Clinical Sciences Division

Communication Skills Manual SEMESTER THREE

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Content
F. Semester Three
F.1 Activities in Semester 3 F.2 Motivation Interview F.3 Rotation Posting F.3.1 Video recording with difficult patient F.3.2 Facilitated Peer Review F.3.3 Reflective Writing F.3.4 Clinical Case Discussion

Page

64 65 68 68 72 73 74

F.4 Giving information to patients on the use, effects and side effects of prescribed medication

75

F.5 Taking Sexual History

80

Appendix I : Boeninks Criteria for marking Reflective Writing Appendix II : Calgary Cambridge Checklist Appendix III : Checklist for difficult patient Appendix IV : Process of Motivation Interview

86 87 92 93

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F. Semester Three
Introduction
In this semester, your communication skills learning will be integrated in the Gastroenterology Module, Rotation posting to Hospital Kuala Kubu Baru, Endocrine, Reproductive and Renal Modules. In this manual, only the activities with communication skills learning will be highlighted. You will need to refer to both your physical examination manual and this manual together.

F. 1.

Activities in Semester Three

The following activities are outlined in different system modules : 1) Gastroenterology module i. ii. iii. To elicit a comprehensive medication history from a patient (refer GI manual) To obtain details of a patients alcohol consumption (refer GI Manual) To recognise the issues involved in changing behaviour and to carry out a motivational interview (refer F.2. below)

2) Rotation posting i. Trip to Hospital Kuala Kubu Bharu (KKB) refer instruction given in the e-learning ii. To communicate effectively with anxious, angry, talkative or demanding patients Video recording / facilitated peer review / reflecting writing/ Clinical case Dissusion 3) Endocrine module i. ii. To carry out an effective follow-up interview in a patient with chronic disease (in the context of diabetes) (refer Endo manual) To give information to patients on the use, effects and side effects of prescribed medication (refer F.3. below)

4) Reproductive module (refer Repro manual)

i. ii. iii. To sensitively elicit the menstrual history, obstetric history and sexual history in patients presenting with gynaecological problems. To carry out a comprehensive and sensitive interview in a patient attending for antenatal examination. To recognise particular legal and ethical issues relevant to reproduction.

5) Renal module (refer renal manual) i. To demonstrate clinical reasoning in the course of a diagnostic interview

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F.2. Motivational Interview

Lecture on this topic will be deliver by Behaviour Sciences Team. You will be practicing on the principles of motivating patients during your rotation posting after the GI module.

Doctors see patients for whom they suggest changes in lifestyle or medication. Too often, doctors resort to standard statements (you have to change, You have to quit smoking., and You have to lose weight.. Doctors typically try to advise them to change, using a directing style, which in turn generates resistance or passivity in the patient. Studies performed during the last three decades indicate that only 30% to 70% of patient followed their doctors recommendati on only partially or not at all. This is because the patients are often ambivalent or unmotivated. The motivational interview is an approach developed by psychologists Miller and Rollnick to treat alcoholism and substance abuse, can help physicians structure the interventions designed to effect change in patients behavior. Their systematic approach is intended to motivate patients to change and fosters a constructive doctor-patient relationship and leads to better outcomes for patients.

Definition of Motivational interview:

A collaborative, person-centered form of guiding to elicit and strengthen motivation for change.

It is a conversation about change because simply giving patients advice to change is often unrewarding and ineffective. Patients and health professionals relationship are more of a partnership than doctors performing expert roles as collaboration helps to build rapport and the focus is on mutual understanding. Change is more likely to occur if patients are determined to change. Motivational interviewing uses a guiding style to engage with patients, clarify their strengths and aspirations, evoke their own motivations for change, and promote autonomy of decision making. Remember, the power of change rests on the patients !

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Principles of motivational interview:

1. Expressing empathy - Looking at patients conditions/problems through their perspectives 2. Supporting self-efficacy - The belief that patients have the ability to change themselves - It is the role of doctors to draw on patients previous success in changing by highlighting patients strengths 3. Accept resistance - Accept resistance and understands why patients resist change. Take patients suggestions on the best way they are able to change 4. Develop discrepancy - Motivation to change (e.g. lifestyle) occurs when there is a perceived mismatch between where a person is and where he or she would want to be - The role of doctors is to point out to the patients the fore mentioned mismatch. - When patients understand that their current behavior is in conflict with their health, they are more likely to experience increased motivation to change their lifestyle

Summary:
The basic approach in motivational interview includes the following steps: O A R S Open-ended questions Affirmations Reflections Summaries

Open-ended questions Open-ended questions let patients explains their problems and needs. This also helps patients to explore the possibilities of change Affirmations Statements using affirmations recognize patients strengths. It helps patients to see themselves more positively Reflections Reflections or reflective listening convey to the patients that doctors are empathetic and understands patients issues from patients point of view

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Summaries Summaries recap important components that had occurred during motivational interview. This communicates interest and understanding Motivational interviewing is not a quick fix method, let alone a set of clever techniques for getting patients to do what they otherwise would not want to do. It is not done "to" or "on" patients, but "with" or "for" them. It can be used in any consultation about change, and evidence of its effectiveness is growing. It is helpful to consider your patient as your teacher. If he or she responds positively, and becomes an active participant in talk about change, this feedback tells you that you are doing a good job.

Refer to Appendix IV for extra reading on process of motivation interview

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F.3. Rotating Posting

You will be having rotating posting to Skill Centre and Hospital Kuala Kubu Bharu (KKB). Please refer to the instruction in the e-learning for KKB rotation. In the Skill Centre, the following activities will take place: Video recording of difficult patient angry, demanding, long winded Facilitated peer review Reflecting writing Clinical Case discussion

F.3.1. Video recording with difficult patients

1. You will be given specific date and time to come to Skill Centre whereby you will be interviewing a difficult patient in 5 mins. This interview will be recorded to be use in the next activity in Skill Centre (Facilitated peer review). 2. You will not be allow to attend the session on Facilitated Peer review if you miss the video recording and will not be able to write the reflective report which is part of your portfolio.

