IMPROVING CLINICAL CONSULTING SKILL

Transcription

1 IMPROVING CLINICAL CONSULTING SKILL Dr M Osman Gani MRCP (UK), MRCGP (INT) Assistant Professor, Dept of Medicine, Dhaka Central International Medical College KEY MESSAGES Communication is an art. Clinical Consulting is actually a meeting of two experts- doctor and patient. To become a successful doctor, consulting skill needs to be discussed, reflected upon and practised. Consulting skill is one of the determinants of the acceptance or rejection of a doctor by the patient. Consulting a patient is an interaction between two complicated and differently motivated human beings. Doctors need to be able to get to the heart of both the patient and the problem as efficiently as possible. Consulting skill is the synthesis of medical expertise and successful communication with the patient. To become a successful doctor, consulting skill needs to be discussed, reflected upon and practised. Main objectives of consultation are A. Building a good doctor-patient relationship B. Gathering all the relevant information C. Making sense of consultation D. Making a management plan Clinical consulting skills are discussed in the following steps: A. BUILDING A GOOD DOCTOR-PATIENT RELATIONSHIP Traditionally patients regard a doctor as Next to the God. Unfortunately this feeling is being reduced and the other end of the spectrum is being dominant. To rebuild the sense a doctor can follow the steps bellow: 1. Meet and Greet Doctor can start talk with the word Hello or any other word culturally acceptable to the patient. A religious patient will be very happy if he/she is welcomed by hearing a religious word. During introduction, doctor should note that a patient should be regarded as a human counterpart at the other end of the consultation table. Better to keep in mind that different patients require different introduction style and first few seconds of introduction is very important. 2. Putting the patient at ease Putting the patient at ease is very important for a successful consultation outcome. But one thing needs to be remembered; some patient may be angry at the beginning of consultation for some awkward situation happened before and patient wants the responsible person should be criticized by the doctor. Doctor should be impartial here. Doctor can say Sorry for your inconvenience at best. 3. Utilizing body language and eye contact Person s expressions, posture and mannerism can give many valuable information. Careful observation is necessary. For example, if a patient can t keep eye contact, this may be a case of depression. But there is a matter of cultural difference. Excessive engagement can appear intrusive or discomfortable for some patient. Keep in mind that incorrect or insensible use of body language and eye contact can have a negative impact on the consultation. Keeping eye contact becomes more difficult if the patient is accompanied by more persons and this is the common scenario inside the doctor s chamber. 1

2 Patient usually is accompanied by parents, friends, spouse or offspring. In such case attention should be divided very intelligently. B. GATHERING ALL THE RELEVANT INFORMATION Actually doctors are getting the Story rather than History to identify problems of the patient. The holistic approach necessitates exploring Biological, Social and Psychological problems of the patient. 1. Questioning Getting information is based on proper questioning and answers and it is very important part of combined skills. Opening lines may be variable for person to person as patient may be new one or follow up. For example How can I help you ( It means what is your problem to be solved)? or What happened since we last met? This initial question should be OPEN type which elicits a lengthy answer. Open questions will be followed by CLOSE type question which usually elicits a short response, for example: How long do you have your cough? Multi barreling of questions should be avoided. For example: Do you have diarrhea or vomiting? Patient can mean yes to diarrhea only. Again, leading question also should be avoided as patient can think that doctor is expecting the indicated problem is existing. For example: You have burning foot, isn t it? To get some very personal information, it is better to ask I like to know some personal information which will be helpful for your management plan, its ok? 2. Active listening It does not mean saying nothing. Doctor can respond in between talk as Hmm, Yes, Ok Fantastic, Tell me more please etc. to encourage the patient to talk. When patient narrates sad story, doctor can respond as I am sorry for your sufferings. It is better to hear the patient uninterruptedly for first 1 minute. 3. Silence and interruptions Silence can handle many conflict. Specially, if doctor encounter an angry patient, silence will be the best weapon to solve it. Again, to break a sad news to the patient Silence will be a golden approach after breaking the news to observe the patient s reaction. It allows the patient to get his/her emotion out in this silent pause. Interruption can be tolerated differently by different patient. Doctor should be cautious regarding this. Besides, doctor should have the control of the consultation also. 4. Reflection It is a technique to get back some told story. Without a question, doctor utters just a few words what exactly used by the patient. Then patients feel to tell the whole story by themselves. For example You told me that you are feeling low. 5. Clarification When patients use a word or sentence which is ambiguous to the doctor, patient should be asked to clarify what patient actually means by this word. Patient can use word Strong diarrhea, Unclear bowel, Difficult urination etc. Clarification is a two way process. What doctor is asking should be understood by the patient also. Clarification of the question and the answer can give the doctor a very different picture of the patient s symptom. 6. Cues Patient may not be explicit about all the reasons of consulting a doctor. There are always some hidden agenda with the patient. Patient may give little cue which should be detected by the doctor intelligently. Male patient may tell Hormone problem to denote his Erectile Dysfunction. There are various explanation for why the patients are not always explicit with their agenda. Patients may not feel the consulting hour as appropriate time or patient may not get appropriate word to tell. More over there may be fear of being judged by the doctor for patient s some negative experience in the past. Doctor should be skilled to find appropriate ways of eliciting the whole story. Hidden agenda of the patient may only be revealed in a word or phrase or even by facial 2

