Psychology
Dr Nesif Al-Hemiary
Lec. 19 Communication skills part 2Communication Skills in Patient Interview
Bio-psycho-social Model of diseaseIn 1977, George Engel at the University of Rochester, published a seminal paper that described the bio-psycho-social model of disease, which stressed an integrated systems approach to human behavior and disease.
The bio-psycho-social model is derived from general systems theory. The biological system emphasizes the anatomical, structural, and molecular substrate of disease and its effects on the patient's biological functioning;
the psychological system emphasizes the effects of psychodynamic factors, motivation, and personality on the experience of illness and the reaction to it;
and the social system emphasizes cultural, environmental, and familial influences on the expression and the experience of illness.
Engel postulated that each system affects, and is affected by, every other system.
Models of patient-doctor interaction
Paternalistic model.
Informative model.
Interpretive model.
Deliberative model.
The paternalistic model
In a paternalistic relationship between the doctor and patient, it is assumed that the doctor knows best. He or she will prescribe treatment, and the patient is expected to comply without questioning.
Moreover, the doctor may decide to withhold information when it is believed to be in the patient's best interests. In this model, also called the (autocratic model) the physician asks most of the questions and generally dominates the interview.
Circumstances arise in which a paternalistic approach is desirable : in emergency situations the doctor needs to take control and make potentially life-saving decisions without long deliberation. In addition, some patients feel overwhelmed by their illness and are comforted by a doctor who can take charge.
In general, however, the paternalistic approach risks a clash of values. A paternalistic obstetrician, for example, might insist on spinal anesthesia for delivery when the patient wants to experience natural childbirth.
The informative model
The doctor in this model dispenses information. All available data are freely given, but the choice is left wholly up to the patient.
For example, doctors may quote 5-year survival statistics for various treatments of breast cancer and expect women to make up their own minds without suggestion or interference from them.
This model may be appropriate for certain one-time consultations where no established relationship exists and the patient will be returning to the regular care of a known physician.
At other times, the informative model places the patient in an unrealistically autonomous role and leaves him or her feeling the doctor is cold and uncaring.
The interpretive model
Doctors who have come to know their patients better and understand something of the circumstances of their lives, their families, their values, and their hopes and aspirations, are better able to make recommendations that take into account the unique characteristics of an individual patient.
A sense of shared decision-making is established as the doctor presents and discusses alternatives, with the patient's participation, to find the one that is best for that particular person.
The doctor in this model does not abrogate the responsibility for making decisions, but is flexible, and is willing to consider question and alternative suggestions.
The deliberative model
The physician in this model acts as a friend or counselor to the patient, not just by presenting information, but in actively advocating a particular course of action.
The deliberative approach is commonly used by doctors hoping to modify injurious behavior, for example, in trying to get their patients to stop smoking or lose weight.
The Medical Interview
Initiation of the interview
Gathering of information
Physical examination
Explanation and planning
Closing of the interview
Old versus New Approaches
2 Fs (Find it & Fix it).
4 Es (Engagement, Empathy, Education, Enlistment).
Initiation of the interview
Greet the patient
Introduce yourself
Show respect and care: make sure that the patient is sitting comfortable.
Ask about the reasons of the consultation
Make a list of the problems that need to be discussed.
Gathering of information
Encouragement
Open versus closed-ended questions
The biomedical perspective
The patient perspective
Listen carefully
Pay attention to emotional cues
Pay attention to non-verbal cues
Clarify unclear information
Summarize
Avoid medical jargon( language)
Providing a structure for the interview
Make a logical order of the different parts of the interview
At the end of each part ; summarize and clarify before moving to the next.
Make short pauses between different parts and use appropriate opening sentences.
Keep time limits so that you can finish the interview within 45-60 minutes.
Building of a relationship
Show a proper non-verbal cues: eye to eye contact, facial expression , attention to patient’s gestures , movements, and tone of voice
Don’t remain busy with recording notes
Show trust
Accept patient views
Be empathic
Be supportive
Be sensitive and delicate during emotional upsets.
Make a mutual relationship with the patient(share the patient in decision making).
Physical examination
Explain before each step.
Ask for permission before each step.
Explanation
Give enough information( like etiology, management, and prognosis of the illness)
See what kind of information the patient have , give information that can be understandable by the patient and that can be satisfactory.
Avoid difficult language and medical terms.
Use pictures and drawings
Avoid premature advice and reassurance.
Integrate the patient perspective
Planning
Participation in decision making ( let the patient understanding the process of decision making, make him a partner in decision making and increase his commitment to the decision).
Explain the available options for management.
Consider what the patient prefers.
See if the patient has any concerns before making a decision.
Closing the interview
Agree with the patient to review the next steps.
Safety network : explain expected and unexpected complications and explore how the patient can get help.
Agree on the next visit.
Provide a suitable closing remarks.