Communication All Topics PDF

Or Fisher Exam topics list “A”: 1. The significance of medical communication. Misconceptions and facts about medical communication. Significance of medical communication- Patients primarily judge doctors based on their communication. Impression determines extent to...

Or Fisher Exam topics list “A”: 1. The significance of medical communication. Misconceptions and facts about medical communication. Significance of medical communication- Patients primarily judge doctors based on their communication. Impression determines extent to which the patient trusts the doctor, follows their recommendations, and whether they will remain in contact with the physician. Determines patient satisfaction- doctor’s style of communication, relationship established with patient, and manner in which patient is informed. Improves patient adherence- sound doctor patient relationship leads to higher adherence, which, in turn, improves patient’s health and recovery rate. Decreases the stress level of physicians- communicating well decreases the doctor’s level of stress when they have to deal with delivering bad news. Reduces the risk of burnout- good communication leads to higher satisfaction with their work but also less disillusionment from medical profession, exhaustion, and indifference to patients or cynicism). Reduces the number of medical malpractice suits- patients more likely to sue physicians with poor communication skills than those whose skills are inadequate. Misconceptions and facts about medical communication- Widespread belief that communication cannot actually be learned and that it is an attribute someone possesses or not. In reality, we acquire our communication skills through learning from the moment we are born. Our parents, teachers, peers, colleagues, and media all influence the way we communicate. o Study done at American universities showed that medical students who underwent communication training outperformed their pre-intervention peers in relationship development and maintenance, patient assessment, and patient education and counseling. A doctor needs good communication skills precisely because they have so little time- they need to be effective at gathering information from patient, delivering information, making sure that the patient adheres to the prescription. Good communication skills save time. Good communication is measured in quality content rather than quantity- patient satisfaction determined not by how long patient perceived the visit to be but by how empathetic the patient deemed the doctor to be. Often methods employed in everyday life may be time-consuming but recommended communication techniques can save the doctor time. Average capacity of short-term memory is 7+/- 2 items of information so much information is lost if conveyed in bulk. Encouraging patient to ask questions, providing pamphlets, and recommending trustworthy websites effective. Communication is a fundamental part of medicine- good communication is part of healing process and good communication does not necessarily depend on quantity but rather quality. Or Fisher 2. Doctor-patient consultation. Daily form of communication between the doctor and the patient regarding the patient’s symptoms, improvements, conditions, exam results, etc. Three function model- doctor’s goal is: o To gather information from the patient with appropriate questioning methods o To respond to the patient’s emotions through expressing empathy o To deliver necessary information to the patient E4 model- Engage, Empathize, Education, Enlist. Doctor should listen to patient’s complaints and concerns, empathize, convey appropriate information and check their understanding, and reach a common agreement on the treatment plans and improve a patient’s commitment to achieving it. SEGUE framework- o Set the stage- establish relationship, give polite introduction, make eye contact o Elicit information- gathering information, using funnel principle, actively listening to the patient’s narrative (open posture, nodding, mirroring facial expressions, sounds expressing attention), clarifying questions, summarizing what was said. o Give information- providing the appropriate type and amount of information suited to the patient, encouraging the patient to ask questions, use clear language, delivering information in logical blocks, repeating important information, transcribing important information, confirming whether the patient has actually understood. o Understanding the patient’s perspective- empathizing with the patient (reflecting emotions, normalizing) o End the encounter- formulating a final summery, discussing the next step, giving heads-up on what may be coming (possible side effects). Calgary-Cambridge guide- o Initiating session o Gathering information o Physical examination- ensuring intimacy (examination conducted behind curtains), explaining the examination procedure o Explanation and planning- recommending instead of ordering. o Closing the session Kalamazoo consensus- o Build the doctor-patient relationship o Open the discussion o Gather information o Understand the patient’s perspective o Share information o Reach agreement on problems and plans o Close the session How should the doctor begin a consultation? Problems in initial phase of doctor-patient relationship- no introduction and failure to clarify roles, interrupting patients too quickly, putting too much weight on first Or Fisher complaint, differing order of important in information (patients more concerned with consequences, doctors with complaints), immediately reverting to previous meeting during follow-up visits. Communication techniques of initial phase of doctor-patient consultation- o Preparation- set aside other tasks, prepare to meet the next patient o Establishing the initial relationship- making eye contact, greeting, introductions, ensuring the dignity and physical comfort of the patient. o Defining the reason for consultation- opening question (How can I help you, open ended), listening, overview of topics (list problems patients highlighted). How can gathering information be