Transcript Professional skills- 2 part two 2008- 2009

Professional skills- 2
part two
2010- 2011
By
Dr. Aziza Rajab
Assistant professor
Head of Nursing dep.
King Abdul Aziz University
Professional skills- 2
course contents
1. empathy, sympathy and empowerment
2. Doctor-patient Relationship
building a rapport with patients
3. How to Interview Patient
4. Principles of taking medical history from patient.
5. Who are the difficult / patients( angry, anxious,
demanding, fearful ), and how to deal with them.
6. Strategies for effective consultation.
7. Principles of Breaking bad news
8. How to apply the steps of breaking bad news in
clinical setting
2
Lecture 1
empathy, sympathy and empowerment
By
Dr. Aziza Rajab
Assistant professor
Head of Nursing dep.
King Abdul Aziz University
Dr. Hashim Fida
Assistant professor
Family & community health
king Abdul Aziz University
What are the importance of empathy and
sympathy?
• Can not build rapport or gain trust without
showing those feelings
• Back bone for establishing and solidifying
helping relationship
• Help in developing mutual understanding
• Guide us to build appropriate perceptions
• Help us to understand the message
how to differentiate between empathy and
sympathy?
• Sympathy is to identify and communicate that
you understand the patients feelings.
( e.g. I understand what you are saying, I know
how you are feeling)
• Empathy is to share his/her feelings ( e.g. I do
feel exactly what you feel )
What is empowerment?
• Empowerment is helping others to trust
themselves, to identify, know, and believe in
them selves and their abilities
• Enable others to act independently for
him/her self, choose and decide for them
selves.
• Enhancing people’s creativity, cooperation,
inspiration, and productivity.
How to be sympathetic ?
• Try to listen effectively,
• try to understand and perceive things as they are
• Try to accept the feelings and point of views without
changing them, stop them, or judge them,
• try to pay attention
• Try to be consistent
• Try to reflect on the patients feeling verbally by
summarizing, paraphrasing to show your caring attitude
to patient
• Try to be genuine and sincere in your relation with
patient
• Try to Respect and accept patient feelings
• Try to set limits ( I don’t have time now but we will talk
next visit)
What are the type of empathic responses
that we should avoid?
1. Judging response: to evaluate another’s feelings:
Tell patients in various ways that they should not feel
discouraged or frustrated, they shouldn’t worry
,they shouldn’t question their treatment by other
health professionals.
Any message from you that indicate you think patient is
wrong or bad, will make patient think and feel that
you are not worth his trust and he cant build
confidence for a helping relationship.
2. Advising response: we can offer quick solution to
another person’s concern with or without correct
perception to his exact needs
The best source of solution to the problem is always
within the patient him/her self.
Rely on other for advise may keep patients dependent
this is against the empowerment idea we talked earlier
When there are times when patients are not capable of
coping or understanding or deciding for a solution to
their problem, you should walk them and direct them to
the solution without dictating it to them. It has to be
and show that it is coming from them not you.
3. Reassuring response: telling patients who is facing
surgery do not worry, every thing will be fine, you will turn
out just fine.
It may seems to be helpful but it is conveying that the
person should not feel upset , scared of the procedure,
and concerned about the outcomes.
You should tell the patient with exact words what is the
procedure steps briefly in understood words, explain the
risk in an honest words, state the expected outcomes, and
the assurance part has to be in the part how practices,
competent you are, how careful you will be, and how
common this procedure is, and that his fear is very normal
to feel.
4. Distracting response: changing the subject, or
cutting off patient’s talk or feeling just because
we don’t know how to response to them
We might direct the communication to topics we
feel comfortable with such as medication
regimens and so forth
These responses tend to convey to patients that
we are not listening, or we don’t want to listen.
Lecture 2
Doctor-patient Relationship
building a rapport with patients ?
By
Dr. Aziza Rajab
Assistant professor
Head of Nursing department
Abdul Aziz University
Dr. Hashim Fida
Assistant professor
Family & community health King
king Abdul Aziz University
Doctors’ Mission
Doctors’ primary goals are:
• To treat and cure where possible
• To bring relief in suffering
• To help the patient cope with illness, disability
and death.
Doctor- patient relationship
•
1.
2.
3.
The doctor – patient relationship is built on :
Honesty
Confidentiality
Trust and reliability
How to enhance doctor- patient relationship
?
Developing rapport to enable the patient to feel understood, valued and
supported.
Encouraging an environment that maximizes accurate and efficient information
gathering, planning & and explanation.
Using the verbal responses and non verbal behaviors appropriately
Involving the patient so that he/she understands and is comfortable with the
process of interview and the consultation.
Increasing both the physician’s and the patients’ satisfaction with the
communication.
Developing and maintaining a continuing relationship of trust & respect over
time.
Why doctors Communicate?
Gain Mutual trust & respect
Exchange information
Ask your seniors
Do your share of work
Interview and consult patients
Conduct Seminar & workshops
with whom doctors Ccommunicate?
• patient
• psychologist
• family
• nurse
• physician
• social worker
• health care
administrators
• Dietician
• Media
• others
• Pharmacist
Communication & Medical care
• Good communication should be established on
admission between clients, family and the treating
multidisciplinary team.
• Client & family are encouraged to participate and
verbalize in the ward round discussion about:
– Offered medical care & treatment
– Rehabilitation
– Follow- up/re-admission plans
– Doubts & worries.
Communication & Medical care
 Proper information to clients and family regarding services
available and how they can utilize them.
 Information should be made available on:
– Health Education/ Counseling & Psychiatry.
– Endocrine, Metabolic, Neurology & nephrology.
– Cardiology, Respiratory, GIT & hematology.
– Nutrition, Immunization & ambulatory care.
– Infections & infection control.
– Clinical pharmacy & therapeutics.
– Hygiene and Safety.
We need to communicate to build a trust
relationship with whom ?
Patients & care-givers
Nurses & auxiliary staff
Colleagues
Administrators
Evidence in court
Reporting research findings
Talking to the media
Public at large
How can doctors build a
positive rapport with their
patients ?
What is rapport?
Rapport is the ability to connect, the ability to
trust, the ability to express feeling and
thoughts, the ability to understand, the ability
to accept the other as is without judgment,
and the ability to exchange information
honestly and freely during formal or informal
interviews. It is the process of creating a
goodwill between the interviewer and the
interviewee.
