1 The Consultation Process

2 Communication Skills
3 Counselling Skills
4 Changing Behaviour
5 Disease Management Skills
6 Emergency Care Skills

SECTION 05

CONSULTATION SKILLS

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SECTION 05 CONSULTATION SKILLS

CHAPTER 1

THE CONSULTATION PROCESS

Outline
The consultation and referral defined
Steps of an effective consultation
Initiating the consultation
Approaches to problem solving
Understanding why patient came
Hypothetico-deductive method of problem solving
Referral to a specialist

THE CONSULTATION AND REFERRAL DEFINED

The consultation is a situation when a patient seeks medical information, advice and
treatment from a doctor. In general practice, the family physician is able to deal with
some 90% of the problems presented to him. For the remainder, he needs to refer his
patient to a consultant or specialist to seek an expert opinion.
The referral is a situation when a family physician refers his patient to a specialist for his
expert opinion, treatment or both. The consultant specialist takes over the management
of this referred patient and subsequently refers the patient back to the family physician
after the treatment has been completed.

STEPS OF AN EFFECTIVE CONSULTATION

The steps of an effective consultation has been described by Pendleton in the 1980s.
The family physician needs to complete the following seven steps or tasks:
(1) Find out why the patient has come, also called the reason for encounter (rfe) and from
there go on to take a history which covers the following:
(a) the nature and history of the problem.
(b) the patient's ideas, concerns and expectations.
(c) the effects of the problem on the patient and significant others.
(2) Consider the other problems that the patient may have:
(a) continuing problems.
(b) risk factors.
(3) Choose with the patient as appropriate action for each problem. In general practice,
there is a need to prioritise the action to take if the patient has more than one problem.
(4) Achieve a shared understanding of the problems with the patient.
(5) Involve the patient in the management and encourage him to accept appropriate responsibility,
(6) Use time and resources to good advantage.

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(7) Establish or maintain a relationship with the patient that helps to achieve other tasks.
Steps (1) and (2) together correspond to what we sometimes refer to as the approach to
the problem and the remaining steps (3) to (7) correspond to the management of the
patient and his problem. Note the steps (3), (4) and (5). These are crucial steps that form
the cornerstone of the patients compliance to the doctors management plan.

INITIATING THE CONSULTATION

When your patient enters your consultation room, the first minute is very important.
(a) Make your patient feel welcomed, relatives included. Greet all of them.
(b) Show him his chair, make him comfortable and make him feel at ease.
(c) Your opening remarks are also important. They are different depending on whether
the patient is new, a recent follow-up patient or an old patient making a reappearance.
(d) Strike a good rapport.
(e) Eye contact is essential. Having a computer in front of you may be a distraction.
Use it discreetly.
(f) Body language tells the patient your attitude. The patient can tell whether you have
a sincere interest in him and his problems.

APPROACHES TO PROBLEM SOLVING

The method of problem solving taught in the hospital setting is the inductive method
where a full history is taken, a full examination is done and also investigations are ordered
to arrive at the diagnosis. Such an approach is suitable for medical conditions which are
diagnostic problems or where the extent of disease is not clear. An example of the first
category is the fever for investigation or Pyrexia of Unknown Origin (PUO) and an
example of the second category is the staging required for assess the extent of spread of
a cancer.
Notwithstanding such situations, the initial approach to problem solving either in the
hospital setting and the ambulatory care setting is the hypothetico-deductive approach in
problem solving where based on cues from appearance and/or history, a short list of
possibilities are considered and these are narrowed down by considering relevant features
in the history, confirmation with more selective history taking and selective physical
examination is done to arrive at a working diagnosis.
Although the general principles of problem-solving are the same in all fields of medicine,
each discipline applies them differently. The problem-solving strategies of family physicians have evolved because of the unique features of family practice. These are:
Patients present with early, undifferentiated complaints, which include psychological
and social factors.
Problems and complaints may be expressed in indirect or non-verbal language.
Much of the information presented by the patient is not useful ("noise") in solving
his problem.
Symptoms change as the illness advances, and may have different diagnostic value in
different stages of the illness.
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Problems are often not presented in order of priority.

