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CONTENTS
Section A . 1
Introduction to Behavioural Sciences 1
Holistic vs. Traditional Allopathic Medicine 2
Health Care Models and their Clinical Applications 3
1. Bio-Psycho-Social (BPS) model of health and disease 3
2. The Integrated ModeL of Health Care: Correlation of Body, Brain,
Mind, Spirit and Behavioural Sciences 5
3. The Public Health Care Model g
Non-pharmacologicaL Interventions (NPIs) in Clinical Practice 11
1. Communication Skills 11
2 Counselling 14
3. Informational Care (IC) 16
. Handling Difficult Patients and their Families i8
5. Breaking Bad News 20
6. Crisis Intervention and Disaster Management 27
7. Confticl. Resolution 29
Empathy 32
Sample MCQs and Essay Questions 33
Section B 35
Medical Ethics and Professionatism 36
Relevance of Ethics in the Life of a Doctor 37
;. Scope and Meaning of Medical Ethics 37
2. Guiding Principles of Medical Ethics 38
3. Common Ethical Issues in Medical Practice 39
4. Common Ethical Dilemmas in a Health Professonat’s Life 43
. Doctor-Patient Relationship 48
Rights and Responsibilities of Patients and Doctors 49
a. Rights of the Patient 49
b. Responsibilities of the Patients 50
c. Rights cf the Doctor 50
d. esponsibilities of the Doctor 50
Psychological Reactions in Doctor-Patient Relationship 52
a. Social bonding 52
b. Dependence 53
c. Transference 53
U. Counter-transference 54
e. Resistance 55
f, Unwell Physician / Burn-out 56
Professionalism in Heatth Care 57
- a. Knowledge 57
b.Skills 57
c. Attitudes 58
Sampte MCQs and Essay Questions 61
Section C 63
Psychotogy in Medicat Practice 63
a. Role of psychologicaL factors in the aetiology of health probLems 63
b. Role of psychological factors in the precipitation (triggering) of iltnesse 63
c. Role of psychological factors in the management of illnesses 64
U. Role of psychological and social factors in diseases causing disability.
handicap and stigma 64
e. Role of psychological factors in patients reactions to illness 64
f. Medicat[y Unexplained Physical Symptoms (MUPS) 64
Principles of Psychology 65
1. Learning 65
2. Metacognition 72
3. Memory 74
4. Perception 81
5. Thinking 85
6. Emotions 92
7. Motivation 94
8. Intelligence 97
9. Personality Development 101
NeurobiologicaL Basis of Behaviour 108
Emotion 109
Language 114
Memory . 116
ArousaL . 117
Sleep 118
Sample MCQs and Essay Questions 123
Section D 125
Socio[ogy and Anthropology 125
Introduction 125
1. Sociology and Health 127
2. Anthropology and Health 135
Sample MCQs and Essay Questions 141
Section E 143
Psychosociat Aspects of Health and Disease 143
Health and NormaLity 143
Defence Mechanisms 145
Psychosocial Assessment in Health Care 14$
ClinicaL Situations Demanding a Comprehensive PsychosociaL Assessmer 148
Psychological reactions to IlLness and Hospitalization 149
Psychosociat Assessment ... 153
Psychosocial Issues in SpeciaL Hospital Settings 157
a. Coronary Care Unit 157
b. Intensive Care Unit 158
c. The Emergency Department 159
d. Psychosocial Aspects of Organ Transplantation 159
e. The Dialysis Unit i6o
f. Reproductive Health 161
g. Paediatrics Ward 163
h. Oncology 167
i. Operating Theatre 168
PsychosociaL Peculiarities of Dentistry 170
PsychosociaL Aspects of Atternative Medicine 174
Common Psychiatric Disorders in General Health Settings 175
a. Mixed Anxiety and Depression in
b. Panic Disorder 179
c. Unexplained Somatic Complaints: Persistent Complainers 181
d. Dissociative and Possession States 182
e. Drug Abuse, ALcohol & Tobacco Use 184
f. Suicide and Deliberate SeLf harm (DSH) 188
g. Delirium 189
PsychosociaL Aspects of Gender and SexuaLity 192
Sexual Identity 192
Gender Identity 193
Sexual Behaviour 194
Gender differences in Sexual Behaviour 194
Masturbation 195
Sexual orientation 195
Psychiatric morbidity ig6
SexuaL Disorders 196
SexuaL Dysfunction 196
Disorders of SexuaL Preterence/ Paraphilias 197
Gender Dysphoria (DSM V) or Gender Identity Disorder (lCD io) 198
Management of Gender and Sexuality Issues 199
PsychosociaL Aspects of Pain 201
Psychosocial. Aspects of Aging 207
Psychosocial. Aspects of Death and Dying 210
Psychotrauma 211
Psychosocial Aspects of Terrorism 214
Stress and its Management 220
Job-related Stress & Burnout 222
Response to stress 222
Stress Management 225
Sample MCQs and Essay Questions 228
Appendix 230
Suggested Reading 232
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t’
hitroduction to Behavioura’ Sciences
As the name implies, behavioural sciences deal with the study of human
behaviour through an integrated knowledge of psychology. neuroscience,
sociology and anthropology. It is now widely recognised that the
psychological and social sciences play a role equal to biotogical sciences
in determining states of health and disease.
Amongst the behavioural sciences, psychology and neuroscience
contribute to the study of the human mind and the roLes played by its
various functions. They examine the role of functions such as emotions.
thoughts, cognitions. motivations, perceptions, and intelligence in
maintaining health or causing disease. Psychology also seeks to
understand how the development of personality takes place.
Another major influence on human behaviour is the role ptayed by the
family, the society and the community. The study of sociology helps a
doctor understand the influence of society and its various units and
institutions on the processes of heaLth and how they can change to cause
disease. The role of family. gender issues, social classes, socioeconomic
circumstances, housing, employment, social supports and social policies in
maintaining health or causing disease is studied in this domain.
Medical anthropology is the study of the effects of the evolutionary
history of human beings. It highlights their cultural history, racial
classification, geographic distribution of human races, and effects on
health and signs and symptoms of disease. It also involves the study of
cultural methods of deating with diseases and other distressing events
of human life. What disease is to be stigmatised, which symptom is to be
kept secret, what is to be handed over to the doctors and what is to be
dealt with by the faith healers is determined largely by anthropological
influences on a culture. Understanding the health belief model, attitudes
of a society and the rote culture assigns to a sick person can highlight the
importance of anthropology for a health professionaL
F
ECTIONA
èhaviourai Sciences and their Relevance to Healthcare
— OUTLINE
Introduction to Behavioural Sciences
Holistic vs. Traditional Medicine
Models of Health Care
Non-pharmacological Interventions
A
The behavioural sciences add to the disciplines of anatomy,
physiology, and biochemistry to support the study of holistic medicine.
t
Chapter 1
Holistic vs. Traditional Allopathic Medicine
Holistic medicine is inspired from the theory of Holism, which states that
reality (including all living matter) is made up of unified wholes that are
greater than the sum of their parts. Each sub-part is linked with the other in
a dynamic way. Holistic medicine considers mind, body and spirit sub-parts
that form the person; a whole that is greater than the sum of its parts. It
denies the separation of mind and body advocated in traditional atlopathic
medicine.
Traditional allopathic medicine works on a biomedical model that aims to
treat the diseased part of the human being. Holistic medicine on the other
hand is committed to the restoration of health and wellness to the
person as a whole, rather than focusing on the diseased part alone. A
health professional committed to holistic medicine is expected to
understand the following elements of this approach: Person, Environment,
Health and Physician.
Person: A human being who has the well-integrated etements of mind,
body and spirit held in a dynamic balance.
Environment: A set of external forces that can inftuence our experience
of health and disease such as family, community, culture, socioeconomic
resources, access to health care and quality of heaLth care. These external
factors help shape our attitudes and health beliefs, Attitudes and beliefs
that we learn from our environment have the capacity to either support or
disrupt the dynamic balance of our mind, body and spirit.
TraditionalADopathic Medicine
methodology: Ju5t x the pmbLem
Artist Laura Zomhie
HeaLth: A dynamic state of well-being achieved through a mind-body-spirit
balance that hetps an individual realise their full potential.
While the former three teach about the body, psychotogy and
neuroscience educate the physician about the mind, sociology and
anthropology illustrate the evolution of human spirit and the factors that
constantly inftuence it.
T
I.:
Physician: A person who supports health (as defined above) rather than
one who merety treats disease. A practitioner of holistic medicine,
therefore, believes that health results from a dynamic and interactive
reLationship between the person, his environment and the physician.
4
Holistic medicine demands that a physician must be a person who has the
following characteristics:
• BeLief in the potential of the heating act
• Capacity to listen and empathise
Respect for the dignity of human beings
• Tolerance for difference of opinion 4’
• A gentte spirit
• Ability to mix creative thinking and intuition with scientific thought
• Will to never give up hope even against heavy odds
The knowledge of physical sciences and anatomy, physiology, and
biochemistry provide adequate basis for the practice of traditional
allopathic medicine. The practice of holistic medicine, however, demands
the knowledge of behavioural sciences as welt as natural sciences.
Chapter 2
Health Care Models and their Clinical
Applications
;. Bio-Psycho-Sociat (BPS) modeL of heatth and disease
In 1977, George Enget theorised the importance of integrating the
traditional biological (pathophysiological or structural) aspects of
medicine with the behavioural sciences (psychology, sociology and
anthropology). He put forward the concept of the Bio-Psycho-Sociat
(BPS) perspective of health and disease. Engels BPS model was based
on three principles:
a) Disease is a result of multiple factors that interact to make an
individual feel ilL Illness and disease are not a consequence of
biologicaL factors alone.
b) An individual is composed of a complex, integrated system
composed of interacting subsystem elements of mind, body, spirit
and social relationships, alt having feedback loops. Any change in
one will result to changes in other systems.
c) Biological, psychological, and social factors form a triad to interact
and serve as determinants of disease.
BIOLOGICAL
Biopsychosociat Modet
He proposed that the biological, psychological and social systems work
together to cause disease. The biological system ensures a structural,
biochemical and a molecutar study of a disease. The psychological
system provides insight into the role of personality, attitudes, attributes and
motivation in the genesis of the illness. The social system emphasises the
impact of family, society, social forces and culture on the aetiotogy,
presentation and the management of a given illness.
The biopsychosocial model stresses that understanding and manipulation
of the psychosocial environment of a patient is just as important to
recovery as the study of pathophysiological processes and methods of
treatment. Engel proposed that death of a significant other, grief, loss of
self-esteem, a threat to one’s life, property or integrity, even victories and
reunions were events that can trigger a medical, surgical or a psychiatric
condition. The biopsychosocial model, therefore, provides a
comprehensive clinical approach towards the practice of holistic medicine.
This approach lays great emphasis on the doctor-patient relationship. This
involves psychosociat assessment, the use of communication skills, infor
mational care, counselling crisis intervention and extension of care to the
family. One of the significant contributions of the BPS model in health care
is the emphasis it assigns to the use of interventions that do not
involve surgery or drus: the non-pharmacological interventions.
Ctinicat AppLication of BPS Model
It is useful for a health professional committed to holistic medicine to
approach patients using the BPS model. Research shows that biomedical
and behavioural factors come into play in infectious as well as non-infec
tious disordets. A patient of dengue fever is suffering at a biological level
on account c breakdown of the body’s reticuloendotheLial system. Social
issues related to drainage of fresh water, poor disposal of waste, however,
are also contributing factors. Psychological and anthropologicalfactors
such as risk taking behavior and inappropriate dressing in high risk settings
are equally important in the spread of this infectious disease. Sexually
transmitted diseases, HIV-AIDS, and hepatitis epidemics may atl occur due
to risk taking behavior and poor protection strategies.
Non-infectious disorders ar- also affected by biopsychosocial factors. This
includes heart disease, di&’• tes mellitus, cancer, and depression. This is
because changes n hormones, immune factors, metabolism and
neurotransmitters re alt associated with socioeconomic stressors.
Occupational hazards, dietary habits, child rearing practices, personality
development, exposure to childhood trauma are alt governed by culture
and geography. Many metabolic disorders are now called ‘life-style
disorders’ due to the socio-cultural and psychological factors that work
hand in hand with biological factors. Another example of the BPS model
determining disease is seen in road traffic accidents due to drug and
alcohol abuse.
‘U -
college together Hamid decidedto stayin the hostel ashe belonged to a
dtstant village while Hassanpreferred to cometo cottege ftam home eveiy
day Soon the stress ofmedical studies started to mount Hatndpraposed
that theyshould trysmoking a cigarette to qchieve ‘betterconcent,r%ion
white studying Hassan readily agreed and they both started to iridutge ip
smoking white studying togetherin the evenings. Hamidsoon developed a
cough, but continued to smoke HassdAsparet7tsfound out and discussed
the dangerous consequences ofhis habit Hassan opted out ofsmoking,
joined a gym andstarted to exercise regularly He consulted his
behavioural sciencesteacher to learn some innovative methods oftudyIng
and techniques to give up smoking This helped him feel healthier and
conceritmte befterin his studies He tned to convince Hamid tojoin him in
these newly learnt techniques btHamtd did not Usten Within ayear Hamid
went on to startuseofcannabis and a few months laterbecame addicted
to a stimuLantMsgiades as welt as his physicat health detenoratedand he
failed his annual exams. He started to develop repeated episodes ofchest
infections Repeated absence fann classes and poorperfoiwance in the
academics ted to his eventuat wfthdrawat from medicat college, while Hassan
went on to’continue his medicqt studies enjoying goodfi7ysicathealth.
The story of Hamid and Hasan illustrates an interplay of bioLogicaL
psychologicaL and social factors resulting in contrasting outcomes on
account of the differences between the two friends in these domains. The
story highlights how homeostatic mechanisms failed Hamid. On the other
hand, restorative and predictive atlostatic behavior (discussed below) such
as parental concern, joining a gym and counselling by the behavioural
sciences teacher helped Hasan overcome a stress they both shared. The
outcome of disease in Hamid and health in Hasan was decided by an
integrative interplay of all three domains, Social support and allostatic
mechanisms were in place for Hasan, but none of these were avaiLable for
Hamid. Hasan managed to effectively turn the stress of studies into
eustress, He was, thus, able to achieve a better state of heaLth.
a The Integrated ModeL of HeaLth Care: CorreLation of Body,
Grain, Mind, Spirit and BehaviouraL Sciences
The integrated model of health care is a step ahead of the
biopsychosocial modeL It suggests a dynamic functional link between five
domains of human beings: biological, cognitive, behavioural, sociocu[tural,
and environmental. In this model, health is a state of a harmonious
equilibrium between these domains which occurs in response to eustress
or distress. This state is achieved through processes called homeostasis
and attostasis.
‘1
p
Homeostasis is a reactive state that ensures harmony within the body
systems through adaptive negative feedback loops. It also uses reactive
behavioural adjustments in domains operating outside the body.
-*
BEHAViOURAl.
Integrated Modet of Heatth Care
Attostasis is an adaptive mechanism in which the individual makes the
adaptations by predicting changes in advance, rather than in reaction.
These adaptations are creative and organised multisystem changes made
in anticipation of a possible challenge to health.
A typical example of homeostasis is the increased intake of fluids and salts
while working on a hot summer day. Allostasis on the other hand would be
to organise your work schedule in advance to be undertaken at the time
of the day when it is Least hot, so that you may not need the extra salt and
fluids.
In the Integrated Model, an optimum degree of stress called Eustress is
considered appropriate and necessary for a person to function and stay
healthy.
Eustress is seen as moderate, motivating and inspiring. It ensures optimum
functioning of homeostatic and atlostatic mechanisms that keep alt five
domains (biological, cognitive, behavioural, socioculturat, and
environmental) working in synergy.
SOCIO- ENVIRON
cucll.rnAL MENTAl.
Distress is a state in which the homeostatic and atlostatic mechanisms of
biological, behavioural, cognitive, environmental and sociocultural
domains are challenged by extrinsic or intrinsic factors. Challenge to any
one domain influences alL the other domains and sets up a restorative
feedback loop. If the systems respond with effective homeostatic and
allostatic responses health is restored. If the stressor worsens to result
in distress, a failure of homeostatic and allostatic mechanisms resuLts in
disease and illness.
Clinical Application of Integrated Heatth Care Model
Separating Disease from Sickness, Distress and Stress
Alt patients who develop symptoms and report to hospitals are not
suffering from disease. The body and mind respond to any disturbance
in biological, sociaL cognitive, behavioural and environmental domains
through unpleasant experiences which can be called symptoms. Most
of the time, symptoms serve as a stimulus for adaptive mechanisms and
homeostasis is restored through changes in the body, mind, social support
and environmental manipulation. Not all individuals reporting to hospitals
are, therefore, ‘patients’ in the biomedical sense. They may not require
Distress: This is the earliest unpteasant departure from a state of
happiness and health. This state appears when homeostatic and allostatic
mechanisms in the body and mind are challenged by stress. This sets into
motion immediate restorative mechanisms in the body in order to attain a
feeling of health through physiologicat means. No structural or
psychologicat damage takes place at the level of the body and mind.
Changes are visible, however, in the individuaL’s behaviour and social roles
as functioning of the individual may be affected. S/he can readity return
to normal following the restoration of homeostasis without any biological
interventions in the form of medication or surgery. Minor environmental
manipulation, mobilisation of social support and adjustments in cognitive
and behavioural domains may be all that is required.
Distressful states may present with the same symptoms as that of a
disease. Common distress symptoms include headache, backache, vague
bodily discomforts, feelings of indigestion, heaviness in abdomen, lack of
sleep, appetite, lethargy, fatigue. weakness, dizziness and Light
headedness. Individuals may also experience an urge to remain silent,
avoid responsibility at home or work and have a general feeling of inability
to cope.
These feelings in a state of distress usually last for a few hours, or a day or
two, but never beyond a week in one go. They are self-limiting, and
improve with pleasant occurrences such as meeting friends, sharing
feelings, indulging in a hobby orjoyful pursuit or even a couple of
paracetamot tablets.
PERFORMANCE
RELAXED
A
INACTIVE
ANGER/FRUSTRATION/
PANIC
FATIGUE EXHAUSTION
- I.
EUSTRESS STRESS BURNOUT
OVERLOAD
STRESS
Stress-Performance (Yerkes-Dodson) curve
laboratory and radiological tests or treatment with medication. It is, thus,
important to separate disease from distress, sickness and iltness.
STRESS
UNDERLOAD
FAILUREI
‘,, BREAKDOWN
Sickness: The state of distress can sometimes give way to or be replaced
by a feeting of being sick’ or unwell, or nauseous. This unpleasant state can
appear without any disease or any pathological change. On the other hand
one may have a disease and not appear to feel sick at all (as in the case of
some diseases in early stages, like cancer).
Sick Rote: This is a state that an individual may assume at home or in office
settings to show his inability to perform his routine roles or duties. This role
may succeed in freeing the individual from their routine duties. S/he is
expected to seek medical help and follow the advice of his well-wisher. If
they do not do so, they may be seen as a malingerer.
Malingering is a derogatory term used to describe a frauduLent sick role
that an individual assumes to avoid responsibitity or gain a social or a
financial advantage. A competent doctor is hesitant to jump to this
‘diagnosis’ and always seeks a more experienced colleague’s opinion
before labelling a patient as a ‘malingerer’. Many patients who are seen
initiatly to be feigning an illness have been known to develop the same or
some other serious disease,
Ittness: is an overall view that an individual, the family and the society take
of a person who is feeling sick or unwell. The explanation that each has of
the sickness decides the course of actions and health care plan that wilt
follow. If the family and the community have no obvious or known
explanation of the symptoms experienced by the sick individual, the
likelihood of a medical consultation is rare. The patient wilt, instead, be
taken to a spiritual healer, an aamil, or a charlatan. This is especially true of
patients suffering from psychiatric disorders, epilepsy, and many
behavioural disorders. Most patients suffering from anxiety and depressive
disorders experience physical symptoms for which they prefer to undergo
tab tests and consultations with physicians and neurologists rather than
psychiatrists.