Difficult patients include patient who are : angry and aggressive anxious demanding withdrawn and appear difficult to engage in conversation talkative and long winded having hearing or/and speech problems

Learning objectives: At the end of the session you will be able to a) Identify a difficult patient b) Describe measures to be adopted in a case of a difficult patient c) Successfully manages a difficult patient

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1. Guidelines for helping the anxious patient Be calm and prepared to spend time with the patient Explain that most patients feel some anxiety and that this is appropriate If the patient is talking too much, try to keep them to the point by summarizing what they have told you and explaining what further information you need and why you need it. Be specific about what you may want them to do during and after the consultation If the patient presses you for the cause of their symptoms and seeks reassurance, explain that you are a student and refer them to the doctor.

2. Guidelines for dealing with the angry or aggressive patient Is the patient agitated, restless or ready to explode? What does their behaviour communicate to you? Show willingness to talk and listen. Acknowledge their anger or annoyance. Never redefine their behaviour as fear or anxiety, even if they seem to manifest these feelings Keep a safe distance: neither too close, nor too far away Do not: - interrupt their outburst - caution a swearing person about their choice of words - threaten them in any way Ask open rather than closed questions. Encourage them to talk: talking is preferable to violent behaviour Do not make agreements or promises that cannot be kept; be reasonable and honest. Help the patient to feel they have choices: people are most often aggressive when they feel they have few or no choices Do not talk to them from behind: this can be threatening and unnerving. Also, do not attempt to touch them: any movement could seem threatening. On the other hand, do not block their path: ensure they have an escape route. Do not take personal offence at what might be said; this could make you aggressive or defensive and so escalate violence Never let down your guard until the incident is over. Fatigue, or a sense that the argument is ending, could lead you to take risks and so start up the problem again If security staffs are summoned, try to supervise their actions so that you maintain some control over the situation

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3. Guidelines for helping the uncommunicative patient: Be prepared to spend time over the consultation Do not become bored, frustrated or angry Observe the patient carefully: be alert and respond to their verbal and non -verbal cues Show empathy by your own body language (e.g. lean forward and maintain eye contact) Explain the purpose of the interview: why you want the information Use facilitatory language, e.g. 'I can see that you're finding it difficult to talk about this' Use more closed questions than open questions, if this seems appropriate

4. How NOT to respond to a person with communication difficulties: Repair language (to someone who is stuttering): 'What you are trying to say is: "Will I go home this week?". The answer is "Yes".' Tell them what to do and think: 'If you don't say anything, we must assume you don't want to go on the day trip. So you'll have to stay behind and sit in the day centre.' Avoidance: 'Leave her alone; she doesn't understand what we're saying. You'll only upset her.' Speak louder: there is a tendency to increase the volume of speech rather than use different words, believing that the louder we speak, the more easily the other person will understand us. Use another person as conduit for communicating (in front of the patient): 'What is he saying? Can you understand?' [under your breath and exasperated]: 'I give up!' Become impatient and angry: 'Look, I've got a busy clinic. If there's something else, speak to one of the nurses.' Offer meaningless reassurance (after incomprehensible sounds from a patient): 'Don't worry, we'll take care of everything for you.'

5. Learn how to say Yes or No tactfully. In the past a straightforward reply Yes was unequivocal, but now Yes often seems to be a little less than absolute, almost inviting patients to say Yes, but which may be perfectly legitimate way for them to request further information. If you want to convey an unequivocal Yes say Absolutely. If you wish to say No but wish to emphasise that you are not responsible for the negativity a useful ploy is to say Im afraid the answer has to be no because..

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6. Try to exhibit a neutral approach. It may be difficult to remain neutral when you have distinct thoughts about a particular individual. Whatever you may feel about various groups of patients, your job is to look after individuals to the best of your ability and this demands a wide repertoire of communicational skills and tolerance. Some patients exasperate but never forget there may be understandable medical or situational reasons why some patients irritate or annoy. Assess how problems are affecting the patient. Tell me how this affects you? or This must cause you problems in day -to-day living: could you tell me about these problems? Try to see problems from the patients point of view. What to you is trivial may be much more important to the patient. Acknowledge this. I can appreciate that this is a major worry.

Summary: When communicating with patients who seem withdrawn, anxious or angry, try to understand the underlying reasons for their behaviour and adapt your style to facilitate communication. Notions of 'appropriateness or 'normality' are not fixed: they depend on the individual culture and life experiences of both doctor and patient. When confronted by an angry patient, do not do anyth ing that may escalate the threat of violence. Act conservatively; try to prevent situations from becoming worse by being attentive and concerned. Do not avoid patients with a disability, especially those whose hearing, speech and memory is impaired. Use both verbal and non-verbal forms of communication creatively. Use an interpreter where necessary. It can be helpful and important to ask the interpreter to translate exactly what the patient has said. Check that the patient has understood what has been said. Allow time for communicating with patients who have the difficulties discussed in this chapter.

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Useful questions to a person who is overweight What makes you think, you want to change? What will happen if you dont change? What would be the good things about changing your eating habits? If you were to decide to change, what would you have to do to make this happen? Do you mind if we talk about your weight problem? I noticed on your medical history that you have high cholesterol level, do you mind if we talk about how eating habits contribute to this?

F.3.2. Facilitated Peer review

You will watch your recorded interview together with a small group of students (about 6-7) facilitated by a lecturer. You will reflect and comment on your own strength and weakness. Feedback from peers and lecturer will be given to you. All of this is done through a checklist based on the Calgary Cambridge Guide.

