Communication Skills for Medical

Interview
 Background

Medical Interview is important in our professional

career. There are many problems occur during the
interview between doctor and patient

There are evidence that communication skills could
overcome those problems. We can teach and learn
communication skills
 Background
It’s important
• Hundred of thousand interview will be performed
during a professional lifetime
• Way to help the patient
• A bridge from evidence based knowledge and
working with individual patient
• It a unit of our medical practice
 Background
There are too many problems
• 54 % of patient complaints and 45 % their concern
are not elicited
• 50 % visit, patient and doctor are not agree with the
nature of the presenting problems
• Doctor frequently interrupt the patient, doctor
centered – close approach during gather information
• Evade patient’s ideas and concern, doctor use
jargon, patient recall and understanding was poor
Doctor and Patient Relationship

• Their complaints
•Only need disease and concerns
• Focus on illness
related • Focus on what
information should they do
•Focus on disease in daily life
•Focus on
medication PATIENT

DOCTOR USSUALLY ARE NOT

EQUAL
 Background
Communication skills : the benefit
• A good interviewing process : patient will likely to tell
their stories – broader issues
• Patient satisfaction : acknowledging patient expectation,
nonverbal communication, amount of information
• Patient recall and understanding : increased 30 % by
signposting, good organizing, summarizing, repetition
• Adherence : by asking patient beliefs, concern, their
illness
• Outcome : psychosocial and physiological problems
Doctor and Patient Relationship

•Their complaints and

•Only need disease
concerns
related information
Communication Skills •Focus on illness
•Focus on disease
•Focus on what should
•Focus on medication
they do in daily life

DOCTOR PATIENT
 How can we learn the skills ?
Understanding on disease and illness
(patient’s perspectives)
Doing communication rather than becoming
‘a talk-able checklist’
More attention on the explanation and planning
part

PATIENT CENTERED INTERVIEW

Patient Centered Interview
Patient Centered
Interview Result
1.Fulfill patient’s needs
1.Better Satisfaction
2.Focus on disease and
2.Better patient
illness
compliance
3.Involvement in
3.Better treatment
decision making
result
process
4.Better doctor patient
4.Appropriate
relationship
information and
instruction
Broad types of communication skills

CONTENT SKILLS What doctors communicate –

the substance of their
questioning and response
How they do it – the ways
they communicate with
patient; how they discover
the history; verbal and non
verbal skills they use; how
PROCESS SKILLS
they develop relationship
with patient; the way they
organize and structure What they are thinking and
communication feeling – their internal decision
making, awareness

PERCEPTUAL SKILLS
 Process Skills
Patient Doctor

Illness Five-point Plan Disease

1. Initiating the session Sacred Seven / Basic
Unorganized
2. Gathering Four
information
Someone to talk to Need a working dx/
3. Building the
relationship
Think their problems Think about the th/
4. Explanation and
planning
Common language Medical jargon
5. Closing the session
A shared decision Only their own
making Five Basic Tasks opinions
 Medical Interview
Expanded framework

Five-point plan 1. Initiating the session

Roughly in sequence
a. Establishing initial rapport
1. Initiating the session b. Identifying the reason (s)
2. Gathering information 2. Gathering information
a. Exploration of problems
3. Building the b. Understanding patient’s
relationship perspective
c. Providing structure to the
4. Explanation and consultation
planning 3. Building the relationship
5. Closing the session a. Developing rapport
b. Involving the patient
4. Explanation and planning
a. Correct amount and type
b. Aiding accurate recall &
Five basic tasks understanding
5. Closing the session
 Individual Skills
• Element of the frame work, it could be a
verbal or a non verbal expression
• Those individual skills are organized in form of
Calgary Cambridge Observation Guide (CCOG)
• As a student you should master ALL of
individual skills. It is an obligatory!!
• You should apply appropriate skills for each
medical encounter.
 Initiating the session
Establishing initial rapport
Identifying the reason(s)

Establishing initial rapport

• GREETING : “Hello, I’m dr. Jones. Do come and sit down”
• CLARIFYING YOUR ROLE : “Hello, my name is Catherine. I’m a student doctor
working with dr. Ko. I’’m learning how to interview patients. We might spend 15
minutes for this interview. Would that still be alright?”

• OBTAIN Px/ NAME : “Hello, I’m dr. Jones. Do come and sit down. Can I just
check – is it Mrs. Mary? [pause] I don’t think we’ve met before, what do you prefer
that I call you?”

• DEMO INTEREST AND RESPECT : our position, posture, eye contact, our
perception and attitude, sit at knee-to-knee angle.
 Initiating the session
Establishing initial rapport
Identifying the reason(s)

Identifying the reason(s)

• THE OPENING QUESTION : Use our favorite question
‘What can I do for You ?’ (New patient)
‘How are you getting along with the new pills?’ (Follow up px/)
• LISTENING : Attentive listening skills
1. wait time – shift from speaking to listening, 3 seconds
2. facilitative response – `uh-huh`, `okay`, `go on`, `I see`
3. non-verbal skills – eye contact, posture, movement, affect, vocal
cues, facial expression, environment cues.
4. picking up verbal and non-verbal cues – listening and observe :
patients’ ideas, concern and expectation.
 Initiating the session
Establishing initial rapport
Identifying the reason(s)