Physical signs may be minimal or absent.
The illness or problem is often a complex mix of physical, psychological and
socio-economic elements.
One patient may present with multiple illnesses or problems.
There is a high incidence of acute, short-term illness, much of it transient and
self-limiting.
The family physician can use, by his continuous relationship with the patient his
personal and close knowledge of his patients to diagnose or understand the
patients' problems.
Often, the family physician cannot make a "formal diagnosis" (pathological condition) or
put a diagnostic label (illness-centred diagnosis), as students are taught in hospitals.
More often he makes a patient-oriented comprehensive diagnosis, comprising details of
the patient as a person, his lifestyle, his family, and his environment, and of the specific
anxieties (of the patient or his family) connected with his symptoms and physical signs.
This is actually a definition of the patient's problems.
The family physician's decisions have to be made under pressure of the short time
available for each consultation; he has to separate, in the early stage of illnesses, the
serious and life-threatening conditions from the transient and minor. However with his
continuing contact with the patient, he can use (observation over) time as a tool for
diagnosis (and even for management).
Thus the family physician must have a high degree of suspicion, with a wide perspective
(by study) and experience (based on his knowledge of the epidemiology of diseases, the
natural history of common illnesses, and of the normal status of his patients).
His problem-solving strategies must be aimed at ascertaining and dealing with the
patient's main problem (with a plan for longer-term assessment and management of the
problem), and at putting the patient's other problems in priority order (with a similar plan
for their longer-term assessment and management).
Family physicians in solving problems must be particularly aware of the patients
perspective of his or her illness and its management including the environment-social,
psychological, economic, etc in which the patient lives. All the above elements interact,
making problem solving more difficult. Very often, the family physician, even after the
physical examination and history taking is unable to come to a diagnosis, i.e. he is dealing
with an unknown diagnosis. Here, it is important that, as primary care doctors, if the
symptoms could indicate a potentially lethal condition, such as perforated peptic ulcer,
ectopic pregnancy, or a myocardial infarct, prevarication is inadmissible and specialist
referral or hospital admission must be arranged. Thus, by always considering and
identifying any serious life threatening disease presenting at an early stage and in so
doing prevent serious morbidity or mortality.
After excluding any serious pathology, the family physician is then faced with a wide
variety of symptoms to which he must then address the following questions:
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 What is the real motive behind the symptoms that has prompted the consultation?
What is the significance of the problem or disease to this particular patient?
Are there other factors present that should be considered when solving or managing
the patients problems?

UNDERSTANDING WHY DOES THE PATIENT COME

Reason for Encounter
The consultation is more likely to be effective if it seeks out why the patient came which
is also called the reason for encounter (RFE), and his views, concerns and expectations
(ICE) of the problem he is experiencing.
It is easy to make wrong assumptions why the patient came:
(a) It may be assumed that the patient has come to the doctor because of the symptoms;
but for every patient who presents there are many more who are coping with similar
symptoms themselves and not seeking help. Thus, it is not sufficient to know what
symptoms have been experienced; we need to know what sense the patient has made
of the symptoms in order to know why he or she has come.
(b) It is often assumed that the patient has come for treatment, but what he is looking for
may be an assurance that something more serious is not going on, simply because he
has seen someone with a serious problem having similar symptoms. His concern is
that he may have the same problem.
Patient can come to see the doctor for a variety of reasons.
The symptom(s) given by the patient may be explicit of his reason for seeing the doctor or
it may be the "ticket of entry" for something that troubles the patient but which he finds
difficulty for some reason to express directly (the so-called hidden agenda of the patient).
The following is one classification of possible reasons for encounter.
Pain or other symptoms:
Most medical encounters would concern physical complaints. The patient presents
because his limit of tolerance has been reached. The symptoms are causing pain,
discomfort or disability.
Continuity of care/Continuing care:
A family physician has a role to play in both acute and chronic care. In an acute
situation he may not be able to make a diagnosis on first encounter e.g. PUO. He may
then extend his consultation by inviting his patient to return whereby the illness would
undoubtedly unfold thereby enabling him to institute the appropriate management.
In the care of chronic illness such as diabetes, hypertension, asthma and epilepsy, the
family physician has much to do in clinical management. He however also co-ordinates

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the activities of other members of the primary health care team e.g. nurse practitioners,
DAC nurse, dietitians and therapists in providing holistic care for his patient.
Prevention of disease:
The patient may request for some form of prevention in health such as (a) well person
care e.g. well-child or well-woman clinics, (b)& utine immunizations, (c) pre-employment/
retirement checkups or (d) periodic health examinations. This may result in multi-phase
screening. A point to note is that this request may have arisen out of anxiety and it is
important for the family physician to pick this up.
Opportunistic screening is another method which family physicians can adopt to
detect disease at an early stage.
Accident and emergency:
The physical nature will be obvious. In dealing with a specific emergency, the doctor
adopts a different approach. Instead of taking a history and performing an examination
in the usual way, he replaces this with a technique of rapid assessment and immediate
management. You are expected to have knowledge about the patient's illness which
gives rise to emergencies, but in addition will be expected to know the immediate
steps on diagnosis and management which are required on the road side, in the home
or consulting room. The anxiety and fear of the patient or close ones that may
accompany the situation may require management.
Problems with living:
These can arise as a result of:
personality disorders
family related situations
work related situations
the community

e.g.
e.g.
e.g.
e.g.