How can we build a rapport?
• Using therapeutic communication techniques
• Use the non verbal body language ( time, space, touch,
smile, eye contact, dress, distance, location, expressions,
grooming), and the verbal ( the way we talk and address
each other, the tone, voice, words used), and the
formality levels should be used appropriately as needed
to enhance connectivity.
• Avoid being judgmental, labeling, and criticizing
• Empower patients and lower their feeling of
powerlessness, helplessness, dependability.
• Show sympathy and empathy as needed.
How do I know that there is a
positive rapport between me and
the other party?
• When the interviewer and the interviewee share a
similar world view or situational view
• When we are not jugging the person but rather
trying to understand them more
• When we are able to express and communicate our
thoughts and feeling without fear or criticism to
the other person
• When we mutually are understood correctly.
What are the doctors attitude and behaviors
that can damage a helping relationship and
obstruct you from building rapport?
1. Stereotyping: seeing a patient as a person with
stereotype behavior, then ,most probably you as
a doctor will fail to listen without judgment, and
your judgmental thoughts will reflect in your
behavior & words , and patient will not build
trust, there won’t be no rapport.
we must see patient as an individual and accept
him/her as is
2. . Depersonalizing :if we focus our
communication on specific problems and
cases only, without taking the patient and
his culture, background, thoughts& feeling in
account, then we are really not
understanding the person as a whole, and
trying to implement solutions that are
inapplicable because we don’t have enough
connectivity with patient to comprehend the
big picture about his/her circumstances.
3.Controling : doctors usually try to run the show when
it comes to diagnose and treat patients, they rely
on what they know more to decide for care, rather
than trying to understand more from the patient
about his feelings and thoughts about the disease
it self and their preferences of the treatment.
Increased levels of patients participation and control
over the health care interventions, usually
empowers patients, and gives positive results that
includes improved health, less complications &
general quality of life positive outcomes.
Lack of communication and poor doctorpatient relationship : why?
Clinicians focus often on relieving patients' bodily pain,
less often on their emotional distress, seldom on their
suffering.
Some of them view suffering as beyond their
professional responsibilities.
If clinicians feel unable to, or simply do not want to,
address the powerful issue of patient suffering, it is
appropriate to refer the patient to another professional
on the healthcare team who is more comfortable in this
area.
Lecture 3
How to Interview Patient
By
Dr. Aziza Rajab
Assistant professor
Head of Nursing dep.
King Abdul Aziz University
Dr. Hashim Fida
Assistant professor
Family & community health
king Abdul Aziz University
What is an interview?
Professional Interview in the medical field is an
interpersonal communication method and
process to gather or/ and exchange
information by using therapeutic
communication techniques.
It is one of the most common methods used in
patients assessment
with whom and why to do Interview ?
The medical interview is the usual
communication encounter between the
doctor and the patient.
It can be classified according to the purpose
of the interview into 4 types:
History taking
Breaking bad news
Consultations
Obtaining informed consent
What are the steps of the interview?
1. Determine the purpose of the interview
( job interview, patient assessment, …)
1. Determine the objectives of the interview
2. Pre- research the topic and the person
3. Prepare the questions and the context
4. Organize the interview (opening, body, and
closing)
5. Record and document the interview
What are the differences between formal and
informal interview?
• In the Informal interview: there is small social
talks at the beginning to get self comfortable,
oriented, and prepare to be ready for the real
sensitive issues.
• In the formal interview: the interviewer takes
more direct, focused, serious, and in-depth
elaborative approach to patients concerns and
complains.
What are the Components of effective
interview?
1. Differentiate between therapeutic and non
therapeutic communications
2. Establish rapport
3. Prepare the environment, choose right time,
get client comfortably situated
4. Listen instead of just hearing
5. Differentiate between empathy sympathy
6. Avoid being superficial and routines, Get to
the sensitive issues
How therapeutic comm. Is different than
social comm.
Therapeutic communication characteristics unlike
the social interactions, must be :
1. Goal oriented, planned, and focused on specific
objectives.
2. Leagal accountability and responsibility for the
given information.
3. Credibility of information and good reputation
of the informer.
4. Mutual understanding between all parties
involved in the communication.
Strategies to conduct an interview?
1-Use open ended questions always that makes the
person think and elaborate on the question, and
encourage the patient to tell their own story, specially
in the start, such as:
What exactly happened, how do you feel about it , why
do you think this is the problem, can you explain to me
this, can you talk more on this…
(this will be time consuming at the beginning of the
interview and hard to control, but that is ok because
you want to build trust and understand your patient
well(
Strategies to conduct an interview? Cont.
2. Lower patients defensiveness by:
- Asking proper type of questions such as the what?
and how?
- Minimize the why question, it makes patients feel
that they need to give justifications always and that
might intimidate them, and make them feel guilt
and responsible for what ever situation they are
facing
- Use silence to allow patient to finish answering before
asking next question and to avoid feeling of being
interrogated
Strategies to conduct an interview?
Cont.
3. Use closed ended questions appropriately
only when you need to establish factual
details quickly such as :does it hurt you when
you cough? The yes and no answer gives you
the exact information that you need for
understanding the problem , but they often
will not allow patients concerns and anxieties
to be expressed.
Strategies to conduct an interview?
Cont.
4- use probing questions for clarification and
verification of information:
( e.g. for clarification: exactly what do you mean
by that? )
( e.g. for verification : did I hear you say that you
do not take your medication at all?)
Strategies to conduct an interview?
Cont.
5. Do not Use and avoid leading questions such as
( e.g. I think your pain increases at night ?)
They specify the answer you expect to get, there is no
advantage of using it.
6- always listen and use silence and touch whenever
needed to express sympathy and keep building trust
7- accept and respect patients
Strategies to conduct an interview?
Cont.
8- summarize : always summarize to patients
what has been discussed in brief and points (
e.g. so we can conclude from our session
today that you agreed to control your diabetes
by measuring blood sugar twice a day, eat
seven small meals instead of three big ones,
and walk at least half an hour daily, right? Is
there something else?)
Critical thinking questions
1. What are the most important concepts
doctors need to take in consideration in
building a helping relationship with
patients?
2. What are the main obstacles in building a
rapport in any interpersonal relationship?
