or course materials

Developing reflection

Answered most questions across each category (e.g. skills, feelings, rationale, patient’s reactions) some evidence of analysis rather than mere description.

General suggestions for maintaining strengths and improving weaknesses

Incorporated up to two of the following – patient feedback, past experience, evidence for patient-centred interviewing etc

Some clear links with the literature and course materials

Deep reflection

Answered all questions

Specific and targeted suggestions for maintaining strengths and improving weaknesses

Incorporated at least two of the following - patient feedback, past experience, evidence for patient-centred interviewing etc

Integrated use of literature and course materials.

References

COLE, S. A. & BIRD, J. (2000) Chief complaint and survey of problems (ch 8, pp 68-77). The Medical Interview: Three Function Approach. 2nd ed. Missouri, Mosby.

COLE, S. A. & BIRD, J. (2000) Patient profile and social history (ch 12, pp 95-100). The Medical Interview: The Three Function Approach. 2nd ed. Missouri, Mosby.

LLOYD, M. & BOR, R. (2004) Basic communication skills (ch 2, pp 9-25). Communication Skills for Medicine. 2nd ed. London, Churchill.

PENDLETON, D., SCHOFIELD, T., TATE, P. & HAVELOCK, P. (1984) An approach to learning and teaching (ch 6, pp 61-72). The Consultation: An Approach to Learning and Teaching. Oxford, Oxford University Press.

SILVERMAN, J., KURTZ, S. & DRAPER, J. (2004) Skills for Communicating with Patients (2nd ed), Oxford, Radcliffe Medical Press.

SMITH, R. C. (2002) Interviewing [ch1, 1-16]. Patient-Centred Interviewing: An Evidence-Based Method. 2nd ed. Philadelphia, Lippincott William and Wilkins.

SMITH, R. C. (2002) Facilitating skills (ch 2, pp 17-33) (patient-centred comm). Patient-Centred Interviewing: An Evidence-Based Method. 2nd ed. Philadelphia, Lippincott William and Wilkins.

SMITH, R. C. (2004) Patient-Centred Interviewing (ch 3, pp 35-71). Patient-Centred Interviewing: An Evidence-Based Method. 2nd ed. Philadelphia, Lippincott William and Wilkins.

SUMMERTON, N. (2007) Patient's story: symptoms (ch 4, pp 36-56). Patient centred diagnosis. Oxford, Radcliffe.

WASHER, P. (2009) How to take a medical history (Ch 3, pp18-25). In WASHER, P. Clinical Communication skills. Oxford, OUP.

Session 7

History Taking (iii): Social History (Diet, alcohol, drug and tobacco use)

Introduction

This session is an expansion on session 1 and aims to prepare you for tackling topics relating to a *social history including a patient’s dietary habits, alcohol and tobacco consumption. It also addresses the issue of cross cultural communication. Your patient’s eating habits and lifestyle patterns can be the cause of other more serious health problems and if not clearly identified can result in ineffective treatments and exacerbating symptoms. For example, Obesity has also been linked to key health problems, such as type 2 diabetes and heart disease and overall can have a significant impact on life expectancy. Cultural beliefs and practices too, can impact on a patient’s health.

In addition to providing some practical guidance, this session will consider these issues from the point of view of the communication process with patients. One of the difficulties is that patients can have strong beliefs about what they eat and drink and may not recognise the connections with their health. Moreover, in asking about diet and alcohol consumption etc patients can become defensive and give vague responses which can present a barrier to effective information gathering. It is important then that should the occasion arise where you feel you have to inquire into a patient’s dietary habits and lifestyle, that you are equipped with the basics to do so.

Diet and lifestyle

Food allergies are becoming increasingly more common and can in some instances be difficult to diagnose which can be problematic particularly when the occur in children and young people. NICE has set out guidelines for consultation on the diagnosis and assessment of food allergies in children and young people.

http://guidance.nice.org.uk/CC116

The problem of obesity has exploded in the past 10 years. A person is considered obese if they have a body mass index (BMI) of 30 or greater. Over time, eating excess calories leads to weight gain. Without lifestyle changes to increase the amount of physical activity done on a daily basis, or reduce the amount of calories consumed, people can become obese. In 2008, the latest year with available figures, nearly a quarter of adults (over 16 years of age) in England were obese (had a BMI over 30). Just under a third of women, 32%, were overweight (a BMI of 25-30), and 42% of men were overweight. http://www.nhs.uk/conditions/obesity/pages/introduction.aspx

*NB We do not advocate that you should necessarily think about the structure and sequence of the medical history in this way. We have divided it in this way for instructive purposes. Often times information pertaining to the patient’s social history may come in very early on when asking about the presenting complaint etc.