hypochondriasis, alcoholism and drug addiction

the empty nest syndrome, bereavement
unemployment, shiftwork
the problems of a minority race, immigrants
and social delinquents

Seeking of reassurance:
Patients whose real need is reassurance frequently, if not usually, present their
symptoms rather than express their fears. And in response to these symptoms, the
physician may achieve a diagnosis and proceed to treatment without recognising the
patient's major problem. Cartwright has shown that in Britain patients interviewed at
the end of consultations had seldom received adequate reassurance, and many of
them had found their experience alarming rather than comforting.
Need to legitimise sick role:
Society has given doctors a statutory role in the certification of illness. The patients
who wish to take up the sick-role are by no means confined to those who want to be
excused from work; the school child wishing to avoid school and the housewife who
desires to manipulate her environment are almost as common.
Ideas, Concerns and Expectations
The motivation to see the doctor is driven by the patients ideas, concerns and expections.
The patient attaches a meaning to his symptoms which is coloured by what he has
observed or learnt about the symptom from others around him. What is apparently trivial
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to the doctor may be of great worry to the patient. Our job as effective doctors is to elicit
if the symptom has a special meaning and concern to the patient. Only then could we
begin to help the patient.

History taking
How much history should be taken? There is a need to evaluate each symptom. Beyond
that, the depth of questioning will depend on what is perceived to be the problem.
Symptom presentation in ambulatory care is often early and undifferentiated. Hence the
doctor should develop a systematic approach to evaluate each symptom presented by
the patient. In ambulatory care, ninety percent of diagnosis is made on the basis of
history alone.
The meaning of the symptom will have to extend beyond biomedical possibilities.
The value of the symptom as a marker of biomedical disease may also be different from
that encountered in the hospital patient.
It is important to include in the history taking, the effect of illness on the patient, his work
and his family.

Selective physical examination

How does the history guide the doctor on how much to examine? What do you see as
the purpose of the physical examination in general practice?
When should a comprehensive physical examination be conducted in the outpatient setting?

Selective investigations
How is the decision made on how many investigations to order for the patient?
What in-house investigations should be available?
Management Options
To treat or to refer:
When should a referral be done?
Can you describe what a referral letter should contain?
Therapeutic interventions:
How would you attempt to convince the patient if you think that medication is not
necessary? What would you do if the patient remains unconvinced?
What surgical and medical procedures could be done in the FAMILY Physicians clinic?
Patient education:
At the end of the posting can you describe the opportunities and difficulties
encountered in patient education?

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Follow-up and staggered consultations:

When should the patient come back for follow up?
What is meant by using time as a tool?
Can you describe a staggered consultation and its use in general practice?
Family as a resource:
At the end of the posting you should be able to list the various ways and give examples
of how the family can be a resource to the patient in health and illness.
Achieving Satisfactory Outcomes
Knowing the patient's concerns and expectations, the doctor will be in a better position
to bring about outcomes they want. At the conclusion of the consultation, we should like
to have reduced the patient's concerns as far as possible, and to have explained matters
sufficiently clearly for the patient to understand and remember all what has been said and
be committed to the management planned.
Common barriers to a satisfactory consultation process:
(a) Poor eye contact.
(b) Over reliance on notes.
(c) Lack of clarification.
(d) Misinterpretation.
(e) Insensitivity to Language/cultural difference.
(f) Omitting to ask what the patient thinks of his illness.

HYPOTHETICO-DEDUCTIVE APPROACH OF PROBLEM SOLVING

We are now ready to put the elements of the GP consultation into the hypotheticodeductive approach. It consists of the following steps:
(1) Gathers subject/objective data (CUES)
symptom cues, sign cues, behavioural cues (from patients behaviour or from his own
subjective sensations) and contextual cues (some incongruity that he senses in the
whole pattern of the consultation).
(2) Combines this with his prior knowledge (BACKGROUND CUES) of:
the patient and his family.
the patients past medial (physical, psychological and social) history.
the patient as a person.
the environmental factors that affect this patient.
past experience (his own or other doctors) of other similar events.
(3) Makes ELIMINATIVE DIAGNOSIS:
e.g. urgent or non-urgent
acute or chronic
pregnant or not pregnant
bacterial or viral infection
psychological or organic
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(4) Lists the diagnostic probabilities in a priority order (HYPOTHESES).