Lecture 4
Taking History
By Dr. Aziza Rajab
Assistant professor
Head of Nursing dep.
King Abdul Aziz University
What are the reasons for history taking?
• For understanding the patient holistically, and has a
complete picture
• Serve as the mean to start building rapport,
relationships and trust
• To gather detailed specific information
• To identify the problem / problems
• To make proper conclusions about patient’s
condition
• To make accurate diagnosis about patient disease
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Where can we take history?
• In the out patient clinic when the patient
comes for the first time or after a long absent
from a periodic appointments.
• In the in-patient different hospital units, after
the patient been hospitalized and arrived in
the unit clerking or history taking is a must.
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Does history taking has a defined process or
steps ?
Yes in order to take history from any patient the following should be
set up:
• Specify the patient name, room & bed number
• Collect any medical forms, record, or equipment that will be needed
during the history taking process.
• Situate patient comfortably to allow confidentiality and privacy for
the patient, and his information provided and shared with you.
• Prepare your self to dedicate your full attention, time and focus on
the process of history taking and the patient
• Be sensitive to patient and his needs by being conscious to your
verbal and non verbal communication techniques.
• Introduce your self and explain clearly what and why are you doing
this
• Get assistant ar a translator as needed
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What are the components of history needed
to be documented?
1.
2.
3.
4.
5.
6.
7.
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Patient’s demographic data
Past medical history
Family medical history
Present complains
Physical examination to review body systems
Laboratory and radiology investigations
Differential and accurate diagnosis
1.









Patient demographic data
Age
Name
sex
Marital status
Occupation and, Nature of work, hazards
Personal habits, smoker, drinker
hobbies such as painting, carpenting, welding
Address / type of residence
Travel abroad where, when, length of stay
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2- Past medical history
 Past medical problems chronic disease: (hypertension,
diabetes, anemia, renal failure….), duration & treatment.
 Number of times hospitalized , when was the last one and
why?
 Past surgical problems (number of surgical procedures, where,
when was each.
 Drug history, is he /she on any regular medications, names,
doses, routes, frequency.
 Immunization history, when what type (mumps, measles,
tetanus, rubella, poliomyelitis, T.B., smallpox, typhoid,
diphtheria, flu…)
 Any exposure to infections
 Sensitivity against any medication, food, materials.
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3- Family medical history
 Any family member has any chronic diseases
(hypertension, diabetes, liver cirrhosis, renal failure,
cancer, congenital anomaly, depression, psoriasis….)
 Any family is sensitive to any thing
 Any family member has infection (hepatitis)
 Causes of deaths, ages,
 Nature and type of relationship with patient
 Presence of any violence, stress, abuse or
relatedness problems
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4- Present complaints





Ask what seems to be the problem now?
The time of onset of the complaint
The duration of the problem
The severity of the problem
What is done toward the complaints to relieve it before arrival
to the hospital ?
 Any medication or remedy was used?
 What are the exact sign and symptoms
- Sign is what you can actually see on patient
- symptoms is what the patient is feeling and complaining of
without you being able to see it.
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5-Physical examination to review body
systems
Use the four major skills in performing physical examination:
1- observation
2- palpation
3- auscultation
4- percussion
You only need to know what are they for now but you will learn
to perform them in the future levels of professional skills.
The aim is of using these specific techniques in physical
examination on patients is to reach to an accurate conclusion
about patients diagnosis by the help and mean of these four
steps.
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5-Physical examination to review body
systems
• Respiratory system: in this system you will
assess if the patient is present with or
complains of the following:
Cough, Sputum, colour of sputum
Heamoptesis/ blood in cough
Dyspnea/ difficulty in breathing short of
breath, gasping for air, chest pain,..
Orthopnea , difficulty breathing at night
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5-Physical examination to review body
systems
• Cardiovascular system: in this system you will assess
if the patient is present with or complains of the
following:
 Chest pain
 Patients color, skin moisture,
 Palpitation
 Dizziness and headache
 Weakness, easy fatigueness
 Ankle swelling or edema
 bleeding
 Vital signs: pulse rate, blood pressure, respiratory
rate, temperature
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5-Physical examination to review body
systems
• Gastrointestinal system: in this system you will assess
if the patient is present with or complains of the
following:
 Appetite, Diet, and eating habits
 Weight now, gain or loss, amount, and in duration of,
reasons for gain or loss
 Vomiting, diarrhea, colour, amount, consistency
 daily bowl motion habits
 Abdominal pain, tenderness, distension,
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5-Physical examination to review body
systems
• Nervous system: in this system you will assess if the patient is
present with or complains of the following:
 Cognitive Mental status
 Consciousness level
 Fits or seizers
 Transient ischemic attack
 Loss of sensation or ability to move
 Loss of balance , gait, posture
 Speech abilities
 Attention, concentration, memory
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5-Physical examination to review body
systems
• Urogenital system: in this system you will assess if
the patient is present with or complains of the
following:
 Pain during micturation, blood, pus, ….
 Menstruation habits, duration of fllow, amount,
pain….
 Pregnancies, number, type of deliveries,
complications
 Breast engorgement, pain, swelling, lumps..
 Secondary sex characteristics normally present or
absent
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5-Physical examination to review body
systems
• Musculoskeletal system: in this system you will
assess if the patient is present with or
complains of the following:
Joint pain, stiffness, swelling
Limitation in movements
Absence of movement
Amputation / prosthetics /moving aids such as
chair, zim-frame, cane,
Infection, gangrene, bleeding deformity.
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6- Laboratory and radiology investigations
Usually the doctors will order three major types of
investigation to confirm their diagnosis:
1- laboratory tests of blood, urine, sputum, or tissue
biopsy in hematology, biochemistry, cytology,
immunology, microbiology or other labs.
2- radiological examination such as x-ray, CT scan
ultrasound,, MMRI, Tomography, echo, …
3-Electrocardiography or electro encephalography
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7- Differential and accurate diagnosis
What we gained form all the previous steps of history taking is to reach to an
accurate diagnosis by analyzing differential diagnosis.