Please Print Appendix III and bring it to Clinical Skill Activity

We hope by the end of the session, you should be able:

1. To self-reflect on process of interview 2. To accept effective feedback from: simulated patient, peers and lecturer. 3. To deliver effective feedback to your peers

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F.3.3. Reflective Writing

After you have completed the session on Facilitated peer review, you will have to write a reflective report on your experience of the interview and the peer review of the recorded video within ONE WEEK. Submit an online post in about 300 words on your experience. Reflect on some of the lessons you have learnt from the experience. What would you emulate? What would you have done differently? Give your reasons for doing so. Note the following. (You may wish to include all or choose on one or two issues to reflect):

Describe the experience briefly. Explain your feelings and perceptions surrounding the experience. What key message did you learn from the video recording? Compare your experience of interviewing a difficult patient to role play with peers, interviewing a simulated patient and to a real patient in the hospital. What are the differences? What key message did you learn from the facilitated peer review? Give your conclusions and recommendations

Submit to the e-learning portal : http://elearning.imu.edu.my/login/index.php. Login using your own password. Go to Clinical Sciences under Learning Spaces. Select Communication Skills and History Taking Select (5) Reflective Writing Semester 3 Select the lecturer you were assigned to and submit your assignment.

Please take note the following: 1) Make sure you submit to the right lecturer or else your submission will not be accountable. To know your assigned lecturer, please refer to the list in the e-learning portal. Your will receive an email to alert you when your assigned lecturer has graded your reflective report, which will be done as soon as they can. 2) Marks will be minus if you exceeded 10% of the required word counts. 3) You will not be able to summit your report after one week. 4) Your grade for the reflective report is final. No appeal or changes is allowed. 5) This reflective report is part of your portfolio.

Refer to Appendix I for marking criteria

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F.3.4 Clinical Case Discussion

Cases clerk from the hospital Kuala Kubu Bharu will be discuss in Skill Centre with Clinical Lecturers from Hospital Seremban, Clinical School. Please refer to KKB Posting instruction from the e-learning.

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F.4 Giving information to patients on the use, effects and side effects of prescribed medication
Please read E.3. : Giving Patient Information before proceeding to this chapter.

By the end of the session, you will be able to give information to patients on the use, effects and side effects of prescribed medication for examples Insulin, oral hypoglycemic drugs, S/L GTN, antibiotics and others. Giving information on prescribed medication begin with the process of choosing a rational drug treatment. First you need to define the patients problem. After that you have to specify the therapeutic objective and to choose a treatment of proven efficacy and safety, from different alternatives. You then start the treatment and provide the patient with clear information and instructions. After some time you monitor the results of the treatment to know if it has been successful or you may need to re-examine all the steps if the problem is not resolved.

(P treatment = Personal treatment) Choosing a treatment should start by considering your first choice treatment, then to verify that your first choice treatment is suitable for this particular patient. Specify your therapeutic objectives (Eg: to suppress a cough with the patient presenting with cough), make an inventory of possible treatment (eg: just give advice to avoid fume and smoke, treat with a drug, refer) and choose your treatment on the basis of a comparison of their efficacy, safety, suitability and cost. The therapeutic objective is that the drug should work as soon as possible. Consider the drugs side effects and whether it is suitable to that particular patient. (eg: A - giving soluble aspirin to a patient with myocardial infarct and history of peptic ulcer disease. B giving long-acting, extended-release form of Metformin instead of giving the

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regular Metformin which require patient to take three times a day. C giving Bactrim to a pregnant lady with UTI). Consider patients financial status and whether he can afford the medication on long run. (Eg: giving Angiotensin II receptor blockers (ARBs) instead of ACE inhibitor in a Hypertensive patient with Diabetes mellitus) A prescription is an instruction from a prescriber to a dispenser (can be a pharmacist or nurse in the ward). Prescription should be clear, legible and indicate precisely what should be given. It should contain the following information: * Name, address, telephone of prescriber * Date * Generic name of the drug, strength * Dosage form, total amount * Label: instructions, warnings * Full name, address, age of patient * Signature of prescriber
Patients detail: Mr Samy Vello IC no: 640321-10-5387 12, Jalan Pinang, 52100 Kuala Lumpur Dr Sow Chew Fei Clinical Sciences Division, International Medical University No: 126 Jalan Jalil Perkasa 19 (Jalan 19/155B) Bukit Jalil, 57000 Kuala Lumpur Tel : 03-2356 2771 ______________________________________________________ Rx : Date : 01 February 2012 Tablet Amoxycillin 250mg tds x 1 week. Syrup Pholcodine 5mg tds x 1 week.

Sow

Many patients do not take prescribed drugs correctly. The most common reasons are that either the symptoms have ceased, side effects have occurred, the drug is not perceived as effective, or the dosage schedule is complicated for patients, particularly the elderly. Patient adherence to treatment can be improved by prescribing a well-chosen drug treatment, create a good doctor-patient relationship; take time to give the necessary information, instructions and warnings. A well-chosen drug treatment consists of as few drugs as possible (preferably only one), with rapid action, with as few side effects as possible, in an appropriate dosage form, with a simple dosage schedule (one or two times daily), and for the shortest possible duration. A good doctor-patient relationship is established through respect for the patient's feelings and viewpoint, understanding, and willingness to enter into a dialogue which empowers the patient as a partner in therapy. Patients need information, instructions and warnings to provide them with the knowledge to accept and follow the treatment and to acquire the necessary skills to take the drugs appropriately. Information should be given in clear, common language and it is helpful to ask patients to repeat in their own words some of the core information, to be sure that it has been understood. Use the name of the medication as much as possible so that patients know the name of the medication they are taking. However, in those

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patients who have difficulty understanding even common terms, a functional name, such as a heart pill is often easier to remember and clearer in terms of indication. Obtain reliable information on the medication from accountable resources like the British National Formulary (BNF), leaflet from the drug company and product information from the drug company. Before giving the medication, five factors often referred to as the "five rights" should be addressed. 1) Right patient. Identify patient by name. 2) Right drug. Check record for drug name & compare with drug on hand. Once a medication is taken out its prescription bottle or mixed with others it can become confusing as to which pill is which.

