Year 2 Tutorial 1 Patient Centred Communication Flashcards Preview

Foundations of Primary Care > Year 2 Tutorial 1 Patient Centred Communication > Flashcards

Flashcards in Year 2 Tutorial 1 Patient Centred Communication Deck (68):

Good communication improves

Patient satisfaction
There will be better outcomes of care


Clinical competence

Problem Solving
Communication (this bridges the gap between examination and actually working with patients)


Content of interviewing skills

What doctors communicate

Substance to ques and responses
Information both gathered and given


Perceptual Skills

The ability to understand what the patient and the doctor is both thinking and feeling

Internal decision making
Clinical Reasoning
Awareness of own biases, attitudes and distractions


Process skills

How they communicate

Way they communicate with patients
How they explore the patient history and provide information and explanations
Verbal and non-verbal skills
How structure and organise the communication


Physical factors that can influence a consultation

Site and environment
Adequacy of medical records (continuing health problems, adequate history of illness, patient background and drug history all prevents time wasting in reviewing these when a patient comes for a consultation)
Time constraints
Patient status (are they known or unknown to you)


Personal factors that can influence a consultation

Age (younger doctors can be saught by younger patients etc)

Sex (female doctors may be sought by female patients)

Social class and ethnicity (language difficulties)

Knowledge and skills (important to doctor but less ot patient except when doctor becomes patient)

Beliefs (doctors influenced by medical training whereas the publics are often not medically accurate)

Illness (the type of illness can effect how the consultation will go)


Ethnicity can affect consultations at three levels

Patient level (mastery of local language)

Provider level (provider skills and attitudes)

System level (organisation of referral and appointment systems)


Publics health beliefs are influenced by

Other people
Past experiences


Variables that determine type of doctor patient relationship

Degree of participation
Patients feeling of autonomy
Degree of domination by the doctor


Authoritarian/paternalistic relationship

This is promoted by the medical model. The doctor uses all authority inherent in their status and resides in expertise and skills. The patient feels no autonomy and tries hard to please the doctor. Their views are excluded and as a result they will not actively participate in treatment.


Guidance/cooperation relationship

The doctor still exercises authority but the patient is obedient, has a greater feeling of autonomy and participates more actively in relationship.


Mutual partnership

Appropriate moderation of use of authority by the doctor. The patient is given some responsibility for the successful outcome.

Gives the greatest range of information and the most successful treatment outcome.


Open interview

o Doctor listens and facilitates
o Discusses possible ways forward (treatment, referral)
o Patient acts in partnership
♣ Should be aspired to but at the least ask preferences e.g. tablets or capsules, antidepressants or counselling


Listening and Silence

Asking the patient questions logically from what they have told you

Encouraging them to talk via nodding and eye contact

Picking up on body language



Encourages communication

Attentive facial expression and posture tells the patient non-verbally that you are an interested listener



Communication using manner, gestures or words that don't specify the type of information being sought.

Changing facial expression or posture to display greater interest


Open ended question

Not seeking any particular answer but signals to patient to tell story

Tell me about the pain


Direct question

Asks about specific question

Where is the pain


Closed question

Can be answered with a yes or no

Is the pain severe


Leading question

Presumes answer

The pain is severe


Reflected question

Allows the doctor to avoid answering direct question from the patient

You want to know the cause of the pain



When the doctor sense the patient is not speaking clearly or freely.

"you seem frightened, tell me more about that"


Break down of communication

• 7% verbal, 38% tone of voice and 55% non-verbal


Instinctive non-verbal communication

Crying, expressions of pain or laughter


Learned from life experiences non-verbal communication

These are acquired at an early age and dependent on the culture and family experience


Learned from training non-verbal communication

Communication training courses provide greater insight into communication with others and understanding ourselves


Clinical observation non-verbal communication

Recognising clinical syndromes


Gesture clusters

Single gesture easily misinterpreted. Need to base interpretation on gesture clusters.


Congruence of non-verbal communication

Incongruence between verbal and non-verbal communication requires attention.

Lack of congruence implies omission, inaccuracy, suppression of info


Gaze behaviour

Eye contact indicates interest. If there is no eye contact it can indicate a person being dishonest or holiday back information.



Depressed person looks literally depressed

Anxious person may have folded arms, lefs or feet crossed, also fidgeting or moving around



Holding handbag or fiddling



hand to face gestures e.g. mouth guard, nose touch, eye rub, ear rub, neck scratch


Interest and evaluation

cheek and chin gestures; boredom = head support, hand on cheek = interested evaluation, index finger pointing = negative or critical thoughts



hands clenched. Correlation between hand height and degree of negative mood


Theory of planned behaviour states that behaviour is influenced by

Attitude: positive or negative evaluation of behaviour

Subjective norm: beliefs about significant others behaviour and how important it is to comply with this

Perceptions of control over behaviour: beliefs about internal and external factors which make behaviour easier or harder to perform and change