These will reflect the community morbidity (incidence and prevalence of disease in
family practice) and the doctors personal knowledge of his patients; will comprise a
large amount of chronic and transient illness; and will be very different from that in
specialist or hospital practice. Higher priority will be given to serious (even if infrequent)
and to treatable conditions.
(5) Asks questions and looks for physical signs (FURTHER CUES) to confirm or exclude one
or more of the hypotheses.
The extent of gathering will depend on the objective of the consultation i.e. it will be
less if the object is simply to exclude serious illness, and more comprehensive if a
precise etiological or pathological diagnosis is required, or if the cues are obscure.
These further cues include pathological and radiological investigations.
(6) Makes a PRESUMPTIVE DIAGNOSIS or DEFINITION OF THE PROBLEM(S) if a hypothesis
is validated. This is probabilistic statement about what is wrong with the patient.
(7) If all initial hypotheses are invalidated, revises the hypotheses and formulates new
ones, followed by further cues till another presumptive diagnosis or definition of
problems are made.
As indicated by the feedback loop, the process is a cyclical one, the physician
constantly revising, testing and further revising his hypothesis until he has refined it to
the point at which he feels justified in making management decisions. Even after this
point, he will still be prepared to revise his hypothesis if the progress of the patient is
not as predicted.
(8) Makes and implements MANAGEMENT DECISIONS.
A decision is made by taking the probabilistic statement and integrating it with a large
number of other variables, e.g., the patient's wishes, the main problem. The patient's
other problems, prognosis, personality and life situation of the patient (including fears
or skepticism), the risks and benefits of the decision alternatives, the family's wishes,
ethical issues and financial factors.
Management decisions would include any one or combination of the following:
Liquidation of the problem as a problem - by reassurance, or by leaving along
(self-limiting condition).
Elimination of the underlying cause - by treatment of disease.
Elimination of a behavioral pattern - by counselling/advice.
Adjustment of the patient's own (physical or psychosocial) environment.
Referral to specialist, physiotherapist, social worker etc - for treatment (or even
for diagnosis).

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REFERRAL TO A SPECIALIST
This may sometimes be necessary. There are several tasks that must be done:
(1) Explain to your patient and accompanying relatives your reasons for seeking a second
opinion or for requesting a specific treatment.
Prepare them mentally and financially especially when surgery is contemplated.
Try to match the skill and expertise of the specialist to the condition, personality and
financial capability of the patient.
Do not refer your patient to a close friend or relative without the above consideration.
Try to make the appointment for your patient.
Write a good referral letter: Brief and to the point, include relevant history, lab results,
X-rays, ultrasound, CT scan results and treatment and give your opinion, ask
specific questions
Phone directly for urgent conditions and early appointments.
Reference
Pendleton D. Consultation analysis. Update Jan 1989:803-807

CHAPTER 2

COMMUNICATION SKILLS

Outline
Scope of communication
Communication in medicine
Analysing the verbal communication process
Understanding non-verbal communication
Written communication
The communication part of the consultation
Overcoming problems of communication
Breaking bad news

THE SCOPE OF COMMUNICATION IN PATIENT CARE

Listening and talking to patients is an essential skill. In the healthcare setting, such
communication is an admixture of spoken words (verbal communication), non-verbal
communication and sometimes supplemented by written communication. The ability to
exchange information and feelings correctly needs to be given due attention.

COMMUNICATION IN MEDICINE
Communication in medicine differs from communication in any other field in three
important aspects:
It deals with the essential aspect of living, called health. People in all walks of life and
all ages have a vested interest in what you are communicating as a doctor. They take
what you say seriously.

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 Society allows the medical and nursing professional to touch the patient, and not only
allows, but encourages such activity. In all other professions touching the recipient,
apart from shaking hands, is disallowed and may be misinterpreted. Notwithstanding
this, it is important to make sure such an activity is not misinterpreted by the patient.
This can be done by announcing what you intend to do. I am going to examine your
abdomen to make sure it is normal., I am going to listen to your chest to hear if
there is any abnormal sounds coming from your lungs.
There is a great deal more of a personal and emotional nature in medical communication
than in any other types of communication.