Disease: The diagnosis of disease is made when the symptoms of an
individual are attributed to a cause or aetiology. This can be in the form
of injury, an organism, a substance, a pathological or structural change or
a defect leading to changes in functioning in biologicat, behavioural, and
social spheres. These factors are severe enough to not only challenge but
disrupt and even destroy homeostatic and allostatic mechanisms. They
have the capacity to change the restorative negative physiological loops in
the body so that pathological processes begin to worsen the state of the
individual, instead of initiating repair and equilibrium. In a diseased state, it
is assumed that a reversaL of the causative pathoLogy would result in heal
ing of the disease. Typical examples would be enteric fever, a fracture, or
insulin dependent diabetes mellitus, Here, a complete return to health and
reversal of disease is guaranteed through a medicat or surgical
intervention.
It is important for health professionals to note that all of the above states
may or may not co-exist in the same patient at a given point in time. A
person may feel distressed and sick without any disease. S/he may move
around performing routine roles and duties even while harbouring a
serious disease.
WelL trained health professionals, clear about distress, sickness and
disease should not call for unnecessary lab and radiological tests, They
should also not prescribe ptacebos in the form of pain killers,
muttivitamins, intravenous drips, ‘brain tonics’ and ‘high energy pills’ to
individuals who report to hospitals in a state of distress. All medical and
surgical interventions are, thus, only to be used once the diagnosis of a
disease has been made.
I
I
Integrated Model of HeaLth Care Cilnicat Scenario
Mr Xis aiar oLdcterkk the tnxatianoffica HepresenL5 to the physician
with increased thirstand appetite toss ofsexualfeetings al?d weightgain.
His Ibstiog bLoQd UgatwaSfeufltb3OO mg/dL He has a (omityhistory
ofdibete& He is nqsedas Iiawng Type II Diabetes MeUitus The treat
ment armsare maintenance ofasgar- dIeL j%xstrng blood glucose levels j
or infections He isp1aced on.z gram ofmetlbnntn/day Hers ciskedto have
F tyhome ‘. meats waik to his offIce in the mornings andtakea3
km walk with dieirithe averii#
Biotogis.trzsulin istc dIstUrbedarbohydratemetaboLisnz
encfzctors
Magee,tMetfi2rmii7. Thishelped in ave gtheb7sutin ies&dnce
andknpxove the carbohrate metqkoffstn
8ebavawoiiPeferencef&h Ca esugarithfaO asedentary
tifestyte shssft(jØband unhappy mari&Life.
ManngenentAttreversed with a change inea& habits. shaitbursts of
pIcaLe’re dLiring working hours andin7pioved interaction with hIs wife
dJrinre9uIarevenfrg walks
CDislk..frpersonai physiqueand thoughts ofgrowing
oLd, overweight and ugly. rnaritatstress anda satIsed maritaLlife
Management Information andunderstandingrofhazards ofovereating ond
.entanj Lifestyle, and cQmrnitment toa healthierway ofthinking about self
future, his fqrnily and his work! in generaL
sociocuLturaLjactoxs Clerks in such oie regularly receive sweets and
unheatthy food and eat unhealthy high calQrle and carbohydrate nchfood a
the office canteen, cuture ofworking long hOurs
Enviro)metaLfactois Colleagues wiihsfmllar unhealthyeating hat’its and
lifestyles Availability ofunhealthy food at the canteen absence ofopportuni
ties for exerciseand tack ofaccess tohealthyfood Minorchonges in lifestyte
t work and home reversed the environnentatkl&1ence,
Management Mr X’s refusot to accept swAts bip lunch from home,.
simple physical exercises during ofñcehours for5 to 10 minutes insteadof
constantty sitting on the choir alt helped in improving the culture in the office
and other workers soon started to copy Mr. X
3. The PubLic HeaLth Care Modet
Treatment at Primary Care Levet, Prevention of ILlness, Promotion
and Protection of Health
Hospital based health care models work primarily to emphasise treatment
of disease, This kind of health care approach is one of damage control
Public health care models on the other hand, work not only to treat disease
but also to prevent it.
The World Health Organisation (WHO), a premier stakeho[der in the field of
li
.4
heatth care, promotes a public health care approach in addition to hospital
based care. This model is committed to treatment of common diseas
es and basic health issues through primary health care centres. Primary
heatth care centres are estabLished at the grassroot level, where the
maximum rural, and semi-urban population resides. In Pakistan these are
called Basic Health Units (BHU), and Rural Health Centres (RHCs). These
Centres work towards prevention of illness and promotion and protection
of health by working with the community in the delivery of heaLth care.
The strategies in place include immunization campaigns, mother and child
health programmes, reproductive health, HIV-AIDS programmes, nationaL
programme of mental heaLth, narcotics control, antimaLarial and dengue
controL programmes. These run in collaboration with national and
international governmental and non-governmentaL organisations. Health
legislations on smoking, healthy diets, seat belts, helmets, safe sex,
population welfare, and reduction in mentaL health gap are some of the
initiatives undertaken to achieve the promotion of health.
SUMMARY
KnowLedge, skills and attitudes rooted in Behavioural Sciences are an
essential component of alt the models of health care currently in practice.
A comprehensive understanding of psychology, sociology and
anthropology as well as biological determinants of health and disease is
cruciaL for the practice of scientiIc medicine.
The traditional biomedical model of reversing biological causes of disease
has proven to be inadequate. An integrated model of health care in which
the psychosocial, cognitive, behaviouraL and environmental stressors are
considered as important as biological causes of disease is the future of
modern medicine. This approach aims at restoration of homeostasis, and
stress reduction to optimise functioning. It also helps attain equilibrium
between the internal and external world through allostatic processes.
Interventions that go beyond medication and surgery to include
non-pharmacological measures heLp achieve health in a far more effective
and lasting way. This includes measures such as mobilising social
support, influencing existing health belief modeLs, ensuring a healthy and
safe environment, providing informational care, conflict resolution and early
handling of psychotrauma.
A public health approach of primary and secondary prevention which
emphasise treatment of disorders and promotion of health as cLose to
the community as possible helps to achieve a more global perspective of
health.
Chapter 3
Non-pharmacological Interventions fNPIs) in
Clinical Practice
The use of these interventions is advocated in the BPS model for their
established efficacy (as seen by extensive research) in augmenting the
impact of drug treatment and surgical procedures. Non-pharmacological
interventions (NPIs) enhance patient satisfaction, improve adherence to
treatment, and strengthen the bond between the doctor and his patients
as well as the community.
The NPI5 in particular that a medical or a dental student can use to
diagnostic and therapeutic advantage include the following:
1. Communication Skitts
While communication seems like the most basic and innate part of being
human, effective communication is a vital toot in clinical settings as it forms
the basis of the doctor-patient interaction. The doctor and patient
undertake a joint voyage, many a times into an unknown territory of
disease. Problems may arise when the two travelers 9nd it difficult to
communicate or understand each other. While the physician is expected
to know the patient’s language, the patient is often unaware of medical
jargon. As the service provider, the responsibility for effective
communication ties with the physician. The tools that can be employed to
make this communication effective and skillful are:
i) Attending and listening: Attending is the act of truly focusing on the
patient. It involves a conscious effort by the doctor to be aware of
what the other person is saying and trying to imply. This may only
be possible if the interaction with the patient is done in a setting of
exclusivity
Standing on a patient’s bedside with fellow students, amidst the
traffic in a ward, attending to mobile calls simultaneously. or
eating/drinking while talking to the patient may signal that you are
not exclusively attending to the patient and/or his family member. A
screen next to the bed, or a relatively quiet corner of the ward meant
for interaction of patients with the students may provide a setting
that allows for more effective communication.
ii) Active listening: This is a process that goes beyond merely hearing
and making notes of what the patient says. It involves a simultaneous
focus on the linguistic and the paralinguistic aspects of speech. The
linguistic aspect refers to the words and verbal aspect of the speech
Paralinguistics refers to nonverbal features of speech such as timing.
votume, pitch, accent, fluency, pauses and ums’ and ‘errs’. These are
important as they indicate how the person is feeling beyond just the
spoken word. An understanding of body language of the patient is
important for a doctor to communicate with the patient. Body
language refers to the way a patient expresses himself through the
use of non-verbal cues such as facial expressions, proximity to the
doctor, use of gestures. body position, movements and eye contact.
Li
Use of minimal prompts Lark of exclusivity
Sit squarely in relation to the patient Preoccupied oranoious health professionals
Open body position In relation to the patient Uncomfortable seating
- - Lack of attention to non-verbal cues
Leanmg shghtly towards the chont
during active listening
Maintaining reasonable eye contact Offensive remarks orjudgmcnt
by the health professional
Pelaxed attentive health professional Frequent interruptions
Listen and respond to feelings Selective iintening
- - - Oay dreaming or dosing off during
Note all pamlrnguist,c and nonverbal cues
the communication
It shoutd be borne in mind that body language expressions are only
cues and not ‘ctinical signs. These cues should be pointed out to the
patient to draw his attention to them, to understand his feelings or
their meaning to him, e.g. “I notice that you took angry, how are you
feeling at the moment?’, or ‘your eyes filled up with tears when you
told me the name of your father.” This is more rational than making
the wrong assumption about his gestures or body language.
This is essential as methods of non-verbal communication vary in
patients and their family members, according to their upbringing,
culture and background. Active listening also involves customizing
your style and language to match that of your patients or anybody
you are listening to. This can be done by using the same language
as the patient wherever possible. Another important aspect of active
listening is respecting the pauses and silences of the patient. This
would mean not immediatety jumping in and talking whenever the
patient pauses for breath or reflects silently.
iii) Verbat techniques.’ These are pivotal in making the communication
effective and thus contribute towards the therapeutic process. These
are vital skitls for the doctors and can be mastered through practice.
Any verbal communication in a clinical setting involves the following
components:
Questions: these can be closed or open ended.
Ctose ended questions elicit a yes/no or a fixed response e.g. 4What
is your name?” “Are you married?” 5Do you get nausea after taking
your meals”? These questions are vital at the start of an interaction
both, to collect data as well as establish familiarity and comfort with
the patient.
The open ended questions do not elicit a particular answer. They are
intended to encourage patients to talk more about their story or
to expand more upon their issues. Questions are usually used for
exploration of a particular aspect, for obtaining further information,
to clarify any details and to encourage a patient to talk. E.g. “What
brings you to the hospital today” or 5Kaisay aana hua?° or even
simply 5Jee, kohiye.”
Fadorsthatrmptøv. cotrimintcaUon
It is important to start an interaction with the patient or his family
members with an open ended query, such as What brings you
to the hospitaL?” What can I do for you”? This gives the patient a
chance to open the conversation, with what s/he considers most
significant.
Leading questions are those that prompt the patient to answer in a
certain way. These lead to skewed information as we tend to give
the answer that we feet the person is looking for. These should be
avoided as should value laden ones. Some examples of these are
e.g. Don’t you think your pain radiates into the left arm?” or “Do you
feet ashamed of your short stature?”
Moreover ‘why’ questions should be used sparingly e.g. “Why do
you think you have developed shortness of breath?” An effective
communication therefore revolves around questions starting with
what, when, where and how
Funneling: This refers to the use of questions to guide the
conversation from a broader area to a more specific one. These
should follow open ended questions. This technique hetps the
interviewer move from general statements by the patient to
specific areas of clinical relevance e.g. “Now that you have
described your complaint of feeling weak and lethargic. can you
describe which specific part of the body you were referring to?”
Paraphrasing: It refers to the process of repeating the last few
words the patient said and summarising what the patient has
communicated so far, in your own words, and then ask him or her
to validate if you have understood it correctly, e.g. “you have told
me about the weakness in your legs and lethargy that you feel after
walking for only few yards. Is that right?” ‘Aap ne bataya k aap kal
maiday mal 2 haftay sejatan ho rahi haijo khanoy k baud barhjaati
hai, kya also he hal?”
Setective reflection: Reflection is a technique to bring out the
feelings attached to various symptoms and problems that a patient
has stated. It refers to the method of repeating back to the client a
part of something s/he said that was emphasised in some way or
which seemed emotionally charged. e.g. How does it feel when
you start to feel fatigued only walking for a few minutes? You told
me earlier, that you were once an athlete who could easily run a
mile.”
Empathy buitding: This refers to statements made by the doctor
that make the patient see that his or her feelings have been well
understood. It helps the patient understand that his/her feelings
are valid and that the doctor would have felt the same if s/he was
in the patient’s place. It is important here to refrain from expressing
sympathy instead, which would imply that the doctor feels sorry for
the patient’s plight.
can imagine how difficult it must be for you to live with your pain
for such a long time” is an empathetic statement, which is highly
desirable; a statement such as “Poor you, really feel bad hearing
your story” is an expression of sympathy which may not have the
desired therapeutic effect and also undermine the effectiveness of
communication.
Checking for understanding: From time to time during the session
the doctor needs to summarise patients statements or ask the
patient to comment on the summary. to ensure if s/he has
understood the problem and its associated feelings correctly.
An effective communication based on the above principles is
bound to form a bond and a relationship between the patient and
the doctor in which both feel understood and connected. It is this
feeting of mutual understanding that is traditionally described by
patients as Hatfmy ittness was retieved after tatking to my doctor.
WhiLe the principles of effective communication should be part of
all clinical interactions between a doctor and his patient, the best
use of these principles is in counselling individuals, couples, family
members or groups.
2. Counsetting
Counselling is a technique that aims to hetp peopte help themselves by
the development of a therapeutic relationship between the counsetlor
and the patient or family member, a colleague or anybody who seeks
counsel. The process aims at helping a person achieve a greater depth of
understanding, and clarification of’ the problem mobilises personal coping
abilities. It is not an ordinary every day conversation, in which one person
• asks the other for advice and gets the other person’s opinion on what to do.
Counselling is a limited supportive activity aimed at developing a person’s
ability to decide upon and initiate a constructive change. A doctor or a
medical student may come across a variety of situations in clinical settings
and professional interactions in which they may require counselling skills.
Some of the common scenarios where this skill can become a useful
intervention include: breaking bad news to patients or their families, or
resolving professional conflicts. These may include announcing that a
patient’s biopsy report has revealed a malignancy, or that cardiopulmonary
resuscitation has failed to revive the patient. It may be required as part of
sharing the news of a baby with congenital malformations or a stillborn
baby with the expectant parents, resolving a conflict between a colleague
and a nurse in the ward, or handling a relative who feels that his patient is
being ignored and denied a particular investigation or intervention. A coun
selling session aims to:
a) Establish a relationship of mutual trust and care in which patients
and/or their families feel secure and able to express themselves in
any way or form necessary.
b) Give patients or their families a chance to seek clarification and
expLanation of terms, issues and misgivings.
c) Provide an opportunity to patients or whoever is being counselled
to freely express his or her feelings and emotions.
d) Provide reassurance.
e) Achieve a deeper and a clearer understanding of a heatth related
issue based on scientific and evidence based data.
f) Identify the various choices and options alongside their pros and
cons through a process of discussion and dialogue between the
counsetlor and the patient.
g) Help the person make a decision or reach a solution that is most
suitable for him/her.
h) Seek support of the counsellor
i) Mobilise resources required to implement the solution.
j) Learn the necessary skills to cope or deal with the issue.
Under no circumstances is the counsellor expected to make decisions
on behalf of the patient or the one counselled. The responsibility of the
consequences of the proposed solution thus always rests on the shoulders
of the patient seeking counsel and never on the counsellor. If a medical
student or a doctor opts to take up the role of a counsellor s/he needs to
develop and exhibit certain attributes, discussed below.
What traits must a counsettor have?
Unconditionat positive regard
This involves a deep and positive feeling for the patient, being
non-judgmental and trusting.
Empathic understanding
This is the ability to accurately perceive others’ feelings, validating
them and communicating this understanding to them effectively.
As highlighted above, it is different from sympathy which implies
feeling sorry for the person.
Warmth and consideration
This can be achieved by remaining open-minded and non
judgmental. Avoiding over emphasis of your professional role and
being consistent in behavior helps convey that you are genuinely
there to help. Also by remaining respectful and tactful, the counsel
tor would be able to show warmth and consideration to his patient.
Clarity
The counselling relationship should remain clear and without
mystery to the patient. As a counsellor you are required to be clear
and explicit. Encourage the person being counselled to be similarly
explicit in his requirements. Use of the techniques of paraphrasing
and checking for understanding described above can ensure
successful communication.
Here and now thinhing
The distressed patients would like to talk excessively about their
past in order to avoid the reality of the present. As counsellor you
need to help identify present thoughts and feelings to enhance
problem solving attitude on the basis of here and now’, and focus
on the present day issue(s).
Do not ask why” questions, These imply interogatiorv Does not involve giving direct advice to patients
Do not say should ought or icarna chahiye tha. Does not solve people’s problems for them
These imply moralisation.
Do not blame the patient Does not challenge a patient’s feelings and perceptions
t)o not compare the patient’s experiences witi,
Does not impose the counsellor’s own views
your own, or gite examples from your life
onto the patient
The patient is a different petson from you
and has different life experiences. Does not make people less emotional
Do not invalidate the patient’s feelings,
Does not work to fulfil the counsellor’s need
to make people feel better
3. Informational Care (IC)
Memoirs of a patient’s son
I took my etderly mother to a targe hospitat in our city when she became
sick She was very embarrassed to go to the doctor because she said that he
would examine herand cause bepardagi but! convinced her that they have
welt trained doctors who are trustworthy and wilt take care ofher without
causing her any embarrassment We went to the outdoor department where
we were told that she had a breast lump which coutd be °a tumOur.” This
was like a bolt of lightning for the whole family as we had heard that nobody
survives from cancer I borrowed 5000 rupees from a friend and admttted
her in the sUrgery ward in the big hospitaL We were hoping that through
these doctors, A(tah would help us through this trial, Ajunior doctor took her
medical history and startedsome medicines. I asked him whether my mother
woutd be okay, but he said he didn’t knowyet and we needed some tests. He
then went away and a nurse gave us a slip to do some tests but nobody told
us how much the tests would cost woutd it be painful for my mother how
long would the results take, how tong would we need to stay in the hospitat,
any precautions we need to take for herrecovery? When the test results came
thejunior doctor looked at the results and told us that the senior doctorsahib
wilt decide during “the round I thought maybe they wilt tell us when they
decide after the round The senior doctor sahib came for the round but he
discussedsomething in English with the other doctors and moved on from our
bed without telling us anything. Later on, a group ofstudents came to our bed
andsaid that they needed to examine my mother’s chest My mother was very
ashamed but they sqid that it was necessary for her treatment, and so We
had to agree Seven ofthem examined my mothers chest turn by turn and we
were constantly worried about how manypeopte might be watching her like
this. Later on, I asked for the senior doctorsahib to find out about the treat
ment ofmymother and the questions I had in my mind, but the peon said that
he was in a meeting. I asked for thejunior doctor who had taken our history
but he had left after his duty and would be coming back the next day I asked
the nurses too but they did not know anything about my mothers treatment
plan. A newjunior doctor came that evening on Ucity and told us that we had
to prepare formy mothers surgery two days later, and that we also needed
to arrange for3 units ofblood and about 20,000 rupees for the items required
in the surgery. We were very confused, as no one had discussed anything with
us about this surgery. When I asked thejunior doctor about how much money
we needed in 4otat how many days we would need to stay in the hospital
caun4Ipon
7 MIsconcptfons about Counselling.
after thaL and ifthere was any otheroption besidesthe surgery he gotangry
andsaidthat Don tyou trust the doctors advice2 and you care about mon
eymore thanyourmothers health 57
was very hurt andembarrassed bythese
comments On the otherhand my motherand sisters were very hopetess as
they had heard thatnobodysunuvesfrom 5cancer even afterthesurgery
Veiywomedand confused we were totd bya neighbturthat a local pirsa
R2LJ
We didnotknow what to do All we reallywanted was someone to listen and
answersome ofour quenes in this confusion and desperation, a consultation
with the pirsahib seemed like our onty ray ofhope So the nextmorning we
left the hospital fora meeting with the pirsahTh’_..