Person more likely to make positive behaviour change ifL

o ositive attitude towards it
o Brings about consequences important to them
o Believe others think its important they do it
o Feel have necessary resources, skills or opportunities to overcome barriers and lose weight

Also dependent on self-efficacy (the belief of how well one can perform a difficult task or cope with adversity)


Stages of change

o Precontemplation
o Contemplation
o Preparation
o Action
o Maintenance
o Relapse


Communicating with patients with disability

o Don’t give assistance before first asking if pt wants it
o Don’t be upset if assistance refused
o Don’t be afraid to use figures of speech which refer to the impairment
o Don’t use disabled as a noun (i.e. the disabled)
o Don’t use negative language e.g. handicapped, crippled, retarded, deformed

Dont use nouns ending in ic



Cornerstone of free society

♣ People free agents with same right to actions and choices as we ourselves would wish to have in a free society
♣ Accepting people for what they are; different attitudes and beliefs and may choose to live in ways different from us
♣ Not making value judgements about differences and not acting superiorly or inferiorly
♣ Position of superior knowledge and strength in medical and legal professions can arise but this doesn’t mean we are superior – need to avoid medical paternalism


Limitations to autonomy

♣ Acceptability of effects of individual actions on other people
♣ Applied through social pressure and the law of the land



ability to understand predicament of another and respect their autonomy without necessarily sympathising (feeling sorry) for them


Autonomy of health WHO

♣ The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition
♣ The health of all people is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and States.


Patients under hospital care



Patients attending GP



Patients who have symptoms and take action



Patients who have symptoms and take no action



Patients with no symptoms




Symptoms, signs and diagnosis from biomedical model



ideas, concerns and expectations from a patient’s perspective


Percentage of GP appointments with no disease



Patients sources of referral information

o Peers and family
o TV
o Health pages of newspapers and magazines
o “What should I do?” booklet
o SHOW website
o Practice leaflet or website


Increasing role of community pharmacists in

o OTC contraception
o Statins
o Heath checks
o Smoking cessation
o Minor ailments service


Medical factors affecting the uptake of medical care

♣ New symptoms
♣ Visible symptoms
♣ Increasing severity
♣ Duration


Non-medical factors affecting the uptake of medical care

♣ Crisis
♣ Peer pressure – “wife sent me”
♣ Patient beliefs
♣ Expectations
♣ Social class
♣ Economic
♣ Psychological
♣ Environmental
♣ Cultural
♣ Ethnic
♣ Age
♣ Gender
♣ Medical


Sick role

Exempt from daily responsibiliteis

Not responsible for being ill and unable to get better without help from the healthcare professional

Must seek help

Under social obligation to get better ASAP to be able to take social responsibilities again


Health care professional role

Must be objective and not judge pt morally

Must not act out of self-interest or greed but put pt’s interests first

Must obey to professional role of practice

Have and maintain necessary knowledge and skills to treat pts
Right to examine pt intimately, prescribe treatment and has wide autonomy in practice


Adopting the sick role when it's not necessary may lead to

Lack of sympathy from others


Secondary gains from adopting the sick role

♣ Care and sympathy
♣ Concern from family and friends
♣ Financial allowances associated w/ disability
♣ Using apparently disabling illness as explanation for failures
♣ Avoiding work
♣ Restoring status or domination in family
♣ Achieving revenge for bad treatment or pay from employer or insurance company


Advantages of house calls

Useful info on pt’s ability to cope w/ chronic condition or disability

Useful info obtained from relative or carer

Provides social contact for socially isolated


Disadvantages of house calls

Lack of proper examination facilities -> delay in diagnosis

No chaperone

Time consuming

Presence of relative may lead to lack of confidentiality


Other doctors that work in the community

o Community child health specialists
o Community geriatric specialists
o Community family planning services


Bypassing GP's

o NHS 24 and G-Med
o Family Planning and GUM clinics
o Pharmacy minor ailment services
o Physiotherapy
o A&E
o Some parts of private sector


Illness presentation of trivial disease

Trivial disease may present w/ acute and severe illness e.g. viral enteritis with pain and violent diarrhoea


Illness presentation of serious illness

bowel cancer with gradual change in bowel habit


Differences between GP's and hospital doctors

Hospital doctor deals w/ individual pt for short periods of time for specific purpose (to investigate and treat episode of melena or perform a surgical procedure). Decide if specialty can offer pt anything. Matches pt’s needs to expertise and does whatever possible (may be nothing)

The GP is pt’s personal medical adviser until pt death or retirement of dr parts relationship. Role is complex, continuing and personal and difficult for either party to define limits. Apart from terminally ill (many dealt w/ in hospital) deal w/ many unfortunate pts whose illness is difficult to diagnose in diagnostic/medical science terms. Because “buck stops” w/ GP may have to operate outwith boundaries of medical science and give practical help and support


Common conditions seen in GP

o Acute infections (usually upper respiratory)
o Skin disorders
o Psycho-emotional complaints
o Minor accidents
o Intestinal complaints
o Rheumatic complaints
o Symptomatic illnesses of uncertain origin
o Established chronic complaints