What is the definition of a patient-centred interview?
- Focuses on patient's needs in the interview
- Makes history-taking and problem-solving more accurate
- Promotes an active role for the patient in planning and carrying out treatment plans
- Enables more efficient practice
Why should we use patient-centred interviews?
- Improves diagnostic efficiency
- Increases patient satisfaction
- Increases concordance with management plans
- Improves recovery
- Reduces numbers of symptoms
What are the main consultation models?
- Organise the consultation around phases or stages
- Generic ways of working to achieve specific goals
- Combination of Structural & Functional
What are the 7 categories of consultation competence in the Leicester Assessment Package?
- 1. Interviewing/ History taking
- 2. Physical Examination
- 3. Patient Management
- 4. Problem-Solving
- 5. Behaviour/relationship with patients
- 6. Anticipatory care
- 7. Record-keeping
List the tasks and functions of the Calgary Cambridge Model.
- 1. Commencing the consultation
- 2. Gathering information
- 3. Physical examination
- 4. Explanation & Planning
- 5. Closing the consultation
- 1. Building the relationship
- 2. Providing structure
What skills are required for commencing the consultation?
- Put aside the last task
- Attend to personal needs & comfort
- Shift focus to consultation at hand
- Conclude these activities before greeting the patient
- Establishing initial rapport
- Greet the patient, obtain patient's name
- Introduce self, role, nature of interview
- Obtain consent
- Explain confidentiality
- Demonstrate interest and respect, attend to patient's physical comfort
- Identifying the reasons for the consultation
- Open questions
- Use wait time
- Non-verbal skills
- Facilitative responses
- Listen attentively
- Pick up verbal and non-verbal cues
- Confirm list
- Negotiate agenda taking into account, patient & dr
What skills are required for gathering information?
- Explore the patient's problem
- � Encourage patient to tell their story
- � Use open and closed questioning techniques listen attentively
- � Facilitate patient's responses
- � Pick up verbal and non-verbal cues
- � Check out and acknowledge as appropriate
- � Clarify patient's statements
- � Avoid jargon
- � Avoid leading questions
- � Avoid multiple questions
- Actively determine & explore
- � Patient's ideas
- � Patient's concerns
- � Patient's expectations
- � Encourage patient to express feelings
What are the skills associated with effective patient-centred interviewing?
- Exploring the patient's problem
- Establishing a rapport
- Identifying the reasons for the consultation
- Non-verbal communication
- Involving the patient
- Attending to flow
- Forward planning
- Making organisation overt
- Ensuring appropriate point of closure
What skills are required for closing the consultation?
- Forward planning
- Contract with patient re next steps
- Safety net
- Ensuring appropriate point of closure
- Final Check
What skills are required for building the relationship?
- Demonstrate appropriate non-verbal behaviour
- Use of notes
- Pick up patient's non-verbal cues
- Developing rapport
- Accept legitimacy of patients views and feelings
- Use empathy, overtly acknowledge patient's view
- Provide support
- Deal sensitively with embarrassing and disturbing topics
- Involving the patient
- Share thinking with the patient
- Explain rationale
- During physical exam, explain process, ask permission
What skills are required for providing structure?
- Make organisation overt
- Summarise to confirm understanding
- Signpost/use transitional statements, include rationale for next section
- Attend to the flow
- Structure the interview in a logical sequence
- Attend to timing and keeping the interview on task
What is the recommended maximum units allowance for alcohol?
- Men 3-4 units per day (<20 units per week)
- Women 2-3 units per day (<15 units per week)
How do you work out alcohol units?
- Vol (ml) x ABV (%) = Unit
- Bottle of wine: 75 (cL) x 0.12 = 9 units
What is the CAGE analysis used for alcohol?
- C - Have you felt the need to Cut down your drinking?
- A - Have you been Annoyed by criticism of your drinking?
- G - Have you felt Guilty about your drinking?
- E - Have you taken an Eye-opener in the morning?
What is the CONTROL analysis used for alcohol?
- CO - Can you always Control your drinking?
- N - Has alcohol ever led you to Neglect your family or 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, Leave nothing out.
What information would you gather if alcohol abuse is suspected?
- Nature & quantity consumed
- Amount of money spent on alcohol/week
- Age of onset of drinking
- Previous drinking habit
- Episodes of the shakes
- Time first drink in the day
- With whom and where drinking occurs
What mnemonic is used in conjunction with taking a drug history?
- D - Doctor
- R - Recreational
- U - User
- G - Gynaecological
- S - Sensitivities
What questions would you ask a patient about smoking?
- Do you smoke?
- Have you ever smoked?
- When did you stop?
- Why did you stop?
- How many do you smoke?
- Did you ever smoke more than that?
- When did you start smoking?
