What kind of questions must you ask?
Open questions and probing questions
What are the two types of history taking?
Content and Balint
Content is a tradition approach and doesn’t consider the patient’s experience and views.
It also leads to closed question interrogation
Balint considers patient’s experience.
What does WWHAM stand for?
Who is it for?
What symptoms
How long have symptoms been presents?
Action already taken?
Medication – any other being taken?
What do we use for Pain Assessment Model?
SOCRATES
S – Site – Where exactly is the pain
O – Onset – What were they doing when the pain started?
C – Character - What does the pain feel like?
R – Radiates – Does the pain go anywhere else?
A – Associated symptoms – eg. Nausea/vomiting
T – Time/duration - How long have they had the pain for?
E – Exacerbating/relieving factors – Does anything make the pain better or worse?
S – Severity – Obtain an initial score
What is process?
Process – this is about having the skills to conduct consultation, developing a rapport, obtaining and having a discussion with the patient.
What is the Calgary-Cambridge technique?
- Initiating the session
- Gathering information
- Physical examination
- Explaining and planning
- Closing the session
What are Zola Triggers?
A list of 5 trigger of why people come and seek advice about their health.
What are the Zola triggers?
- Interpersonal crisis – They have a personal experience of the condition/symptoms which creates worry
- Relationship/perceived social inference – A desire for the symptoms to not draw attention or change people’s view of you.
- Sanctioning – Someone else tells them to go
- Activities – The conditions or symptoms are/might be preventing them from doing something
- Temporalizing of symptoms – A patient’s perception of how long something should last
What is Fundamental Attribution Error?
We tend to believe someone’s behaviour is a direct result of their innate personality and do not consider the contextual factors.
Why do patients complain?
- Concerns with investigations and treatments (do you know what you are doing as a professional and do you do your job properly)
- A perceived lack of respect for the patient
- Problems with communication
Number 2 and 3 are the commonest reasons for patients complaining.
What are some problems with communicating?
Content – the information you provide to the patient, the words you say.
There could be poor quantity and quality of information provided to them.
Verbal – how you say things. Are you actually listening to patients or just talking all the time (active listening). Inappropriate choice of words could occur
Non-verbal – Eye contact, facial expression and paralanguage
Poor attitudes – Lack of respect and empathy
What can do we to make ourselves more trustworthy?
Explain things clearly - chunk and check; explain numbers too!
Share your thinking
Involve the patient
What is Paternalistic?
What is Collaborative/shared?
Paternalistic – telling patients what to do
Collaborative/shared - involving the patients. Just sharing your thoughts with them.
How do you prepare for difficult conversations?
Dump your emotional baggage
Affective biases – how our mood can impact our decision making. We process information depending on our mood – angry, happy, sad etc.
Privacy e.g. Consultation room
How do you start a difficult conversation?
Introduction
Gather information - check what the patient already knows. Don’t assume the patient knows something
Start with a warning shot - “unfortunately, I have some bad news for you”
Be honest - don’t hide or underplay something.
Deliver in a fairly neutral tone as news could be good or bad for them.
Say what negative or positive results means
What is Duty of Candour?
This is means that we should be owning up to our mistakes.
If a mistake is made, you have to tell the patient.
Is an apology an admission of guilt?
No!
What should you do if a mistake occurs?
Tell the patient
Apologise for the mistake - state the type of mistake “…sorry for this dispensing error”
Don’t trivialise it
Offer to rectify the issue - what would the patient like to happen?
What are the common mistake of communicating mistakes?
- Over apologising
- Over promising - don’t say you will do something straight away or deliver something to them. Think about what is practical.
- “It’ll be OK”
- Pre-mature reassurance
Advantages of face-to-face consultations on video call?
- Saves patient’s time/money
- Saves the professional doing a home visit
- Infection prevention (COVID-19)
- MDT – Multi-disciplinary team - Link multiple people easily - You might want the district nurse, the GP etc., involved in the conversation.
Disadvantages of video and phone consultations?
- Health inequality – Access to good internet and device.
- If patients don’t have these things, they can’t access these services.
- Same human connection – Emotional distance
- Less appropriate for acute issues
- Physical examination is restricted
- Can be difficult to implement – need good Wi-Fi, device etc.
What must you do on video consultations?
- Check call quality – this is absolutely critical
- Check where the patient is – privacy (are they on the bus or at home?), who else is present
“Can I just check where you are?”
“Can I just check who else is there?”
- Note their phone number, just in case – in case video call fails
- Eye contact – not really a problem. You can choose to look at the lens to make eye-contact or look at the screen.
Advantages and Disadvantages of telephone consultations?
- Easy and convenient for most people
- Easy to implement
- No body language – physical signs
- Deaf patients? – doesn’t work for them…obviously