Learning objectives

Give examples of the range of problems to which diet contributes

Discuss some of the problems in establishing a patient’s dietary habits

Give examples of the key screening questions to ask every patient when taking a nutrition history

Identify the skills necessary for an effective assessment of drug, alcohol and tobacco use

Use a range of other questions to explore each area more deeply

Activities

1. What information do I need about patients dietary habits?

2. Assessing diet and lifestyle

3. Assessing alcohol, drug and tobacco use

Activity 1: What information do I need about a patient’s dietary habits?

Discuss in 2s or 3s for 5 minutes and then report back to the group:

Activity 2: Assessing a patient’s nutrition history

Take a Dietary History

Many diseases have dietary components and this has been increasingly recognised in recent years. Exploration of your patient’s diet is a crucial part of your understanding of their health and wellbeing

What do you think are the key questions that would allow you to begin to assess a patient’s nutrition history?

What do you think you need to know about a patient’s typical day’s food and drink?

What if the patient is on a special diet? What do you need to know and why?

What about the patient’s height, weight and BMI?

NB when you come to Paediatrics in year 5 you will explore this area with particular relevance to children

Activity 3: Assessing alcohol, drug & tobacco use

Aim: To provide you with an opportunity to focus on specific elements of medical histories

There are many subjects that patients may find it difficult to talk openly about if you do not create the appropriate atmosphere and enquire in appropriate ways. Among these areas are alcohol, tobacco and drug use.

a) Alcohol use

Would it be easy for you to answer questions about your own alcohol consumption? How might you feel about being asked such questions? How honestly / accurately might you answer? Many individuals are unaware of how much alcohol they drink and its potential impact on their health. Whilst it is important to obtain information about alcohol intake from all patients as part of a medical history this needs to be done sensitively.

There are a number of ways in which information can be gathered about alcohol consumption. Most people, who drink alcohol in our society, do so sensibly without leading to health problems. Ascertaining that their drinking habits are in the region of the recommended ranges may be all you need to do at this early stage. However patients can underestimate their alcohol intake and tobacco usage and you may feel it is worth asking about alcohol in an additional way e.g. “so what would your usual pattern of drinking be over a working week?”

Alcohol consumption is usually expressed in terms of units. One unit of alcohol comprises 10 g, equivalent to half a pint of beer, one glass of wine or one measure of spirit.

Recommended maximum units:

Women:	<14 u/week

Men:	<21 u/week (higher levels are controversial)

This equates to:	no more than 2-3 units per day for women

no more than 3-4 units per day for men

Should be taken regularly with food and not in binges.

Consumption over these levels confers a significant risk of an alcohol-related disorder (chronic liver disease; peripheral neuropathy; cerebral atrophy; pancreatitis; and alcoholic cardiomyopathy). Hospital-based surveys report that up to one-third of men admitted to medical and surgical wards have alcohol-related problems. In accident and emergency departments, as many as 40% of male patients may have alcohol-related problems. (Hearne et al, 2002)

The amount of alcohol contained in any alcoholic drink is measured in units. A unit is equivalent 10ml of pure alcohol.

How to measure units

Any drink that you buy will contain a measurement of its alcohol by volume (ABV). ABV is a measurement of how much of that drink is made up of pure alcohol.