Recommendedexercise
Read this case scenario once before studying this sectlonr and then a sec
ond time after completing the section Discuss whythis chath of events ted
to this tonsequence and what actions could have been taken differently
by the health care team to avoid such an unfortunate outcome
LI
H
Informational care is defined as provision of information to patients using
principles of communication regarding the disease, the drugs and the
doctor (the 3 Ds). This helps to fill the gap in the patient’s knowledge and
understanding in these areas. In order for the patient to fully achieve this
understanding, informational care must be provided using Language that
the patient understands. During ill health, the patient and his caregivers
feel a desperate need to know what exactly is wrong, how it is being or will
be managed, who will deliver the care and how.
The amount of information provided, timing, Language and setting in which
informational care is imparted has to be tailored according to the individual
needs of the patient, This includes considerations such as what stage the
illness or recovery is at and what questions bother the patient the most.
Seven ESSePtIISIfl iflformatlonal Care:
The physician must set aside time within a consultation to
give a reasonable level of information to the patient and his family about
the disease and treatment.
The IC session must take place in the language that the patient can understand.
it must start with patient’s knowledge, understanding and expectations.
Aap apni bemari kal baray ma) kya Jantay haln The doctor must than remove any
myths and misconceptions that the patient mentions in his description. These
misconceptions must be clarified and replaced with evidence-based information,
The task of giving intormation should be professional, evidence
based facts are provided without fear of causing a negative reaction in
patient and/or family. It must however be done with compassion, empathy and
sensitivity. Vague statements and building false hope should be avoided.
Both aspects of the disease and treatment, negative and posItive should
be communicated to th, patient, but information overload is to b, avoided,
Use of simple figures, diagrams and sketches are often helpful to enhance
the patient’s understanding. Most patients or relatives may like to keep the
sketches at the end of the session, which consolidates their
interest and the titility of the IC etetcise in the therapeutic process.
The IC session ends with th. patient briefly summerising his new understanding
of the 3 Os. This helps to evaluate how much of the InformatIon has been retained,
The doctor finally reassures that any future concerns and clarifications
that ar. needed will also be addressed.
What is wrong with me (diagnosis)?
Why have developed this disease (aetiology)?
Is there an effective treatment to my problem? Is the treatment safe? Are there any serious or
danoerous side effects (management)?
How long iIl I take to recover (prognosis)?
Is therea ‘Perhez’ (restrictions)?
Is there a risk of illness being spread to those APOUND me or passing It
onto my offspring (transmission)?
How will the illness and the treatment effect or influence my functioning?
(Can I continue to work or rest? What will happen to my
sex life, sleep, appetite etc.?)
4. Handling Difficutt Patients and their Families
Health professionals find certain types of patients and their families
exceedingly difficult to deal with. These include individuals who
• have long, meaningless and repetitive discussions with the doctor
• waste precious time.
• become too dependent and clingy
ask for undue favours
• make unprofessional demands.
• try to manipulate the doctor
• become angry when things do not go their way
• become rude or behave aggressively.
• refuse diagnostic tests and treatment.
Other patients who are seen as difficult are those with medically
unexplained symptoms (MUS) such as vgue physical complaints, aches
and pains, mentat health problems and patients who may be drug users,
are obese or mute.
Management:
It is important to be aware of factors operating in a health professional that
can give a false feeling that the patient is behaving in a difficult way. These
commonly include having a heavy work load and what time of the day the
interaction with the patient occurs, as health professionals tend to become
irritable towards the end of the day. Inadequate knowledge and skills to
deal with a demanding clinical situations may also cause the health pro
fessional to become panicked or overly sensitive. Lack of training in com
munication and counselling skills may worsen this situation. Some health
professionals trained in a biomedical model feel that addressing patient’s.
psychosocial and spiritual issues is not their job. They may, therefore,
Seven Questions a Patient NeedsAnSwered man CSessian
become irritable when a patient brings up these aspects for discussion.
Whatever ones views may be, as a heatth professional you are likely to
come across at Least one if not all of the aforementioned situations.
The following steps may help in dealing with a difficult patient or family
effectively:
a) Have an understanding of the biopsychosocial model and
integrated health care model and believe in the effectiveness of
these well researched models.
b) Train yourself well in principles of effective communication and
counselling. Seek specialised training in handling of difficult patients
by trying to form a relationship or bond with difficult patients in the
ward. Looking at videos of how seniors ideally handle such patients
and discussions with health team members will help educate you.
c) Learn relaxation techniques to manage your own anger and feelings
of frustration.
d) Approach difficult patients with tolerance, patience and use of
principles of active listening and unconditional positive regard,
keeping your cool. Concentrate on breathing deeply and easily while
listening to the angry patient or a family member.
e) Do not take remarks being passed as personal insult’ or challenge to
your integrity or authority. Consider them a different viewpoint of an
individual who is hurt or is uninformed and unguided.
f) Allow the patient or family member to express anger and validate it
by statements such as “your anger is understandable”, “I can
understand your feelings”, “this must be frustrating for you’.
“mujhe andaza hal kaiye aap k tiye kitna mushkft waqt hal”
g) Offer a chair and a calmer setting to discuss the issue at hand in
more detail. Offer an apology or an explanation for any unintended
offense but do not appear defensive. Stay calm, maintaining an open
body posture, a safe distance and always keep an eye at the
emergency exit. Always ask for assistance from colleagues or staff at
the earliest signs of aggression or threatening postures by a patient
or famity members.
h) For difficult pai. its in particular, define the objectives and duration
of consultatio ri advance.
i) Offer referral to a colleague or a senior consultant, particularly if you
are not making any headway.
j) Use humour while collecting further data, reassure, undertake
detailed physical examination, and a more extensive diagnostic work
up. or seek opinion from a mental health professional.
k) Involve family members, friends or significant others in the life of the
patient for support as well as help in understanding of the patient’s
issues.
5. Breaking Bad News
Any news that adverseLy and seriously affects an individual.’s view of his or
her own future is considered bad news. There are many clinical situations
where bad news has to be communicated to patients and/or their
relatives, e.g. disctosing the diagnosis or relapse of cancer, birth of mal
formed baby or death of a loved one. Breaking bad news is an unpLeasant
task and can be learned from the senior physicians or through own profes
sional experience. Most patients and families expect full disclosure
delivered with empathy, kindness and clarity.
There are five different schools of thought regarding the provision of
information to patients. The biopsychosocial model has the least number
of limitations and is therefore strongly recommended for use in health
settings.
a) Blo-Psycho-Sociat Modet:
This model provides clear, crisp, evidence based information on the
patient’s condition but tailors the flow and amount of information accord
ing to the needs of the patient. A vertical flow of all data on the disease
(particularly the parts that the patient or his family have not asked for), is
avoided. The bad news is broken using principles of effective communi
cation, counselling and informational care discussed earlier. The patient
is encouraged to involve his family members, particularly the ones who
can provide psychosocial support, during the session as well as in the
long run. This model suggests the following steps for a session that aims
at breaking bad news:
Step 1: Seating and Setting (Environment):
Exclusivity
The environment where bad news is being broken can have serious
repercussions on the outcome of the interview. A patient’s mistrust
and antagonism may simply result from a poorly chosen location.
It is, therefore, worth trying to find a private room where the doctor
and patient can focus on the subject attentively.
invoLvement ofsignificant others
Some patients like to have family members or friends around them
when they receive bad news, while others prefer to hear bad news
alone. Ask the patient who they would like to accompany them. If
there are more than a few people supporting the patient, ask one
person to act as representative. This gives the patient support and
alleviates some stress from the doctor in the face of an emotionally
charged interview.
Seating arrangements
It is advisable for the interview to take place with both octor and
patient comfortabty and respectfully seated next to each
other, preferably at a distance of an arm’s length. The arrangement
should never impart an intimidating image of the doctor. It should
provide an appropriate setting for discussions and any emotional
outbursts or ventilation of feelings that may arise.
Be attentive and calm
Most doctors feet anxious when breaking bad news and it is worth
spending some time to eliminate any signats that may suggest our
own anxieties. Maintain eye contact and show your attention. If the
patient starts to cry, try shifting your gaze because nobody Likes
to be watched while crying. This should however be done with
sensitivity and must never send a signal that you do not realty care
about the patients feelings.
Listening mode
SiLence and repetition of last few words that the patient has said.
are two communication skills that wiLt send across the message
that you are Listening weLl.
Avaitabitity
If you have appointments to keep, give your patient a cLear
indication of your time constraints but make yourself available to
the patient for all his queries and doubts for the duration that you
are with him or her.
Step 2: Patient’s Perception:
Ask: What do you know?
“Aap apni bemoan kai baray mai kyajantay ham?”
The principle involved in this step is “before you tell, ask.” Before
you break the bad news to the patient, try to ascertain as
accurately as possible the patient’s perception of his or her
MEDICAL condition. Obtaining this information depends on your
own communication style. As your patient responds to your
questions take note of the language and vocabulary that s/he is
using and be sure to use the same vocabulary in your sentences.
This alignment is very important as it hetps you assess the gap
between patient’s expectations and actual medical condition. If
the patient is in denial, try not to confront him in the first interview,
as denial is an unconscious defense mechanism that facilitates
coping.
Step : Invitation:
Ask: What would you tike to know?
“Aap bemari k baray mai kyajanna chahain ge?”
Although most patients want to know all about their illness but
assumption towards that should be avoided. Obtaining overt
permission respects the patient’s right to know or not to know.
Some examples to address this are: “Are you the kind of person
who likes to know alt the details about what’s going on?”, “How
much information would you like me to give you about your
diagnosis and treatment?”, “Would you like me to give you details
about what is going on or would you prefer I tell you about the
treatments I am prescribing to you?.”
Step : Knowledge:
Before you break bad news, give your patient a warning of some
sort to help him prepare e.g. “Unfortunately I have some bad news
for you Mr. X” or “I am sorry to have to tell you...” When giving your
patient bad news, use Language similar to his. Avoid scientific and
technical language. Even the most well informed patients find
technical terms difficult to comprehend in that state of emotional
turmoil. Give information in small bits and clarify whether s/he un
derstands what you have said so far, e.g. “Do you see what I mean?”
or “Is this making sense so far?” As emotions and reactions arise
during the interview, acknowledge them and respond to them.
Ask: What have you understood?
“Kya mal aap ko baat theek se samjha saka/saki hoon?”
Step 5: Empathy:
For most doctors responding to our patients’ emotions is one of
the most difficult parts of ourjobs. In our effort to alleviate our own
discomfort it is tempting to withhold certain information or give a
more hopeful picture than actually exists. These tactics may appear
to help in the short term but seriously undermine aft your efforts in
the long run. It is much more useful and therapeutic to acknowl
edge the patient’s emotions as they arise and address them. The
technique that is most useful is termed the empathic response. An
empathic response involves listening and identifying the emotion
or mix of emotions that the patient is experiencing and offer an
acknowledgement for them. Identify the source of that particular
emotion and then respond by showing that you understand the
emotional expression of the patient. Statements such as “mai bhi
agar aap ki jagah hon toh aisa he mehsus karoon” reassure the pa
tient that you understand the human side of the medical issue and
that you have a respect for his feelings.
Step 6: Summarise:
Before the discussion ends, recapitulate the information in a short
summary of all that has been discussed and give your patient an
opportunity to voice any major concerns or questions.
Step : Ptan of Action:
You and your patient should go away from the interview with a
clear plan for the next steps that need to be taken and the role
you both would play, in the management of the issues. Also allow
the patient to have a way of contacting you, through the hospital
exchange or after rounds the next morning, in case they have any
questions.
b) Individuatised Disclosure Model:
In this model the amount of information disclosed and the rate of its
discLosure are tailored to the desires of the individual patient by
doctor-patient negotiation. First the doctor and patient work together to
clarify what information the patient wants. The doctor then imparts that
information in a way that the patient understands. This is an on-going and
developing process. It implies a tevel of mutual trust and communication
that takes time and effort to develop. The distinguishing features of this
model are that it takes time and skills and its assumptions are supported
by evidence. It has the capacity to maximise quality of life for the patient.
The underlying assumptions in this model are that it takes each individual
a different amount of time to absorb and adjust to bad news. A
partnership between the doctor and the patient for decision making is.
therefore, in the patient’s best interest. Its disadvantages are that it is a
time consuming process that might be difficult for a busy physician to
undertake. It also tends to drain a health care providers’ emotional
resources. The advantages are that the amount of information given and
rate of disclosure is taiLored to needs of the individual and a supportive
relationship with the doctor is established.
c) FuLL Disclosure Model:
This model involves giving full information to every patient as soon as it is
known. It argues that this promotes doctor-patient trust and
communication and facilitates mutual support within the family unit. The
underlying assumptions in this model are that the patient has a right to
full information about himself and the doctor has an obligation to give it. It
assumes that all patients want to know bad news about themselves and
that patients themselves should decide what treatment is best for them.
The disadvantage of this model is that discussion of options in detail may
frighten and confuse some patients. The doctor insisting on providing
information may undermine defenses such as deniaL which are otherwise
important for the survival of the patient. The provision of full information
may, also, have negative emotional consequences for some. The mod
el holds some advantages as well, such as promotion of doctor-patient
trust, family support and allowing patients time to put affairs in order in
case of a poor prognosis. It also helps those patients who cope better
with their diagnosis by having the maximum amount of information about
their illness.
c) PaternaListic Disctosure ModeL:
This model implies that information about the patient’s disease is the
right of the doctor. The doctor delivers the information to the patient as
and when s/he deems appropriate, in a ‘sugar coating’ to minimise the
pain and distress of the patient. It also involves the expression of sympa
thy and a sharing of emotions on the part of the doctor. This model is no
longer recommended for use.
d) Non-Disctosure Modet:
This model is based on the view that under no circumstance should
patients be informed that they have acquired a lethal disease. It states
that deception should be used if necessary, on the basis that the patient
needs protection from the terrible reality of terminal illness. This model
has been traditionally adopted as part of a paternalistic and nurturing
attitude of doctors towards their patients. The underLying assumptions in
this modet are that it is appropriate for a doctor to decide what is best for
the patient; patients do not want to hear bad news and they need to be
protected from it. This model has obvious disadvantages such as:
denial of the opportunity to adjust to illness, which the patient is ob
• viousty experiencing
•
trust in doctor is undermined
opportunities for helpful interventions are lost
• patient compliance is less tikely
• patients may acquire wrong information that can lead to avoidance,
isolation and a perception of rejection
• the patient may experience a sense of loss of control in what is hap
pening to his own body
Advantages of following this model are that it is easier and less time
consuming for the doctor and suits those people who prefer not to know
their condition. This model s fast fatling out of favour and is now widely
rejected by modern day doctors as welt as patients and their families.
What expectations do the patient and [amity have when receiving bad
news?
According to research, the most important factor to the patient and family
receiving bad news, is the attitude of the health professional. The heatth
professional should, thus, be knowledgeable, empathetic and give hon
est and clear answers in simple language. The second most important
factor is the setting in which the news is broken. A quiet, private place
• where the news is broken in an uninterrupted way is preferred.
What are the common reactions that a patient experiences upon receiv
ing bad news?
The reactions that a person goes through when they hear bad news, can
be summarised as the stages of denial, anger, bargaining, depression
and acceptance. These stages are rarely clearly delineated, and often
patients go through one or more stages at the same time and for each
individual the length of time each stage lasts may vary. It is important
that the health professional empathise with and provide support for the
patient during each stage.
What are the common reactions in a heatth professionaL breaking bad
news?
Delivering bad news can be equally taxing and demanding for the health
professional. S/he may experience strong emotions of being a failure, or
of not having done enough for the patient. Feelings of helplessness, sad
ness and fear that they may harm the patient emotionally by telling them
the truth may be experienced. Some may feel shame and disiltusionment
with their profession, and others may experience fear of their own death
and disability.
These feelings are essentially normal reactions to a challenging and a
difficult situation. A young health professional is advised to share these
feelings with a senior colleague. S/he may even assist in a few situations
before undertaking this specialised communication in clinical settings.
ChaLlenges In Non-pharmacological Interventions
As health professionals the biggest hurdle we face in the administration
of any non-pharmacological intervention is the Lack of time. In busy cLin
ics and overcrowded wards where patients go from being humans with
names to beds with numbers, it seems impossible to find the time to give
someone all they need. It seems to suffice that we are there at alt, that
we are doing the bare minimum to keep afloat in the never-ending sea
of patients that threatens to drown us. In such a situation we must keep
in mind two things: Research shows that by not spending the required
amount of time the first time we see a patient, we tend to misunderstand.
misdiagnose and mistreat. The inevitable result of this is that not only
does a patient not improve, s/he may return to a different doctor in a
worsened condition. This means that for the majority of our time, we are
redoing work that a colleague has done improperly (due to lack of time)
and vice versa. There are millions of patients stuck in this loop, who keep
reappearing for consultations, thereby increasing the workload of heatth
professionals as a whole. Secondly. it is important to understand that our
job is not to mistreat the most number of people in a day, but to actuaLly
treat the minimum number of people we can to the best of our abilities.
Using non-pharmacological interventions, such as providing informational
care and breaking bad news saves us time in the Long term. For example,
if we are able to take the time to explain to a patient that the true mea
sure of whether their blood glucose levels is normal is fasting btood glu
cose, or an HbAic, they will not waste our time (and that of the path lab)
by getting random blood glucose Levels done and showing them to us.
Breaking bad news is another time-consuming procedure, how
ever, one of utmost importance. To inform an individual that s/he
may have cancer or AIDS is to inflict a major psychological trauma.
People will remember, for the rest of their lives, the details of the
occasions when important news was broken. No surgeon would
think of operating without booking an operating theatre and setting
aside sufficient time to do the job properly. S/he would not ‘skip
the anaesthesia” just because it takes time. The procedure for
breaking bad news must have a similar importance. A health pro
fessional must think for a moment how they would feel if they were
to receive such news. There is a world of difference between the
doctor who breaks this news in relaxed atmosphere with a support
ive attitude and the caLlous consultant who flings bad news at the
patient in a public ward.
Before teLling people what we think they need to know, we should
find out what they already know, or think they know, about the
situation and what their priorities are. If they use words like cancer’
or death’, we should check out that these words mean the same to
them as they do to us. ‘There are many kinds of cancer, what does
the word mean to you?’. ‘Have you seen anyone die? How do you
view death?’ will often reveal considerable ignorance and open the
door to positive reassurance and explanation. Too often, doctors
fail to invite questions and miss the opportunity to help people with
the issues that are concerning them most. The patient has a right to
know the truth about an illness, but we must respect their right to
monitor the amount of new and painful information that s/he can
cope with at any given time. It is just as wrong to tell people too
much, too soon, as it is to tell them too little, too late.
• Life-threatening illness can undermine our confidence and trust
and members of the caring professions can do a great deal to help
peopte through these psychosocial transitions. Accurate informa
tion is essential to planning. Many patients may react with relief
when they are told they have cancer, as without any information
they have already imagined the worst. It is easier to cope with a Le
gitimate diagnosis than to live in an unplanned state of uncertainty.
• Many of the different ways people cope with threats reflect the
coping strategies that have been found to minimise stress earty
in life. At times of threat, those who tack confidence in their own
resources may seek help of others, express clear signals of distress
and cling inappropriately. Those who lack trust in others may keep
their problems to themselves, bottle up their feelings and blame
hea[thcare providers or therapies for their symptoms. Their tack
of trust makes it necessary for them to control us rather than be
controlled by us. A few, who lack trust in themselves and others.
may keep a low profile, turn in on themselves and become anxious
and depressed. To those who lack self-esteem the most important
thing we have to offer is our esteem for their true worth and poten
tial. To those who lack trust in others we can show that we under
stand their suspicion and their need to be in control of us. Doctors
must act as advisors rather than instructors and show that they
accept that trust must be earned: and that ‘it is not our right to be
trusted’.