What are the elements of constructive feedback?
- Cover what has been done well and what areas need developing
- When identifying areas of improvement, work with colleague to develop alternatives
- Give feedback as soon after as possible
- Be descriptive not evaluative
- Talk about specific behaviours & give examples
- Use 'I' and give your experience of the behaviour
- Be honest, accurate
- Do not overload
- Show empathy, respond to colleague's cues
- Use silence effectively
What are the 3 different communication styles?
- Effective - Friendly, effective communicators, relaxed under pressure and leave an impression on people
- Dominant - Argumentative, dramatizing, speak a lot and dominate conversations. May have difficulty moving towards a patient focused style and active listening.
- Non-verbal - Non-verbally expressive using face, eyes and gestures to encourage people and are therefore perceived as empathic and supportive.
What are the sources of non-verbal communication?
- :ye behaviour: Eye contact, gaze, stare
- Facial expression: Smile, frown, crying, raised eyebrows
- Touch: Handshake, pat physical contact during physical examination
- Proximity/ Interpersonal distance: Use of space, physical distance between communicators
- Body movements: Hand and gestures, fidgeting, nodding, foot and leg movements
- Vocal cues: Tone, pitch, rate, volume, rhythm, silence, pause, speech, errors, affect
- Setting: Location, furniture placement, lighting, temperature, colour
- Use of time: Early, late, on time, overtime, rushed, slow to respond
What makes an effective presentation?
- Beginning: Intro, state aims, structure, time, questions/interruptions
- Middle: Interesting, avoid jargon, use aids, stay with theme
- End: Summarise, questions
- Personal Characteristics: Lively, enthusiastic, interested, audible, confident, knowledgeable, appropriate dress/ appearance
- Environmental Characteristics: Equipment, lighting, background noise, arrangement of seating
What aspects of non verbal communication would you take into consideration during a consultation?
- Facial Expressions: If not controlled we can reveal what we are thinking
- Eye Behaviour: Express emotions, maintains feedback, flow of conversation
- Body Positioning: Posture is a key indicator of s dis/interested attitude, Good rapport may be indicated by posture and gesture mimicking, Gender differences in body posture, body movements can be distracting, deception can be indicated by either excessive movement or unusually restricted
- Spatial Distance: Different cultures expect different distances, status and gender influence amount of body space, In consultations a desk between dr and patient can act as a physical barrier which in turn can be interpreted as a psychological one and affect rapport
- Paralanguage/ Vocal behaviour: tone of voice and rate of speaking can reveal emotional state, interruption behaviour is influenced by status and gender, ummms and eerrrrs may reflect difficulty speaking or a habitual way of talking
- Touch: Can be therapeutic, use and degree of touch is influenced by culture and gender, can enable dr to diagnose and directly communicate care and concern for patient, can trigger positive feelings
Why are interpreters underused on the NHS?
- Lack of awareness of the service
- Lack of available service
- Lack of training or confidence in working with interpreters
- Time it takes to organise and conduct a consultation
- Involves sharing a degree of control with a third party
- (Unconscious) institutional racism
What are the advantages of working with trained interpreters?
- More accurate
- More Effective
- Cultural Insights
- Better management plan
What are the difficulties of using a family member as an interpreter?
- From patients perspective a reluctance to discuss sensitive subjects
- Concerns about confidentiality
- Mistranslation may occur
- Can introduce difficulties due to family relationships, emotional involvement, maturity of relative
- Relatives may have their own agenda
What should you do if a patient insists on using a relative or friend as an interpreter?
- Explain the importance of using a professional interpreter and possible serious consequences of misinterpretation
- Respect their wish and record in notes
- Record and impression that interpretation was not full or adequate
- IF you feel there is a conflict of interest you may assert your right to have a trained interpreter on your behalf
What should one check if the interview does not seem to be going to plan?
- Check that the
- - Interpreter speaks English and the patient's language fluently.
- - Interpreter is acceptable to the patient.
- - Patient prevented from telling you things because of the interpreter
- - There is a good relationship with the patient
What are interpreters trained to do with regards to preparation of the interview?
- Name and role of health prof
- Date, time and duration of consultation
- Name, age, sex of pat
- Context of consult (e.g. breaking bad news)
- Exact lang and dialect spoken by pat
- Is any reading or written translation required
- Whether a relative or advocate will be present
What are interpreters trained to do with regards to during the interview?
- Must observe confidentiality at all times
- Conduct themselves professionally
- Respect the values and practices of health prof organisation
- Attentive to wishes of patient
- Respect right of patient to object to interpreter
- Interpret accurately and competently
- Be competent in both lang
- Respect rights of parents being involved with child as patient decisions
- Aware of sensitive factors that vary among individuals and groups - Health beliefs and attitude to illness
What practical things should you do prior to a consultation to make it more effective?