3) Right route. Check medication record for how to administer the drug and check labeling of drug
to ensure it matches prescribed route. Should the medicine be taken with a meal, 2 hours before a meal, or on an empty stomach. 4) Right dose. Is not just how much to give and how often but what to do if you miss a dose or the patient vomits just after giving them a pill. Compare ordered dose to dose on hand. At times, calculations is needed to ascertain the correct dose. For eg, a scored tablet, may need to be halved in order to administer the correct oral dose. This requires simple division.

5) Right time. Verify that frequency or time ordered. Does three times a day mean every 8 hours,
(6AM-2PM-10PM) or could it mean 8AM-12N-4PM?

Process of giving information

1. Introduce yourself, your role and obtain consent.

2. Make sure you have the right patient. 3. Assess patients pre-knowledge of the medication and the disease he is having. 4. Name the medication and what it is for. (eg: glibenclamide for diabetes mellitus) 5. How to take the medication and what happen if you forget. 6. Make sure patient is compliant to the medication and explain what happen if not taking regularly. 7. What is the possible side effect of the medication? (eg: lower sugar too much) 8. What are the signs the patient should look out for as a result of the side-effect of the medication? (eg: tremors, sweating, giddy in hypoglycemia)

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9. Is there is such sign as in (8) what to do? (eg: eat a sweet immediately) 10. Advise of storage of medications. (eg: insulin in fridge, sublingual GTN only effective 1 month after opening, etc) 11. Advise regular monitoring of the disease (eg: BP, blood sugar) and to come back for follow up as per schedule so that doctor can monitor the patient. 12. Life-style modification exercise, diet, alcohol, smoking, stress etc. 13. Check patient understand by asking patient to repeat what you have told her. 14. Ask if any questions. 15. Is the patient agreeable with your discussion? Any worries? Any issue she might want to express?

** Remember to signpost and to chunk the information (Chapter E3, Sem Two) Summary
Giving medication information to patient

What is it? (Name, Action )

How to take the medication ? (dose, frequency)

Possible effect from the medication

How to store / keep

from the medication itself (eg: metformin - GI symptom)

What happen if you missed?

from overdose (eg: hypoglycemic symptom)

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F.5 Taking sexual history

By the end of the session, you will be able to 1. To sensitively elicit the menstrual history, obstetric history and sexual history in patients presenting with gynaecological problems. 2. To carry out a comprehensive and sensitive interview in a patient attending for antenatal examination. 3. To recognise legal and ethical issues relevant to the examination of the reproductive system.

A sexual history is necessary for all patients to provide information to guide risk-reduction counseling, to identify those at risk for sexually transmitted diseases, including HIV, and to identify what anatomic sites are suitable for STD screening.

Common assumptions and misconceptions about sexuality

Elderly people don't have sex A married person couldn't possibly have a sexually transmitted disease Patients with sexual problems will recognize them and attend an STD clinic Young people under the legal age don't have sex. (In Malaysia, the legal age to give consent for sexual activity is 16) Everyone understands the basics of reproduction Patients will raise the issue of sexual problems with their doctor if they have any concerns The presence of sexual problems usually means that the patient also has psychological problems All patients understand medical terms doctors tend to use when describing sexual activities and the genitalia You can tell a person's sexual orientation by their appearance

Advantages and difficulties of taking a routine sexual history

Advantages: Sexual problems are seen as a normal part of the spectrum of problems discussed with a doctor By talking about sexual issues, even when they are not seen as problems, one opens the door for future consultations about sexual problems Discussion about sexual activities can be an opportunity for health promotion

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Difficulties: It may be embarrassing for the patient and doctor The patient may misinterpret the purpose of the discussion and feel that their lifestyle is being judged or condemned The patient may begin to worry about something that was not previously a problem

Getting started
1. Teens Care needs to be taken when introducing sensitive topics such as sexuality with teenagers. It is important to interview the teen alone and reinforce confidentiality. Start with asking about neutral topics like school, sports, or other activities. Discussions should be appropriate for the teens developmental level and you should be explicit. If you identify the teenager as sexually active, youll want to clarify what kind of sex she/he has engaged in, as some teenagers have different definitions of sex. Now I am going to take a few minutes to ask you some sensitive questions that are important for me to help you be healthy. Anything we discuss will be completely confidential. I wont discuss this with anyone, not even your parents, without your permission. Some of my patients your age have started having sex. Have you had sex? What have you done to protect yourself from, AIDS, HIV, or other STDs? 2. Adults Now I am going to take a few minutes to ask you some direct questions about your sexual health. These questions are very personal, but it is important for me to know so I can help you be healthy. I ask these questions to all of my patients regardless of age or marital status and they are just as important as other questions about your physical and mental health. Like the rest of this visit, this information is strictly confidential. Avoid using terms that make assumptions about sexual behavior or orientation. Ask about a patient's sexual orientation and use the term partner rather than boyfriend, girlfriend, husband, or wife. Ask patients how many partners they have rather than whether or not they are married and/or monogamous. Patients will generally say that they are married and monogamous, if that is the case, when asked about partners. Avoid moral or religious judgment of the patient's behavior, instead relating information from a point of view that includes emotional and psychological health. One aspect of sensitivity is respecting the patient's reluctance to disclose all sexual and relationship details during the first discussion.