ANALYSING THE VERBAL COMMUNICATION PROCESS

The doctor needs to be able to analyse his communication efforts before he is able to
make stepwise improvements. This should be an ongoing and almost subconscious effort
throughout this professional career.
There are three approaches (models) that the doctor can use for such a self appraisal.
Each model by itself yields helpful but only partial information. When the models are used
together they provide a fuller understanding of the communication process.
Component Analysis
The component analysis model pays attention to factors in the speaker, message and
listener that are barriers to communication.
Sender barriers:
negative image - diffident, defensive, not looking at listener.
distracting behaviour - head scratching, twirling pencil.
aggressive behaviour - staring, mocking.
judgemental behaviour.
uncaring, insensitive.
Message barriers:
information overload.
long words and long sentences in the message.
not being specific enough.
Receiver barriers:
emotional distress.
judgemental reactions.
visual or hearing disability.
different frame of reference.
Transactional Analysis (TA)
Communication may also be regarded as a transaction between personality states.
The transactional model pays attention to these states and the aim of analysis is the
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appropriateness of personality states that are transacted. In TA theory, persons are said to
normally exhibit three personality states regardless of their age:
parent (P) - scolding tone, authoritarian attitude : uses words shouldn't, never, always
adult (A) - logical : uses words "important that ...", "consider the ...."
child (C)
- demanding : use words "I want", "I can't", "I need"
Transaction that are adult-to-adult, child-to-parent, parent-to-child are uncrossed. If the
transactions are crossed as for example child-to-adult or parent-to-adult, then problems
of communication will arise.
Transaction analysis is useful in analysing communications that seek to elicit a particular
action in the receiver. A statement can be made that reflects the personality state of the
speaker; some statements are better than others.
Example 1: There are different ways the doctor can tell the patient to stop smoking.
Doctor: It is important that you give up smoking (adult) or
Doctor: You must stop smoking (parent) or
Doctor: I want you to stop smoking (child)
Which statement is the best for the doctor to use?
The statements made by the doctor is picked up by the patient and the response will in
term depend on the personality state of receiver and this too can be analysed:
Example 2: Different kinds of response
Doctor: It is important that you give up smoking (adult)
The patient's reply (amongst other things said) can be:
Patient: I can't (child), or
Patient: I know it is difficult but I'try (adult), or
Patient: You should leave me to decide for myself (parent).
What response will each elicit in you if you are the doctor who receives such a reply.
Life-Space Analysis
Each of us lives within a particular life-space or context. Our context is the world as we
know it. There are six major areas that make up our world : (a) vocational, (b) family,
(c) social, (d) spiritual, (e) physical, (f) financial. Communication efforts will fail unless
the sender understands the life-space of the receiver. The ongoing self-appraisal and
improvement will be the ability to recognise the context of these six areas in a patient and
the appropriate response that will be necessary.
Take the vocational area for example. We will need to recognise what being a taxi-driver
mean in terms of the demands of the job, the daily struggles that he goes through to be

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able to have the empathy and appropriate response when he complains of backache or
headache. Is his presenting problem therefore physical, social or emotional?

UNDERSTANDING NON-VERBAL COMMUNICATION

It has been estimated that more than half of the content in a communication is done
through non-verbal communication. Some understanding of its importance in the process
of doctor-patient communication is therefore necessary. Spoken communication in the
clinical setting generally deals with facts. Feelings, emotions, values, wants and interest/
disinterest are usually communicated non-verbally.
Its Importance
(a) The ability of the doctor to respond to cues to the patient's feelings and emotions is as
important in establishing rapport as the ability to understand the facts about his illness.
From the non-verbal cues the doctor can read a lot about the patient's anxieties
and concerns.
(b) Non-verbal communication may be intentional (e.g., a nod to indicate understanding),
but is often unintentional. Cues to dissatisfaction, "yes" or "no" are often unintentionally
displayed. Observing these cues can be a great help in knowing what the patient
actually wants. Non-verbal cues are more reliable than spoken words.
(c) Non-verbal cues can give one's disinterest. Patients can read such non-verbal cues.
They are quite sharp in deciding whether the doctor is interested in listening to what
they have to say.
Classifying Non-Verbal Communication
Classifying the different categories of non-verbal communication allows us to understand
the different components of the phenonmenon called non-verbal communication.
There are seven categories. These are:
(a) Proxemics e.g., personal space, seating arrangement at meetings, distance between
individuals while in conversation, and time.
(b) Artifacts, e.g., clothing, make-up, eye glasses, jewellery.
(c) Kinesics (body language), e.g., hand gestures, body postures, facial expressions and
eye movements, gait.
(d) Paralanguage, e.g., vocal pitch and emphasis, intonation, expressions such "uh huh",
"well", "you know".
(e) Touch, e.g., handshake, skill at which physical examination is done.
(f) Environment, e.g., furniture, room decorations.
(g) Physical characteristics, e.g., state of health, body shape, skin colour, skin, deformities,
characteristic body odours (diabetic ketosis, uraemia and alcohol consumption).
A brief description of each follows:

Proxemics
This is concerned with space, position and time.
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Space and position. People maintain certain distances during conversations. The way
family members sit as a group can tell much about relationships amongst one another.
A good consultation position is to sit on adjacent sides of a table. Sitting across the table
puts a barrier between the doctor and the patient. Some may find it more emotionally
comfortable to keep it that way.
Time. The doctor may give the impression that he is very busy if he appears hurried,
impatient, time-conscious and attending to many things at the same time. The patient
may feel that he should not waste the doctor's time and go away dissatisfied. It is possible
to project a different impression that the doctor has time through the use of non-verbal
communication: listening to the unhurried patient, speed and unhurried tone of speech,
use pauses for the patient to reply without hurrying and not allowing interruptions, e.g.,
from the telephone.

Artifacts
Clothes bias positively or negatively the doctor-patient communication; being appropriately dressed is therefore important.

Kinesics (body language)

Kinesics tell us about people's level of interest, acceptance, agreement, satisfaction and
feelings of anxiety, depression or fear.
Face. The face is a carrier of emotions (e.g., anger, joy, happiness).
Shoulders. They are raised if tensed; lowered if relaxed.
Head position. Raised if showing openness, interest and control over situation; lowered
if in doubt, defeated, in fear or insecure; tilted sideways if interested.
Body posture. Upright posture indicates confidence, upright and backward leaning
indicates defensive or reticent frame of mind.
Hand gestures. Fear or uncertainty is expressed by hand-to-nose gesture. Hand over
mouth indicates doubt of what is being said. Steepling (joining hands, with fingers
extended and fingertips touching) indicates confidence and assurance in the comments
being made.
Folded arms. Folded arms are a nature position of comfort; however, they can also
communicate messages of defensiveness, disagreement or insecurity.
Legs. Sitting forward in the chair with feet placed in the "ready to run"position
indicates disinterest.

Paralanguage
Emphasis. The emphasis on different parts of the sentence conveys the meaning of the
message. Thus, it is important to note not only what is said but how it is said.
Rate of speaking. Fast speaking occurs in anger, joy or excitement; slow speaking occurs
in sadness.
Tone. A soft voice, low pitch and irregular pauses are some of the vocal characteristics
associated with depression. Anger or irritation is also displayed through the tone
of voice.
Non-fluences. Slips of the tongue indicate anxiety, discomfort evoked by the situation;
"er", "ah", "um" may indicate being unsure of what is being said.
Pause. Being a good listener is rated very highly as an attribute. It appears that one of
the factors involved is the ability to use pauses and hesitations.
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Touch
Touch is the most important of the areas of non-verbal communication and especially so
for the healing professions. The "laying of hands", "the healing touch" tells us of the
value of touch as part of the consultation. Notwithstanding this, one has to guard
against the risk of misinterpretation of intentions. For touch to be effective, it must (a) be
acceptable to the patient, (b) be acceptable to the doctor, and (c) recognised that it has
an unique meaning for each patient. It is important to get the patient's consent before
one carries out a physical examination ("Shall I examine you?" or "Please get on the
couch, let's see what you have got").

WRITTEN COMMUNICATION
Written communication is necessary in (a) as proof of a decision (e.g., consent for
operation), (b) to eliminate confusion, and (c) to aid comprehension and retention of
information given. Clarity and simplicity in written communication is the essence of good
doctor-patient communication.

THE COMMUNICATION PART OF THE CONSULTATION

Byrne and Long (1976) studied 1,000 audio recordings of consultations and found that 6
phases can be identified:
(a) the doctor establishes a relationship with the patient.
(b) the doctor attempts to discuss, or actually discusses, the reason for the patient's
attendance; that is, he finds out the reason for encounter.
(c) the doctor conducts a verbal or physical examination, or both.
(d) the doctor, or the doctor and the patient, or the patient (in that order of probability)
discusses the patient's condition.
(e) the doctor or occasionally the patient, details treatment or further investigations, and;
(f) the doctor makes arrangement for follow-up care and the consultation is terminated
and, usually by the doctor.
The communication part of a consultation thus can seen to consist of two parts:
(A)the clinical interview to find out what is troubling the patient which covers phases (a),
(b) and (c).
(B) the exposition in which the doctor explains his diagnosis and what is to be done about
it immediately and as a follow-up which covers phases (d) and (e).
The Clinical Interview
How can we conduct it effectively? The following are points to take note of:

(a)

Start the interview right

It is important to start the interview right.
(1) Greet the patient - to show that you welcome the patient and wish to put him
at ease.
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(2) The first question must always be open: "What has brought you to see me today?"
In the hospital, when the patient comes with a doctor's letter, the opening
question can be: "Your doctor has written to me, but I want you to tell me about
it all yourself." In the ambulatory care setting, the opening question can be:
Good morning, Mr Tan, what has brought you to see me this morning?
(3) Many patients first offer a symptom that may not be what they really want to
discuss, so they must always be encouraged to say what is really troubling them
by a question "Is there anything else you would like to tell me?".
(4) The patient has trepidations in seeing the doctor. There is a need for the doctor
to be aware of how the patient is feeling, and to show this understanding and
to try to put the patient at ease by facial expression and verbally.

(b) Be patient centred

Bynre & Long found that in the 1,000 consultations study in general practice only
were patient centred, the rest were doctor centred.
(1) "Doctor centred" consultation - Here the doctor concentrates on "closed
questions", e.g., "do you sleep badly?" (as opposed to open question of "tell me
about your sleeping"); ignores or brushes aside hints of other problems so that
an organic diagnosis can be reached and a prescription given.
(2) "Patient centred" - Here the doctor listens to the patient and takes up hints of
non-organic problems, the doctor explores the patient's concern, fears
and expectations.
The "doctor centred" doctor may be good at diagnosing organic illness, but will miss
many simple opportunities of relieving anxiety, depression or psychological causes or
consequences of illness. Is that important?

(c)

Facilitation
(1) This may be verbal: "Go on, tell me about that" or non-verbal - just an
encouraging noise (paralanguage), or nodding and waiting.
(2) The proper use of silence is important and needs to be learnt. By jumping too
soon with the next question you may lost important clues.

(d) Clarification
(1) This requires direct questions about the onset of symptoms, their development,
precipitating factors and relieving factors.
(2) Avoid technical terms.
(3) Do not ask a rapid string or questions all at once.
(4) Throughout the inquiry attention must be paid to clues on unexpected emotion
which the patient may give.

(e)

Tolerance
(1) Most doctors have inhibitions or prejudice in certain areas. Interviewing however
must be dispassionate.
(2) Tolerance of emotionally disturbing things that a patient may say is needed.

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(3) A doctor has no warrant for passing judgement on what a patient tells him
however shocked he may feel.

(f)

Avoid jargon
(1) The patient and doctor may have quite different ideas of the meaning of even
simple medical terms.
(2) If there is any doubt, seek clarification or explain any technical words used.

(g) Summarising
(1) It is helpful for both doctor and patient if at the end of the interview, the doctor
summarises what he has learnt, and;
(2) The doctor asks the patient if the doctor has got it right or is there anything
more to be said.

(h) Note taking

(1) Though essential, note taking must not be allowed to spoil the interview.
(2) A doctor who never looks up from his notes cannot interview well.
(3) Writing can be done, in occasional pauses, "Just a moment, I want to make a
note of that".

(j)

Dealing with too little time

(1) Shortage of time is the commonest reason advanced for poor interviewing.
This is not entirely valid. The important facts about many patients with common
disorders may be learnt in a few minutes, a minority who may need a more
lengthy interview can also be detected quickly.
(2) Much time can also be saved by avoiding the "by the way" phenomenon.

(k)

Avoiding the "by the way" phenomenon

In the study of 1,000 consultations, Byrne and Long found 79 of them were telling
the doctor, "by the way......" in phase (e); of these 50 showed that there was no
evidence of phase (b), that is the doctor did not attempt to discuss, or actually
discuss, the reason for the patient's attendances. It appeared that even in a 5
minute consultation a short phase (b) enabled an effective consultation to take
place, and no "by the way" took place. Thus the patient should be asked if there is
anything else bothering him before going to phase (c).

The Exposition
Exposition describes the second part of a consultation, where the doctor explains his
conclusions and tells the patient about investigations, treatment, or changes in his way
of life.

(a)

Organise verbal information and ensure understanding

Studies by Ley have shown that patients' recall of what they have been told can
be improved:
-- use explicit categorisation of information
-- tell the most important first
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-- tell in simple language

-- have patient repeat the more important things told

(b) Supplement spoken with written or recorded information

This helps the patient to remember.

(c)

Encourage patient to write down their questions

Patients should be encouraged to write them down their questions before they see
their doctor the next time round.