SUMMARY
The breaking of bad news is a difficult situation for both the health
professional and patient and the family members. The task should be
undertaken in an exclusive and an uninterrupted setting. The information
provided should be based on what the patient and famity wants to know.
The information should build on what is already known to them. Opening
statement should be on the lines of “I have to share information that may
be unpleasant” or “I know it may be tough for you to know.” The contents
may be broken into short sentences making sure that the patient gets
adequate chance to process the unpleasant data. Accept and respect
the emotional reactions that follow the sharing of the information. In the
end leave enough time for clarifications and questions. Always schedule
a follow up meeting and mobilization of any immediate support that the
patient or the family may need after learning the bad news. The session
should not end without assessing the risk of the individual harming them
selves, and putting in place clear preventive interventions in this regard.
Reassurance that you as a health professional stand committed to pro
vide support and be with the patient during these trying moments is a
source of comfort for the patient and the family. This is a safe note on
which to leave. A calm, compassionate. empathetic health profession
alwho has adequate knowledge of the patient’s condition can leave a
calming effect on the patient and the family.
Young health professionals need to be aware of the strong emotional
reactions that they themselves may experience before, during or just
after breaking the bad news. These feelings are normal and their impact
can be reduced significantly by sharing them with a more experienced
colleague.
6. Crisis Intervention and Disaster Management
The word crisis is derived from a Greek word meaning decision makkig.
Chinese language has an expression for it in two words; danger and
opportunity. A crisis is, therefore, a situation which holds potential for great
individual growth provided that the appropriate decisions are taken. People
in individual crises or natural disasters find themselves in situations that
require deep and insightful decision-making and lead to a permanent
change in their lives. Crises are periods of disorganization, characterised
by trial and error, disequilibrium, and attempts to reduce feelings of dis
comfort. Resotution of a crisis can result in either an increase or decrease in
person’s level of functioning or a return to the previous baseline of
functioning. Individuals and communities who undergo major disasters
may. however, never be the same again. At a psychological tevel, they may
become more vulnerable to future crises. They are at a higher risk to
become victims of a variety of post traumatic conditions such as
post-traumatic stress disorder (PTSD). depression, anxiety and/or
dissociative states. They may become resilient and battle-hardened’, and
thus, better equipped to deal with challenges of life. This change that
foltows major trauma may be the basis of the positive shifts in human be
haviour called post-traumatic growth occur in response to stressful periods
of human maturation and transition. These inctude childbirth, early child
hood, schooling, adolescence, marriage, parenting, divorce, hospitalization,
death of a loved one etc. A situational crisis is where a person is faced with
a stressful or traumatic event which could be a natural or a manmade
disaster e.g. ftoods, earthquakes, rape, terrorist attacks, war, murder etc.
Ak.
GENERATE AND EXPLORE
ALTERNATIVE RESOURCES AND
COPING SKILLS
EXPLORE FEELINGS AND EMOTIONS
(USING ACTIVE LISTENING AND VAUDATION SKILLS)
IDENTIFY DIMENSION OF PRESENTING
PROBLEMS. INCLUDING CRISIS PRECJPITANTS
ESTABLISH RAPPORT AND COLLABORATIVE RELATIONSHIP
PLAN AND CONDUCT CRISIS AND BIOPSYCHOSOCIAL ASSESSMENT
(INCLUDING LETHALI1’! MEASURES)
Roberts’ seven stage modet ofcrisis intervention
Communication Strategies In Crisis intervention
Using silence gives the person time to reflect and become
more aware of feelings. Silence can prompt elaboration. Simply
being with the person can make them feel supported.
Using non-verbal communication- maintaining eye contact, head nodding,
caring facial expressions, and occasional “uh-huhs lets the person know
that you are in tune with them
Paraphrasing, expressing understanding, empathy and interest are conveyed by
repeating portions of what the person said. Paraphrasing also checks for accuracy
,clarifies misunderstandings, and lets people know that they have been heard.
You could say, “So you are saying that..”, or”Aap k kehne ka matlab ye hai kaL.
1efiecting feelings helps the person identify and
articulate emotions. You could say. “You sound angry...” or “You look scared...”
Allowing the expression of emotions is an important part of healing.
Venting often helps the person work through feelings
and helps in problem solving
Disaster Management:
A crisis involves three main phases: emergency phase, rehabilitation phase,
and recovery phase. Each of these phases has its unique characteristics.
The common factors for a medical student to remember regarding
disasters include:
a) The consequent trauma is never surgical and medical atone: nearly
all those affected suffer psychosocial changes.
b) Most psychosocial consequences of trauma are essentially normal
reactions to the overwhelming nature of the disaster. More people
dont get PTSD than do get PTSD.
c) Groups most vulnerable to deyeloping post traumatic conditions
include women, children and the elderly, but young adults and
males are not immune to developing psychological reactions.
d) Provision of early psychosocial support by trained professionals
prevents long term psychiatric morbidity. It also enhances the
impact of surgical and medical interventions and promotes early
recovery from the physical, psychological and socioeconomic
effects of trauma.
e) All medical and psychosocial care should be part and parcel of the
larger disaster relief in form of food, shelter, clothing and security.
Psychosocial and mentat health care should be made an integral
part of medical and surgical care. This will help to prevent stigma
of mental and psychosocial issues. It also helps to ensure a holistic.
biopsychosocial model of health care delivery
fl Traumatised individuals and communities best recover through pro
viding psychological, social and economic support to each other
(rather than relying on outside help alone). An early return to their
homes or shelters close to home and active participation in social,
educational, economic, and reconstructive activities ensure a
quicker rehabilitation.
g) The use of psychotropics, particularly. the benzodiazepines should
be avoided and simple. evidence-based, culturally rooted, non-phar
macological interventions are preterabte. Only short-term use of up
to two weeks for morbid anxiety and insomnia may be advised.
h) Rescue workers and health professionals involved in provision of
relief work require psychosocial support. They need adequate rest
and recreation as well as constant appreciation and patronage. They
should work using the buddy system, which involves individuals
teaming up and caring for and monitoring each others psycholog
ical and physical wellbeing. Preferably they should remain in touch
with their families and friends back home. This prevents early
fatigue. burn out and long term psychosocial complications.
j)
Up to one third of the affected population may develop long term
post traumatic conditions characterised by disabling flashbacks of
the trauma, autonomic hyper-arousal. avoidance (of cues, settings
and circumstances that are [inked in anyway with the traumatic/di
saster event), anxiety, depression and dissociative states.
A second disaster wave hits soon after the first. This is largely in the
form of epidemics, wound infections, malnutrition, death and dis
ease due to exposure to extremes of temperature.
7. Conftict Resolution
Conflict is a state where two forces oppose each other. Conflicts arise in
situations where individuals and groups are not getting what they want
or need. This includes marital conflict, conflict amongst colleagues, the
attendant of a patient and the nursing staff, medical students on a clini
cal rotation in conftict with hospital staff, or the college administration etc.
Conflicts are inevitable situations and are usually seen where there is poor
communication, power seeking. dissatisfaction with management style.
weak leadership. lack of openness and change in leadership. Conflict has
the quality to divert attention from the main activity, undermine morale,
polarise people and groups, reduce cooperation, sharpen differences and
thus Lead to irresponsible or harmful behaviour. It is, therefore, important to
understand that at times the individuals involved may be unaware of their
needs or wants. Conflicts have the potential to be constructive when they
are raised in the spirit to clarify and solve problems. In these circumstances
conflict and timely resolution may help relieve tension and pent up
emotion as well as help build cooperation through learning more about
each other.
a) Common Causes of Conflict in Heatthcare Settings:
Assumptions are being made e.g. the doctor assumes that the
patient knows that his absence from the ward is on account of an
unavoidable academic commitment like attending an international
conference. The patient instead may not be aware of the activity or
may not attach the same importance to it as the doctor.
ii) Knowledge is minimal e.g. the family has inadequate information on
the indication of biopsy in a patient and may see it as a suspicion of
malignancy in the patient.
H
i)
i)
‘St Las/a Zombie
iv) Knowledge is minimal e.g. the family has inadequate information on
the indication of biopsy in a patient and may see it as a suspicion of
malignancy in the patient
v) Expectations are too high: e.g. the patient believes that a course of
chemotherapy should have completely cured him of his lympho
ma, when instead s/he develops a complication of the treatment
and deteriorates.
vi) Personality, race, gender or social class differences exist e.g. a
trainee nurse may have a tow frustration tolerance and take offence
of an innocent remark by a patient; a visitor or a medical student or
the janitorial staff goes on a strike for being poorly paid.
vii) Needs and wants are not being met e.g. a patient dissatisfied with
food, bedding or facilities in the ward.
viii) Values are being tested e.g. a welt-clad female patient reluctant to
allow a male student to examine her.
ix) Perceptions are being questioned e.g. a confident medical student
distressed about not being given a chance by the surgical resident
to undertake an incision and drainage procedure independently.
b) Methods of Conflict Resotution:
The underlying emotion in all conflicts is bottled up anger, frustration
and/or an impression of being ignored, or of being ‘taker for granted’.
The most common underlying cause is often not a clash of interests but a
faulty communication or unfounded concerns. The worst ways of dealing
with conflicts is to brush them under the carpet, or to ignore or postpone
their resolution.
A formalised strategy to resolve conflicts is called Organised Conflict
Management (0CM). The following steps of 0CM help resolve most
conflicts readily:
i) Meet conflicts head on.
/
CAUSES OF CONFLiCT IN
NEALTHCARE SETTINGS
HEALTH OUTCOMES
PERFORMANCE
iii) Assumptions are being made e.g. the doctor assumes that the
patient knows that his absence from the ward is on account of an
unavoidable academic commitment like attending an international
conference. The patient instead may not be aware of the activity or
may not attach the same importance to it as the doctor.
P.ERK5ANOPPWEXGE
qUA#voPuFg V V
ii) Show mutual respect by separating the person(s) from the problem.
Do not try to corner, attack or undermine the individual(s) involved
in the conflict.
iii) Set goals that lead to a win-win situation for both the parties in
conflict rather than a victory of one party at the expense of the
other.
iv) Resolve the conflict through free communication.
___________
__
VV._ VV1
v) Be honest about concerns and reservations and verbalise them as
early as possible.
vi) Agree to disagree. as healthy disagreements lead to better
decisions.
vii) Leave individual egos out of negotiations, and avoid serving or
pleasing one individual. Aim at satisfaction of the group, rather
than the leader alone. Exploitative and deceptive methods of
resolving confticts can succeed temporarily but are Likely to
generate bigger issues in future.
viii) If you are the one coordinating the dialogue, tet the negotiating
team create solutions rather than handing over the solutions -
people support what they create.
ix) Discuss differences in values openly.
x) Undertake a deeper anaLysis of the situation that generated the
conflict. Conftict resolution based on a superficial analysis is likely
to result in a bigger conflict in future. A conflict arising out of hurt
feelings, and emotional reasons is likely to settle on its own with
passage of time and an improved communication between the
parties. A conflict that arises out of morality issues, religious
differences, or cultural differences is unlikely to resolve. Here
the two parties can agree for a peaceful co-existence in spite of
the conflict. Realistic, fact based conflicts can be best resolved
through creative solutions put forth by the parties themselves.
The best method of dealing with conflicts is, however, by preventing
them. A sound management system in medical colleges. departments,
wards and hospitals helps to ensure this. It involves mechanisms of quali
ty control, free horizontal interactions and sharing of information. Leader
ship should be based on principles of following a middle path rather than
extreme measures. Ensuring equity and justice and imparting feelings
of security and predictability can prevent the rise of conflicts as welL as
ensure their early resolution.
Do’s and Dont’s In Crisis Intervention
Do Say: Dont Say:
These are normal reactions to ft could have been worse
an abnormal situation
It Is understandable that you i this W8
You can always get another
car/house or have another child
It was not your fault; you did the best you could It is best if you just stay busy
lam sorry that this happened I know just how you feel
Things will get batter, and you will I
feel better, although things may You need to get on with your life
never be the same again I
Empathy
The single thread that tinks alt the above non-pharmacological interven
tions is the demand on the doctor to empathise with the patient and the
family. The most important step in building a therapeutic bond is the doc
tors ability to experience the feelings of his patients and to gain a deeper
understanding of their distress, disease or disability.
Most medical students start their career in medical college with a huge
capacity to empathise. Alt that they have to learn is to communicate it
effectively. The biomedical modeL with its emphasis on the disease, rather
than the person experiencing it provides few opportunities to develop
and use this skill. Medical students, eager to perform well, are rewarded
for their abiLity to memorise anatomical and biochemical facts, causes of
diseases and classification systems. Their ability to empathise or relate
with patients at a human level is not marked, rewarded or appreciated.
As a resu[t of this, slowly but surely they start to focus more on acquiring
knowledge, with their skill at treating patients as humans and empathis
ing with them fading into the background.
The best time to learn how to empathise is in your relationships with each
other as medical students. The first step in this direction is to opt to study
in a group rather than alone. Once you are part of a group, try and under
stand the reactions of a fellow student who is struggling with language.
or a concept; who fails in a class test, a sub-stage or a viva. Sitting next to
someone who has failed, or is in pain, and thinking of how s/he is feeling
is an important exercise by which you can eventually learn to empathise
with patients. Let the person you are trying to empathise with, express
their feetings. The best technique in this pursuit is to share their silence.
Sit quiet. Listen actively: let the person know, that you care and it is ok
for them to share feelings with you. This effort on your part to empathise
with your colleagues in the first couple of years in medical college will
make you comfortable with your own world of emotions. It is this import
ant ability in a human to stay in touch and be aware of one’s own feelings
that helps them to relate with feelings of others and thus enhances their
ability to empathise. During clinical years, try and sit with patients, even
after you have taken the history and have completed the clinical exam-.
nation. Encourage them to talk about how they feel in reaction to their
illness, hospitalisation, and treatments being offered to them. Share their
fears, disappointments and sorrow without trying to take sides of the
health professionals and hospitaL authorities. Ask questions about the
influence of the disease and the treatment on their life at home, at work
and in general. These apparently irrelevant” steps will take you ctoser to
your patients and thus increase the chances of empathising with them. It
is this ability to bond, and eventually feel the way your patients feet, that
wilt help you have an insight into how patients think.
i
1. A patient from a vilLage in ChoListan desert presents to a health
professionat in Lahore. He appears to be suffering from diabetes
mettitus, according to his HbAic and fasting bLood glucose reports.
The heaLth professional does not speak or understand his tanguage.
The best way to provide informational care would be:
a) Drawing pictures
b) Using sign language to communicate effectively
c) Seeking help from a colleague who partially knows the patient’s
language
d) Exclude medical jargon from communication and state essentiat
facts through an interpreter
e) Make an attempt to learn patient’s Language and then communicate
effectively
2. During a counseLling session, the most important aspect is:
a) Charismatic personality
b) Asking why the patient feels the way they do
c) Speaking to the patient in their language
U) Unconditional positive regard.
e) Empathising with the patient’s situation
3. Active Listening is best accomptished by the doctor understanding
and using:
a) Body language.
b) Paralinguistic aspects
c) Active prompting
d) Adequate eye contact.
e) Responses to open ended questions.
4. White deaLing with a patient who is fearfuL about not waking up from
anaesthesia for her hysterectomy, an empathic response is:
a) I assure you that your concerns are not scientific, everybody wakes
up from anaesthesia
b) I do understand your concern, in your situation I, too may have felt
the way you are feeling
c) I know that you are scared but you are a brave person who can face
this
d) We are experts in the field; we will make sure that nothing happens
to you.
e) Please relax, everything will be fine
SAMPLE MCQ FOR SECTION A
5. Effective communication skills are considered essentially important
for a doctor. The most important reason for a doctor to develop
effective communication with his patients is:
a) It is a vital tooL in clinical settings.
b) It forms the basis of the interaction between the doctor and patient.
C) It is used in informationat care sessions with the patient and their
famiLies.
d) Doctors can convey their message on various health topics better.
e) Doctors will gain respect and popularity with the public.
Sampte Short Essay Question For Section A
Qi. Briefly describe the seven questions that need to be answered in an
informational care session.
Q2. What are the steps invoLved in breaking bad news to a patient?
Answers
l.a
2.d
3.b
4.b
5.b
For answers to short essay questions see Chapter 3, Non-pharmalog
ical interventions.
b
ECTION B
edical Ethics, Professionalism and Doctor-Patient
elationship
I sb,ear [‘p scuLapus, Lpgeta. anb anacra. anb 3 take to b%tite%%
all tfje gobs, all d gobbeaea, to keep arcorbing to mp aWftp anti nip
ubgmeiu, tt (otLobng atfj. to con%iber bear to me aS mp parentS
tdm to(io taug me tl.ü art: to Cibe m cmnmmt it im anti if nws%arp
to sbare nip goats tnittj m: to took upon his cljilbrcn aS nip aton
.—c beatberL to teach tm this art it tfrp so bcsirr k%tfjmd fee or britten
omt%e; to Impart to nip sans anb tbe SonS of ttje master [‘ibjo taughi
me anti tk bisnptes bfjo babe enrotkb ttjemwetbes anti babe agreeb to
tlje rute% of the profeSSion, but to these atont the prtce5 anti tljt
instruction. I UnIt prescribe rtgimtns tar the goat of nip patients
,, acarbingtompabititpanbmpiumeiUanbneberboarmloanpcnc
r to please no one tofU I prescribe a beatitp brug nor gibe abbece Wijicfj
map cause $S tieatlj. lor bsI( I gibe a boman a pessarp to prorure
abortion. ut I bitt preSerbe the puritp of nip (itt anti nip art. I bill
nof cut tar Slant, tUtu for patients in bhom the tüea%t is manitt%t
I bill (taUt tts operation to be performeb [‘p practitioners, sptclat&s
arLInebtrpbousebfrrticome)bstt.tronlptrxdgxb
at mp patients. keeping mp%elt far tram alt intentional Ilt-boing anti
Th altsebwtionanbesptdaltptromtttp(easureso((bstfjbionietior
beth men, be the? fret or stabes. Alt that map come to mp knobeebgey
tn the exercise of mp profession or In baitp commerce bath mni Wjlcfj
ongljnoftobesprtabaheoab,3bittkeepftcrtianbbellntbertebeaL -
It I keep (tO oath taithtuttp. map 3 tnwp nip tite anti practice nip ..
art. etsptcteb bp alt men anti In alt times; but it I s’wtrbe (rain U
I map the reberft be mp tnt.”
- -. --— .-
7
Retevance of Ethics in the Life of a Doctor
Medical. Ethics
Ethical. Omissions in Medical. Practice
Ethical. Dil.emmas in a Doctor’s Life
Doctor-Patient Rel.ationship
Ptofessiona[ism in Heal.th Care
After ordering a hot cup ofDoodh Patti, the tocat preferred version ofEnglish
tea Ahmed, Fazat, Javed and Safdarstarted their evening chat. The topic
today was not potitics but the attitude ofdoctors.
Ahmed remarked ‘The new Doctor Saheb who has opened his ctinic is very
different from Dr Raheem who died tastyear after serving the community as
a generat practitioner for thirtyyears. Dr. Khatid has a neon sign ofhis name
and qualifications outside the clinic. He runs his clinic more like a ‘health
shop He asks his patients to deposit a fixed amount with him prior to the con
sultation, irrespective oftheir financial status. The other day Dr Khatid insisted
that I shoutd get the Hepatitis vaccine whether I like it or not without giving
me a choice to do so.”
Safdar quickly added: “Dr. Saheb removed my appendix in surgery, a few
weeks ago, after telling me that the appendix would burst ifI did not get it
operated there and then.”