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The sexual history can be linked to the patient's medical history or current health problem. You may say, Many people with diabetes notice a change in their sexual function. Have you noticed any change?

Process of the interview

1. Be clear and clarified vague comments - When patient talk about embarrassing subjects, they are often vague and circumlocutory, and what they are trying to say must be clarified.

2. Be particularly sharp in picking up what the patient is trying to say and be relaxed and unfazed by the subject matter.

3. Starting with an open questionHow can I help you? and continuing with open questions What's the problem? or What do you think caused the difficulty?gives patients an opportunity to expand and to say what is really bothering them. Many younger doctors are worried that a garrulous person might get out of hand, but remaining in control is a skill a good interviewer learns quickly.

4. Judgmental questionsDon't you think you're past that sort of thing now?should be avoided.

5. Observe patients' body language throughout the interview may be helpful. Example :

Their use of their hands and armssuch as uneasily twiddling with a ring, defensively crossing arms, or protectively holding a bag or briefcase on a lap Pectoral flush, which creeps over the upper chest and neck (in some younger men as well as women) and which indicates unease despite outward appearance of calm Body's position in the chairthe depressed slump, tautly sitting bolt upright, or the relaxed sprawl Postural echo, when doctor and patient sit in mirror images of each other's positionadopted when there is harmony and empathy between the speakers

6. Silence is a powerful tool in taking a good history. However, many find it extremely difficult not to

end a silence, speaking prematurely because they are embarrassed by the quiet or feel that it is rude not to say anything, whereas the patient is often using the time to order his or her thoughts. Valuable details may be lost if those thoughts are cut across by an inappropriate statement from the doctor. The rule is, have patience.

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7. Repetition of the last word or phrase, especially if it is one which is emotionally loaded, is a

powerful technique to get a patient to elaborate on what he or she is trying to say. Doctor, I think I need a check up Check up? Yes, I'm not performing as well as I used to Performing? Yes, well, you know, I think I'm impotent. My wife is very good about it and doesn't complain, but I feel so guilty and ashamed Ashamed? I feel terrible. I don't feel a man any more, especially as we used to have such a good sex life .

Content of the Interview - The 5 Ps Partners, Prevention of pregnancy, Protection from STDs, Practices, Past STDs

1. Partners For sexual risk, it is important to determine the number and gender of a patients sexual partners. One should make no assumptions of partner gender in the initial history taking. If multiple partners, explore for more specific risk factors, such as condom use with partners and partners risk factors, such as, other partners, injection drug use, history of STDs and drug use with sex. If one partner, ask about length of the relationship and partners risk, such as, other partners and injection drug use. 2. Prevention of pregnancy Based on partner information from the prior section, you may determine that the patient is at risk of becoming pregnant or of causing a pregnancy. If so, determine first if a pregnancy is desired. Are you and a partner trying to get pregnant? Are you concerned about getting pregnant or getting your partner pregnant? What are you doing to prevent a pregnancy?

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3. Protection from STDs What do you do to protect yourself from sexually transmitted diseases and HIV? With this open-ended question, you allow different avenues of discussion: condom use, monogamy, patient self-perception of risk, and perception of partners risk. 4. Practices If the patient has had more than one partner in the past year or a partner with other partners, you may want to explore further her/his sexual practices and condom use. Not limited to physical act of intercourse but also includes cultural and personal perception and belief belief in using contraception in Roman Catholic, etc However, only explore this if you feel it is relevant in your diagnosis. Exp: in a case of urethra discharge in an elderly man, you may wish to explore his sexual practices as you might suspect an STD

5. Past history of STDs A history of prior gonorrhea or chlamydia infections increases a persons risk of repeat infection. Recent past STDs indicates a higher risk behavior. The complication from it may be a cause of the current problem. Eg. Previous history of pelvic inflammatory disease (PID) may be the cause of infertility now. Have you ever had an STD? If yes, Do you know what the infection was and when was it? Have any of your partners had an STD? If yes, Do you know what the infection was and when was it? Sample questions for a Sexual History
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Are you currently sexually active? Have you ever been? How many partners have you had in the past month? Six months? Has there been any change in your (or your partner's) sexual desire or the frequency of sexual activity? Do you have, or have you ever had, any risk factors for HIV? (List blood transfusions, needlestick injuries, IV drug use, STDs, partners who may have placed you at risk.) Have you ever had any sexually related diseases? Have you ever been tested for HIV? Would you like to be? What do you do to protect yourself from contracting HIV / STD? What method do you use for contraception? Are you trying to become pregnant (or father a child)? Do you ever have pain with intercourse? Do you have any difficulty obtaining and maintaining an erection? Difficulty with ejaculation? Do you have any questions or concerns about your sexual functioning?
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Finishing up
By the end of this section of the interview, the patient may have come up with information, or questions that she/he was not ready to discuss earlier. Is there anything else about your sexual practices that I need to know about to ensure you good health care? At this point, thank the patient for honesty and praise protective behaviors. For a patient identified at higher risk for STDs, be sure to praise the safer sex practices you have identified. After reinforcing positive behavior, it is appropriate to specifically address concerns regarding higher risk practices. Your expression of concern can then lead to your risk reduction counseling or a counseling referral.

Summary:
Emerging medical and social problems, such as HIV/AIDS, confront us with complex and sensitive issues which may need to be raised with patients. Cultural taboos, a fear of upsetting patients and lack of skills in sexual counseling are obstacles to more open communication about sexual matters in health care settings. There is a tendency to make assumptions about lifestyle and behaviour where stereotypic views are held. Sexual problems invariably have an impact on other relationships. Special skills can be learned which can help in counseling patients about sexual matters. The do's and donts of discussing sexual matters include: Be purposeful Don't make assumptions Don't stereotype Ask questions; don't judge people Use the patient's words and language Remain professional Address relationships Ask when you don't understand a term or activity Ask questions about sexual activities rather than lifestyle Address confidentiality and privacy.