3 expression or body movement. The verbal or nonverbal cues are effectively a signal to the doctor to respond. If it is not picked up, it may result in a less satisfactory outcome. Cues can occur at any time of consultation, not just at the beginning only. 7. Observational Comments Doctor can comments. I understood you have terrible cough for your smoking. By this, patient can tell spontaneously more of his smoking habit as well as his cough. 8. Choosing the words Layman terms are very important to be understood. It is mentioned before that the patients word should be understandable to the doctor. Reciprocally, doctor s word also should be understandable to the patient. Medical terminology or jargon should be avoided in general. But some commonly used words are easily understandable. For any confusion, used words should be explained. Migraine may mean Tension headache, Unclear bowel may mean Constipation, but it is not always true. 9. Psychological issue It is vital for a holistic consultation to consider psychological and social issues always with clinical problem. But it s not very easy to ask about his/her private life including work, partners, spouse or children. Following ways can be utilized to encourage patient to answer rather than resist psychological question: Warning the patient that doctor is going to ask some personal questions, OR, Asking the permission, Can I ask you to describe where you are living now? We encounter some typical conditions regularly that have a link to the patient s psychological state. Conversely, it is almost rare that there is no link between the illness and the remainder of the patient s life. It is not enough to ask only who is with you at home, rather to explore the accompanying person is helpful or not, is very important. Like wise to ask the job is not sufficient, whether the income is sufficient or not is more important. 10. Idea, Concern and Expectations or Health beliefs Patient s own thoughts and feelings about their conditions is very important for a good doctor-patient relationship, understanding of differential diagnoses by the patient, negotiation of investigation and treatments and likelihood of adherence to a management plan. Of course, in emergency situations patient`s view may be less important. Patient s compliance to the medical advice varies according to the social and cultural influences, previous experience, media representations of medicines, and the knowledge and experience of friends, colleagues and family members. By considering this factors doctor can tailor their ongoing investigation and management plan. Idea, Concern, expectation (ICE) is important to specifically and explicitly explore these issues in order to gain an accurate insight into patients view and outlook on their illness or diagnosis. C. MAKING SENSE OF CONSULTATION This is the extra ordinary part of consultation to finish information gathering. The ways are as below: 1 Framing and Meta communication: Introducing new topic may be embarrassing to the patient. So before starting any embarrassing topic there should be sign posting. This is the framing or meta communication. For example, I like to ask some questions which may be little embarrassing but very important for your proper management. After such sign posting patients get little time to prepare themselves for such question. In such way consultation runs smoothly. Sign posting is important also for clarifying the things. 2. Sanctioning Thanking the patient for coming for follow up or to deliver some important information which was not asked before is very rewarding. Again appreciating patient s use of inhaler in a correct way will encourage the patient for its future long term use for persistent asthma. Don t worry, I will not be embarrassed if you tell me your private information will increase the confidence of the patient upon doctor. 3. Summarizing 3