• Differential or working diagnosis: is to assess the
why most likely,
Why less likely,
why least likely
• accurate diagnosis: always consist of
Anatomical part
Renal +
Brain +
Heart +
Cervical +
Liver +
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+ pathological part
failure
tumor
failure
cancer
cirrhosis
Documentation of all the steps of
history taking process doctors can
develop a clear understanding of
causes and nature of the problem,
and based on that they can make
medical plans to manage and cure
patients.
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Lecture 5
WHO ARE THE DIFFICULT PATIENTS AND
HOW TO DEAL WITH THEM
By
Dr. Aziza Rajab
Head of Nursing dep.
DR. HASHIM FIDA
FAMILY & COMMUNITY MEDICINE
king Abdul Aziz University
Objectives
By the end of this session, participants will be
able to:
• list the 4 categories of “difficult” patients and
discuss strategies for dealing with each, and
• list the components of the “CALMER” strategy
for dealing with difficult patients.
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Difficult patient
The term difficult patient refers to
a group of patients with whom a
physician may have trouble
forming a normal therapeutic
relationship.
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Dealing with emotional Patients
Get patients’ attention: lower your voice,
move so they must turn in your direction.
encourage them to sit down but let them
control their emotions.
Listen not just to the patients needs, but
also for underlying issues/concerns and
unexpressed expectations.
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Dealing with emotional Patients/2
The use of “uh- huh” and “um” has been shown to
help patients settle down on their own. Feels like a
lot of time, but really isn’t.
Avoid arguments, use disarming statements.
Consider rolling with the resistance and agreeing
with the patient if possible.
Take a step back from the demand and ask probing
questions to find underlying concerns. This may
change a rant into a conversation.
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Dealing with emotional Patients/3
• Don’t assume things, ask to find out
• Don’t get emotionally involved, keep your
professional attitude.
• Don’t give false reassuring comments.
• Say no in a tactful manner to the patient’s
unrealistic wishes & demands.
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Handling the Difficult
Patient
73
What are some typical
problem behaviors?
74
Problem Behaviors
• Multiple symptoms involving multiple body
systems
• Vague and shifting complaints
• Dependent, clinging behavior
• Undue concern about minor symptoms
• Excessive preoccupation with physical disease
• Poor response to usual methods of treatment
• Difficult to communicate with
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• Hostile, demanding, dissatisfied
• High utilization of health care services
• Manipulative [calculating], exploitative
[abusive], controlling
• Seductive
• Unrealistic expectations of care
• Raises new problems as visit ends
• Resistant to physician’s recommendations
• Noncompliant with treatment program
• Rambling, unfocused
• Self-destructive
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Three Characteristics of Difficult Patients
• Underlying psychiatric symptoms
• Vague, functional and changing complaints
• Difficulty in forming normal relationships with
physicians
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Malcolm, et al. (1977)
Physician Emotions
• Transference v. Countertransference
• Hatred of Patients
• Typing of Patients
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Transference v. Countertransference
• Transference=feelings experienced by the
patient toward the physician that recapitulate
other important relationships within the
patient’s life
• Countertransference=the analogous emotions
experienced by the physician in this relation
with the patient
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Hatred of Patients
• Hatred toward a patient is a natural
phenomenon.
• The responsibility of the physician for the
patient is similar to that of the mother toward
an infant.
• Like the mother, it is okay to feel the hatred
but essential to refrain from acting upon it.
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Winnicott, 1949
Typing of Patients
•
•
•
•
Dependent clingers
Entitled demanders
Manipulative help-rejecters
Self-destructive deniers
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Groves, 1978
Dependent Clingers
Patients who have inexhaustible needs for
medical attention
• Initial honeymoon period when the physician
is likely to be praised and receive stroke from
the grateful patient, who then goes on to
steadily increase the demands made on
physician time
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Sohr, 1996
Dependent Clingers
These patients produce feelings of AVERSION on
the part of the physician or treating team.
• The natural response is to put off seeing such
a patient as long as possible and perhaps to
send subtle messages to the patient that his
presence is less than enthusiastically
welcomed.
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Sohr, 1996
Dependent Clingers
It is important for the physician to do the
opposite of his inclination.
• Instead of putting off the patient’s
appointment, the patient should be scheduled
promptly and frequently.
84
Sohr, 1996
Dependent Clingers
The use of frequently scheduled but timelimited visits does the following:
• Encourages the development of a more useful
physician-patient relationship
• Stabilizes the patient by setting limits on the
time spent at any one sitting
• Gives the patient permission to come back to
see the physician without the need to develop
a new symptom
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Sohr, 1996
Entitled demanders
Resemble clingers in their neediness, but rather
than flattery and seduction, they use
intimidation, devaluation and guilt-induction
to place the doctor in the role of the
inexhaustible supply depot.
• They appear less naïve about their effect on
the physician than clingers and buttress their
hold on the doctor by threatening
punishment.
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Sohr, 1996
Entitled demanders
These patients arouse ANGER in the physician
and sometimes FEAR of loss of reputation.
• Frequently, the patient will threaten litigation.
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Sohr, 1996
Entitled demanders
The recommended strategy is to acknowledge
the patient’s entitlement to good medical care
and request that the patient stop misdirecting
his anger.
• Try to resist projecting your value system onto
the patient—the APOSTOLIC
FUNCTION=notion that the doctor knows how
the illness is supposed to feel and how the
patient should be handling it.
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Sohr, 1996
Manipulative help-rejecters
These patients are ungrateful. Their demands
are not threatening as with Entitled
Demander. Instead, they seem to believe that
nothing will help.
• Pessimistic, yet strangely content
• When one symptom disappears, another
surfaces.
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Sohr, 1996
Manipulative help-rejecters
These patients first elicit ANXIETY that a
treatable illness has been overlooked.
Eventually, the physician becomes IRRITATED
with the patient. Finally, the physician
becomes DEPRESSED and full of self-doubt.
They can make the physician feel INADEQUATE
and GUILTY.
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Sohr, 1996
Manipulative help-rejecters
A reasonable management strategy for
somatization includes frequent patient visits.
• Once the relationship is established, it
becomes easier to employ “tincture of time”
and to avoid unnecessary and invasive
procedures.
• Seeing the patient on a regular basis
decreases the patient’s need to develop new
symptoms in order to see the physician.
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Sohr, 1996
Manipulative help-rejecters
These patients are sometime called “crocks.”
• Need to create a situation where the patients
need not remain ill in order to maintain the
relationship with the doctor.