Appendix I

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Scoring instructions for overall reflection scores

A D Boenink, A K Oderwald, P DE Jonge, W Van Tilburg & J A Smal

Score

Description

1-2

Oversimplified, intolerant opinion, only emotional reaction

3-4

Limited / restricted, narrow-viewed, one-sided reaction, mostly just one perspective, no weighting up or balancing, no attention paid to context

More than one perspective, but neither balancing nor attention paid to context

6-7

More perspectives, general as well as personal, some balancing between perspectives

8-9

Differentiated balancing, room for dilemmas and or doubt, explicit attention paid to the patient

10

A subtle/balanced approach, considering all relevant perspective, weighing up of different interests, a keen eye for dilemmas and uncertainties, paying attention to the patients viewpoint and an evaluation of ones own position and latitude.

Appendix II : Calgary Cambridge Guide

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INITIATING THE SESSION Establishing initial rapport 1. Greets patient and obtains patients name 2. Introduces self, role and nature of interview; obtains consent if necessary 3. Demonstrates respect and interest, attends to patients physical comfort Identifying the reason(s) for the consultation 4. Identifies the patients problems or the issues that the patient wishes to address with appropriate opening questions (e.g. What problems brought you to the hospital? or What would you like to discuss today? or What questions did you hope to get answered today?) 5. Listens attentively to the patients opening statement, without interrupting or directing patients response 6. Confirms list and screens for further problems (e.g. so thats headaches and tiredness; anything else?) 7. Negotiates agenda taking both patients and physicians needs into account

GATHERING INFORMATION Exploration of patients problems 8. Encourages patient to tell the story of the problem(s) from when first started to the present in own words (clarifying reason for presenting now) 9. Uses open and closed questioning technique, appropriately moving from open to closed 10. Listens attentively, allowing patient to complete statements without interruption and leaving space for patient to think before answering or go on after pausing 11. Facilitates patient's responses verbally and nonverbally e.g. use of encouragement, silence, repetition, paraphrasing, interpretation 12. Picks up verbal and nonverbal cues (body language, speech, facial expression, affect); checks out and acknowledges as appropriate 13. Clarifies patients statements that are unclear or need amplification (e.g. Could you explain what you mean by light headed") 14. Periodically summarises to verify own understanding of what the patient has said; invites patient to correct interpretation or provide further information. 15. Uses concise, easily understood questions and comments, avoids or adequately explains jargon 16. Establishes dates and sequence of events Additional skills for understanding the patients perspective 17. Actively determines and appropriately explores:

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patients ideas (i.e. beliefs re cause) patients concerns (i.e. worries) regarding each problem patients expectations (i.e., goals, what help the patient had expected for each problem) effects: how each problem affects the patients life

18. Encourages patient to express feelings

PROVIDING STRUCTURE Making organisation overt 19. Summarises at the end of a specific line of inquiry to confirm understanding before moving on to the next section 20. Progresses from one section to another using signposting, transitional statements; includes rationale for next section Attending to flow 21. Structures interview in logical sequence 22. Attends to timing and keeping interview on task

BUILDING RELATIONSHIP Using appropriate non-verbal behaviour 23. Demonstrates appropriate nonverbal behaviour eye contact, facial expression posture, position & movement vocal cues e.g. rate, volume, tone 24. If reads, writes notes or uses computer, does in a manner that does not interfere with dialogue or rapport 25. Demonstrates appropriate confidence Developing rapport 26. Accepts legitimacy of patients views and feelings; is not judgmental 27. Uses empathy to communicate understanding and appreciation of the patients feelings or predicament; overtly acknowledges patient's views and feelings 28. Provides support: expresses concern, understanding, willingness to help; acknowledges coping efforts and appropriate self care; offers partnership

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29. Deals sensitively with embarrassing and disturbing topics and physical pain, including when associated with physical examination Involving the patient 30. Shares thinking with patient to encourage patients involvement (e.g. What Im thinking now is....) 31. Explains rationale for questions or parts of physical examination that could appear to be nonsequiturs 32. During physical examination, explains process, asks permission

EXPLANATION AND PLANNING Providing the correct amount and type of information 33. Chunks and checks: gives information in manageable chunks, checks for understanding, uses patients response as a guide to how to proceed 34. Assesses patients starting point: asks for patients prior knowledge early on when giving information, discovers extent of patients wish for information 35. Asks patients what other information would be helpful e.g. aetiology, prognosis 36. Gives explanation at appropriate times: avoids giving advice, information or reassurance prematurely Aiding accurate recall and understanding 37. Organises explanation: divides into discrete sections, develops a logical sequence 38. Uses explicit categorisation or signposting (e.g. There are three important things that I would like to discuss. 1st... Now, shall we move on to.) 39. Uses repetition and summarising to reinforce information 40. Uses concise, easily understood language, avoids or explains jargon 41. Uses visual methods of conveying information: diagrams, models, written information and instructions 42. Checks patients understanding of information given (or plans made): e.g. by asking patient to restate in own words; clarifies as necessary Achieving a shared understanding: incorporating the patients perspective 43. Relates explanations to patients illness framework: to previously elicited ideas, concerns and expectations 44. Provides opportunities and encourages patient to contribute: to ask questions, seek clarification or express doubts; responds appropriately 45. Picks up verbal and non-verbal cues e.g. patients need to contribute information or ask questions, information overload, distress