thorough and effective? Problems in explanation and planning phase- patients receive insufficient information, patients do not necessarily understand medical explanations, patients do not necessarily remember information, many patients do not follow medical instructions. Communication techniques of the explanation and planning phase- o Providing the type and amount of information suited to the individual characteristics of the patient. o Encouraging the patient to ask questions. o Facilitating comprehension and remembering information- clear language, use of “signposts” (phrases indicating boundaries of information), structuring, confirmation, highlighting important information at the beginning, emotional highlighting, repetition, transcribing important information, use of patient information leaflets, recommendation of professionally reliable sources. o Planning: involving the patient to enhance adherence- justify recommendations, decisions, get to know the patient’s previous experiences, offer choices, recommendations instead of instructions. How should the doctor end a consultation- objectives- summarize important information, determine responsibilities, perform final check of understanding and consensus. Problems in the consultation closure phase- o Patients often leave doctor’s office without formulating their questions/concerns o Doctors often do not make it clear what the patient has to do next. Communication techniques for closure phase- formulate a summary, discuss the next steps, tighten the safety net, perform a final check. How can the doctor structure a consultation? Setting an order, partial summaries, signposts How can the physician express their attentiveness and empathy?- Active listening- o Nonverbal signs- eye contact, open posture, facing the patient, mirroring facial expressions, nodding, keeping appropriate distance, sounds expressing attention o Verbal signs- repetition, paraphrasing, partial summary Expressing empathy- understanding the feelings, experiences, and perspectives of another person and the capability to communicate this understanding. Reflecting emotions, normalization. Or Fisher 3. Promoting lifestyle change: the 5A and 5R methods; the transtheoretical model of behavior change. 5A- brief consultancy model. Ask- about the behavior- do you smoke? How many cigarettes? When? Advise- suggest how to quit smoking. It is important because… should be tailored to each patient’s medical history. Assess- willingness to quitting- do you want to quit? When? Plans of cessation should be supported. If no willingness 5R/motivational interview Assist- change attempt- setting a date, encourage to reorganize the environment, make and tell a plan to family members, friends to increase commitment. Have patients minimize or avoid locations and actions that prompt the behavior. Discuss experiences of previous cessation attempts, recommend replacement therapy or medication. Identify patient’s role as a role model to children. Help establish a new identity associated with behavior change. Arrange- at least 2 follow ups- first in first few days, second within a month. Supervise/monitor, results, achievements, relapse prevention. First 3 steps are referred to as “minimal intervention” and related guidance. 5R- brief motivational intervention. Relevance- explore to what extent quitting would be important to patient. What can later be the consequences of the behavior? How important is it to quit? Risks- What problem is caused by the behavior? What do you know about? Emphasize that cigarettes containing less tar/nicotine or flavored cigarettes do not reduce hazards. Rewards- focus on benefits of quitting. Advantages of the change- what would the benefits of quitting be for you? Cost, health concerns, worry of children. Roadblocks- perform overview of factors hindering cessation and find possible solutions. What are the difficulties? What makes it difficult for you to quit? Repetition- Summarize it- patient’s intentions should be addressed again. What do you think now about your behavior and are you willing to change? Motivational intervention is not a one-time conservation, repeat during future encounters to promote prolonged success. NRL stages of change- Pre-contemplation- others (family, friends, doctor) have recognize the problem but the patient does not see it and even denies its existence. Tend to show reaction hen pressured but nonetheless remain passive toward situation. No intention of changing behavior Strategies implements in this stage are: o Asking permission to discuss o Giving information and encouraging them to this about this issue. o Doctor’s role is to elicit discussion and have the patient slowly begin to consider their problem by providing relavent information. o Reluctant patient- passively opposed to change because do not understand risk, no urge to change because situation is perceived as good. Or Fisher o Rebellious patient- actively against making a change. Aware of dangers but do not seem to care. o Resigning patient- little energy and has lost hope in possibility of change. o Rationalizing patient- looks for explanations on why problematic behavior is not detrimental to them. o Ask questions about their behavior, no judgement, explaining risks. Contemplation- aware that a problem exists, but with no commitment to action. Patient asks for information, thinks about solutions and begins to consider behavioral change. o Doctor should elicit more perspecitives, help consider the pros and cons of change, suggest trials. o Pros and cons, encouraging them by specifying next step Preparation- intent on taking action to address problem. Patients perceive that change is needed and are committed to taking action, except the start date for change keeps getting postponed. Doctor’s role is to help the patient set specific start date and discuss action plans, in terms of how the patient would go about changing the behavior. o Helpful to involve social support around the patient, making the change more public. o Reminding of the benefits, positive encouraging Action- active modification of behavior. Patients follow