2. is a dialog of a Medical Doctor (MD)
with a patient. According to structure this dialogue
includes gathering of complaints with details, gathering
of history of disease (anamnesis morbi) and history of life
(anamnesis vitae).
•To get complete information about patient to make
correct diagnosis and prescribe appropriate treatment.
3. Welcome and self-presentation
• What does a doctor need? – contact with the patient and information.
Information (doctor-patient)
Сontact Diagnosis
Treatment (doctor-patient)
4. Interview
•Free interview
•Standardized interview
•A free interview is a good way to achieve relaxation,
which results from a frank conversation with a doctor.
•The disadvantage of a free interview is its duration is the
frequent inconsistency of the patient's statements.
5. Standardized interview
The time can be very brief, but informative.
Its disadvantages are:frequent violation of emotional
contact with the patient,the inclusion of psychological
defense mechanisms in the patient that complicate
confidential communication with the doctor, a feeling of
dissatisfaction after a visit to the doctor.
6. Three interview blocks:
1. Greetings and introduction.
2. Gathering of information.
3. Conclusion and completion of interview.
7. Aim of the 1 block:
Establishing contact with the patient,creating a
friendly atmosphere,forming the impression in the
patient that the doctor wants and can help him. This
is a rather short phase in duration, it determines the
further success of communication with the patient
by 40%.
8. Welcome and self-presentation
• MD greets the patient.
It must be appropriate to age and social experience of the patient.
Verbal greeting should me accompanied with nonverbal communication
(handshaking, turn the body toward to the patient, the nod of the head, smiling).
• Self-presentation (name and role)
MD says his/her full name, occupational title – clear and understandable.
«Hi, come in, please, take a seat, my name is…and I’m your treating doctor…»
• Ask your patient to represent him/her self too
“What is your name? And how can I call you?”
Calling patient’s name during conversation helps to build trust-based relationship.
• Keep eye contact
9. Keeping of the distance
Comfort distance should be kept between participants of communication,
depending on aim. There are 4 main types of distance, knowing them helps to
determine the optimal one.
• Close (15-45 cm) – used in communication with close people (family, friends)
• Personal (45 -120 cm) – used for informal conversations with known people
• Social (120 - 360 cm) – used for professional formal communication.
• Public (3,5 m and more) – used for public performances and communication with
large groups of people
10. Keeping of the distance
- Keep the distance, optimal for the patient.
- The best distance between a MD and a patient is stretched arm distance, because
such position helps to a MD touch the patient when it’s needed (check pulse, blood
pressure etc) without additional movements.
- Same level of eye contact
- Care for patient comfort (Ask: “Is it comfortable for you to sit like this?”)
Orientation and placement of seats, general rules
- not opposite (especially 1st meeting, V o’clock position of chairs is optimal)
- absence of barriers
- comfortable chair with back to lean on it if it’s necessary
- same height chairs
11. Aim of the 2 block:
•Collection of high-quality, structured, complete and
understandable information about the patient's disease (this
includes examination);clarification of the purpose of the
visit to the doctor.
12. Interview management
Skills 1.
Collecting information balance of open, closed and other
issues.
The ability of the doctor to clarify and generalize the statements
of the patient.Active and non-directive listening skills. Proper
use of pauses and silences.Finding out the patient's problems
and expectations.
13. Open questions
Questions that cannot be answered briefly and in
monosyllables. They give the patient the opportunity to tell,
describe and explain in their own words.They often begin
with "How?", "When?", "Where?", "What?", "Why?".
These questions are asked in orderto obtain additional
information,clarify the motives and positions of the
interlocutors.
14. Closed questions
These are questions that are expected to be answered
"yes" or "no".
They: allow you to shorten and structure the conversation;
they require much less time to listen to the answers; they are
useful in communicating with verbose, unassembled, overly
emotional patients; they are used in cases where it is
necessary to obtain consent or confirmation of an earlier
agreement faster; used to end the conversation.
15. Motivating questions
The goal is to identify the patient's relationships,
feelings and experiences;
They are used when establishing a sufficient degree of
confidence.
"I would like to know more about ...", "Could you tell me
more about your feelings during the attack...","Could you
explain to me..."
16. Critical issues
They are set in cases when enough information has
already been received on one problem and there is a need to
"switch" to another.
The danger in these situations lies in the imbalance between
communication partners.
17. Mirror questions
The question consists in repeating with an interrogative
intonation the part of the statement just entered by the
interlocutor in order to make him "see" his statement as if
from the outside.
18. Leading questions
They assume a certain answer and push the patient to it.