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46. Elicits patient's beliefs, reactions and feelings re information given, terms used; acknowledges and addresses where necessary Planning: shared decision making 47. Shares own thinking as appropriate: ideas, thought processes, dilemmas 48. Involves patient by making suggestions rather than directives 49. Encourages patient to contribute their thoughts: ideas, suggestions and preferences 50. Negotiates a mutually acceptable plan 51. Offers choices: encourages patient to make choices and decisions to the level that they wish 52. Checks with patient if accepts plans, if concerns have been addressed

CLOSING THE SESSION Forward planning 53. Contracts with patient re next steps for patient and physician 54. Safety nets, explaining possible unexpected outcomes, what to do if plan is not working, when and how to seek help Ensuring appropriate point of closure 55. Summarises session briefly and clarifies plan of care 56. Final check that patient agrees and is comfortable with plan and asks if any corrections, questions or other items to discuss

OPTIONS IN EXPLANATION AND PLANNING (includes content) IF discussing investigations and procedures 57. Provides clear information on procedures, eg, what patient might experience, how patient will be informed of results 58. Relates procedures to treatment plan: value, purpose 59. Encourages questions about and discussion of potential anxieties or negative outcomes IF discussing opinion and significance of problem 60. Offers opinion of what is going on and names if possible 61. Reveals rationale for opinion 62. Explains causation, seriousness, expected outcome, short and long term consequences 63. Elicits patients beliefs, reactions, concerns re opinion IF negotiating mutual plan of action

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64. Discusses options eg, no action, investigation, medication or surgery, non-drug treatments (physiotherapy, walking aides, fluids, counselling, preventive measures) 65. Provides information on action or treatment offered name steps involved, how it works benefits and advantages possible side effects 66. Obtains patients view of need for action, perceived benefits, barriers, motivation 67. Accepts patients views, advocates alternative viewpoint as necessary 68. Elicits patients reactions and concerns about plans and treatments including acceptability 69. Takes patients lifestyle, beliefs, cultural background and abilities into consideration 70. Encourages patient to be involved in implementing plans, to take responsibility and be selfreliant 71. Asks about patient support systems, discusses other support available References: Kurtz SM, Silverman JD, Draper J (1998) Teaching and Learning Communication Skills in Medicine. Radcliffe Medical Press (Oxford) Silverman JD, Kurtz SM, Draper J (1998) Skills for Communicating with Patients. Radcliffe Medical Press (Oxford)

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Appendix III

Checklist for Difficult patient Sem 3 2 Adequate 3 Done really well

Dr. Sow CF

0 Not done 1- Attempted but not adequate

Student s Name : Pls write assessor full name in first column for self assessment Initiating the session
1 2. 3.

Greets patient appropriately. Introduces self and role and nature of interview Demonstrates respect, interest, patients comfort & privacy. Obtains consent for interview

Gathering information Exploration of Problems

44 5 6 7 8 Use appropriate opening question and appropriately moves from open to closed questions Listens attentively, allow patient to complete statements without interruption Facilitates patients responses verbally (eg: encourage patient to tell the story, paraphrasing) Establish dates and sequences Signposting

Gathering information - Understanding Patients Perspective

9 10 11 Determines & acknowledges patients ideas/worries, explores concerns & expectations. Determines and appropriately explores how each problem affects the patients life Picks up patients verbal & non-verbal cues (body language, speech, facial expression)

Building Relationship
12 13 14 15 16 Demonstrates appropriate non-verbal behaviour (eg: eye contact, posture, vocal volume and tone) & use of notes does not interfere with dialogue / rapport Expresses caring, concern, empathy Provides support (expresses understanding, acknowledges coping effort) Non-judgemental Deals sensitively with embarrassing and disturbing topics / able to calm patient down

Closing the interview

17 18 19 20 Summarises at the end of interview Obtains patients view of need for action, perceived benefits, barriers, motivation . Asks if any questions or issue to discuss. Checks that patient agrees & is comfortable with plan (including acceptability of plan) Organises explanation. Chunks and checks

Total Ticks ( Items)

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Appendix IV : Process of Motivation Interview

Process of motivating patient

Step 1: Practice the guiding style

Among the broad communication styles commonly used to address patients problems are directing, guiding, and following. Although each is appropriate to certain situations in everyday practice, a guiding style is best suited to consultations about change. Emphasize the patients autonomy over decision making, and elicit their motivation for change. You retain control over the direction and structure of the consultation and provide information as needed, but you ensure that your patients retain responsibility for change. Box 1 shows the contrast in styles between directing and guiding.

Box 1 Contrasting styles Directing style : "OK, so your weight is putting your health at serious risk. You already have early diabetes. Overweight is conceptually very simple, if you think about it. Too much in, not enough out. So you need to eat less and exercise more. There no way you can get around that simple fact." Guiding style : "OK, lets have a look at this together and see what you think. From my side, losing some weight and getting more exercise will help your diabetes and your health, but what feels right for you? So you can see the value of these things, but you struggle to see how you can succeed at this point in time. OK. Its up to you to decide when and how to make any changes. I wonder what sort of small changes might make sense to you. Patient says how change might be possible. Patient often expresses ambivalence at this point. Patient often resists at this point.

Patient replies with a "yes, but . . ." argument.

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Step 2: Add useful strategies to your toolbox Motivational interviewing aims to work with their strengths rather than just talk about problems and weaknesses. Different strategies are available to achieve these aims in a guiding style. This "menu of strategies" has been used successfully among college students to reduce use of alcohol, tobacco, and cannabis. 1. Agenda setting (what to change?) Patients often face more than one option for change. Rather than impose your priority on patients, you conduct an overview by inviting them to select an issue that they are most ready and able to tackle. For example, "Thats very helpful. Are you more ready to focus on eating or on increased activity? Or is there some other topic that you would prefer to talk about? Id like to talk about those test results at some point, but what makes sense to you right now?"