(d) Avoid conflicting information

This often happens in hospital where patients may ask various people about their
illnesses. An "information sheet" in the case sheets of questions asked and answers
given may help. In ambulatory care where a patient doctor hops, a similar situation
may arise. A useful strategy is to find out what the patient has been told with a
starting sentence like this, Perhaps as a starting point we could review what your
doctors have told you, so we can see where are the areas I could help to
explain things.

OVERCOMING PROBLEMS OF COMMUNICATION

Physical Disabilities

(a)

Deaf patients
If they are using hearing aids make sure they are on and working.
If you have to speak very loud avoid sounding angry.
Be sure the patient is able to watch you speak so that he can lip read you.

(b) Blind patients

Blind people can hear very well.
Help your patient transfer from chair to couch; give a commentary as you go along
so that he is able to follow you.

(c)

Stroke patients
People who cannot talk freely may understand speech normally.
The handicapped are quick to non-verbal indicators of lack of concern or respect.

About Fatal Illness

(a)

The patient who has a fatal illness

There is a perpetual problem of when to tell the patient, how to tell the patient,
what to tell and how much. There are two schools of thought. One is that the
patient should be told of his fatal illness and the doctor will be accused of keeping
too much information from the patient if he does not do so. The other is to
withhold such information.

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The
(i)
(ii)
(iii)

guiding principles for not revealing too much to the patient are:
if the diagnosis is not yet definitely confirmed.
if the doctor perceives that the patient is not ready for it.
if the relatives are convinced that it will do harm than good to the patient.

At some point of time some patients may really want to know; some patients are
content to read the answer from the situation and do not ask their doctors a
direct question.
If the patient that wants to know, the unpalatable fact could be cushioned with
something that could still be done. ("It does not appear very good, but let us
concentrate on making you feel comfortable").
In some patients, the need to tell earlier may be necessary in view of their
commitments or social responsibility. ("As your medical problem is going to affect
your health substantially, I would recommend that you make the necessary
arrangements for others to look after your business, etc").

(b) Patients who think they have a fatal illness

This is easier to deal than one that indeed has a fatal illness. Nevertheless, unless
the patient is convinced otherwise, he may go through unnecessary worry. Spending
time with such patients to find out their misperception may help. Showing the
patient reports from the lab or specialist opinions to read for themselves helps to
reinforce your reassurance.

BREAKING BAD NEWS

What is Bad News?
Bad any news that drastically and negatively alters the patients view of his future
Can be: terminal illness, diagnosis of chronic illness and abnormal investigation.
ABCDE of Breaking Bad News
A helpful way to remember how to break bad news are the ABCDE checklist.
Advance preparation
Arrange for adequate time, privacy and no interruptions (turn pager off or to silent mode).
Review relevant clinical information.
Mentally rehearse, identify words or phrases to use and avoid.
Prepare yourself emotionally.
Build a therapeutic environment/relationship
Determine what and how much the patient wants to know.
Have family or support persons present.
Introduce yourself to everyone.
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Warn the patient that bad news is coming.

Use touch when appropriate.
Schedule follow-up appointments.
Communicate well
Ask what the patient or family already knows.
Be frank but compassionate; avoid euphemisms and medical jargon.
Allow for silence and tears; proceed at the patient's pace.
Have the patient describe his or her understanding of the news; repeat this
information at subsequent visits.
Allow time to answer questions; write things down and provide written information.
Deal with patient and family reactions
Assess and respond to the patient and the family's emotional reaction; repeat at
each visit.
Be empathetic.
Do not argue with or criticize colleagues.
Encourage and validate emotions
Explore what the news means to the patient.
Offer realistic hope according to the patient's goals.
Use interdisciplinary services.
Take care of your own needs bad news also has a negative impact on the messenger.
References
Byrne PS, Long BE. Doctors talking to patients. Exeter: Royal College of General Practitioners. 1976.
VandeKieft GK. Breaking bad news. Am Fam Physician 2001 Dec 15;64(12):1975-8

CHAPTER 3

COUNSELLING SKILLS

Outline
The Counselling Process
BATHE Technique
Problems Of Living
The Difficult Patient
The Angry Patient

THE COUNSELLING PROCESS

The medical consultation is a helping process. Often, the help required is not a
prescription for medicines helping the person deal with the problems at hand or
counselling. Helping sometimes needs only a one-time encounter with the person-inneed; at other times more than one session is needed. The relationship established is
specific and purposeful as it aims at dealing with the problem that is presented. In this
sense, it is a special relationship.

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