They meet with doctors with an authoritarian style of
communication.These questions are undesirable, especially
at the beginning of the interview.You can't use them often,
especially one after the other.
19. Skill 2. Active identification of the patient's point of
view
Purpose: to make clear to both the doctor and the
patient what has been said. Constant refinement,
clarification and generalization.Clarification of the meaning
that the patient put into a particular word.Ask additional
open-ended questions.To rephrase the patient's statements.
The doctor should not be ashamed to show that he did not
understand or did not hear something.It is necessary to
summarize, summarize what was found out during the
interview.
20. Active identification of the patient's point of view
Clarification of the patient's problems and his expectations
from the consultation
- Problems (purpose of the visit, complaints)- Ideas (understanding the
problem and causes of the disease/condition)
- Expectations (what I expect from a doctor)
- Worries (what is the worst outcome that can happen to
me)Influences (how an illness or condition can affect my life, what
can change in it)
Find out the purpose of the patient's visit to the doctor
How can I help you? Tell me what you came to me with?
What would you like to talk about today? How are you?
21. Goals and reasons for the patient's visit to the doctor
chronic diseases: visiting a doctor for observation, evaluation and
moral support;
consultation: only advice or an unbiased opinion on any occasion is
needed from a doctor;
getting any benefit from a visit to a doctor: sick leave, using a
medical opinion in lawsuits, etc.;
receiving emotional support is a need to talk about yourself and be
listened to, share fear of a deadly disease
overcome a sense of loneliness.
22. • The doctor interrupts the patient at the 18th second of his introductory statement.
The reaction of the doctor and, in particular, the early interruption and interrupting of
patients during their initial statement during the visit, specially reserved for this,
prevents the further identification of additional problems in the patient.
Beckman HB, Frankel RM. The effect of physician behavior on
the collection of data. Ann Intern Med.1984; 101:692–6.
If the doctor does not interrupt the patient, then his monologue lasts up to 30 seconds
in PHC and up to 90 seconds during consultations of narrow specialists
Langewitz W. Spontaneous talking time at start of consultation in outpatient
clinic: cohort study. BMJ 2002; 325: 682–3.
• The 90-second rule - most patients finish a story in less than 90 seconds and will tell
you almost 80% of the information you need.
• The doctor listened attentively, without interrupting the patient. Observed adequate
pauses.
• Pauses in conversation give more than words, and they are most important for
revealing the hidden experiences of the patient. And the verbosity of the doctor may
indicate his lack of self-confidence and unconscious protection from the patient's
problems.
“Active listening”
23. • Volume, pitch, speech speed, articulation and tone
The tone of the voice indicates feelings and emotions. A loud voice may
indicate a position of authority or aggressiveness Too quiet a voice may
indicate weakness or disinterest A monotonous voice indicates a lack of
interest or boredom. If the tone of your voice is unfriendly or harsh, then it
will be difficult for you to convince or influence the personToo slow or too
fast speech can lead to the fact that it will be difficult for a person to keep
track of it.
• General rules:
Maintain a clear tone that changes in response to the feelings and emotions
expressed by the person. Adjust to the speed of the interlocutor's speech,
generally adhering to the average speed.
• An effective voice is:
Friendly, conveying a feeling of warmth Natural, reflecting your true
personality and sincerity Dynamic, giving the impression of strength and
power - even when it is not particularly loud Expressive, depicting various
shades of meaning and never sounding monotonous or without emotion
Easy to hear with clear articulation
Speech management.
24. • Read aloud
A whisper quiet, louder, louderhigh voice, lower, low voice
monotonous, melodicmumbling, with clear articulation slow (slow),
fast (accelerated), smooth/freeinsensitive, conveying emotions easy
to hear, clear articulation, low tone, smooth (speed) and conveying
emotions
What did you notice during the exercise?
The voice is the main link in communication between people.
A good, controlled voice is an advantage in any contact with people.
The characteristics of the voice can be crucial for establishing good
relationships with people.
The doctor observes the appropriate intonation and pace of speech
when talking to the patient. Highlights the main points with his voice.
Speech management.