The easiest way to work out how many units of alcohol a drink provides is:

find out what the drink’s ABV is

then multiply that by how many milli-litres of liquid are in the drink

then divide that by 1,000

So for a standard pint of strong lager:

its ABV would be 5%

a pint contains 568ml

5 times 568 equals 2,840

divide that by 100, to give a measurement of 2.8 units

The units found in some standard drink sizes are listed below:

a can of standard lager, beer, bitter – 1.8 units

a can of strong lager, beer, bitter – 2.2 units

a pint of standard lager, beer, bitter – 2.3 units

a pint of strong lager, beer, bitter – 2.8 units

a small glass of wine (125ml) – 1.5 units

a large glass of wine (250ml) – 3 units

a bottle of alcopops – 1.4 units

a glass of spirits (25ml) – 1 unit

a bottle of wine – 9 units

a one litre bottle of standard cider – 4 units

a one litre bottle of strong cider – 9 units

a 700ml bottle of spirits – 27-28 units

If a patient tells you they are drinking above the recommended level or you have reasons to suspect they may be at risk (e.g. examination or blood tests suggest alcohol-related problem) then you may want to consider using one of the screening tool such as those outlined below.

Individuals whose repeated drinking may harm their work or social life may be alcoholic. Denial is a leading feature of alcoholism. The level of alcohol related illness encountered by doctors has led to the development of a number of screening tools. Many of them are known by a mnemonic, you do not need to learn all of these but they are useful to explore specific alcohol related concerns.

Mnemonics are often used in order to help you remember to ask about certain conditions etc. They are a form of checklist and need to be used wisely to support your information gathering rather than driving it – this could reduce the flow and relationship building stage of the interview. You may find it helpful to experiment with each and find what works for you (and for your patients).

CONTROL

CO	Can you always COntrol your drinking?

N	Has alcohol ever led you to Neglect your family or your work?

T	What Time do you start drinking? Do you sometimes start before this?

R	Do friends comment on how much you drink or ask you to Reduce intake?

O	Do you ever drink in the mornings to Overcome a hangover?

L	Go through an average day’s alcohol, Leaving nothing out.

This can be used if you suspect that your patient may have problems with drinking.

Clearly not relevant to ALL patients. (Hope et al, 1998)

The following information should also be obtained if alcohol abuse is suspected:

the nature and quantity of alcohol presently consumed per week

the amount of money spent on alcohol per week, as sometimes this reveals a striking discrepancy

the age of onset of drinking

previous drinking habit, including maximum weekly intake and presence or absence of bout drinking

previous episodes of the shakes, delirium, tremors and admission to hospital

time of taking the first drink in the day (regular morning drinking is strongly suggestive of dependence)

with whom and where drinking occurs, at home or in a pub

A recent comparison of alcohol assessment tools identified FAST as the most efficient screening questionnaire for primary care and emergency settings. (Parker et al, 2008 Diagnosis and management of alcohol disorders BMJ, Vol. 336)

Fast Alcohol Screening Test (FAST)

1 drink = 1/2 pint of beer or 1 glass of wine or 1 single spirits

1 MEN: How often do you have EIGHT or more drinks on one occasion?

WOMEN: How often do you have SIX or more drinks on one occasion?

Never	Less than monthly	Monthly	Weekly	Daily or almost daily

2 How often during the last year have you been unable to remember what happened the night before because you had been drinking?

Never	Less than monthly	Monthly	Weekly	Daily or almost daily

3 How often during the last year have you failed to do what was normally expected of you because of drinking?

Never	Less than monthly	Monthly	Weekly	Daily or almost daily

4 In the last year has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?

No	Yes on one occasion	Yes on more than one occasion

If the response to question 1 is Never then the patient is not misusing alcohol. If the response to question 1 is Weekly or Daily or almost daily then the patient is a hazardous, harmful or dependent drinker.

Over 50% of people will be classified using just this one question.

Only consider questions 2, 3 and 4 if the response to question 1 is Less than monthly or Monthly.

If the response to question 1 is Less than monthly or Monthly then each of the four questions is scored 0 to4. These are then added together, resulting in a total score between 0 and 16. The person is misusing alcohol if the total score for all four questions is 3 or more.

In summary:

Score questions 1 to 3: 0, 1, 2, 3, 4

Score question 4: 0, 2, 4

The minimum score is 0

The maximum score is 16

The score for hazardous drinking is 3 or more.