the action plan and are vulnerable to impulses for giving up. When slipping, patients may exhibit frustration, anger, insomnia, etc. As doctor: o Discuss with patient any modifications to be made to their action plan o Help how to hand slips and relapses o Emphasize benefits of change to keep patient going. Maintenance- sustained change, new behavior replaces old. Have resisted/experienced some slips and feels improvements as result of change. o Recognizing success and admiration on achievement, reminding of possibility of relapse, advise on what to do if relapse. o Talk about long term benefits of change. Relapse/termination- fall back into old patterns of behavior. Cycle may revert back to precontemplation or contemplation stage, in which case it is important to point out that relapsing is normal and a natural part of learning process. Should tell patient it is: o Opportunity to learn, an experience that would be beneficial to change o Remind patient of benefits of change o Discuss difference between what went well and what did not and find ways to improve. Goal is to spend lesser and lesser time at this stage. o Accepting, understanding, pointing out what has worked before, discussing triggers. Or Fisher 4. Promoting lifestyle change: motivational interviewing. Collaborative, person-centered counseling method aimed at mapping and resolving ambivalence related to change, as well as identifying and reinforcing motivation to promote change. For alcohol, lifestyle changes, patient adherence. Can be applied to patients who are not even thinking about changing. Understanding and listening are key to this model (not telling the patient what to do). Spirit is partnership, acknowledging and accepting the patient’s ambivalence while helping the patient explore the possibility of motivation. The goal is to resolve ambivalence and have the patient find his own motivations to change. Promoting the patient’s involvement, sense of responsibility, self-efficacy, and self- confidence. Guiding consultation style. RULE- o Resist the righting reflex- resistance to “problem soliving” reflex. Many doctors want to immediately tell their patient to fix things but the patient should find their own motivations. o Understand your patient’s emotions- only those motivations that are important to the patient will work. o List to your patient- give feedback, not instructions. o Empower your patient- encouraging self-confidence and proactiveness. 4 steps: o Engaging- shall we work together? OARS § Open-ended questions- encourage patient to talk about what is on their mind (What do you think about smoking? What role does alcohol play in your life) § Affirmation- simple statements about anything positive that you notice in patient (it takes a lot of courage to come here, it is hard work what you are doing) § Reflective listening (active listening)- listen to what patient says, recognize their feelings, express empathy by saying it back to patient. Paraphrase what they said, reflect their feelings, normalize (many people feel that way too). § Summary- reflection by framing narrative in solution-oriented direction. o Focusing- what to change? § Permission- requesting permission in discrete way to get consent to talk about topic. § Inquire- how do you see your own alcohol consumption? § Elicit-provide-elicit- first relates to patient’s current knowledge, then about additional information, then closing addresses the next steps. o Evoking- why change? § Looking backward- what has changed in your life since you began? § Looking forward- what will happen if you quit? § Querying extremes- providing you keep drinking, what is best/worst outcome? Or Fisher § Exploring personal goals and deploying discrepancies- by pointing them out, doctor gets patient to reconsider their own conduct. § Ruler technique- on a scale, how important is it to quit? § Patient may exhibit resistance- Resistance to doctor- interrupting physician, arguing, questions skills or patient feels uncomfortable, constantly apologies, etc. Resistance to change- expresses perceived inability to change, states they have tried before without success. § Employ- Simplified reflection- by repeating words of patient, doctor holds mirror up to patient with objective description of situation. Amplified reflection- doctor mirrors patient’s words in slightly exaggerated and more intense manner. Double-sided reflection- physician reflects both sides of ambivalent behavior. Shifting focus- doctor highlights importance of change rather than factors that inhibit it. Reframing- doctor imparts a new, positive meaning to words of patient. Emphasizing personal control (autonomy) o Planning- how to change? § Setting goals § Change options (double bind)- offers number of equally suitable alternatives and patient chooses from these § Arriving at a plan- primarily, patient should be asked about how they want to implement their plan and in what they need support. The physician may ask permission from patient to make recommendations. § Eliciting commitment- highlight plans, ask patient if they can undertake these plans. Effectiveness of motivational interviewing- 1-4 sessions, 20min per session. Longer the session, more effective. Or Fisher 5. Communication options for developing health literacy. What is health literacy? An individual’s ability to obtain, understand and evaluate healthcare information and apply it to their own life. Person with high health literacy can- o Orient themselves in healthcare information- know who to turn to and when. Aware of trustworthy health-related websites, printed publications, radio or TV programs, educational talks. o Understand healthcare information- understanding doctor’s explanations and written materials and proper interpretation of person healthcare documentation. o Evaluate healthcare information correctly- can distinguish between advertisements in media and professionally certified sources. o Apply healthcare information- monitor their symptoms and implement medical recommendations. How prevalent is low health literacy- o Every second patient may have difficulties in understanding and