2. Pros and cons (why change?) It can be helpful to invite patient to say how they see the pros and cons of a situation. Then your next step is to ask them to clarify whether change is a possibility (Box 2).
Box 2: Seeing the pros and cons Patient responds

"I want to try to understand your smoking better Use your curiosity to elicit a good understanding. from your perspective, both the benefits for you and the drawbacks. Can I ask you firstly what you Remember its their experience that counts, so avoid like about your smoking?" offering your perspective for the time being. "Now can I ask you what you dont like about (Then you summarise both sides, as briefly as your smoking?" possible, capturing the words and phrases that the patient came up with.) OK, so lets see if I have this right? You like the fact that smoking helps you unwind and, addicted or not, you like that first smoke in the morning. On the other hand, your main concern is about its effect on your health. Is that about right? OK." "So where does that leave you now?" Patient usually describes readiness and any need for advice or information. (Then you invite the patient to consider the next step.)

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3. Assess importance (why) and confidence (how) To be efficient you need to spend time where it is most needed. Those who are not convinced of the importance of change are unlikely to benefit from advice about how to change, and a focus on the why of change is pointless if the main issue is how to achieve it. This focused strategy (box 3) has produced successful outcomes in the smoking field, where a recent review also provides support for the efficacy of motivational interviewing.
Box 3 Assessing importance and confidence An invitation promotes collaboration and "Would you mind if we took a moment to see exactly how patient autonomy. you feel about using these tablets? "How important is taking this medicine for you right now?" "How confident do you feel about taking these tablets regularly?" Elicit a brief review of patients feelings, fears, and aspirations, then ask: Elicit, and then summarise patients view of importance and confidence. Then tailor your next step accordinglyfor "Well, do you mind if I just give you some information about how these tablets might help, but it will be up to you to decide in the end." example, if importance is low, consider something like:

4. Exchange information Once you give information, check patients understanding and again provide some more information on a one to one basis.
Box 4 Information exchange "OK so can I check your understanding of the situation? What Elicit understanding. do you know about the risks of being overweight?" "Well you are right about it being very common and that people are generally living longer, but as you say it does put Provide information. an extra strain on the heart and causes diabetes, which again affects the heart, kidney, and so on. It also causes high blood pressure. OK, now can I ask, how do you think this information applies to you?" ME1/13 Elicit patients interpretation.

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5. Make decisions about change (setting goals)

Goals and targets for change that come only from your side are often met with "Yes, but. . ." explanations about why they will not work from the patient. Box 5 shows how you can, if the patient is ready for it, use a guiding style to elicit practical solutions from the patient and offer suggestions from your side as well.
Box 5 Making decisions "It sounds like you really want to try quitting smoking, but youre struggling with imagining how you can do it. Summarising the patients situation.

emphasising the patients freedom of "It will be up to you to decide when and how to do it but choice. I am wondering how do you see yourself succeeding with this? Inviting the patient to envision change. Patient responds, usually identifying main challenges. "So you are hoping you can find a way of breaking through the withdrawal period. Listening, in response to what patient has said.

Inviting patient to clarify what will be There are all sorts of quitting aids that others have found helpful. useful, but what makes sense to you? Patient clarifies what will be helpful, and Or maybe you want to bring your husband down to talk the discussion narrows down in favour of a with us so we can all make a plan together?" plan that is agreed jointly.

Step 3: Respond skillfully to patients language You can refine your skills further by paying attention to the language that patients use. You will notice that they talk about why or how they might change (this is called change talk)"I guess I should take my medicine more regularly"; "I want to quit smoking"; "I am going to eat less fried food"or about the opposite: "I dont like tablets"; "I enjoy my smoking"; "Ive never succeed in losing weight." You can choose whether to elicit change talk or not. The assumption is that if you do, motivation to change will be enhanced, and subsequent change is more likely take place.

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Referances : 1. Teaching and learning communication skills in medicine. Kurtz SM, Silverman J D, Draper J. 2 ed. Oxford: Radcliffe, 2005. 2. Skills for communicating with patients. Silverman J D, Kurtz SM, Draper J. 2 ed. Oxford: Radcliffe, 2005. 3. Communication Skills Training: Describing a New Conceptual Model. Richard F. Brown and Carma L. Bylund, Academic Medicine, Vol. 83, No. 1 / January 2008, page 37-44. 4. Communication Skills in the medical Interview manual by Philip Welsby, Edingburgh. 5. Communication Skills: A Call for Teaching to the Test. Anna Headly, Perspectives, 2007 The Association of Professors of Medicine, doi:10.1016/j.amjmed. 2007.06.024, page 912 915. 6. Patientdoctor communication, Carol Teutsch, Med Clin N Am 87 (2003) 11151145. 7. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Walker HK, Hall WD, Hurst JW, editors. Boston: Butterworths; 1990. 8. Handbook for tutors, communication skills year 3, University of Glasgow. 9. Clinical Skills for OSCEs, 2nd edition, Neel L. Burton & Kuldip Birdi, informa healthcare 10. Motivational Interviewing. Stephen Rollnick et al, BMJ 2010;340:c1900 11. Guide to Good Prescribing, World Health Organization Action Programme on Essential Drugs, Geneva, WHO/DAP/94.11, Distr: General, Original: English 12. Miller, W.R. (1983). Motivational interviewing with problem drinkers. Behavioural
Psychotherapy, 11, 147-172. doi: http://dx.doi.org/10.1017/S0141347300006583
nd nd

13. A definition of motivational interviewing. Retrieved from http://www.motivationalinterview.org 14. Motivational interviewing strategies and techniques: Rationales and examples. Retrieved from
http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf

15. Motivational interviewing introduction. Retrieved from

http://www.wales.nhs.uk/sites3/documents/368/Motvation.pdf

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