For more information see

http://www.nice.org.uk/aboutnice/whoweare/aboutthehda/hdapublications/manual_for_the_fast_alcohol_screen_test_fast_fast_screening_for_alcohol_problems.jsp

b) Drug use

Use of illegal drugs is widespread in all Western societies, and many young people experiment with so-called recreational drugs such as cannabis or ecstasy. For most people, there’ll be no long term mental or physical health consequences. Other people are not so fortunate, and you’ll encounter people who have mental health problems related to their drug use (such as cannabis psychosis), or who are addicted to stimulants, particularly cocaine and its derivate ‘crack’, or to opiates such as diamorphine (heroin). At the extreme end of the spectrum, some chaotic drug users may use a variety of drugs (poly-drug use). As with alcohol, any enquiries around drug use you make should be sensitive and non-judgemental.

Enquiries into drug use can be made as part of a medication history. This DRUGS mnemonic was developed for use in taking a history prior to anaesthesia. Its use identified a range of drug sensitivities not elicited by “general” history taking. Broad questions like, “Are you taking any medications?” may not lead patients to volunteer information that may be important in any management plan (e.g. paracetamol or non-steroidal anti-inflammatory drugs). Hospital staff need to be sure they are not giving toxic doses by adding to existing treatment. Be aware that an “allergy” may often be interpreted as a side-effect by patients (e.g. sleepiness after morphine). Failure to apply your basic communications skills to question more closely may lead to a patient being denied an effective medication. (Hocking et al, 1998)

Doctor	Any medications prescribed by a registered medical or dental practitioner

Recreational	Tobacco, alcohol, illicit drugs, anabolic steroids etc obtained for non-medicinal use

User	Over-the-counter purchases from a pharmacy, alternative medicines/homeopathy

Gynaecological	Oral contraceptives, hormone replacement therapy

Sensitivities	Response to anaesthetics, including the exact nature of the response

The NO TEARS acronym was reported (Lewis, 2004) in the BMJ. It aims to improve assessment of patient’s current medication use. It is useful for patients on long-term medication or those taking multiple medications – to identify if they are all needed still, if doses need reviewing, if there are newer alternatives etc.

Need and indication	Are they still needed? Does the patient know why they are taking them? Is the dose appropriate?

Open questions	“Do you have any problems with your medication?” “Can I check we both agree what you are taking regularly” “Do you think your tablets are working?”

Tests and monitoring	Assess disease control – is anything untreated? Does any condition require monitoring?

Evidence and guidelines	Has the evidence base changed since the prescription was initiated? Is the dose appropriate?

Adverse events	“Are there any side effects?” remember the prescribing cascade – often side-effects are misinterpreted for a new condition. Is the patient taking any over the counter or alternative medication that may interact?

Risk reduction or prevention	What are the risks to this patient? Are the drugs optimised to reduce the risks?

Simplification and switches	Can treatment be simplified? Replace several low dose agents with a single full dose. Consider cost effectiveness as well as convenience.

c) Tobacco use

What information do you need from patients in order to assess their tobacco use?

How do you raise these topics with patients?

After you have heard the patient’s story, signpost the structure of the interview, e.g. ‘I need to ask you some questions about your, past medical history, family history, social history’ and so on.

Normalise the content, “We ask this of all patients…I need to know about whether you drink alcohol, whether you smoke, or if you use drugs’

Since smoking is implicated in so many illnesses and diseases it is essential that a smoking history is recorded for all patients. Remembering how being judgemental can have an impact on the relationship-building process and try to convey a non-judgemental attitude whilst gathering information. (There may be opportunities at a later stage to mention support to stop smoking etc) There is evidence that merely raising the issue of smoking, in this neutral way during a consultation can be sufficient to help some patients consider changing their behaviours.

Activity 4: Consultation demonstrations

You will observe and then discuss role-plays acted out at the front of the lecture theatre. The demonstrations portray different interview approaches to introducing lifestyle topics such as diet and alcohol. You are encouraged to identify the skills used and why they are used. You are also encouraged to identify how best to approach these potentially sensitive topics.