• Share pessimism with the patient and say that
the treatment may not be entirely curative.
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Sohr, 1996
Self-destructive deniers
These patients exhibit a form of suicidal
behavior.
• It is not unusual for physicians to wish
occasionally for such patient to die quickly.
• Many recommend a psychiatric consult for
these patients to rule out depression.
• These patients are not necessarily aware of
their death wishes.
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Sohr, 1996
Stereotype
Mechanism
Physician
Emotion
Strategy
Dependent
Clinger
Regression into
dependency.
Patient has
inexhaustible
needs.
Feelings of
power initially
followed by
aversion
Set limits before
total destruction
of the
relationship.
Schedule more
frequent visits and
limit interruptions.
Entitled
Demander
Unaware of
dependency.
Terrified of
abandonment.
Guilt, fear, anger Never disparage
feeling of
entitlement.
Redirect feeling
of entitlement to
acknowledged
right to good
health care.
94
Sohr, 1996
Stereotype
Mechanism
Physician
Emotion
Strategy
Manipulative
HelpRejecter
Afraid to get
well for fear of
losing
relationship with
physician.
Anxiety that
treatable illness
has been
overlooked.
Put limits on
unrealistic
expectations.
Share pessimism
with patient.
Selfdestructive
Deniers
Dependents
who have
given up. May
appear to take
pleasure in
their
destruction.
Frustration.
May with the
patient’s death
and experience
guilt about such
wishes.
Realize that the
patient has
given up and
may truly want
to die. Order
psychiatric
consultation.
95
Sohr, 1996
The CALMER Approach
• Physicians must understand how their own
attitudes and behavior may contribute.
• The CALMER approach assists physicians in
reducing distress associated with interactions
with problem patients.
96
Pomm, et al. (2004)
CALMER
C=catalyst for change
A=alter thoughts to change feelings
L=listen and then make a diagnosis
M=make an agreement
E=education and follow-up
R=reach out and discuss feelings
97
Pomm, et al. (2004)
Catalyst for Change
• Physicians should remind themselves of what
they can and cannot control about the
situation.
• Physicians cannot control the patient’s
behavior, but they can control their own
reaction and try to be helpful by offering
practical advice.
98
Pomm, et al. (2004)
Alter Thoughts to Change Feelings
• The only way individuals can control their
reactions is to alter their thoughts about the
situation.
• Physicians should identify which feelings they
are experiencing in response to the patient
and then ask how these feelings might be
affecting the physician-patient relationship
and the management plan.
99
Pomm, et al. (2004)
“What can I tell myself
about this situation that
will make me feel less
_______?”
100
Pomm, et al. (2004)
Listen and Then Make a Diagnosis
• As a result of a physician’s negative response
to a difficult patient encounter, he/she may
not accurately hear what the patient is trying
to verbally or nonverbally communicate.
• By engaging in the first two steps, the
physician will be better equipped to truly hear
what patients are trying to communicate.
101
Pomm, et al. (2004)
Make an Agreement
• Make an agreement with the patient to
continue the physician-patient relationship.
• “So, after all we have discussed, it is my
understanding that you would like to continue
to see me, and we have agreed that we will
work together to keep you as healthy as
possible. Is that your understanding, too?”
102
Pomm, et al. (2004)
Education and Follow-Up
• After the physician and patient agree to
continue their relationship and work together,
how they will accomplish this needs to be
addressed as specifically as possible.
103
Pomm, et al. (2004)
Reach Out and Discuss Your Feelings
• “How do I now feel about this patient and
his/her behaviors?”
• Identify how they will care for themselves the
next time a patient elicits these types of
feelings.
104
Pomm, et al. (2004)
CALMER
C=catalyst for change
A=alter thoughts to change feelings
L=listen and then make a diagnosis
M=make an agreement
E=education and follow-up
R=reach out and discuss feelings
105
Pomm, et al. (2004)
Objectives
By the end of this session, participants will be
able to:
• list the 4 categories of “difficult” patients and
discuss strategies for dealing with each, and
• list the components of the “CALMER” strategy
for dealing with difficult patients.
106
Lecture 6
The Art of Consultation
By
Dr. Aziza Rajab
Assistant professor
.
DR. HASHIM FIDA
FAMILY & COMMUNITY MEDICINE
king Abdul Aziz University
CONSULTATION
•
•
•
•
108
Definition
Models of consultation
Difficult consultations
Communication skills
Definition
Most text books describe interviewing as a
diagnostic procedure which is a systematic
process of data-gathering designed to identify
problems and to arrive at a conclusion,leading
ultimately to a treatment plan. This is only
partly true.To achieve its maximum value, the
consultation should be therapeutics. The most
important skill of family physician is ability to
interview patient effectively as follow ;
109
1.To provide health care to all patients, regardless of
their age, sex, socio-economic standing and disease
status.
2.To treat disease and promote healthy lifestyles in
individuals and communities.
3.To provide comprehensive, continuous care, bearing
in mind the cultural, social, psychological and
economic factors that influence health and disease.
4.To provide care either directly or through other
members of the team, depending on the needs of
the patient and the resources of the community.
110
Models of consultation
1.Bio-medical model (hospital model).
2.Bio-psychosocial model.
3.Byrne and long model doctors styles.
4.Balint model.
5.Pendelton model
6.Stott an Davis.
7.Neighbour model.
111
Byrne and long model doctors styles.
Patient-centered
Use of patient’s knowledge
And experience
Doctor-centered
Use of doctor’s knowledge
And skills
112
Balint model
•
•
•
•
113
The doctor as a drug
Elimination by physical examination
The child as a presenting complaint
Inappropriate referral
Pendleton model
1.To define the real reason for attendance
2.To consider other problems
3.To choose "with the patient" the appropriate
action for each problem
4.To achieve a share of understanding
5.To involve the patient in management
6.To use time and resources effectively
7.To establish and maintain doctor-patient
relationship
114
Stott and Davis model
1.Management of Presenting Problem
2.Management of Continuous problem
3.Modifiation of help Seeking behavior
4.Opportunistic health promotion
115
Neighbour model
1.Connecting (establish a relationship)
2.Summarizing( physical. psycho ad social
diagnosis)
3.Handling-over(management of presenting
problem)
4.Safety-netting(anticipating care)
5.House-keeping(taking care of yourself)
116
Difficult consultation
10-20% of daily consultation are difficult. This
difficulties are either due to;
1.Difficult patient
2.Difficult Doctor
3 .Difficult communication between the doctor
and patient
117
Initiating the Consultation
Establishing a supportive environment.