25. EMPATHIC LISTENING AND EMPATHY
an attempt to hear another person deeply, accurately and unbiased.
skillful reflexive listening, which clarifies and enhanced a person's own
experience and meaning, without imposing the material of the listener
himself.
the ability to experience the feelings and thoughts of others while remaining
objective (putting yourself in their place)
EMPATHIC LISTENING INCLUDES:
presentation of a person's acceptance demonstration of empathic
understanding evocation of a sense of truth and authenticity demonstration
of concern about the issue of human self-determination demonstration of
respect for the individuality of a person showing interest, transmitting
warmth, creating an atmosphere of trust
EMPATHIC RESPONSE
Listen (body language and gestures)Be present (adjust to the
situation)Listen without judgment
Don't talk about yourself, try to feel what the other person feels
Application of empathy
26. WHAT SHOULD BE AVOIDED IN EMPATHICARE YOU REACTING?
• No answer
• Meaningless repetition
• Understatement of feelings
• Distracting questions
• Cliches
• Interpretations
• Tell your own stories instead of listening to another person's story
• Exaggerations
• TipsNon-empathic reactions can make people feel worse,
misunderstood /unheard, insulted, judged and indifferent to others
Application of empathy
27. The nonverbal component of empathy
Corresponding to words expressing empathy:
• Gestures
• Facial expression (facial expressions)
• Pose
• Look
• Distance
• Touch
Application of empathy
28. Mnemonic scheme for demonstrating the verbal component of empathy
– N.U.R.S.E
For example, consider a case with recently diagnosed bronchial asthma, the patient
expressed concerns about the upcoming discharge from the hospital, saying: "I don't
think I can cope with an inhaler."
An empathic response according to this scheme may look like this:
Name - name and mirror the emotion. - "You look worried.“
Understand – understand the emotion – "It's really a lot of stress to learn this about
your health“
Respect – show respect – "You did a very good job with the inhaler today“
Support – support – "We will work on this again with you, while taking the next
dose of the inhaler“
Explore – reveal emotions in more detail – "Tell me what else is bothering you in
connection with the appointment of the inhaler? “
The Doctor showed verbal components of empathy.
Application of empathy
29. Encouragement: interest without evaluation, we encourage the patient to talk
further.
"Uh-huh...", "This is interesting...", "Please continue...“
Summary: a brief repetition of what the patient said
• Problems
• Anamnesis details
• Ideas
• Concerns
• Expectations
• Question for clarification
For example: So, you have a cough with mucous sputum, shortness of breath during
exercise, an increase in body temperature to 38.0 *, stabbing pains in the chest when
coughing. You are sick for a week, after hypothermia. Suprax was taken for 5 days,
without improvement. Did I miss anything?
The doctor used the technique of "summarizing", for a more complete and accurate
understanding of what the patient said.
Active listening (summarizing, encouraging).
30. Goal of Summary:
To form an idea of the patient's problems, to make a preliminary
diagnosis ("internal summary")
• To show the patient that he is listened to
• Make sure that you have heard and understood everything correctly
• Give the patient the opportunity to hear his own problem from the
outside Give the patient the opportunity to add something if he forgot,
and correct if you misunderstood him
The consequence is trust between the doctor and the patient, effective
diagnostic search
The ultimate goal is the correct diagnosis and the patient's commitment
to treatment
Active listening (summarizing, encouraging).
31. Providing of appropriate volume and type of information – patient is a «main point».
• What patient already knows?
• What patient wants to know?
• What patient needs to know according to medical case? – for conscious decision-
making
What patient needs to know according to medical case?
d - с - е - р – т (Diagnosis – Cause– Expected course – Prognosis & Seriousness –
Treatment)
Dr doses and checks: offers information with small portions; checks understanding;
uses reaction of a patient as an instruction to further action.
Dr assesses first patient’s point of view: clarifies awareness of a patient by the
moment of an appointment; discovers how much patient wants to get information.
Dr asks the patient, what else data is he/she interested in, foe example, etiology and
prognosis of a disease.
Dr gives explanation in good time: avoids to give unseasonable advice, information,
encouragement.
Informed consent
32. Skill 2. Providing information in a form that facilitates the patient's
understanding and helps him to remember it.
Clear and unambiguous information, without medical terms or with their
explanation.
The information should be divided into logical sections – to increase
memorization. "I would like to discuss three important issues. The first ...’’
The pace corresponding to the patient's ability to understand and assimilate
information
Use visual means of transmitting information: diagrams, models, written
information, instructions.
Active verification of what the patient has understood. Ask the patient to
repeat what he said in his own words; if necessary, clarifies.
Informed consent
33. To ensure patient comfort and "transparency" of interaction, it is
important to use commenting:
To say what, why and how you will do before and during the
examination.
"I will look at your lymph nodes to see if there is inflammation, if they
are enlarged“
To tell the patient what to do – "raise your hands, turn around, stand
here"
To warn about possible unpleasant sensations during examination
/manipulation – "it may be a little unpleasant“
To ask distracting questions if the patient is very tense.
To announce the results of the examination/manipulation and what it
means for the patient.