- Check patient and interpreter speak the same language and dialect
- Allow for pre-interview discussion
- Ask interpreter how to pronounce patient's name correctly
What practical things should you do during to a consultation to make it more effective?
- At the start:
- � All interpreter to greet patient
- � Explain his/her role
- � Introduce you and your role
- � Explain interview is confidential
- � Is patient happy with interpreter
- � Encourage interpreter to interrupt and intervene
- � Active listening
- � Allow enough time for consultation
What practical things should you do after to a consultation to make it more effective?
- Check patient has understood everything
- Check whether patient has any questions
- Have a post consultation discussion with interpreter
Identify the skills required for giving out information to patients.
- To gauge the correct amount and type of information
- To provide explanations that the patient can remember and understand
- To use an interactive approach to ensure a shared understanding
- To involve the patient and plan collaboratively to the level that the patient wishes
Why do people not adhere to behaviour changes?
- Dr unclear about advice
- Patient not understood/accepted
- Patient may disagree with advice
- May have secondary gains from illness
- Discrepancy between the doctor's and patient's perception of risk
- May understand/agree but too difficult -Impractical/expensive
- Unnaturalness of manufactured drugs
- Danger of addiction and dependency
- Danger of becoming 'immune over time'
What domains should be considered when promoting behavioural changes?
- Cognitive Level: Information: Assess awareness, knowledge, concepts, explain facts, clarify, provide information.
- Attitudinal Level: beliefs, intentions, readiness for change: Assess attitudes, belief, readiness to change, build confidence
- Instrumental Level: Assess cues, consequences and conditions, instruct and practise necessary skills
- Planning & Coping Level: Coping behaviour, coping skills: Assess coping skills, pan reminders, find incentives, reinforcements and rewards
- Social Level: Social support: Assess social support, resources. Mobilise support, resources.
How do you assess motivation?
- On a scale of 1-10, where 1 means I'm not at all interested and 10 means this is top priority for me right now, how motivated are you to stop smoking (lose weight, start an exercise program)?
- 1-2 Need to use precomtemplation interventions
- 3-7 exploring ambivalence would be useful
- 8-10 preparation and action interventions could be bought up
How do you assess Self-efficacy?
- On a scale of 1-10, where 1 means no chance of making it and success to 10 means 'piece of cake' how likely are you to succeed at stopping smoking, losing weight, starting an exercise program.
- 1-2 Patient lacks information, does not know potentially useful action strategies, or perceived major emotional or social barriers to success
- High Score implies patient feels confident
Name the stages of the transtheoretical model of behaviour change.
- 1. Pre-contemplation
- 2. Contemplation
- 3. Preparation
- 4. Action
- 5. Maintenance
- 6. Termination
- 7. Relapse
Using the transtheoretical model of behaviour change, how can clinicians help patients give up addictions?
- Pre-contemplation: Create Doubt
- Contemplation: Help weigh up risks and benefits
- Preparation: Help pt determine what they might do
- Action: Help pt determine best course of action
- Maintenance: Help pt identify and use strategies to prevent relapse
- Termination: Give encouragement
- Relapse: Help pt renew process of change
Identify how patient's feel at each stage.
- Pre-contemplation: Person is unaware that their behaviour is a problem and has no interest in changing
- Contemplation: Person aware that their behaviour may be a problem and may cause ill health and they start to think about acting on it
- Preparation: Person has intention to change
- Action: Person starts to experiment with changing behaviour
- Maintenance: Person integrates new behaviour into their daily life
- Termination: New behaviour becomes the habit
- Relapse: Return to original behaviour
What skills can a Dr use to enhance behavioural change from pre-contemplation to contemplation?
- State diagnosis/problem 'the diagnosis/problem is'
- Personalise message 'this means for you..'
- Offer support 'I can help you by...'
- Assess problem awareness 'Where do you want to start'
- Assess and clarify knowledge 'what do you know about...?'
- Assess and attend to feelings 'What do you feel about...?'
- Assess readiness to change and build commitment 'what are you willing to do...?'
What skills can a Dr use to enhance behavioural change from contemplation through to preparation and action?
- Explain options and alternatives provide specific recommendations - 'your options are...'
- Ask for a decision and start negotiating a plan for a trial - 'how do you feel about that?'
- Assess and reinforce skills and resources - 'how do you want to do it?'
- Anticipate problems - 'what problems might arise?'
- Identify and mobilise support - 'who or what might help you?'
What skills can a Dr use to enhance behavioural change from action to maintenance?
- Offer support - 'I'm glad to see that you have succeeded in...'
- Arrange a follow up - 'I'd like to see you again in...'
- Check and reaffirm agreed plan - ' until we next meet what will you do?'