Developing an awareness of the patient’s
emotional state.
Identifying as far as possible all the problems or
issues that the patient has come to discuss.
Establishing an agreed agenda or plan for the
consultation.
Enabling the patient to become part of a
collaborative process.
118
The Art of Consultation
giving the correct amount and type of information to
each individual patient.
Providing explanations that the patient can remember
and understand & which relate to the patient’s illness
framework.
Using an interactive approach to ensure a shared
understanding of the problem with the patient.
Involving the patient and collaborative planning increase
the patient’s commitment and adherence to plans
made.
Continuing to build a relationship and provide a
supportive attitude.
119
Closing the interview
Confirming the established plan of care.
Clarifying next steps for both doctor and
patient.
Establishing contingency plans.
Maximizing patient adherence and health
outcomes.
Making efficient use of time in the consultation.
Continuing to allow the patient to feel part of a
collaborative process and to build the doctorpatient relationship for the future.
120
Questions to ask yourself after each
consultation
Was I curious?
Do I know significantly more about this
person as a human being than before they
came through the door?
Did I listen?
Did I make an acceptable working
diagnosis?
Did I explore their beliefs?
121
Questions to ask yourself after each
consultation/2
Did I use their beliefs when I started
explaining?
Did I share options for investigations or
treatment?
Did I share in decision-making?
Did I make some attempt to see that my
patient understood?
Did I develop the relationship?
122
Lecture 7
PRINCIPELS OF BREAKING BAD NEWS Lecture 8
HOW TO APPLY THE STEPS OF BREAKING BAD
NEWS IN THE CLINICAL SETTING
By
Dr. Aziza Rajab
Assistant professor
DR. HASHIM FIDA
FAMILY & COMMUNITY MEDICINE
king Abdul Aziz University
.
What is Bad News ?
Any news that drastically alters a patient’s •
view of his or her future
124
What is Bad News?
Any news that seriously
and negatively alters
the patient’s view of his
or her future.
Buckman
125
126
Do You Tell?
• 50 – 90% of patients want the truth
• So the issue is not “do you?”
• Issue is “how?”
127
The Goal
• Help the patient and family understand the
condition
• Support the patient and family
• Minimize the risk of overwhelming distress or
prolonged denial
128
BREAKING BAD NEWS
WHY IS IT SO DIFFICULT TO DO?
WHAT IS THE SOLUTION?
129
130
EMPATHY: THE FOUNDATION
BEING FOCUSSED
UNDERSTANDING FROM THE ‘INSIDE’
RESPONDING WITH CARING
131
WHAT IS THE SOLUTION?
KNOWLEDGE
• HOW TO TELL?
•
•
•
HOW MUCH TO TELL?
WHO TO TELL?
WHEN TO TELL?
SKILL
“LI ST EN”
ATTITUDE
• IMPORTANCE OF SELF AWARENESS
132
Why Is It Difficult to Do
• Worry that the news will cause an adverse
effect
• Worry that it will be difficult to handle the
reaction of patient or family
• Challenge of individualizing the approach
133
Why is this Difficult?
Social factors •
Our society values youth, health, wealth •
Elderly, sick and poor are marginalized •
Sick and dying have less social value •
134
Why is this Difficult?
Physician factors •
Fear of causing pain •
Uncomfortable in uncomfortable situations •
Sympathetic pain due to patient’s distress •
135
Why is this Difficult?
• Fear of being blamed
• Physicians have authority, control, privilege
and status
• When medical care fails patient
•
it’s physician’s fault
• “blame the messenger”
136
Why is this Difficult?
• Fear of therapeutic failure
• Medical system reinforces idea that poor outcome
and death are failures of ‘system’
•
and by extension, our failure
•
“all disease is fixable”
•
“better living through chemistry”
• We are trained to feel this way; “if only……”
137
Why is this Difficult?
• Fear of medico-legal system
• Everyone has “right” to be cured;
• If no cure happens, someone is to blame
138
Why is this Difficult?
• Fear of not knowing
• “we don’t do what we don’t do well”
• Good communication is a skill that is not
highly valued, therefore not taught
139
Why is this Difficult?
• Fear of eliciting reaction
• “don’t do anything unless you know what to
do if it goes wrong”
• Not trained to handle reactions
• Not trained to allow emotion to come out
140
Why is this Difficult?
• Fear of saying “I don’t know”
•
• We are never rewarded for lack of
knowledge
• Can’t know or control everything
141
Why is this Difficult?
• Fear of expressing emotions
•
• Viewed as unprofessional
• Suppressing emotions increases distance
•
between ourselves and patients
142
Why is this Difficult?
• Ambiguity of “I’m sorry”
•
• Two meanings
•
“I’m sorry for you”
•
“I’m sorry I did this”
• Easily misinterpreted
143
Why is this Difficult?
• Fear of one’s own illness and death
• Cannot be honest with the dying unless you
accept you will die
144
What Do Patient’s Want?
Studies show that 50-90% of patients with •
terminal illnesses want full disclosure
Not everyone wants to know •
145
Why is it a critical skill?
The Patient’s Perspective
Patients often have vivid memories of •
receiving bad news
Negative experiences can have lasting effects •
on anxiety and depression
Can facilitate adaptation to illness and deepen •
the patient-doctor relationship
146
Why is it a critical skill?
The Physician’s Perspective
High degree of difficulty
+
Physician
anxiety
=
High risk of performing poorly
147
What do patients want?
For themselves…
• more time to talk
• and show feelings
From the doctor…
• more information, caring,
hopefulness, confidence
• a familiar face
Strauss 1995
148
What do you do?
What have you have found helpful in making •
“bad news” visits go as well as possible?