Javed recalled the differences between the two doctors: “Dr Raheem was a
very kind man. He never charged the poor He always discussed matters with
his patients.” He cited Dr Raheem’s gesture ofexplaining atl the advantages
and disadvantages ofcontraceptives to his wife and then asking her to make
a choice, before he put heron the contraception pilL Javed then came to Dr
Khalld’s rescue and remarked, “Yaar, everything and everybody has changed,
how can doctors be the same?! Dr. Khatid needs a much larger amount of
money than Dr Raheem to run his home and family His family sold a large
piece ofland to afford his medical education and is still under debt, while Dr
Raheem went to a medical college with hardly any expenses involved. He is a
fine surgeon and knows much more than us about illness; why should he ask
us about medical matters as long as he means well?”
Fazal had anotherstory to telL “Dr Khatid gladly accepted a new mobile
phone from a female patient so that she could call him for telephonic advice.
He also went on a holiday to Bhurban with his family and a friend, with all
expenses paid by the pharmaceutical company where lam emptoyed.”
Javed again came to Dr Saheb’s rescue, “But then he never charges any fee
from the medical students and his colleagues and recently appeared on the
television channel and gave free advice on important health matters.”
Ahmed concluded the discussion by saying “Dr Khatid is like all ofus; he has
his positives and has some negatives too. Hebannot be compared with Dr
Raheem as the ethics of the medicat profession may have changed over the
last three decades.”Safdar remarked on his way out ofthe tea bar, “Let us
wait and watch Dr Khalid’s progress.”
Medical Ethics and Professionalism
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Behavioral-sciences-dr-mowadat rana (1).pdf

  • 1. CONTENTS Section A . 1 Introduction to Behavioural Sciences 1 Holistic vs. Traditional Allopathic Medicine 2 Health Care Models and their Clinical Applications 3 1. Bio-Psycho-Social (BPS) model of health and disease 3 2. The Integrated ModeL of Health Care: Correlation of Body, Brain, Mind, Spirit and Behavioural Sciences 5 3. The Public Health Care Model g Non-pharmacologicaL Interventions (NPIs) in Clinical Practice 11 1. Communication Skills 11 2 Counselling 14 3. Informational Care (IC) 16 . Handling Difficult Patients and their Families i8 5. Breaking Bad News 20 6. Crisis Intervention and Disaster Management 27 7. Confticl. Resolution 29 Empathy 32 Sample MCQs and Essay Questions 33 Section B 35 Medical Ethics and Professionatism 36 Relevance of Ethics in the Life of a Doctor 37 ;. Scope and Meaning of Medical Ethics 37 2. Guiding Principles of Medical Ethics 38 3. Common Ethical Issues in Medical Practice 39 4. Common Ethical Dilemmas in a Health Professonat’s Life 43 . Doctor-Patient Relationship 48 Rights and Responsibilities of Patients and Doctors 49 a. Rights of the Patient 49 b. Responsibilities of the Patients 50 c. Rights cf the Doctor 50 d. esponsibilities of the Doctor 50
  • 2. Psychological Reactions in Doctor-Patient Relationship 52 a. Social bonding 52 b. Dependence 53 c. Transference 53 U. Counter-transference 54 e. Resistance 55 f, Unwell Physician / Burn-out 56 Professionalism in Heatth Care 57 - a. Knowledge 57 b.Skills 57 c. Attitudes 58 Sampte MCQs and Essay Questions 61 Section C 63 Psychotogy in Medicat Practice 63 a. Role of psychologicaL factors in the aetiology of health probLems 63 b. Role of psychological factors in the precipitation (triggering) of iltnesse 63 c. Role of psychological factors in the management of illnesses 64 U. Role of psychological and social factors in diseases causing disability. handicap and stigma 64 e. Role of psychological factors in patients reactions to illness 64 f. Medicat[y Unexplained Physical Symptoms (MUPS) 64 Principles of Psychology 65 1. Learning 65 2. Metacognition 72 3. Memory 74 4. Perception 81 5. Thinking 85 6. Emotions 92 7. Motivation 94 8. Intelligence 97 9. Personality Development 101 NeurobiologicaL Basis of Behaviour 108 Emotion 109 Language 114
  • 3. Memory . 116 ArousaL . 117 Sleep 118 Sample MCQs and Essay Questions 123 Section D 125 Socio[ogy and Anthropology 125 Introduction 125 1. Sociology and Health 127 2. Anthropology and Health 135 Sample MCQs and Essay Questions 141 Section E 143 Psychosociat Aspects of Health and Disease 143 Health and NormaLity 143 Defence Mechanisms 145 Psychosocial Assessment in Health Care 14$ ClinicaL Situations Demanding a Comprehensive PsychosociaL Assessmer 148 Psychological reactions to IlLness and Hospitalization 149 Psychosociat Assessment ... 153 Psychosocial Issues in SpeciaL Hospital Settings 157 a. Coronary Care Unit 157 b. Intensive Care Unit 158 c. The Emergency Department 159 d. Psychosocial Aspects of Organ Transplantation 159 e. The Dialysis Unit i6o f. Reproductive Health 161 g. Paediatrics Ward 163 h. Oncology 167 i. Operating Theatre 168 PsychosociaL Peculiarities of Dentistry 170 PsychosociaL Aspects of Atternative Medicine 174 Common Psychiatric Disorders in General Health Settings 175
  • 4. a. Mixed Anxiety and Depression in b. Panic Disorder 179 c. Unexplained Somatic Complaints: Persistent Complainers 181 d. Dissociative and Possession States 182 e. Drug Abuse, ALcohol & Tobacco Use 184 f. Suicide and Deliberate SeLf harm (DSH) 188 g. Delirium 189 PsychosociaL Aspects of Gender and SexuaLity 192 Sexual Identity 192 Gender Identity 193 Sexual Behaviour 194 Gender differences in Sexual Behaviour 194 Masturbation 195 Sexual orientation 195 Psychiatric morbidity ig6 SexuaL Disorders 196 SexuaL Dysfunction 196 Disorders of SexuaL Preterence/ Paraphilias 197 Gender Dysphoria (DSM V) or Gender Identity Disorder (lCD io) 198 Management of Gender and Sexuality Issues 199 PsychosociaL Aspects of Pain 201 Psychosocial. Aspects of Aging 207 Psychosocial. Aspects of Death and Dying 210 Psychotrauma 211 Psychosocial Aspects of Terrorism 214 Stress and its Management 220 Job-related Stress & Burnout 222 Response to stress 222 Stress Management 225 Sample MCQs and Essay Questions 228 Appendix 230 Suggested Reading 232
  • 6. hitroduction to Behavioura’ Sciences As the name implies, behavioural sciences deal with the study of human behaviour through an integrated knowledge of psychology. neuroscience, sociology and anthropology. It is now widely recognised that the psychological and social sciences play a role equal to biotogical sciences in determining states of health and disease. Amongst the behavioural sciences, psychology and neuroscience contribute to the study of the human mind and the roLes played by its various functions. They examine the role of functions such as emotions. thoughts, cognitions. motivations, perceptions, and intelligence in maintaining health or causing disease. Psychology also seeks to understand how the development of personality takes place. Another major influence on human behaviour is the role ptayed by the family, the society and the community. The study of sociology helps a doctor understand the influence of society and its various units and institutions on the processes of heaLth and how they can change to cause disease. The role of family. gender issues, social classes, socioeconomic circumstances, housing, employment, social supports and social policies in maintaining health or causing disease is studied in this domain. Medical anthropology is the study of the effects of the evolutionary history of human beings. It highlights their cultural history, racial classification, geographic distribution of human races, and effects on health and signs and symptoms of disease. It also involves the study of cultural methods of deating with diseases and other distressing events of human life. What disease is to be stigmatised, which symptom is to be kept secret, what is to be handed over to the doctors and what is to be dealt with by the faith healers is determined largely by anthropological influences on a culture. Understanding the health belief model, attitudes of a society and the rote culture assigns to a sick person can highlight the importance of anthropology for a health professionaL F ECTIONA èhaviourai Sciences and their Relevance to Healthcare — OUTLINE Introduction to Behavioural Sciences Holistic vs. Traditional Medicine Models of Health Care Non-pharmacological Interventions A The behavioural sciences add to the disciplines of anatomy, physiology, and biochemistry to support the study of holistic medicine.
  • 7. t Chapter 1 Holistic vs. Traditional Allopathic Medicine Holistic medicine is inspired from the theory of Holism, which states that reality (including all living matter) is made up of unified wholes that are greater than the sum of their parts. Each sub-part is linked with the other in a dynamic way. Holistic medicine considers mind, body and spirit sub-parts that form the person; a whole that is greater than the sum of its parts. It denies the separation of mind and body advocated in traditional atlopathic medicine. Traditional allopathic medicine works on a biomedical model that aims to treat the diseased part of the human being. Holistic medicine on the other hand is committed to the restoration of health and wellness to the person as a whole, rather than focusing on the diseased part alone. A health professional committed to holistic medicine is expected to understand the following elements of this approach: Person, Environment, Health and Physician. Person: A human being who has the well-integrated etements of mind, body and spirit held in a dynamic balance. Environment: A set of external forces that can inftuence our experience of health and disease such as family, community, culture, socioeconomic resources, access to health care and quality of heaLth care. These external factors help shape our attitudes and health beliefs, Attitudes and beliefs that we learn from our environment have the capacity to either support or disrupt the dynamic balance of our mind, body and spirit. TraditionalADopathic Medicine methodology: Ju5t x the pmbLem Artist Laura Zomhie HeaLth: A dynamic state of well-being achieved through a mind-body-spirit balance that hetps an individual realise their full potential. While the former three teach about the body, psychotogy and neuroscience educate the physician about the mind, sociology and anthropology illustrate the evolution of human spirit and the factors that constantly inftuence it. T I.: Physician: A person who supports health (as defined above) rather than one who merety treats disease. A practitioner of holistic medicine, therefore, believes that health results from a dynamic and interactive reLationship between the person, his environment and the physician. 4
  • 8. Holistic medicine demands that a physician must be a person who has the following characteristics: • BeLief in the potential of the heating act • Capacity to listen and empathise Respect for the dignity of human beings • Tolerance for difference of opinion 4’ • A gentte spirit • Ability to mix creative thinking and intuition with scientific thought • Will to never give up hope even against heavy odds The knowledge of physical sciences and anatomy, physiology, and biochemistry provide adequate basis for the practice of traditional allopathic medicine. The practice of holistic medicine, however, demands the knowledge of behavioural sciences as welt as natural sciences. Chapter 2 Health Care Models and their Clinical Applications ;. Bio-Psycho-Sociat (BPS) modeL of heatth and disease In 1977, George Enget theorised the importance of integrating the traditional biological (pathophysiological or structural) aspects of medicine with the behavioural sciences (psychology, sociology and anthropology). He put forward the concept of the Bio-Psycho-Sociat (BPS) perspective of health and disease. Engels BPS model was based on three principles: a) Disease is a result of multiple factors that interact to make an individual feel ilL Illness and disease are not a consequence of biologicaL factors alone. b) An individual is composed of a complex, integrated system composed of interacting subsystem elements of mind, body, spirit and social relationships, alt having feedback loops. Any change in one will result to changes in other systems. c) Biological, psychological, and social factors form a triad to interact and serve as determinants of disease. BIOLOGICAL Biopsychosociat Modet
  • 9. He proposed that the biological, psychological and social systems work together to cause disease. The biological system ensures a structural, biochemical and a molecutar study of a disease. The psychological system provides insight into the role of personality, attitudes, attributes and motivation in the genesis of the illness. The social system emphasises the impact of family, society, social forces and culture on the aetiotogy, presentation and the management of a given illness. The biopsychosocial model stresses that understanding and manipulation of the psychosocial environment of a patient is just as important to recovery as the study of pathophysiological processes and methods of treatment. Engel proposed that death of a significant other, grief, loss of self-esteem, a threat to one’s life, property or integrity, even victories and reunions were events that can trigger a medical, surgical or a psychiatric condition. The biopsychosocial model, therefore, provides a comprehensive clinical approach towards the practice of holistic medicine. This approach lays great emphasis on the doctor-patient relationship. This involves psychosociat assessment, the use of communication skills, infor mational care, counselling crisis intervention and extension of care to the family. One of the significant contributions of the BPS model in health care is the emphasis it assigns to the use of interventions that do not involve surgery or drus: the non-pharmacological interventions. Ctinicat AppLication of BPS Model It is useful for a health professional committed to holistic medicine to approach patients using the BPS model. Research shows that biomedical and behavioural factors come into play in infectious as well as non-infec tious disordets. A patient of dengue fever is suffering at a biological level on account c breakdown of the body’s reticuloendotheLial system. Social issues related to drainage of fresh water, poor disposal of waste, however, are also contributing factors. Psychological and anthropologicalfactors such as risk taking behavior and inappropriate dressing in high risk settings are equally important in the spread of this infectious disease. Sexually transmitted diseases, HIV-AIDS, and hepatitis epidemics may atl occur due to risk taking behavior and poor protection strategies. Non-infectious disorders ar- also affected by biopsychosocial factors. This includes heart disease, di&’• tes mellitus, cancer, and depression. This is because changes n hormones, immune factors, metabolism and neurotransmitters re alt associated with socioeconomic stressors. Occupational hazards, dietary habits, child rearing practices, personality development, exposure to childhood trauma are alt governed by culture and geography. Many metabolic disorders are now called ‘life-style disorders’ due to the socio-cultural and psychological factors that work hand in hand with biological factors. Another example of the BPS model determining disease is seen in road traffic accidents due to drug and alcohol abuse.
  • 10. ‘U - college together Hamid decidedto stayin the hostel ashe belonged to a dtstant village while Hassanpreferred to cometo cottege ftam home eveiy day Soon the stress ofmedical studies started to mount Hatndpraposed that theyshould trysmoking a cigarette to qchieve ‘betterconcent,r%ion white studying Hassan readily agreed and they both started to iridutge ip smoking white studying togetherin the evenings. Hamidsoon developed a cough, but continued to smoke HassdAsparet7tsfound out and discussed the dangerous consequences ofhis habit Hassan opted out ofsmoking, joined a gym andstarted to exercise regularly He consulted his behavioural sciencesteacher to learn some innovative methods oftudyIng and techniques to give up smoking This helped him feel healthier and conceritmte befterin his studies He tned to convince Hamid tojoin him in these newly learnt techniques btHamtd did not Usten Within ayear Hamid went on to startuseofcannabis and a few months laterbecame addicted to a stimuLantMsgiades as welt as his physicat health detenoratedand he failed his annual exams. He started to develop repeated episodes ofchest infections Repeated absence fann classes and poorperfoiwance in the academics ted to his eventuat wfthdrawat from medicat college, while Hassan went on to’continue his medicqt studies enjoying goodfi7ysicathealth. The story of Hamid and Hasan illustrates an interplay of bioLogicaL psychologicaL and social factors resulting in contrasting outcomes on account of the differences between the two friends in these domains. The story highlights how homeostatic mechanisms failed Hamid. On the other hand, restorative and predictive atlostatic behavior (discussed below) such as parental concern, joining a gym and counselling by the behavioural sciences teacher helped Hasan overcome a stress they both shared. The outcome of disease in Hamid and health in Hasan was decided by an integrative interplay of all three domains, Social support and allostatic mechanisms were in place for Hasan, but none of these were avaiLable for Hamid. Hasan managed to effectively turn the stress of studies into eustress, He was, thus, able to achieve a better state of heaLth. a The Integrated ModeL of HeaLth Care: CorreLation of Body, Grain, Mind, Spirit and BehaviouraL Sciences The integrated model of health care is a step ahead of the biopsychosocial modeL It suggests a dynamic functional link between five domains of human beings: biological, cognitive, behavioural, sociocu[tural, and environmental. In this model, health is a state of a harmonious equilibrium between these domains which occurs in response to eustress or distress. This state is achieved through processes called homeostasis and attostasis. ‘1 p Homeostasis is a reactive state that ensures harmony within the body systems through adaptive negative feedback loops. It also uses reactive behavioural adjustments in domains operating outside the body.
  • 11. -* BEHAViOURAl. Integrated Modet of Heatth Care Attostasis is an adaptive mechanism in which the individual makes the adaptations by predicting changes in advance, rather than in reaction. These adaptations are creative and organised multisystem changes made in anticipation of a possible challenge to health. A typical example of homeostasis is the increased intake of fluids and salts while working on a hot summer day. Allostasis on the other hand would be to organise your work schedule in advance to be undertaken at the time of the day when it is Least hot, so that you may not need the extra salt and fluids. In the Integrated Model, an optimum degree of stress called Eustress is considered appropriate and necessary for a person to function and stay healthy. Eustress is seen as moderate, motivating and inspiring. It ensures optimum functioning of homeostatic and atlostatic mechanisms that keep alt five domains (biological, cognitive, behavioural, socioculturat, and environmental) working in synergy. SOCIO- ENVIRON cucll.rnAL MENTAl. Distress is a state in which the homeostatic and atlostatic mechanisms of biological, behavioural, cognitive, environmental and sociocultural domains are challenged by extrinsic or intrinsic factors. Challenge to any one domain influences alL the other domains and sets up a restorative feedback loop. If the systems respond with effective homeostatic and allostatic responses health is restored. If the stressor worsens to result in distress, a failure of homeostatic and allostatic mechanisms resuLts in disease and illness. Clinical Application of Integrated Heatth Care Model Separating Disease from Sickness, Distress and Stress Alt patients who develop symptoms and report to hospitals are not suffering from disease. The body and mind respond to any disturbance in biological, sociaL cognitive, behavioural and environmental domains through unpleasant experiences which can be called symptoms. Most of the time, symptoms serve as a stimulus for adaptive mechanisms and homeostasis is restored through changes in the body, mind, social support and environmental manipulation. Not all individuals reporting to hospitals are, therefore, ‘patients’ in the biomedical sense. They may not require
  • 12. Distress: This is the earliest unpteasant departure from a state of happiness and health. This state appears when homeostatic and allostatic mechanisms in the body and mind are challenged by stress. This sets into motion immediate restorative mechanisms in the body in order to attain a feeling of health through physiologicat means. No structural or psychologicat damage takes place at the level of the body and mind. Changes are visible, however, in the individuaL’s behaviour and social roles as functioning of the individual may be affected. S/he can readity return to normal following the restoration of homeostasis without any biological interventions in the form of medication or surgery. Minor environmental manipulation, mobilisation of social support and adjustments in cognitive and behavioural domains may be all that is required. Distressful states may present with the same symptoms as that of a disease. Common distress symptoms include headache, backache, vague bodily discomforts, feelings of indigestion, heaviness in abdomen, lack of sleep, appetite, lethargy, fatigue. weakness, dizziness and Light headedness. Individuals may also experience an urge to remain silent, avoid responsibility at home or work and have a general feeling of inability to cope. These feelings in a state of distress usually last for a few hours, or a day or two, but never beyond a week in one go. They are self-limiting, and improve with pleasant occurrences such as meeting friends, sharing feelings, indulging in a hobby orjoyful pursuit or even a couple of paracetamot tablets. PERFORMANCE RELAXED A INACTIVE ANGER/FRUSTRATION/ PANIC FATIGUE EXHAUSTION - I. EUSTRESS STRESS BURNOUT OVERLOAD STRESS Stress-Performance (Yerkes-Dodson) curve laboratory and radiological tests or treatment with medication. It is, thus, important to separate disease from distress, sickness and iltness. STRESS UNDERLOAD FAILUREI ‘,, BREAKDOWN Sickness: The state of distress can sometimes give way to or be replaced by a feeting of being sick’ or unwell, or nauseous. This unpleasant state can appear without any disease or any pathological change. On the other hand one may have a disease and not appear to feel sick at all (as in the case of some diseases in early stages, like cancer).