It is important to do this briefly, using understandable words. "The
lymph nodes are not enlarged, this indicates that there is no
inflammation in them"
Commenting
34. An important aspect of communication between the doctor and the patient is the
result of this meeting and whether the patient's adherence to the prescribed treatment will
be achieved. Compliance largely depends on how much the patient will participate in
making decisions about their health. Therefore, the doctor can try not to force the patient
to follow the instructions, but to offer clear and up-to-date information about various
approaches and treatment options. And give the patient the right to choose.
It is important to actively search together and encourage the patient's reaction and opinion
about what is being discussed. Special attention should be paid to possible, in the opinion
of the patient, problems and obstacles in following the examination and treatment plan.
"Planning" - making a joint decision
Skill 1. Achieving a common understanding of what is being discussed.Seek and
respond to the patient's verbal and nonverbal signals during planningI must return to what
was said earlier – to any aspect of the patient's point of view.
• Problems Ideas
• Expectations
• Concerns
• Impacts
Planning and joint decision-making
35. Planning and joint decision-making
Skill 2. Encouraging the patient to participate in decision-making regarding
care.
Patient – "starting point" - how much the patient wants to participate in planning.
Providing clear and up-to-date information on different treatment approaches and
options.
Offering options, not directives!Justify the options, their pros and cons.
Actively seeking and encouraging the patient's reaction and opinion about what
is being discussed - in particular, any problems or obstacles that he foresees.
What should I do during planning?
Achieve a common understanding of the patient's situation.
Ask for his opinion/consent.
Offer the patient options, not a directive.
To justify the options, their pros and cons.
To provide a support system – what to do if the plan does not
work
36. Explanation. They include the ability of the doctor to summarize the
results obtained, to give the patient clear and understandable
information regarding further treatment, prevention, management
tactics, as well as to check the degree of understanding of the
information transmitted to the patient.
Tell about the proposed activities or treatment:
- Mechanism of action
- Benefit and advantage
- Possible side effects
- To identify the patient's views on the proposed treatment, their
understanding of the benefits, obstacles, motivation.
- To accept the point of view of the patient, if necessary, to defend
their position.
- Find out what his concerns are.
Explanation
37. Summation. End of the interview.
Summing up the results of the interview
What is included in the summation?
• The outcome of the discussion of diagnostic and treatment issues with the
patient
(So, we decided ...)
• Main recommendations (Repeat what was prescribed - the most necessary)
• Once again announce the date of the next visit to the doctor
• Ask: "What questions do you have?"
What for?
• Dot the "I" - the patient, due to an overabundance of information, may
lose the thread of the conversation, forget the answers to questions during
the discussion
• Give the patient an opportunity to hear the results of the doctor's visit and
a brief plan of action from the outside
• Give the patient the opportunity to ask the questions he has – "Doctor, I
remembered what I wanted to ask..."
• Eliminate the feeling of "incompleteness“
• Say goodbye to the patient
38. End of the interview.
The accuracy of the end of the conversation is important, the moment for
which only the doctor should determine.
To complete the interview correctly, you must first give the patient several
nonverbal signs (for example, change the pose, stop demonstrating active
listening, increase the distance, close the recordings), then verbal signals follow
that the interview is ending ("so", "thus", "summing up", etc.), and only then
finish the interview.
It is necessary to make sure that the patient agrees with the examination and
treatment plan, understands all the risks of the disease, diagnosis and treatment,
that the patient is fully informed and satisfied with the results of the meeting with
the doctor.
Summation. End of the interview.
39. Collecting feedback
What for?
In order to clarify whether the patient understood the diagnosis and treatment
For the best memorization of recommendations by the patient (booklets,
leaflets, brochures are used)
In order for the patient to realize his responsibility in implementing the
recommendations
Summation. End of the interview.
40. The result of discussing diagnostic and treatment issues with the patient
So, we have decided …
Main recommendations
Repeat what was assigned - the most necessary
Once again announce the date of the next doctor's visit
Ask: "What questions do you have?"
To say goodbye to the patient
What for?
To dot all the "I" - the patient, due to an overabundance of information, may lose the
thread of the conversation, forget the answers to questions during the discussion
To give the patient an opportunity to hear the results of the doctor's visit and a brief plan
of action from the outside
To give the patient the opportunity to ask any questions he has – "Doctor, I remembered
what I wanted to ask..."
Eliminate the feeling of "incompleteness"
Total – the doctor hears his recommendations 3 times during the interview:
1. Speaks for himself in the planning stage
2. Summation at the end of the interview
3. Patient feedback
Summation