149
Six Step Protocol
•
•
•
•
•
•
150
-arrange physical context
-find out what patient knows
-find out what patient wants to know
-share information
-respond to patient’s feelings
-plan follow-through
Arrange physical context
•
•
•
•
•
151
Always in person, face to face
NEVER on telephone
Assure privacy
Verify who is present
Verify who should be present
•
ASK
Arrange physical context
• Remove physical barriers
• Sit down
•
patient-physician eyes at same level
•
appear relaxed, not casual
•
(avoid ‘open 4’)
• Touch patient (appropriately)
•
above the waist, handshake, shoulder
152
Find out what patient knows
• Not just knows, but understands
• Use open questions
•
closed questions excellent for historytaking
•
prevent discussion
153
Find out what patient knows
• Listen effectively to response:
•
tells understanding, ability to
understand
• Repeat back what patient says
• Do not interrupt
• Make encouraging cues
• Maintain eye contact
154
Find out what patient knows
• Tolerate silences
• Listen for “buried question”
• question asked while you are speaking
155
Find out what patient wants to know
• Ask!!
• Do not allow families to run interference
• If patient chooses not to know now, may ask
later
156
Share the information
• Plan agenda
•
know beforehand what information has to
get across
•
eg diagnosis, treatment, prognosis,
support
• Start by aligning with what patient knows
157
Share the information
•
•
•
•
•
158
Allow patients to ‘get ready’
Impart information in small packets
best case retention = 50%
Speak English, not “Doctor”
Verify message is received
Respond to feelings
• Acknowledge emotions
•
strong emotions prevent communication
•
identify and acknowledge them
• Learn to be comfortable with silence and with
emotion
159
Respond to feelings
• Range of normal reaction is wide
•
give latitude[ freedom] as much as
possible
•
stay calm, speak softly
•
be gentle, yet firm
•
stick to basic rules of interview:
•
question-listen-hear-respond
160
Respond to feelings
• Distinguish between adaptive and
maladaptive behaviors
• Adaptive
•
•
•
•
•
•
161
anger
crying
bargain [agreement]
fulfilling an ambition
fear
hope
Maladaptive
rage
collapse
manipulation
impossible “quest”
anxiety/panic
unrealistic hope
Respond to feelings
• Respond with empathic responses
•
“it must be very hard to…”
•
“you sound angry (afraid, depressed)…”
162
Respond to feelings
• In the face of true conflict: act, don’t react
• If you cannot change behavior, get help
163
Planning follow-through
• Have plan of action
• Make certain patient’s understand what is
fixable and what is not
• Always be honest
• Patient leaves with contract:
•
what will happen, who to call, how to
call, when to return
164
S etting up the
interview
P erception of the
patient re their illness
I nvitation from
patient to share info
K nowledge and
Information conveyed
E motions responded
empathically
S ummary and
Strategy for follow-up
165
to
1. Setting up the interview
• Anticipate [expect] the possibility of bad news,
and arrange a follow-up visit after significant
scans, biopsies etc.




166
Avoid telephone
Private setting, sitting down
Turn off beeper, no interruptions
Ensure adequate time
1. Setting up the interview
 Lab reports, X-rays present
 Support person present , if desired
 Review the condition, basic prognosis and
treatments before the visit
 HOPEFUL TONE
167
Assessing the patient’s
2. Perception
• ASK then TELL
• Important if the patient is not well known to you OR
if visits to consultants have occurred
• “Assess the Gap” between what the patient knows
and the diagnosis
• “What have you already been told about might be
going on?
• “What is your understanding of why the CT scan was
ordered?”
168
Obtaining the patient’s
3. Invitation
•
•
•
•
Preferably before the visit
Easier if patient is well- known
Listen to patient cues
“Are you the sort of person who likes to know all the
details of your condition?
• “Would you like me to discuss the results of the CT
scan with you?”
169
Giving
4. Knowledge and Information
• Align yourself with the patient’s understanding and
vocabulary
• Start with a warning shot: “I’m afraid that the scan
shows that the problem is fairly serious.”
• Give diagnosis simply, avoid euphemisms [use of
alternate word for a unpleasant word
• ] or excessive bluntness[word used to hide the real
thing]
• Provide information in small chunks
• Check frequently for understanding
170
Giving
4. Knowledge and Information
• Align yourself with the patient’s
understanding and vocabulary
• Start with a warning shot: “I’m afraid that the
scan shows that the problem is fairly serious.”
• Give diagnosis simply, avoid euphemisms or
excessive bluntness
• Provide information in small chunks
• Check frequently for understanding
171
Giving
4. Knowledge and Information
• Check for knowledge or experience with
condition
• Allow for pauses, use repetition
• Will usually want basic but clear information
re treatment plan and prognosis
BUT
• Tune into patient readiness to hear more, and
know when to stop
172
Respond to
5. Emotions empathically
Observe for and allow emotional reactions •
Kleenex handy, use of touch •
N aming the feeling “I know this is upsetting”
U nderstanding
“It would be for anyone”
R especting “You’re asking all the right questions”
S upporting “I’ll do everything I can to help you
through this.”
173
6. Summary and Strategy
for follow-up
• Summarize discussion
• Clear follow-up plan re: referral, tests, next
contact (in <48 hrs)
• Provide written summary or brochures
• Refer to community resources
• Invite support person for next visit if not
present
174
6. Summary and Strategy
for follow-up
 End on note of hope and partnership
 AFTER: document well
assess your own reaction
175
Six Steps for
Breaking Bad News
S etting up the interview
P erception of the patient re their illness
I nvitation from patient to share info
K nowledge and Information conveyed
E motions responded to empathically
S ummary and Strategy for follow-up
176
SPIKES
• S=
Setting up the interview
• P = Patients Perceptions
• I=
Invitation to ascertain how much the person wants to know
• K = Knowledge and information giving
• E=
Emotion management
• S=
Strategy and Summary summarising the key points
(Taken from Baile et al. 2000 and reproduced by kind permission of AlphaMed Press)
177
How Should Bad News Be Delivered?