  • 13. Sick Rote: This is a state that an individual may assume at home or in office settings to show his inability to perform his routine roles or duties. This role may succeed in freeing the individual from their routine duties. S/he is expected to seek medical help and follow the advice of his well-wisher. If they do not do so, they may be seen as a malingerer. Malingering is a derogatory term used to describe a frauduLent sick role that an individual assumes to avoid responsibitity or gain a social or a financial advantage. A competent doctor is hesitant to jump to this ‘diagnosis’ and always seeks a more experienced colleague’s opinion before labelling a patient as a ‘malingerer’. Many patients who are seen initiatly to be feigning an illness have been known to develop the same or some other serious disease, Ittness: is an overall view that an individual, the family and the society take of a person who is feeling sick or unwell. The explanation that each has of the sickness decides the course of actions and health care plan that wilt follow. If the family and the community have no obvious or known explanation of the symptoms experienced by the sick individual, the likelihood of a medical consultation is rare. The patient wilt, instead, be taken to a spiritual healer, an aamil, or a charlatan. This is especially true of patients suffering from psychiatric disorders, epilepsy, and many behavioural disorders. Most patients suffering from anxiety and depressive disorders experience physical symptoms for which they prefer to undergo tab tests and consultations with physicians and neurologists rather than psychiatrists. Disease: The diagnosis of disease is made when the symptoms of an individual are attributed to a cause or aetiology. This can be in the form of injury, an organism, a substance, a pathological or structural change or a defect leading to changes in functioning in biologicat, behavioural, and social spheres. These factors are severe enough to not only challenge but disrupt and even destroy homeostatic and allostatic mechanisms. They have the capacity to change the restorative negative physiological loops in the body so that pathological processes begin to worsen the state of the individual, instead of initiating repair and equilibrium. In a diseased state, it is assumed that a reversaL of the causative pathoLogy would result in heal ing of the disease. Typical examples would be enteric fever, a fracture, or insulin dependent diabetes mellitus, Here, a complete return to health and reversal of disease is guaranteed through a medicat or surgical intervention. It is important for health professionals to note that all of the above states may or may not co-exist in the same patient at a given point in time. A person may feel distressed and sick without any disease. S/he may move around performing routine roles and duties even while harbouring a serious disease. WelL trained health professionals, clear about distress, sickness and disease should not call for unnecessary lab and radiological tests, They should also not prescribe ptacebos in the form of pain killers, muttivitamins, intravenous drips, ‘brain tonics’ and ‘high energy pills’ to individuals who report to hospitals in a state of distress. All medical and surgical interventions are, thus, only to be used once the diagnosis of a disease has been made. I
  • 14. I Integrated Model of HeaLth Care Cilnicat Scenario Mr Xis aiar oLdcterkk the tnxatianoffica HepresenL5 to the physician with increased thirstand appetite toss ofsexualfeetings al?d weightgain. His Ibstiog bLoQd UgatwaSfeufltb3OO mg/dL He has a (omityhistory ofdibete& He is nqsedas Iiawng Type II Diabetes MeUitus The treat ment armsare maintenance ofasgar- dIeL j%xstrng blood glucose levels j or infections He isp1aced on.z gram ofmetlbnntn/day Hers ciskedto have F tyhome ‘. meats waik to his offIce in the mornings andtakea3 km walk with dieirithe averii# Biotogis.trzsulin istc dIstUrbedarbohydratemetaboLisnz encfzctors Magee,tMetfi2rmii7. Thishelped in ave gtheb7sutin ies&dnce andknpxove the carbohrate metqkoffstn 8ebavawoiiPeferencef&h Ca esugarithfaO asedentary tifestyte shssft(jØband unhappy mari&Life. ManngenentAttreversed with a change inea& habits. shaitbursts of pIcaLe’re dLiring working hours andin7pioved interaction with hIs wife dJrinre9uIarevenfrg walks CDislk..frpersonai physiqueand thoughts ofgrowing oLd, overweight and ugly. rnaritatstress anda satIsed maritaLlife Management Information andunderstandingrofhazards ofovereating ond .entanj Lifestyle, and cQmrnitment toa healthierway ofthinking about self future, his fqrnily and his work! in generaL sociocuLturaLjactoxs Clerks in such oie regularly receive sweets and unheatthy food and eat unhealthy high calQrle and carbohydrate nchfood a the office canteen, cuture ofworking long hOurs Enviro)metaLfactois Colleagues wiihsfmllar unhealthyeating hat’its and lifestyles Availability ofunhealthy food at the canteen absence ofopportuni ties for exerciseand tack ofaccess tohealthyfood Minorchonges in lifestyte t work and home reversed the environnentatkl&1ence, Management Mr X’s refusot to accept swAts bip lunch from home,. simple physical exercises during ofñcehours for5 to 10 minutes insteadof constantty sitting on the choir alt helped in improving the culture in the office and other workers soon started to copy Mr. X 3. The PubLic HeaLth Care Modet Treatment at Primary Care Levet, Prevention of ILlness, Promotion and Protection of Health Hospital based health care models work primarily to emphasise treatment of disease, This kind of health care approach is one of damage control Public health care models on the other hand, work not only to treat disease but also to prevent it. The World Health Organisation (WHO), a premier stakeho[der in the field of li .4 heatth care, promotes a public health care approach in addition to hospital
  • 15. based care. This model is committed to treatment of common diseas es and basic health issues through primary health care centres. Primary heatth care centres are estabLished at the grassroot level, where the maximum rural, and semi-urban population resides. In Pakistan these are called Basic Health Units (BHU), and Rural Health Centres (RHCs). These Centres work towards prevention of illness and promotion and protection of health by working with the community in the delivery of heaLth care. The strategies in place include immunization campaigns, mother and child health programmes, reproductive health, HIV-AIDS programmes, nationaL programme of mental heaLth, narcotics control, antimaLarial and dengue controL programmes. These run in collaboration with national and international governmental and non-governmentaL organisations. Health legislations on smoking, healthy diets, seat belts, helmets, safe sex, population welfare, and reduction in mentaL health gap are some of the initiatives undertaken to achieve the promotion of health. SUMMARY KnowLedge, skills and attitudes rooted in Behavioural Sciences are an essential component of alt the models of health care currently in practice. A comprehensive understanding of psychology, sociology and anthropology as well as biological determinants of health and disease is cruciaL for the practice of scientiIc medicine. The traditional biomedical model of reversing biological causes of disease has proven to be inadequate. An integrated model of health care in which the psychosocial, cognitive, behaviouraL and environmental stressors are considered as important as biological causes of disease is the future of modern medicine. This approach aims at restoration of homeostasis, and stress reduction to optimise functioning. It also helps attain equilibrium between the internal and external world through allostatic processes. Interventions that go beyond medication and surgery to include non-pharmacological measures heLp achieve health in a far more effective and lasting way. This includes measures such as mobilising social support, influencing existing health belief modeLs, ensuring a healthy and safe environment, providing informational care, conflict resolution and early handling of psychotrauma. A public health approach of primary and secondary prevention which emphasise treatment of disorders and promotion of health as cLose to the community as possible helps to achieve a more global perspective of health.
  • 16. Chapter 3 Non-pharmacological Interventions fNPIs) in Clinical Practice The use of these interventions is advocated in the BPS model for their established efficacy (as seen by extensive research) in augmenting the impact of drug treatment and surgical procedures. Non-pharmacological interventions (NPIs) enhance patient satisfaction, improve adherence to treatment, and strengthen the bond between the doctor and his patients as well as the community. The NPI5 in particular that a medical or a dental student can use to diagnostic and therapeutic advantage include the following: 1. Communication Skitts While communication seems like the most basic and innate part of being human, effective communication is a vital toot in clinical settings as it forms the basis of the doctor-patient interaction. The doctor and patient undertake a joint voyage, many a times into an unknown territory of disease. Problems may arise when the two travelers 9nd it difficult to communicate or understand each other. While the physician is expected to know the patient’s language, the patient is often unaware of medical jargon. As the service provider, the responsibility for effective communication ties with the physician. The tools that can be employed to make this communication effective and skillful are: i) Attending and listening: Attending is the act of truly focusing on the patient. It involves a conscious effort by the doctor to be aware of what the other person is saying and trying to imply. This may only be possible if the interaction with the patient is done in a setting of exclusivity Standing on a patient’s bedside with fellow students, amidst the traffic in a ward, attending to mobile calls simultaneously. or eating/drinking while talking to the patient may signal that you are not exclusively attending to the patient and/or his family member. A screen next to the bed, or a relatively quiet corner of the ward meant for interaction of patients with the students may provide a setting that allows for more effective communication. ii) Active listening: This is a process that goes beyond merely hearing and making notes of what the patient says. It involves a simultaneous focus on the linguistic and the paralinguistic aspects of speech. The linguistic aspect refers to the words and verbal aspect of the speech Paralinguistics refers to nonverbal features of speech such as timing. votume, pitch, accent, fluency, pauses and ums’ and ‘errs’. These are important as they indicate how the person is feeling beyond just the spoken word. An understanding of body language of the patient is important for a doctor to communicate with the patient. Body language refers to the way a patient expresses himself through the use of non-verbal cues such as facial expressions, proximity to the doctor, use of gestures. body position, movements and eye contact. Li
  • 17. Use of minimal prompts Lark of exclusivity Sit squarely in relation to the patient Preoccupied oranoious health professionals Open body position In relation to the patient Uncomfortable seating - - Lack of attention to non-verbal cues Leanmg shghtly towards the chont during active listening Maintaining reasonable eye contact Offensive remarks orjudgmcnt by the health professional Pelaxed attentive health professional Frequent interruptions Listen and respond to feelings Selective iintening - - - Oay dreaming or dosing off during Note all pamlrnguist,c and nonverbal cues the communication It shoutd be borne in mind that body language expressions are only cues and not ‘ctinical signs. These cues should be pointed out to the patient to draw his attention to them, to understand his feelings or their meaning to him, e.g. “I notice that you took angry, how are you feeling at the moment?’, or ‘your eyes filled up with tears when you told me the name of your father.” This is more rational than making the wrong assumption about his gestures or body language. This is essential as methods of non-verbal communication vary in patients and their family members, according to their upbringing, culture and background. Active listening also involves customizing your style and language to match that of your patients or anybody you are listening to. This can be done by using the same language as the patient wherever possible. Another important aspect of active listening is respecting the pauses and silences of the patient. This would mean not immediatety jumping in and talking whenever the patient pauses for breath or reflects silently. iii) Verbat techniques.’ These are pivotal in making the communication effective and thus contribute towards the therapeutic process. These are vital skitls for the doctors and can be mastered through practice. Any verbal communication in a clinical setting involves the following components: Questions: these can be closed or open ended. Ctose ended questions elicit a yes/no or a fixed response e.g. 4What is your name?” “Are you married?” 5Do you get nausea after taking your meals”? These questions are vital at the start of an interaction both, to collect data as well as establish familiarity and comfort with the patient. The open ended questions do not elicit a particular answer. They are intended to encourage patients to talk more about their story or to expand more upon their issues. Questions are usually used for exploration of a particular aspect, for obtaining further information, to clarify any details and to encourage a patient to talk. E.g. “What brings you to the hospital today” or 5Kaisay aana hua?° or even simply 5Jee, kohiye.” Fadorsthatrmptøv. cotrimintcaUon
  • 18. It is important to start an interaction with the patient or his family members with an open ended query, such as What brings you to the hospitaL?” What can I do for you”? This gives the patient a chance to open the conversation, with what s/he considers most significant. Leading questions are those that prompt the patient to answer in a certain way. These lead to skewed information as we tend to give the answer that we feet the person is looking for. These should be avoided as should value laden ones. Some examples of these are e.g. Don’t you think your pain radiates into the left arm?” or “Do you feet ashamed of your short stature?” Moreover ‘why’ questions should be used sparingly e.g. “Why do you think you have developed shortness of breath?” An effective communication therefore revolves around questions starting with what, when, where and how Funneling: This refers to the use of questions to guide the conversation from a broader area to a more specific one. These should follow open ended questions. This technique hetps the interviewer move from general statements by the patient to specific areas of clinical relevance e.g. “Now that you have described your complaint of feeling weak and lethargic. can you describe which specific part of the body you were referring to?” Paraphrasing: It refers to the process of repeating the last few words the patient said and summarising what the patient has communicated so far, in your own words, and then ask him or her to validate if you have understood it correctly, e.g. “you have told me about the weakness in your legs and lethargy that you feel after walking for only few yards. Is that right?” ‘Aap ne bataya k aap kal maiday mal 2 haftay sejatan ho rahi haijo khanoy k baud barhjaati hai, kya also he hal?” Setective reflection: Reflection is a technique to bring out the feelings attached to various symptoms and problems that a patient has stated. It refers to the method of repeating back to the client a part of something s/he said that was emphasised in some way or which seemed emotionally charged. e.g. How does it feel when you start to feel fatigued only walking for a few minutes? You told me earlier, that you were once an athlete who could easily run a mile.” Empathy buitding: This refers to statements made by the doctor that make the patient see that his or her feelings have been well understood. It helps the patient understand that his/her feelings are valid and that the doctor would have felt the same if s/he was in the patient’s place. It is important here to refrain from expressing sympathy instead, which would imply that the doctor feels sorry for the patient’s plight. can imagine how difficult it must be for you to live with your pain for such a long time” is an empathetic statement, which is highly desirable; a statement such as “Poor you, really feel bad hearing your story” is an expression of sympathy which may not have the
  • 19. desired therapeutic effect and also undermine the effectiveness of communication. Checking for understanding: From time to time during the session the doctor needs to summarise patients statements or ask the patient to comment on the summary. to ensure if s/he has understood the problem and its associated feelings correctly. An effective communication based on the above principles is bound to form a bond and a relationship between the patient and the doctor in which both feel understood and connected. It is this feeting of mutual understanding that is traditionally described by patients as Hatfmy ittness was retieved after tatking to my doctor. WhiLe the principles of effective communication should be part of all clinical interactions between a doctor and his patient, the best use of these principles is in counselling individuals, couples, family members or groups. 2. Counsetting Counselling is a technique that aims to hetp peopte help themselves by the development of a therapeutic relationship between the counsetlor and the patient or family member, a colleague or anybody who seeks counsel. The process aims at helping a person achieve a greater depth of understanding, and clarification of’ the problem mobilises personal coping abilities. It is not an ordinary every day conversation, in which one person • asks the other for advice and gets the other person’s opinion on what to do. Counselling is a limited supportive activity aimed at developing a person’s ability to decide upon and initiate a constructive change. A doctor or a medical student may come across a variety of situations in clinical settings and professional interactions in which they may require counselling skills. Some of the common scenarios where this skill can become a useful intervention include: breaking bad news to patients or their families, or resolving professional conflicts. These may include announcing that a patient’s biopsy report has revealed a malignancy, or that cardiopulmonary resuscitation has failed to revive the patient. It may be required as part of sharing the news of a baby with congenital malformations or a stillborn baby with the expectant parents, resolving a conflict between a colleague and a nurse in the ward, or handling a relative who feels that his patient is being ignored and denied a particular investigation or intervention. A coun selling session aims to: a) Establish a relationship of mutual trust and care in which patients and/or their families feel secure and able to express themselves in any way or form necessary. b) Give patients or their families a chance to seek clarification and expLanation of terms, issues and misgivings. c) Provide an opportunity to patients or whoever is being counselled to freely express his or her feelings and emotions. d) Provide reassurance.
  • 20. e) Achieve a deeper and a clearer understanding of a heatth related issue based on scientific and evidence based data. f) Identify the various choices and options alongside their pros and cons through a process of discussion and dialogue between the counsetlor and the patient. g) Help the person make a decision or reach a solution that is most suitable for him/her. h) Seek support of the counsellor i) Mobilise resources required to implement the solution. j) Learn the necessary skills to cope or deal with the issue. Under no circumstances is the counsellor expected to make decisions on behalf of the patient or the one counselled. The responsibility of the consequences of the proposed solution thus always rests on the shoulders of the patient seeking counsel and never on the counsellor. If a medical student or a doctor opts to take up the role of a counsellor s/he needs to develop and exhibit certain attributes, discussed below. What traits must a counsettor have? Unconditionat positive regard This involves a deep and positive feeling for the patient, being non-judgmental and trusting. Empathic understanding This is the ability to accurately perceive others’ feelings, validating them and communicating this understanding to them effectively. As highlighted above, it is different from sympathy which implies feeling sorry for the person. Warmth and consideration This can be achieved by remaining open-minded and non judgmental. Avoiding over emphasis of your professional role and being consistent in behavior helps convey that you are genuinely there to help. Also by remaining respectful and tactful, the counsel tor would be able to show warmth and consideration to his patient. Clarity The counselling relationship should remain clear and without mystery to the patient. As a counsellor you are required to be clear and explicit. Encourage the person being counselled to be similarly explicit in his requirements. Use of the techniques of paraphrasing and checking for understanding described above can ensure successful communication. Here and now thinhing The distressed patients would like to talk excessively about their past in order to avoid the reality of the present. As counsellor you need to help identify present thoughts and feelings to enhance problem solving attitude on the basis of here and now’, and focus on the present day issue(s).
  • 21. Do not ask why” questions, These imply interogatiorv Does not involve giving direct advice to patients Do not say should ought or icarna chahiye tha. Does not solve people’s problems for them These imply moralisation. Do not blame the patient Does not challenge a patient’s feelings and perceptions t)o not compare the patient’s experiences witi, Does not impose the counsellor’s own views your own, or gite examples from your life onto the patient The patient is a different petson from you and has different life experiences. Does not make people less emotional Do not invalidate the patient’s feelings, Does not work to fulfil the counsellor’s need to make people feel better 3. Informational Care (IC) Memoirs of a patient’s son I took my etderly mother to a targe hospitat in our city when she became sick She was very embarrassed to go to the doctor because she said that he would examine herand cause bepardagi but! convinced her that they have welt trained doctors who are trustworthy and wilt take care ofher without causing her any embarrassment We went to the outdoor department where we were told that she had a breast lump which coutd be °a tumOur.” This was like a bolt of lightning for the whole family as we had heard that nobody survives from cancer I borrowed 5000 rupees from a friend and admttted her in the sUrgery ward in the big hospitaL We were hoping that through these doctors, A(tah would help us through this trial, Ajunior doctor took her medical history and startedsome medicines. I asked him whether my mother woutd be okay, but he said he didn’t knowyet and we needed some tests. He then went away and a nurse gave us a slip to do some tests but nobody told us how much the tests would cost woutd it be painful for my mother how long would the results take, how tong would we need to stay in the hospitat, any precautions we need to take for herrecovery? When the test results came thejunior doctor looked at the results and told us that the senior doctorsahib wilt decide during “the round I thought maybe they wilt tell us when they decide after the round The senior doctor sahib came for the round but he discussedsomething in English with the other doctors and moved on from our bed without telling us anything. Later on, a group ofstudents came to our bed andsaid that they needed to examine my mother’s chest My mother was very ashamed but they sqid that it was necessary for her treatment, and so We had to agree Seven ofthem examined my mothers chest turn by turn and we were constantly worried about how manypeopte might be watching her like this. Later on, I asked for the senior doctorsahib to find out about the treat ment ofmymother and the questions I had in my mind, but the peon said that he was in a meeting. I asked for thejunior doctor who had taken our history but he had left after his duty and would be coming back the next day I asked the nurses too but they did not know anything about my mothers treatment plan. A newjunior doctor came that evening on Ucity and told us that we had to prepare formy mothers surgery two days later, and that we also needed to arrange for3 units ofblood and about 20,000 rupees for the items required in the surgery. We were very confused, as no one had discussed anything with us about this surgery. When I asked thejunior doctor about how much money we needed in 4otat how many days we would need to stay in the hospital caun4Ipon 7 MIsconcptfons about Counselling.