4 Summarizing is well recognized and effective technique in any professional life. It can be very powerful tool for consultation if used appropriately. By this mean doctor establishes that he/she has explained the preceding dialogue with the patient accurately. This is the opportunity to clarify or rectify the matters.this is a chance also to show the patient how well doctor has actively listened to the patient. Last thing of summarizing is to ask the patient do you like to add anything more? And apparently this is the end of gathering information from the patient. Moreover, mini summarizing can be done in between the dialogue with the patient. D. MAKING A THERAPEUTIC PLAN After gathering information doctor is now ready to make a management plan. Following aspects are important: 1. Linking health beliefs to the management plan As Idea, Concern, Expectation and health beliefs are already known, now the time to link it for a negotiated management plan. If some management plan is mandatory but contrary to the belief of the patient, the necessity of this should be explained to the patient. 2. Explanation Explanation is a core communication and clinical skill of a doctor. This might even have a therapeutic potential by itself. Asking do you agree? in between management plan discussion is more helpful to keep the management plan on right way. Wrong explanation may culminate into lawsuits against the doctor. Explanation encompasses the probable diagnosis, the rationality of investigation, medications necessities etc. Again in between talk, ask do you understand, or is it ok? 3. Collaborative management Doctors should be away from the paternalistic approach in the management of the patient with an assumption that doctor knows the best. Greater availability of medical information, increasing interest in patient choice of healthcare services have empowered the patient in such an extent that doctor s paternalistic approach is losing its importance. It is not true that all patients want to be involved in management planning but some patient prefer to be involved in decision making about their health care. Involving the patient leads to having greater ownership of their condition, improved adherence to treatment and ultimately a better clinical outcome. Patients are expert in their experience of illness. Clinical Consulting is actually a meeting of two experts- doctor and patient. So a shared management plan is important. 4. Exploring understanding of treatment Do you understand what I have said is not enough to ensure patient`s understanding. Sometimes patient is reluctant to admit to have lack of comprehension or they feel feared to ask further question to the doctor. It is unwise to assume that lack of understanding is the patient s fault. Poor communication may be the root of the difficult understanding. We should keep in our mind that misunderstanding obviously has serious consequences. 5. Confirmation of understanding Do you understand? or Is it ok? can compel the patient to answer Yes, though information given might be complicated and ambiguous to the patient. Better, request the patient to narrate their understanding in short. The skill motioned above can help a doctor to make the patient more understanding. 6. Safety netting and Follow up Follow up plan vary with the condition presented or with the patient type. Important follow up should not be missed. Follow up plan should be agreed upon by the doctor and the patient both. If the future plan is not made well there is every chance of suboptimal patient management. Usually follow up will be after a specified duration. But a Safety Netting option should be there to contact doctor or health care center immediately if the condition requires 7. Health promotion Educating the patient to help them to lead a healthier life is very important in a holistic health service approach. But it is not an easy job. Changing the 4

5 behavior of the patient is very difficult. Patients prefer to take pill rather to change them. So doctor can utilize the scope of situation. For example, quitting smoking advice will be very fruitful if given at the scenario of myocardial infarction. Health promoting education can be given to patient s relative also at the same scenario. Barriers of communication- Language barrier or Deafness Language barriers can be overcome a bit by utilizing a translator but to encounter a deaf patient is very difficult. Doctor is to face same situation to handle an unconscious patient also. A translator is to be skilled and oriented in medical communications. In absence of translator, a digital translator may not be purposeful. For a deaf patient, a communication may be established if both doctor and patient can understand sign language or lip reading ; loud voice is not needed, clear wording is enough. CONSULTATION OVER TELEPHONE Telephonic consultation is very difficult and full of disadvantages. Telephone alters the tonal quality of sound and it may create confusion about identity of the patient also. Doctors can t utilize their observatory eye. Moreover, telephone is easy to become distracted. Patients have every intention to call a doctor any time which interferes regular professional works. But patient may find it better for easy access, low cost and for some private talk. In summary Communication is an art. Doctors learn it from their very beginning of clinical studentship. But unfortunately this important skill is getting less importance in our bed side teaching. We are teaching that a good history talking can diagnose 85% of diseases. But we are not proving it in our teaching and in our practice. A good clinical communication skill can improve our clinical practice and patient s satisfaction. 5