Summary and review

Understand the range of problems to which diet contributes

Recognise some of the problems in establishing a patient’s dietary habits

Learn the key screening questions to ask every patient when taking a nutrition history

Identify the skills necessary for an effective assessment of drug, alcohol and tobacco use

Use a range of other questions to explore each area more deeply

Identify how cultural issues may affect communication

Identify a range of solutions for managing cross-cultural communication

Complete your SOLE pages before you leave the session

References

Diet

http://guidance.nice.org.uk/CC116

http://www.nhs.uk/conditions/obesity/pages/introduction.aspx

Alcohol

CLARK, W. (1995) Effective interviewing and intervention for alcohol problems (pp 284-293). IN LIPKIN, M., PUTNAM, S. M. & LAZARE, A. (Eds.) The Medical Interview: Clinical Care, Education and Research. Ann-Arbour, New York, Springer-Verlag.

HEARNE, R., CONNOLLY, A. & SHEEHAN, J. (2002-Feb) Alcohol abuse: prevalence and detection in a general hospital. J R Soc Med, 95, 84-87.

HOCKING, G., KALYANARAMAN, R. & DEMELLO, W. F. (1998) Better drug history taking: an assessment of the DRUGS mnemonic. J R Soc Med, 91, 305-6.

LEWIS, T. (2004) Using the NO TEARS tool for medication review. BMJ 329, 434.

LIPKIN, M., FRANKEL, R., BECKMAN, H., CHARON, R. & FEIN, O. (1995) Performing the interview (ch 5, pp 65-82 : see pp 73). In LIPKIN, M., PUTNAM, S. M. & LAZARE, A. (Eds.) The Medical Interview: Clinical Care, Education and Research. Ann-Arbour, New York, Springer-Verlag.

LLOYD, M. & BOR, R. (2004) Communication Skills for Medicine (2nd ed), London, Churchill.

LONGMORE, M. WILKINSON, I. TURMEZEI, T. CHEUNG, C.K. (ed). (2007) Oxford Handbook of Clinical Medicine (7th ed), Oxford, UK, OUP.

PARKER, A., MARSHALL EJ., & BALL D. (2008) Diagnosis and management of alcohol use disorders. BMJ Vol. 336 No. 7642.

SILVERMAN, J., KURTZ, S. & DRAPER, J. (2004) Skills for Communicating with Patients (2nd ed) (pp 57-105), Oxford, Radcliffe Medical Press.

SMITH, R. C. (2002) Patient-Centred Interviewing: An Evidence-Based Method (2nd ed), Philadelphia, Lippincott William and Wilkins.

SNADDON, D., LAING, R., MASTERTON, G. & COLEDGE, N. (2005) History taking (pp 1-37). IN DOUGLAS, G., NICOL, F. & ROBERTSON, C. (Eds.) MacLeod's Clinical Examination. 11th ed. London, UK, Elseiver Churchill Livingstone.

WASHER, P. (2009) How to take a medical history (Ch 3, pp18-25). In WASHER, P. Clinical Communication skills. Oxford, OUP.

http://www.nice.org.uk/aboutnice/whoweare/aboutthehda/hdapublications/manual_for_the_fast_alcohol_screen_test_fast_fast_screening_for_alcohol_problems.jsp

Appendix: Take a Dietary History

Many diseases have dietary components and this has been increasingly recognised in recent years. Exploration of your patient’s diet is a crucial part of your understanding of their health and wellbeing

Key questions

Can I ask you about your Weight?

Do you have any concerns over your weight?

Can you take me thorough a typical day’s food and drink?

Do you eat a special diet?

You need to cover each of these questions, perhaps quite briefly if there is little evidence of problems, but use the discussion below to explore in greater depth as the need arises.

NB Language: for many patients “diet” means a weight reducing diet. “Can I ask about your diet?” gets the reply “I’m not on a diet” ask about “eating habits”.

What is your Weight?

Do you know how much you weigh? (NB it is still important to weigh your patient – see below under “examination”)

Is it increasing/decreasing?

Are your clothes tighter/looser?

Do you have any concerns over your weight?

losing wt unintentionally (eg malignancy, thyrotoxicosis, inflamm. bowel disease, diabetes),

unexpected wt gain (myxoedema, diabetes)

“How do you feel about your weight?” (anorexia/bulimia/ body image disorders)

Can you take me thorough a typical day’s food and drink?