  • 22. after thaL and ifthere was any otheroption besidesthe surgery he gotangry andsaidthat Don tyou trust the doctors advice2 and you care about mon eymore thanyourmothers health 57 was very hurt andembarrassed bythese comments On the otherhand my motherand sisters were very hopetess as they had heard thatnobodysunuvesfrom 5cancer even afterthesurgery Veiywomedand confused we were totd bya neighbturthat a local pirsa R2LJ We didnotknow what to do All we reallywanted was someone to listen and answersome ofour quenes in this confusion and desperation, a consultation with the pirsahib seemed like our onty ray ofhope So the nextmorning we left the hospital fora meeting with the pirsahTh’_.. Recommendedexercise Read this case scenario once before studying this sectlonr and then a sec ond time after completing the section Discuss whythis chath of events ted to this tonsequence and what actions could have been taken differently by the health care team to avoid such an unfortunate outcome LI H Informational care is defined as provision of information to patients using principles of communication regarding the disease, the drugs and the doctor (the 3 Ds). This helps to fill the gap in the patient’s knowledge and understanding in these areas. In order for the patient to fully achieve this understanding, informational care must be provided using Language that the patient understands. During ill health, the patient and his caregivers feel a desperate need to know what exactly is wrong, how it is being or will be managed, who will deliver the care and how. The amount of information provided, timing, Language and setting in which informational care is imparted has to be tailored according to the individual needs of the patient, This includes considerations such as what stage the illness or recovery is at and what questions bother the patient the most. Seven ESSePtIISIfl iflformatlonal Care: The physician must set aside time within a consultation to give a reasonable level of information to the patient and his family about the disease and treatment. The IC session must take place in the language that the patient can understand. it must start with patient’s knowledge, understanding and expectations. Aap apni bemari kal baray ma) kya Jantay haln The doctor must than remove any myths and misconceptions that the patient mentions in his description. These misconceptions must be clarified and replaced with evidence-based information, The task of giving intormation should be professional, evidence based facts are provided without fear of causing a negative reaction in patient and/or family. It must however be done with compassion, empathy and sensitivity. Vague statements and building false hope should be avoided. Both aspects of the disease and treatment, negative and posItive should be communicated to th, patient, but information overload is to b, avoided, Use of simple figures, diagrams and sketches are often helpful to enhance the patient’s understanding. Most patients or relatives may like to keep the sketches at the end of the session, which consolidates their interest and the titility of the IC etetcise in the therapeutic process. The IC session ends with th. patient briefly summerising his new understanding of the 3 Os. This helps to evaluate how much of the InformatIon has been retained, The doctor finally reassures that any future concerns and clarifications that ar. needed will also be addressed.
  • 23. What is wrong with me (diagnosis)? Why have developed this disease (aetiology)? Is there an effective treatment to my problem? Is the treatment safe? Are there any serious or danoerous side effects (management)? How long iIl I take to recover (prognosis)? Is therea ‘Perhez’ (restrictions)? Is there a risk of illness being spread to those APOUND me or passing It onto my offspring (transmission)? How will the illness and the treatment effect or influence my functioning? (Can I continue to work or rest? What will happen to my sex life, sleep, appetite etc.?) 4. Handling Difficutt Patients and their Families Health professionals find certain types of patients and their families exceedingly difficult to deal with. These include individuals who • have long, meaningless and repetitive discussions with the doctor • waste precious time. • become too dependent and clingy ask for undue favours • make unprofessional demands. • try to manipulate the doctor • become angry when things do not go their way • become rude or behave aggressively. • refuse diagnostic tests and treatment. Other patients who are seen as difficult are those with medically unexplained symptoms (MUS) such as vgue physical complaints, aches and pains, mentat health problems and patients who may be drug users, are obese or mute. Management: It is important to be aware of factors operating in a health professional that can give a false feeling that the patient is behaving in a difficult way. These commonly include having a heavy work load and what time of the day the interaction with the patient occurs, as health professionals tend to become irritable towards the end of the day. Inadequate knowledge and skills to deal with a demanding clinical situations may also cause the health pro fessional to become panicked or overly sensitive. Lack of training in com munication and counselling skills may worsen this situation. Some health professionals trained in a biomedical model feel that addressing patient’s. psychosocial and spiritual issues is not their job. They may, therefore, Seven Questions a Patient NeedsAnSwered man CSessian
  • 24. become irritable when a patient brings up these aspects for discussion. Whatever ones views may be, as a heatth professional you are likely to come across at Least one if not all of the aforementioned situations. The following steps may help in dealing with a difficult patient or family effectively: a) Have an understanding of the biopsychosocial model and integrated health care model and believe in the effectiveness of these well researched models. b) Train yourself well in principles of effective communication and counselling. Seek specialised training in handling of difficult patients by trying to form a relationship or bond with difficult patients in the ward. Looking at videos of how seniors ideally handle such patients and discussions with health team members will help educate you. c) Learn relaxation techniques to manage your own anger and feelings of frustration. d) Approach difficult patients with tolerance, patience and use of principles of active listening and unconditional positive regard, keeping your cool. Concentrate on breathing deeply and easily while listening to the angry patient or a family member. e) Do not take remarks being passed as personal insult’ or challenge to your integrity or authority. Consider them a different viewpoint of an individual who is hurt or is uninformed and unguided. f) Allow the patient or family member to express anger and validate it by statements such as “your anger is understandable”, “I can understand your feelings”, “this must be frustrating for you’. “mujhe andaza hal kaiye aap k tiye kitna mushkft waqt hal” g) Offer a chair and a calmer setting to discuss the issue at hand in more detail. Offer an apology or an explanation for any unintended offense but do not appear defensive. Stay calm, maintaining an open body posture, a safe distance and always keep an eye at the emergency exit. Always ask for assistance from colleagues or staff at the earliest signs of aggression or threatening postures by a patient or famity members. h) For difficult pai. its in particular, define the objectives and duration of consultatio ri advance. i) Offer referral to a colleague or a senior consultant, particularly if you are not making any headway. j) Use humour while collecting further data, reassure, undertake detailed physical examination, and a more extensive diagnostic work up. or seek opinion from a mental health professional. k) Involve family members, friends or significant others in the life of the patient for support as well as help in understanding of the patient’s issues.
  • 25. 5. Breaking Bad News Any news that adverseLy and seriously affects an individual.’s view of his or her own future is considered bad news. There are many clinical situations where bad news has to be communicated to patients and/or their relatives, e.g. disctosing the diagnosis or relapse of cancer, birth of mal formed baby or death of a loved one. Breaking bad news is an unpLeasant task and can be learned from the senior physicians or through own profes sional experience. Most patients and families expect full disclosure delivered with empathy, kindness and clarity. There are five different schools of thought regarding the provision of information to patients. The biopsychosocial model has the least number of limitations and is therefore strongly recommended for use in health settings. a) Blo-Psycho-Sociat Modet: This model provides clear, crisp, evidence based information on the patient’s condition but tailors the flow and amount of information accord ing to the needs of the patient. A vertical flow of all data on the disease (particularly the parts that the patient or his family have not asked for), is avoided. The bad news is broken using principles of effective communi cation, counselling and informational care discussed earlier. The patient is encouraged to involve his family members, particularly the ones who can provide psychosocial support, during the session as well as in the long run. This model suggests the following steps for a session that aims at breaking bad news: Step 1: Seating and Setting (Environment): Exclusivity The environment where bad news is being broken can have serious repercussions on the outcome of the interview. A patient’s mistrust and antagonism may simply result from a poorly chosen location. It is, therefore, worth trying to find a private room where the doctor and patient can focus on the subject attentively. invoLvement ofsignificant others Some patients like to have family members or friends around them when they receive bad news, while others prefer to hear bad news alone. Ask the patient who they would like to accompany them. If there are more than a few people supporting the patient, ask one person to act as representative. This gives the patient support and alleviates some stress from the doctor in the face of an emotionally charged interview. Seating arrangements It is advisable for the interview to take place with both octor and patient comfortabty and respectfully seated next to each other, preferably at a distance of an arm’s length. The arrangement should never impart an intimidating image of the doctor. It should provide an appropriate setting for discussions and any emotional outbursts or ventilation of feelings that may arise.
  • 26. Be attentive and calm Most doctors feet anxious when breaking bad news and it is worth spending some time to eliminate any signats that may suggest our own anxieties. Maintain eye contact and show your attention. If the patient starts to cry, try shifting your gaze because nobody Likes to be watched while crying. This should however be done with sensitivity and must never send a signal that you do not realty care about the patients feelings. Listening mode SiLence and repetition of last few words that the patient has said. are two communication skills that wiLt send across the message that you are Listening weLl. Avaitabitity If you have appointments to keep, give your patient a cLear indication of your time constraints but make yourself available to the patient for all his queries and doubts for the duration that you are with him or her. Step 2: Patient’s Perception: Ask: What do you know? “Aap apni bemoan kai baray mai kyajantay ham?” The principle involved in this step is “before you tell, ask.” Before you break the bad news to the patient, try to ascertain as accurately as possible the patient’s perception of his or her MEDICAL condition. Obtaining this information depends on your own communication style. As your patient responds to your questions take note of the language and vocabulary that s/he is using and be sure to use the same vocabulary in your sentences. This alignment is very important as it hetps you assess the gap between patient’s expectations and actual medical condition. If the patient is in denial, try not to confront him in the first interview, as denial is an unconscious defense mechanism that facilitates coping. Step : Invitation: Ask: What would you tike to know? “Aap bemari k baray mai kyajanna chahain ge?” Although most patients want to know all about their illness but assumption towards that should be avoided. Obtaining overt permission respects the patient’s right to know or not to know. Some examples to address this are: “Are you the kind of person who likes to know alt the details about what’s going on?”, “How much information would you like me to give you about your diagnosis and treatment?”, “Would you like me to give you details about what is going on or would you prefer I tell you about the treatments I am prescribing to you?.”
  • 27. Step : Knowledge: Before you break bad news, give your patient a warning of some sort to help him prepare e.g. “Unfortunately I have some bad news for you Mr. X” or “I am sorry to have to tell you...” When giving your patient bad news, use Language similar to his. Avoid scientific and technical language. Even the most well informed patients find technical terms difficult to comprehend in that state of emotional turmoil. Give information in small bits and clarify whether s/he un derstands what you have said so far, e.g. “Do you see what I mean?” or “Is this making sense so far?” As emotions and reactions arise during the interview, acknowledge them and respond to them. Ask: What have you understood? “Kya mal aap ko baat theek se samjha saka/saki hoon?” Step 5: Empathy: For most doctors responding to our patients’ emotions is one of the most difficult parts of ourjobs. In our effort to alleviate our own discomfort it is tempting to withhold certain information or give a more hopeful picture than actually exists. These tactics may appear to help in the short term but seriously undermine aft your efforts in the long run. It is much more useful and therapeutic to acknowl edge the patient’s emotions as they arise and address them. The technique that is most useful is termed the empathic response. An empathic response involves listening and identifying the emotion or mix of emotions that the patient is experiencing and offer an acknowledgement for them. Identify the source of that particular emotion and then respond by showing that you understand the emotional expression of the patient. Statements such as “mai bhi agar aap ki jagah hon toh aisa he mehsus karoon” reassure the pa tient that you understand the human side of the medical issue and that you have a respect for his feelings. Step 6: Summarise: Before the discussion ends, recapitulate the information in a short summary of all that has been discussed and give your patient an opportunity to voice any major concerns or questions. Step : Ptan of Action: You and your patient should go away from the interview with a clear plan for the next steps that need to be taken and the role you both would play, in the management of the issues. Also allow the patient to have a way of contacting you, through the hospital exchange or after rounds the next morning, in case they have any questions.
  • 28. b) Individuatised Disclosure Model: In this model the amount of information disclosed and the rate of its discLosure are tailored to the desires of the individual patient by doctor-patient negotiation. First the doctor and patient work together to clarify what information the patient wants. The doctor then imparts that information in a way that the patient understands. This is an on-going and developing process. It implies a tevel of mutual trust and communication that takes time and effort to develop. The distinguishing features of this model are that it takes time and skills and its assumptions are supported by evidence. It has the capacity to maximise quality of life for the patient. The underlying assumptions in this model are that it takes each individual a different amount of time to absorb and adjust to bad news. A partnership between the doctor and the patient for decision making is. therefore, in the patient’s best interest. Its disadvantages are that it is a time consuming process that might be difficult for a busy physician to undertake. It also tends to drain a health care providers’ emotional resources. The advantages are that the amount of information given and rate of disclosure is taiLored to needs of the individual and a supportive relationship with the doctor is established. c) FuLL Disclosure Model: This model involves giving full information to every patient as soon as it is known. It argues that this promotes doctor-patient trust and communication and facilitates mutual support within the family unit. The underlying assumptions in this model are that the patient has a right to full information about himself and the doctor has an obligation to give it. It assumes that all patients want to know bad news about themselves and that patients themselves should decide what treatment is best for them. The disadvantage of this model is that discussion of options in detail may frighten and confuse some patients. The doctor insisting on providing information may undermine defenses such as deniaL which are otherwise important for the survival of the patient. The provision of full information may, also, have negative emotional consequences for some. The mod el holds some advantages as well, such as promotion of doctor-patient trust, family support and allowing patients time to put affairs in order in case of a poor prognosis. It also helps those patients who cope better with their diagnosis by having the maximum amount of information about their illness. c) PaternaListic Disctosure ModeL: This model implies that information about the patient’s disease is the right of the doctor. The doctor delivers the information to the patient as and when s/he deems appropriate, in a ‘sugar coating’ to minimise the pain and distress of the patient. It also involves the expression of sympa thy and a sharing of emotions on the part of the doctor. This model is no longer recommended for use. d) Non-Disctosure Modet: This model is based on the view that under no circumstance should patients be informed that they have acquired a lethal disease. It states that deception should be used if necessary, on the basis that the patient needs protection from the terrible reality of terminal illness. This model has been traditionally adopted as part of a paternalistic and nurturing
  • 29. attitude of doctors towards their patients. The underLying assumptions in this modet are that it is appropriate for a doctor to decide what is best for the patient; patients do not want to hear bad news and they need to be protected from it. This model has obvious disadvantages such as: denial of the opportunity to adjust to illness, which the patient is ob • viousty experiencing • trust in doctor is undermined opportunities for helpful interventions are lost • patient compliance is less tikely • patients may acquire wrong information that can lead to avoidance, isolation and a perception of rejection • the patient may experience a sense of loss of control in what is hap pening to his own body Advantages of following this model are that it is easier and less time consuming for the doctor and suits those people who prefer not to know their condition. This model s fast fatling out of favour and is now widely rejected by modern day doctors as welt as patients and their families. What expectations do the patient and [amity have when receiving bad news? According to research, the most important factor to the patient and family receiving bad news, is the attitude of the health professional. The heatth professional should, thus, be knowledgeable, empathetic and give hon est and clear answers in simple language. The second most important factor is the setting in which the news is broken. A quiet, private place • where the news is broken in an uninterrupted way is preferred. What are the common reactions that a patient experiences upon receiv ing bad news? The reactions that a person goes through when they hear bad news, can be summarised as the stages of denial, anger, bargaining, depression and acceptance. These stages are rarely clearly delineated, and often patients go through one or more stages at the same time and for each individual the length of time each stage lasts may vary. It is important that the health professional empathise with and provide support for the patient during each stage. What are the common reactions in a heatth professionaL breaking bad news? Delivering bad news can be equally taxing and demanding for the health professional. S/he may experience strong emotions of being a failure, or of not having done enough for the patient. Feelings of helplessness, sad ness and fear that they may harm the patient emotionally by telling them the truth may be experienced. Some may feel shame and disiltusionment with their profession, and others may experience fear of their own death and disability. These feelings are essentially normal reactions to a challenging and a difficult situation. A young health professional is advised to share these feelings with a senior colleague. S/he may even assist in a few situations before undertaking this specialised communication in clinical settings.
  • 30. ChaLlenges In Non-pharmacological Interventions As health professionals the biggest hurdle we face in the administration of any non-pharmacological intervention is the Lack of time. In busy cLin ics and overcrowded wards where patients go from being humans with names to beds with numbers, it seems impossible to find the time to give someone all they need. It seems to suffice that we are there at alt, that we are doing the bare minimum to keep afloat in the never-ending sea of patients that threatens to drown us. In such a situation we must keep in mind two things: Research shows that by not spending the required amount of time the first time we see a patient, we tend to misunderstand. misdiagnose and mistreat. The inevitable result of this is that not only does a patient not improve, s/he may return to a different doctor in a worsened condition. This means that for the majority of our time, we are redoing work that a colleague has done improperly (due to lack of time) and vice versa. There are millions of patients stuck in this loop, who keep reappearing for consultations, thereby increasing the workload of heatth professionals as a whole. Secondly. it is important to understand that our job is not to mistreat the most number of people in a day, but to actuaLly treat the minimum number of people we can to the best of our abilities. Using non-pharmacological interventions, such as providing informational care and breaking bad news saves us time in the Long term. For example, if we are able to take the time to explain to a patient that the true mea sure of whether their blood glucose levels is normal is fasting btood glu cose, or an HbAic, they will not waste our time (and that of the path lab) by getting random blood glucose Levels done and showing them to us. Breaking bad news is another time-consuming procedure, how ever, one of utmost importance. To inform an individual that s/he may have cancer or AIDS is to inflict a major psychological trauma. People will remember, for the rest of their lives, the details of the occasions when important news was broken. No surgeon would think of operating without booking an operating theatre and setting aside sufficient time to do the job properly. S/he would not ‘skip the anaesthesia” just because it takes time. The procedure for breaking bad news must have a similar importance. A health pro fessional must think for a moment how they would feel if they were to receive such news. There is a world of difference between the doctor who breaks this news in relaxed atmosphere with a support ive attitude and the caLlous consultant who flings bad news at the patient in a public ward. Before teLling people what we think they need to know, we should find out what they already know, or think they know, about the situation and what their priorities are. If they use words like cancer’ or death’, we should check out that these words mean the same to them as they do to us. ‘There are many kinds of cancer, what does the word mean to you?’. ‘Have you seen anyone die? How do you view death?’ will often reveal considerable ignorance and open the door to positive reassurance and explanation. Too often, doctors fail to invite questions and miss the opportunity to help people with the issues that are concerning them most. The patient has a right to know the truth about an illness, but we must respect their right to monitor the amount of new and painful information that s/he can cope with at any given time. It is just as wrong to tell people too much, too soon, as it is to tell them too little, too late.
  • 31. • Life-threatening illness can undermine our confidence and trust and members of the caring professions can do a great deal to help peopte through these psychosocial transitions. Accurate informa tion is essential to planning. Many patients may react with relief when they are told they have cancer, as without any information they have already imagined the worst. It is easier to cope with a Le gitimate diagnosis than to live in an unplanned state of uncertainty. • Many of the different ways people cope with threats reflect the coping strategies that have been found to minimise stress earty in life. At times of threat, those who tack confidence in their own resources may seek help of others, express clear signals of distress and cling inappropriately. Those who lack trust in others may keep their problems to themselves, bottle up their feelings and blame hea[thcare providers or therapies for their symptoms. Their tack of trust makes it necessary for them to control us rather than be controlled by us. A few, who lack trust in themselves and others. may keep a low profile, turn in on themselves and become anxious and depressed. To those who lack self-esteem the most important thing we have to offer is our esteem for their true worth and poten tial. To those who lack trust in others we can show that we under stand their suspicion and their need to be in control of us. Doctors must act as advisors rather than instructors and show that they accept that trust must be earned: and that ‘it is not our right to be trusted’. SUMMARY The breaking of bad news is a difficult situation for both the health professional and patient and the family members. The task should be undertaken in an exclusive and an uninterrupted setting. The information provided should be based on what the patient and famity wants to know. The information should build on what is already known to them. Opening statement should be on the lines of “I have to share information that may be unpleasant” or “I know it may be tough for you to know.” The contents may be broken into short sentences making sure that the patient gets adequate chance to process the unpleasant data. Accept and respect the emotional reactions that follow the sharing of the information. In the end leave enough time for clarifications and questions. Always schedule a follow up meeting and mobilization of any immediate support that the patient or the family may need after learning the bad news. The session should not end without assessing the risk of the individual harming them selves, and putting in place clear preventive interventions in this regard. Reassurance that you as a health professional stand committed to pro vide support and be with the patient during these trying moments is a source of comfort for the patient and the family. This is a safe note on which to leave. A calm, compassionate. empathetic health profession alwho has adequate knowledge of the patient’s condition can leave a calming effect on the patient and the family. Young health professionals need to be aware of the strong emotional reactions that they themselves may experience before, during or just after breaking the bad news. These feelings are normal and their impact can be reduced significantly by sharing them with a more experienced colleague.