Identifying the reason(s)

• SCREENING : checking with the patient all they wish to discuss
“So you’ve been getting headache and dizziness lately. Has anything else
been bothering you ?”
If the patient continues….
“So you’ve also been feeling very tired and irritable and wondering if
you might be anemic. Anything else at all ?”
If the patient stops….
“So as I understand it, you’ve been getting headache and dizziness but
have also been feeling tired rather irritable and a bit low, and your concern is
that you might be anemic, did I get that right? ”
 Initiating the session
Establishing initial rapport
Identifying the reason(s)

Identifying the reason(s)

• AGENDA SETTING : structuring the consultation.
Priorities can be established and negotiated.
‘Shall we start with the new problems, the diarrhea, and then move onto the
problems you have with your medication.’
Doctor agenda can be added :
‘Lets think about your headache. I wouldn’t mind checking on your blood pressure
later on, if that’s all right’
Problem with time
‘I’m not sure that we have enough time to do it all. How about…’
 Gathering information
Exploration of problems
Understanding patient’s perspective
Providing structure to the consultation

Exploration of problems
• STARTING THE PATIENT OFF :
Open ended question
‘Tell me about your headache?’
Patient’s narrative : own word, from when it first start up to the present
‘Tell me about your headache from the beginning’
• ATTENTIVE LISTENING
wait time, facilitative response, non-verbal skills, picking up verbal and non-
verbal cues
 Gathering information
Exploration of problems
Understanding patient’s perspective
Providing structure to the consultation

Exploration of problems
• FACILITATIVE RESPONSE :
– Encouragement : ‘uh-huh’, ‘okay’, ‘go on’, ‘I see’
– Silence : brief silence or pause
– Repetition or echoing : ‘Pain on your chest?’
– Paraphrasing : restating in our word – ‘Kedengarannya anda sedikit
khawatir dalam menghadapi masalah ini’
• FURTHER OPEN QUESTIONS :
‘Tell me more about the pain’
‘You mentioned breathlessness, tell me more about it’
 Building the relationship
Developing rapport
Involving the patient

Developing Rapport
• ACCEPTANCE : accepting response, acknowledging the patients’ rights
to hold their own views and feelings.
Example:
‘I think I might have cancer, doctor. I feel so tired…’, said the patient
‘You’re worried that tiredness might be caused by cancer’ (restating)
‘I can understand that you want to get that check out’ (legitimizing)
‘[stop…]’ (Full stop, allow the patient to continue…)
Building the relationship
Developing rapport
Involving the patient

Developing Rapport
• EMPATHY : overtly demonstrating doctors’ sensitivity to the patient so
that they appreciate doctors’ understanding and support.
Empathic statement are supportive comments that specifically link the
“I” of the doctor and the “you” of the patient.
‘I can appreciate how difficult it is for you to talk about this’
‘I can see that you have been very upset by her behavior’
• SUPPORT : complete the empathic response
Concern, understanding, willingness, partnership, sensitivity
Building the relationship
Developing rapport
Involving the patient

Involving the patient

• SHARING OF THOUGHT : patient and doctor understand each other,
interactive consultation.
‘What I’m thinking now is how to sort out whether this arm pain is coming from
your shoulder or your neck.’ or
‘Sometimes it is difficult to work out whether abdominal pain is due to a physical
or is related to stress’
• PROVIDE RATIONALE : rationale for question or physical examination
 Explanation and planning
Correct amount and type
Aiding accurate recall & understanding

Correct amount of information

• GIVING EXPLANATION AT APPROPRIATE TIME: never give information
prematurely. Give it later after you have all the facts at your disposal.
Example : A mother of an asthmatic child says, ‘Could my daughter have
some antibiotics?’
Prematurely you say, ‘I don’t think so. The cold triggered her asthma…’
But after you check the patient, you find that she has been hot and sick. You feel
has lost the mother confident and say
‘Ah…despite what I said there is a problem here that need antibiotics’
You should answer that question this way
‘That is a good question. We will come back to your question after I examined
your daughter.’
Explanation and planning
Correct amount and type
Aiding accurate recall & understanding

Aiding accurate recall & understanding

• ORGANIZE EXPLANATION : divide into section, logical sequence
‘There are three important things I want to explain. First I want to tell you what I
think is wrong, second, what test we should do, …’
• LANGUAGE : reduction in use of jargon, explanation of jargon when
used, use shorter words, use shorter sentences
• CHECK PATIENT’S UNDERSTANDING : ask the patient to restate in their
own words; clarifies as necessary.
 Closing the session
End summary
Contracting

End summary : summarizing the session briefly and clarify the plan
‘So, just to recap, I think your diabetes has crept out of control a little over the
last year, probably because of the weight that you have put on, but hopefully we
will be able to get your sugar back to a satisfactory level if you can get your
weight down to where it was before. I will find you the diet sheet that I
mentioned and then we’ll see you in two months and see how well you’re
managing. Is that a reasonable summary o what we have agreed?’
Contracting : contracting about the next step for both patient and doctor
‘So, I will dictate a letter to the specialist explaining the problem and fax it later
today. If the test is abnormal, I will phone you before your appointment. Would
you call me after your appointment and tell me what dr Jones has said?’
Thank You !