Go through the day finding out what the patient eats from the time they wake up, throughout the day, until bedtime. Those whose diets are of most concern, may not have proper meals and may have very chaotic eating patterns, living on snacks, bingeing and starving, eating sweets, microwaved frozen food in front of the telly etc, etc. shift/night workers may have unusual (although perfectly satisfactory) eating arrangements. So avoid asking (at least initially) about breakfast, lunch, dinner, etc .

Look for evidence of good diet:

most of energy as carbohydrates especially unrefined/wholegrain,

adequate protein intake (remember)

modest amount of fats (unsaturated –from vegetable oils, mono-unsaturated – olive oil) in diet. “Good” fats: oily fish with omega 3 fatty acids protective against heart disease

plenty of fruit and vegetables, provides fibre, vitamins. NHS Promotion of “five a day” (but benefits disputed)

Evidence of bad diet:

lots of refined carbohydrates (sugary fizzy drinks, cakes, biscuits, sweets, “sweet tooth”),

excess fats eg; fried food, “bad” animal fats (butter, fatty meats eg burgers, chicken nuggets)
(NB palm oil, used in many prepared foods is a largely saturated fat despite vegetable origin)

Ready meals often contain more fat, salt, sugar (to add flavour at low cost)

Junk food: “McDonalds diet” – high fat, sugar, salt

Snacks

Large numbers extra calories assoc with small but frequent eating of biscuits etc

Do you snack in between meals?

Do you snack at bedtime or during the night?

Drinks eg

large amounts of fizzy drinks – associated with obesity,

large amounts of coffee, tea or chocolate (containing caffeine or caffeine like substances )– assoc with anxiety, arrhythmias, irritable bowel syndrome)

alcohol – calories+++ , alcoholics may get energy needs from alcohol and omit other foods becoming vitamin deficient (particularly B group), non-alcoholic “social drinkers” often underestimate calories due to alcohol.

Vegetarian (vegetable diet ± dairy/eggs ±fish) & Vegan diets (nothing derived from animals)

Vegetarian diet may be healthy diet, but extremists may be vitamin (particularly B12) deficient,

Some vegetarian diets lack balance so not healthy.

Plenty of vegetarian junk food available full of salt, sugar & fat, so not necessarily healthy

“Do you have to eat a special diet?” If so why?

Differentiate medically necessary diets (eg gluten free for coeliac disease)

From “popular” (ie mainly scientific sounding, but nonsensical) diets, eg detox regimes, candida diet, Gillian MacKeith: “Internationally Acclaimed Holistic Nutritionist ”

Weight loss / Slimming diets: some sound, some wacky. A well thought out, nutritionally sound one from the BHF is http://www.bhf.org.uk/publications/view-publication.aspx?ps=1000807

Food allergies. Genuine food allergies are common and increasing: eg Peanuts (causing anaphylaxis particularly), gluten enteropathy. (NICE review at http://guidance.nice.org.uk/CG116 is helpful). Also lots of bogus ones from quack nutritionists. Finding out who made the diagnosis often helps sort out which is which.

Food intolerance. Non-allergic reactions to foods. Hereditary Fructose intolerance and Lactose intolerance (NB not same as cows’ milk allergy) are examples. Salicylate intolerance (producing rhinitis, nasal polyps asthma etc) is another.

There is a substantial industry devoted to diagnosing food intolerances (eg wheat) for which there is little strong evidence

“Orthorexia” a term coined in 1997 to describe people fixated on what they consider to be healthy eating, which can be so severe as to result in malnutrition

Examination: Measure height and weight

Measure both weight and height (patients may often creatively under/overestimate!)

Calculate BMI (online tools: http://www.bhf.org.uk/bmi/BMI_Calc.html, http://www.bdaweightwise.com/lose/lose_bmi.html ) or manually:

BMI = (kg/m²)	weight in kilograms
height in meters²

Waist measurement is a useful indicator of central obesity (and likelihood of developing “metabolic syndrome”

NB when you come to Paediatrics in year 5 you will explore this area with particular relevance to children

Session 8

Revision Workshop

Session 8: Revision Workshop

Key learning points from the course will be covered

There will be opportunities to observe and practice communication skills

The exam format will be explained and there will be opportunities to ask questions