•
•
•
•
•
•
178
ABCDE Mneumonic
A-Advance Preparation
B-Build a therapeutic relationship
C-Communicate well
D-Deal with patient and family reactions
E-Encourage and validate emotions
Advance Preparation
• Familiarize with the facts of the case, consultant
opinions, prognosis and treatment options
• Arrange for appropriate environment and time
where there will be no interruptions (silence beeper
and cell phone)
• Mentally rehearse how you will deliver the news
• Prepare emotionally
179
Advance Preparation
• Familiarize with the facts of the case, consultant
opinions, prognosis and treatment options
• Arrange for appropriate environment and time
where there will be no interruptions (silence beeper
and cell phone)
• Mentally rehearse how you will deliver the news
• Prepare emotionally
180
Build a Therapeutic Relationship
• Determine what the patient wants to know
• Have family or other supporters present based
upon patient preference
• Introduce yourself to everyone present
• Foreshadow the bad news
• Assure the patient that you will be availableschedule a follow-up meeting
181
Communicate Well
•
•
•
•
•
182
Find out what they know
Speak clearly-avoid euphemisms like “growth”
Allow silences-proceed at the patient’s pace
Assess understanding
Summarize and make followup plans
Types of Ambiguous Communication
•
•
•
•
•
•
183
Jargon and technical language
Euphemisms
Evasion [ dodging]
Conflicting information
Percentages and statistics
Obfuscation [to make somebody confused]
Example
• Physician: As you may remember, when we
first started chemotherapy, we told you that
we would check blood and x-rays before each
cycle. I have looked at your scans today and
there are signs that things are progressing, so
we do not think that you should have any
more chemo
• Patient: So what happens now?
184
• Physician: Well, we just want you to come
back and see us if you develop any further
problems with your breathing and we will
treat those symptoms
185
• The researcher met with the patient after this
conversation and his interpretation of what
the physician told him was “Well it’s good
news, really…the doctor thinks things are
progressing so I don’t need any more chemo
and to just come back if my breathing starts
up again-getting breathless you know”
186
Deal with patient and family reactions
• Assess and respond to emotional reactions
• Be empathetic-I’m sorry that I couldn’t give
you better news
• Avoid criticizing colleagues
187
Encourage and Validate Emotions
•
•
•
•
188
Offer realistic hope
Offer referals as needed
Use interdisciplinary services to enhance care
Take care of own needs and others affected by
the news
Other Pointers
• Avoid telephone notification
• Be a good listener
• Respect preferences
189
In a meeting
•
•
•
•
•
•
190
Find out who everyone is
Determine what they know
Determine what they want to know
Tell
Respond
Plan future meetings
Ten Important Needs of Families of
Critically Ill Patients
•
•
•
•
•
•
•
•
•
191
Be with the patient
Be helpful to the patient
Be informed of changes in condition
Understand what is being done and why
Be assured of the patient’s comfort
To be able to ventilate emotions
To be assured that their decisions were right
Find meaning in the dying of their loved one
To be fed, hydrated and get rest
Ten Important Needs of Families of
Critically Ill Patients
•
•
•
•
•
•
•
•
•
192
Be with the patient
Be helpful to the patient
Be informed of changes in condition
Understand what is being done and why
Be assured of the patient’s comfort
To be able to ventilate emotions
To be assured that their decisions were right
Find meaning in the dying of their loved one
To be fed, hydrated and get rest
Death Notification
• Prefer to be told by the physician
• Ask the family members what they know about the
situation
• Bridge from what they know with a brief description
of what happened
• Give information about the resuscitative efforts
• Conclude with the victim’s response, the statement
of death and an assessment of the cause of death
193
BREAKING BAD NEWS: CONCLUSIONS
1)
BAD NEWS CANNOT BE CONVERTED TO GOOD NEWS
2)
KNOWLEDGE OF NORMAL PSYCHOLOGY WILL HELP INFORM
THE PROCESS
3)
SPECIFIC SKILLS (LISTEN) CAN BE LEARNED AND APPLIED
4)
SELF AWARENESS AND THE ABILITY TO DEAL WITH
PERSONAL STRESS IS ESSENTIAL TO GOOD
COMMUNICATION
194
2nd lecture(how to break bad news)
195
Case Scenario
• During morning clinic, you receive a phone call
from the radiologist at your local hospital.
A chest x-ray carried out on Mr. Ahmed shows
features highly suggestive of lung cancer.
You remember that Mr. Ahmed is a 50 year old
in your practice area.
What problems confront you and how could
they be dealt with?
196
Case scenario
• 30-year-old lady delivered a baby with down
syndrome 8 hours ago. The pediatrician told
you as an intern to tell her husband about the
diagnosis.
What points would you like to consider in
discussing this request with him?
197
Aims: breaking bad news
• Enhance the psychosocial
adaptation of patients and their
relatives.
198
Principles: breaking bad news
• The most appropriate persons.
• Details of the patient and all necessary
information.
• What information is to be conveyed and in
what order?
199
Principles: breaking bad news
• Terminology.
• Privacy.
• Appropriate setting
• Timing.
200
Principles: breaking bad news
• Respect and absolute attention.
• Active listening
• Empathy
• Honestly and accurately.
201
Principles: breaking bad news
• Check out understanding.
• Patient reactions
• Body language.
• Relaxed, unhurried.
202
Principles: breaking bad news
• Explanatory leaflets.
• Avoid unnecessary distress and minimize
misunderstanding.
• Avoid overload patient with information.
• Summarize the information.
203
Principles: breaking bad news
• Questions.
• Support.
• Early follow up.
• Time for your own felling.
204
Practical and Role play
• Two volunteer student
• Scenario
• Role play
• discussion
205
‫‪conclusion‬‬
‫عن أبي يحي صهيب بن سنان رضي هللا عنه‬
‫قال‪ :‬قال رسول هللا صلى هللا عليه وسلم‪:‬‬
‫(( عجبا ألمر المؤمن إن أمره كله له خير‬
‫وليس ذلك إال للمؤمن‪ :‬إن أصابته سراء‬
‫شكر فكان خيرا له‪ ،‬وإن أصابته ضراء‬
‫صبر فكان خيرا له)) رواه مسلم‬
‫‪206‬‬
Breaking Bad News
clinicians are responsible for delivering bad
news, this skill is rarely taught in medical
schools, clinicians are generally poor at it
breaking bad news is one of a physician’s most
difficult duties.
medical education typically offers little formal
preparation for this task.
207
THE PAST AND THE PRESENT
Hippocrates advised concealing most things
from the patient.
Older physicians, who trained during
the 1950s and 60s, were taught to "protect"
patients from disheartening news.
208
BREAKING BAD NEWS/2
any news that drastically and negatively
alters the patient’s view of his or her future.
it results in a cognitive, behavioral,
or emotional deficit in the person.
receiving the news that persists for some
time after the news is received.
209