- Goal setting - SMART
What does SMART stand for and when is it applied?
- S - Specific
- M - Measurable
- A - Attainable
- R - Relevant
- T - Time related
What skills can a Dr use to enhance behavioural change whilst the patient is in relapse?
- Role: Offer support & Normalise
- - Name feelings and reassess commitment to change
- - What are you thinking?
- - How are you feeling?
- - What do you want to do now?
- - How committed are you to try again?
- - Where should we go from here?
What reflective statements can one use as a Dr?
- Listen to what patient says
- Consider what patient means
- Describe what you think patient means as a statement not as a question
Describe ways in which written communications are used in health care.
- Individual Patient: Correspondence, medical records, prescriptions, consent forms etc.
- Generic Patient: Drug leaflets, information leaflets, print media etc.
- Generic Provider: Drug leaflets, clinical guidelines, professional staff appraisal, print medias.
What are key aspects of effective written communication?
- Tailored to the purpose & audience
- Logical, clear & unambiguous
- Correct grammar & spelling
- Appropriate length and format
- Appropriate use of language
- Contains relevant accurate information
How can a patient's individuality be maintained in written communication?
- Correct spelling of patient's name
- Accurate reflection of what took place
- Language and terms patient can understand
- Use quotes from the patient where suitable
- Use 'you' to be specific
- Be sensitive to issues of confidentiality
What are the 12 standards from the RCP for generic medical record keeping standards?
- 1. The patient's complete medical record should be available at all times during their stay in hospital
- 2. Every page in the medical record should be available at all times during their stay in hospital
- 3. The contents of the medical record should reflect the continuum of patient care and should be viewable in chronological order
- 4. Documentation within the medical record should reflect the continuum of patient care and should be viewable in chronological order
- 5. Data recorded or communicated on admission, handover and discharge should be recorded using a standardised proforma
- 6. Every entry in the medical record should be dated, timed (24hr clock), legible and signed by the person making the entry. The name and designation of the person making the entry should be legibly printed against their signature. Deletions and alterations should be countersigned.
- 7. Entries to the medical record should be made as soon as possible after the event to be documented and before relevant staff member goes off duty. If there is a delay the time of the event and the delay should be recorded
- 8. Every entry in medical record should identify the most senior healthcare professional present (who is responsible for decision making) at the time the entry is made
- 9. On each occasion the consultant responsible for the patient's care changes, the name of the new responsible consultant and the date and time of the agreed transfer of care, should be reorded
- 10. An entry should be made in the medical record whenever a patient is seen by a Dr. When there is no entry in the hospital for more than 4 days for acute medical care or 7 days for long-stay continuing care, the next entry should explain why
- 11. The discharge, record/discharge summary should be commenced at the time a patient is admitted to hospital
- 12. Advanced decisions to refuse treatment, consent, cardio-pulmonary resuscitation decisions must be clearly recorded in the medical record. In circumstances where the patient is not the decision maker, that person should be identified e.g. lasting power of attorney
When is it appropriate to use telephone communication in healthcare?
- Patient telephone consultation
- Telephone follow-up for long term conditions
- Professional handovers
- Consultation with a senior colleague
- Obtaining test results
- NHS direct
- Preventing missed appointment
- OOH triage centres
What are the advantages of telephone conversations?
Some patients may feel they can open up more
What are the disadvantages of telephone conversations?
- Lack of non verbal clues
- No direct observations
- No examinations
- No smells
- No diagnostic tests
- Need for active listening
- Third party consultations
- Technical difficulties
- Hearing impairment
- Cultural & Language obstacles
- Lack of telephone
When could telephone communications are used in health care
- Long term conditions: Stable asthma, Diabetes, Monitoring of depression
- Routine post-op follow up: TURP, children tonsillectomy
- Umcomplicated acute conditions: UTI
- Health promotions: Counselling for smoking cessation
What key aspects are there for structuring a telephone conversation?
- - Check pt notes/results
- - identify known conditions, drug allergies and recent consultations
- - Introduce yourself
- - Build a rapport using tone of voice
- - Thorough history as a lack of physical examination
- - Use open and closed questions to include/exclude conditions
- - Ensure pt's agenda has been established
- - Allow time for pt to ask questions
- - Agree on plan of action
- - Provide treatment/disposition advice
- - Let caller disconnect first
- - Accurate records
- - Record date & time of call
- - Record pt's name, age, gender
- - Summarise points
What key skills are there for presenting information via a telephone conversation?
- Active listening & detailed history taking
- Frequent clarifying & paraphrasing
- Picking up cues
- Offering opportunities to ask questions
- Offering patient education
What key skills can be used for presenting information to colleagues via telephone?
- I - Identification
- S - Situation
- B - Background
- A - Assessment
- R - Recommendation