  • 32. 6. Crisis Intervention and Disaster Management The word crisis is derived from a Greek word meaning decision makkig. Chinese language has an expression for it in two words; danger and opportunity. A crisis is, therefore, a situation which holds potential for great individual growth provided that the appropriate decisions are taken. People in individual crises or natural disasters find themselves in situations that require deep and insightful decision-making and lead to a permanent change in their lives. Crises are periods of disorganization, characterised by trial and error, disequilibrium, and attempts to reduce feelings of dis comfort. Resotution of a crisis can result in either an increase or decrease in person’s level of functioning or a return to the previous baseline of functioning. Individuals and communities who undergo major disasters may. however, never be the same again. At a psychological tevel, they may become more vulnerable to future crises. They are at a higher risk to become victims of a variety of post traumatic conditions such as post-traumatic stress disorder (PTSD). depression, anxiety and/or dissociative states. They may become resilient and battle-hardened’, and thus, better equipped to deal with challenges of life. This change that foltows major trauma may be the basis of the positive shifts in human be haviour called post-traumatic growth occur in response to stressful periods of human maturation and transition. These inctude childbirth, early child hood, schooling, adolescence, marriage, parenting, divorce, hospitalization, death of a loved one etc. A situational crisis is where a person is faced with a stressful or traumatic event which could be a natural or a manmade disaster e.g. ftoods, earthquakes, rape, terrorist attacks, war, murder etc. Ak. GENERATE AND EXPLORE ALTERNATIVE RESOURCES AND COPING SKILLS EXPLORE FEELINGS AND EMOTIONS (USING ACTIVE LISTENING AND VAUDATION SKILLS) IDENTIFY DIMENSION OF PRESENTING PROBLEMS. INCLUDING CRISIS PRECJPITANTS ESTABLISH RAPPORT AND COLLABORATIVE RELATIONSHIP PLAN AND CONDUCT CRISIS AND BIOPSYCHOSOCIAL ASSESSMENT (INCLUDING LETHALI1’! MEASURES) Roberts’ seven stage modet ofcrisis intervention
  • 33. Communication Strategies In Crisis intervention Using silence gives the person time to reflect and become more aware of feelings. Silence can prompt elaboration. Simply being with the person can make them feel supported. Using non-verbal communication- maintaining eye contact, head nodding, caring facial expressions, and occasional “uh-huhs lets the person know that you are in tune with them Paraphrasing, expressing understanding, empathy and interest are conveyed by repeating portions of what the person said. Paraphrasing also checks for accuracy ,clarifies misunderstandings, and lets people know that they have been heard. You could say, “So you are saying that..”, or”Aap k kehne ka matlab ye hai kaL. 1efiecting feelings helps the person identify and articulate emotions. You could say. “You sound angry...” or “You look scared...” Allowing the expression of emotions is an important part of healing. Venting often helps the person work through feelings and helps in problem solving Disaster Management: A crisis involves three main phases: emergency phase, rehabilitation phase, and recovery phase. Each of these phases has its unique characteristics. The common factors for a medical student to remember regarding disasters include: a) The consequent trauma is never surgical and medical atone: nearly all those affected suffer psychosocial changes. b) Most psychosocial consequences of trauma are essentially normal reactions to the overwhelming nature of the disaster. More people dont get PTSD than do get PTSD. c) Groups most vulnerable to deyeloping post traumatic conditions include women, children and the elderly, but young adults and males are not immune to developing psychological reactions. d) Provision of early psychosocial support by trained professionals prevents long term psychiatric morbidity. It also enhances the impact of surgical and medical interventions and promotes early recovery from the physical, psychological and socioeconomic effects of trauma. e) All medical and psychosocial care should be part and parcel of the larger disaster relief in form of food, shelter, clothing and security. Psychosocial and mentat health care should be made an integral part of medical and surgical care. This will help to prevent stigma of mental and psychosocial issues. It also helps to ensure a holistic. biopsychosocial model of health care delivery fl Traumatised individuals and communities best recover through pro viding psychological, social and economic support to each other (rather than relying on outside help alone). An early return to their homes or shelters close to home and active participation in social, educational, economic, and reconstructive activities ensure a quicker rehabilitation.
  • 34. g) The use of psychotropics, particularly. the benzodiazepines should be avoided and simple. evidence-based, culturally rooted, non-phar macological interventions are preterabte. Only short-term use of up to two weeks for morbid anxiety and insomnia may be advised. h) Rescue workers and health professionals involved in provision of relief work require psychosocial support. They need adequate rest and recreation as well as constant appreciation and patronage. They should work using the buddy system, which involves individuals teaming up and caring for and monitoring each others psycholog ical and physical wellbeing. Preferably they should remain in touch with their families and friends back home. This prevents early fatigue. burn out and long term psychosocial complications. j) Up to one third of the affected population may develop long term post traumatic conditions characterised by disabling flashbacks of the trauma, autonomic hyper-arousal. avoidance (of cues, settings and circumstances that are [inked in anyway with the traumatic/di saster event), anxiety, depression and dissociative states. A second disaster wave hits soon after the first. This is largely in the form of epidemics, wound infections, malnutrition, death and dis ease due to exposure to extremes of temperature. 7. Conftict Resolution Conflict is a state where two forces oppose each other. Conflicts arise in situations where individuals and groups are not getting what they want or need. This includes marital conflict, conflict amongst colleagues, the attendant of a patient and the nursing staff, medical students on a clini cal rotation in conftict with hospital staff, or the college administration etc. Conflicts are inevitable situations and are usually seen where there is poor communication, power seeking. dissatisfaction with management style. weak leadership. lack of openness and change in leadership. Conflict has the quality to divert attention from the main activity, undermine morale, polarise people and groups, reduce cooperation, sharpen differences and thus Lead to irresponsible or harmful behaviour. It is, therefore, important to understand that at times the individuals involved may be unaware of their needs or wants. Conflicts have the potential to be constructive when they are raised in the spirit to clarify and solve problems. In these circumstances conflict and timely resolution may help relieve tension and pent up emotion as well as help build cooperation through learning more about each other. a) Common Causes of Conflict in Heatthcare Settings: Assumptions are being made e.g. the doctor assumes that the patient knows that his absence from the ward is on account of an unavoidable academic commitment like attending an international conference. The patient instead may not be aware of the activity or may not attach the same importance to it as the doctor. ii) Knowledge is minimal e.g. the family has inadequate information on the indication of biopsy in a patient and may see it as a suspicion of malignancy in the patient. H i) i) ‘St Las/a Zombie
  • 35. iv) Knowledge is minimal e.g. the family has inadequate information on the indication of biopsy in a patient and may see it as a suspicion of malignancy in the patient v) Expectations are too high: e.g. the patient believes that a course of chemotherapy should have completely cured him of his lympho ma, when instead s/he develops a complication of the treatment and deteriorates. vi) Personality, race, gender or social class differences exist e.g. a trainee nurse may have a tow frustration tolerance and take offence of an innocent remark by a patient; a visitor or a medical student or the janitorial staff goes on a strike for being poorly paid. vii) Needs and wants are not being met e.g. a patient dissatisfied with food, bedding or facilities in the ward. viii) Values are being tested e.g. a welt-clad female patient reluctant to allow a male student to examine her. ix) Perceptions are being questioned e.g. a confident medical student distressed about not being given a chance by the surgical resident to undertake an incision and drainage procedure independently. b) Methods of Conflict Resotution: The underlying emotion in all conflicts is bottled up anger, frustration and/or an impression of being ignored, or of being ‘taker for granted’. The most common underlying cause is often not a clash of interests but a faulty communication or unfounded concerns. The worst ways of dealing with conflicts is to brush them under the carpet, or to ignore or postpone their resolution. A formalised strategy to resolve conflicts is called Organised Conflict Management (0CM). The following steps of 0CM help resolve most conflicts readily: i) Meet conflicts head on. / CAUSES OF CONFLiCT IN NEALTHCARE SETTINGS HEALTH OUTCOMES PERFORMANCE iii) Assumptions are being made e.g. the doctor assumes that the patient knows that his absence from the ward is on account of an unavoidable academic commitment like attending an international conference. The patient instead may not be aware of the activity or may not attach the same importance to it as the doctor. P.ERK5ANOPPWEXGE qUA#voPuFg V V ii) Show mutual respect by separating the person(s) from the problem. Do not try to corner, attack or undermine the individual(s) involved in the conflict. iii) Set goals that lead to a win-win situation for both the parties in conflict rather than a victory of one party at the expense of the other. iv) Resolve the conflict through free communication. ___________ __ VV._ VV1
  • 36. v) Be honest about concerns and reservations and verbalise them as early as possible. vi) Agree to disagree. as healthy disagreements lead to better decisions. vii) Leave individual egos out of negotiations, and avoid serving or pleasing one individual. Aim at satisfaction of the group, rather than the leader alone. Exploitative and deceptive methods of resolving confticts can succeed temporarily but are Likely to generate bigger issues in future. viii) If you are the one coordinating the dialogue, tet the negotiating team create solutions rather than handing over the solutions - people support what they create. ix) Discuss differences in values openly. x) Undertake a deeper anaLysis of the situation that generated the conflict. Conftict resolution based on a superficial analysis is likely to result in a bigger conflict in future. A conflict arising out of hurt feelings, and emotional reasons is likely to settle on its own with passage of time and an improved communication between the parties. A conflict that arises out of morality issues, religious differences, or cultural differences is unlikely to resolve. Here the two parties can agree for a peaceful co-existence in spite of the conflict. Realistic, fact based conflicts can be best resolved through creative solutions put forth by the parties themselves. The best method of dealing with conflicts is, however, by preventing them. A sound management system in medical colleges. departments, wards and hospitals helps to ensure this. It involves mechanisms of quali ty control, free horizontal interactions and sharing of information. Leader ship should be based on principles of following a middle path rather than extreme measures. Ensuring equity and justice and imparting feelings of security and predictability can prevent the rise of conflicts as welL as ensure their early resolution. Do’s and Dont’s In Crisis Intervention Do Say: Dont Say: These are normal reactions to ft could have been worse an abnormal situation It Is understandable that you i this W8 You can always get another car/house or have another child It was not your fault; you did the best you could It is best if you just stay busy lam sorry that this happened I know just how you feel Things will get batter, and you will I feel better, although things may You need to get on with your life never be the same again I
  • 37. Empathy The single thread that tinks alt the above non-pharmacological interven tions is the demand on the doctor to empathise with the patient and the family. The most important step in building a therapeutic bond is the doc tors ability to experience the feelings of his patients and to gain a deeper understanding of their distress, disease or disability. Most medical students start their career in medical college with a huge capacity to empathise. Alt that they have to learn is to communicate it effectively. The biomedical modeL with its emphasis on the disease, rather than the person experiencing it provides few opportunities to develop and use this skill. Medical students, eager to perform well, are rewarded for their abiLity to memorise anatomical and biochemical facts, causes of diseases and classification systems. Their ability to empathise or relate with patients at a human level is not marked, rewarded or appreciated. As a resu[t of this, slowly but surely they start to focus more on acquiring knowledge, with their skill at treating patients as humans and empathis ing with them fading into the background. The best time to learn how to empathise is in your relationships with each other as medical students. The first step in this direction is to opt to study in a group rather than alone. Once you are part of a group, try and under stand the reactions of a fellow student who is struggling with language. or a concept; who fails in a class test, a sub-stage or a viva. Sitting next to someone who has failed, or is in pain, and thinking of how s/he is feeling is an important exercise by which you can eventually learn to empathise with patients. Let the person you are trying to empathise with, express their feetings. The best technique in this pursuit is to share their silence. Sit quiet. Listen actively: let the person know, that you care and it is ok for them to share feelings with you. This effort on your part to empathise with your colleagues in the first couple of years in medical college will make you comfortable with your own world of emotions. It is this import ant ability in a human to stay in touch and be aware of one’s own feelings that helps them to relate with feelings of others and thus enhances their ability to empathise. During clinical years, try and sit with patients, even after you have taken the history and have completed the clinical exam-. nation. Encourage them to talk about how they feel in reaction to their illness, hospitalisation, and treatments being offered to them. Share their fears, disappointments and sorrow without trying to take sides of the health professionals and hospitaL authorities. Ask questions about the influence of the disease and the treatment on their life at home, at work and in general. These apparently irrelevant” steps will take you ctoser to your patients and thus increase the chances of empathising with them. It is this ability to bond, and eventually feel the way your patients feet, that wilt help you have an insight into how patients think. i
  • 38. 1. A patient from a vilLage in ChoListan desert presents to a health professionat in Lahore. He appears to be suffering from diabetes mettitus, according to his HbAic and fasting bLood glucose reports. The heaLth professional does not speak or understand his tanguage. The best way to provide informational care would be: a) Drawing pictures b) Using sign language to communicate effectively c) Seeking help from a colleague who partially knows the patient’s language d) Exclude medical jargon from communication and state essentiat facts through an interpreter e) Make an attempt to learn patient’s Language and then communicate effectively 2. During a counseLling session, the most important aspect is: a) Charismatic personality b) Asking why the patient feels the way they do c) Speaking to the patient in their language U) Unconditional positive regard. e) Empathising with the patient’s situation 3. Active Listening is best accomptished by the doctor understanding and using: a) Body language. b) Paralinguistic aspects c) Active prompting d) Adequate eye contact. e) Responses to open ended questions. 4. White deaLing with a patient who is fearfuL about not waking up from anaesthesia for her hysterectomy, an empathic response is: a) I assure you that your concerns are not scientific, everybody wakes up from anaesthesia b) I do understand your concern, in your situation I, too may have felt the way you are feeling c) I know that you are scared but you are a brave person who can face this d) We are experts in the field; we will make sure that nothing happens to you. e) Please relax, everything will be fine SAMPLE MCQ FOR SECTION A
  • 39. 5. Effective communication skills are considered essentially important for a doctor. The most important reason for a doctor to develop effective communication with his patients is: a) It is a vital tooL in clinical settings. b) It forms the basis of the interaction between the doctor and patient. C) It is used in informationat care sessions with the patient and their famiLies. d) Doctors can convey their message on various health topics better. e) Doctors will gain respect and popularity with the public. Sampte Short Essay Question For Section A Qi. Briefly describe the seven questions that need to be answered in an informational care session. Q2. What are the steps invoLved in breaking bad news to a patient? Answers l.a 2.d 3.b 4.b 5.b For answers to short essay questions see Chapter 3, Non-pharmalog ical interventions.
  • 40. b ECTION B edical Ethics, Professionalism and Doctor-Patient elationship I sb,ear [‘p scuLapus, Lpgeta. anb anacra. anb 3 take to b%tite%% all tfje gobs, all d gobbeaea, to keep arcorbing to mp aWftp anti nip ubgmeiu, tt (otLobng atfj. to con%iber bear to me aS mp parentS tdm to(io taug me tl.ü art: to Cibe m cmnmmt it im anti if nws%arp to sbare nip goats tnittj m: to took upon his cljilbrcn aS nip aton .—c beatberL to teach tm this art it tfrp so bcsirr k%tfjmd fee or britten omt%e; to Impart to nip sans anb tbe SonS of ttje master [‘ibjo taughi me anti tk bisnptes bfjo babe enrotkb ttjemwetbes anti babe agreeb to tlje rute% of the profeSSion, but to these atont the prtce5 anti tljt instruction. I UnIt prescribe rtgimtns tar the goat of nip patients ,, acarbingtompabititpanbmpiumeiUanbneberboarmloanpcnc r to please no one tofU I prescribe a beatitp brug nor gibe abbece Wijicfj map cause $S tieatlj. lor bsI( I gibe a boman a pessarp to prorure abortion. ut I bitt preSerbe the puritp of nip (itt anti nip art. I bill nof cut tar Slant, tUtu for patients in bhom the tüea%t is manitt%t I bill (taUt tts operation to be performeb [‘p practitioners, sptclat&s arLInebtrpbousebfrrticome)bstt.tronlptrxdgxb at mp patients. keeping mp%elt far tram alt intentional Ilt-boing anti Th altsebwtionanbesptdaltptromtttp(easureso((bstfjbionietior beth men, be the? fret or stabes. Alt that map come to mp knobeebgey tn the exercise of mp profession or In baitp commerce bath mni Wjlcfj ongljnoftobesprtabaheoab,3bittkeepftcrtianbbellntbertebeaL - It I keep (tO oath taithtuttp. map 3 tnwp nip tite anti practice nip .. art. etsptcteb bp alt men anti In alt times; but it I s’wtrbe (rain U I map the reberft be mp tnt.” - -. --— .- 7 Retevance of Ethics in the Life of a Doctor Medical. Ethics Ethical. Omissions in Medical. Practice Ethical. Dil.emmas in a Doctor’s Life Doctor-Patient Rel.ationship Ptofessiona[ism in Heal.th Care
  • 41. After ordering a hot cup ofDoodh Patti, the tocat preferred version ofEnglish tea Ahmed, Fazat, Javed and Safdarstarted their evening chat. The topic today was not potitics but the attitude ofdoctors. Ahmed remarked ‘The new Doctor Saheb who has opened his ctinic is very different from Dr Raheem who died tastyear after serving the community as a generat practitioner for thirtyyears. Dr. Khatid has a neon sign ofhis name and qualifications outside the clinic. He runs his clinic more like a ‘health shop He asks his patients to deposit a fixed amount with him prior to the con sultation, irrespective oftheir financial status. The other day Dr Khatid insisted that I shoutd get the Hepatitis vaccine whether I like it or not without giving me a choice to do so.” Safdar quickly added: “Dr. Saheb removed my appendix in surgery, a few weeks ago, after telling me that the appendix would burst ifI did not get it operated there and then.” Javed recalled the differences between the two doctors: “Dr Raheem was a very kind man. He never charged the poor He always discussed matters with his patients.” He cited Dr Raheem’s gesture ofexplaining atl the advantages and disadvantages ofcontraceptives to his wife and then asking her to make a choice, before he put heron the contraception pilL Javed then came to Dr Khalld’s rescue and remarked, “Yaar, everything and everybody has changed, how can doctors be the same?! Dr. Khatid needs a much larger amount of money than Dr Raheem to run his home and family His family sold a large piece ofland to afford his medical education and is still under debt, while Dr Raheem went to a medical college with hardly any expenses involved. He is a fine surgeon and knows much more than us about illness; why should he ask us about medical matters as long as he means well?” Fazal had anotherstory to telL “Dr Khatid gladly accepted a new mobile phone from a female patient so that she could call him for telephonic advice. He also went on a holiday to Bhurban with his family and a friend, with all expenses paid by the pharmaceutical company where lam emptoyed.” Javed again came to Dr Saheb’s rescue, “But then he never charges any fee from the medical students and his colleagues and recently appeared on the television channel and gave free advice on important health matters.” Ahmed concluded the discussion by saying “Dr Khatid is like all ofus; he has his positives and has some negatives too. Hebannot be compared with Dr Raheem as the ethics of the medicat profession may have changed over the last three decades.”Safdar remarked on his way out ofthe tea bar, “Let us wait and watch Dr Khalid’s progress.” Medical Ethics and Professionalism F— -