applying healthcare information. o Social circumstances- linguistic and cultural o Personal factors- age, education, occupation, socio-economic status. o Situational factors- communication skills of healthcare worker, patient’s lever of anxiety, immediate physical environment). Why does a low level of health literacy pose a problem? Related to: o Unhealthy lifestyle o Lower screening participation rates o Diminished adherence to medical recommendations o Poor self-management skills o Deteriorated physical condition and lower quality of life o Higher rates of hospitalization o Higher rates of premature death o Increased healthcare costs How can health literacy level be assessed? o Questionnaires- self reported or performance based tests (Short test of functional health literacy in adults), mixed questionnaires. o With filter questions o By observing the patient’s communication- non verbal communication (expression or incomprehension) or nature of their questions. What are the ways to improve health literacy? o Verbal communication- § Simple phrasing § Use of comparisons (analogies, metaphors) § Teaching self-management skills (life skills relating to disease)- Demonstrate and test it out (device), self-monitoring (record symptoms, test results, decision tables. Or Fisher § Use of teach-back technique- having patient repeat through paraphrasing § Ensuring the opportunity to ask o Preparation of patient information leaflets- written at level of moderate reading comprehension, only essential information, visual illustrations, motivational. o Role of visualizing in development of health literacy- drawings, photographs, visual aids, infographics, comic strip, fotonovelas. o Facilitating understanding of numerical information- § Life expectancy based risk communication § Communicating regimen in accordance with time of day. Or Fisher 6. Communicating risks of treatments. How do we perceive various risks? o Every person lives with a number of health risks every day, environmental, accident related, infection relation, nutrition related and risks pertaining to unhealthy lifestyles. o However there is usually a substantial difference between the objective level of risk and its subjective perception. Some may be downplayed (unrealistic optimism) and others may be perceived as more serious than they actually are (unrealistic pessimism). Most patients tend to underestimate risks associated with their own behavior and exaggerate risks from external hazards. o Risks that are part of mundane, everyday life seem less dangerous o Media can significantly influence the perception of risks. o We live with a number of risks we are not even aware of. o Risks associated with health interventions and treatments are perceived by many to be more serious than they are in reality. What is risk communication- interactive process where o Patient receives information about benefits and risks of medical interventions o Doctor assists patient in interpreting the information o Patient is informed of available options to reduce risks o Physician supports patient in formulating questions, concerns, responds to these What methods can aid realistic assessment of risks? o It is important to quantify risks. o Use of values of absolute risk instead of relative risk. o Natural frequencies (10:100) and percentages are the easiest to understand. o Use standardized words to describe the degree of risk and to interpret them. Very common, common, uncommon, rare, very rare. o Use risk analogies- examples from everyday life help patient in relating risks. o Visually illustrate the risks- bar charts, paling palette (small human figures in numbers corresponding to degree of risk). Perspective scale- extent of current risk in view of other risks from everyday life. o Patient should also be informed about how to reduce risks. o Use balanced framing- negative framing draws attention to hazards, surgeries fail in 5% of cases. Positive framing emphasizes benefits, these surgeries are effective in 95% of cases. Negative framing increases chance of rejection while positive framing increases chance of acceptance. o Weigh the benefits and risks of treatment o Make the dangers of foregoing treatment explicit- in absence of treatment, dangers tend to intensify. Or Fisher 7. Shared decision making. What is shared decision making? o Dialogue whereby physician provides expert knowledge and the patient voices their own preferences (needs, expectations, values), and a decision about treatment is reached jointly between the two parties. o Doctor informs patient of several options to remedy the problem, describes benefits and risks of each option, checks whether patient understands the information, assesses the patients preferences regarding treatment, proposes treatment based on these, and both come to an agreement on which alternative to choose. o Informed consent- voluntary permission granted to the doctor by the patient to perform a planned procedure or test. o Shared decision making connotes more patient involvement. Not only about doctor informing patient and them reaching a decision, it is also about doctor coming to know the patient’s needs concerning treatment. When can shared decision making be necessary? o Several effective treatment alternatives are available. o Various treatments have different benefits/risks o Patient’s preferences play a significant part in decision o Patient wishes to take part in the decision regarding treatment. o Ex: mastectomy vs lumpectomy for breast cancer. To what extent do patients want to participate in decisions related to their treatment? o Proportion of such patients is high and is continuously increasing. 2/3. o Usually have a higher level of education and are middle aged. How can shared decision making be achieved in clinical practice? o Creating a climate that activates the patient- make patient understand their opinion is important in selection. o Presentation of treatment options- with pros/cons/risks. o Checking for understanding- have patient ask questions. o Mapping the patient’s preferences- understand the patient’s opinion o Wording of the doctor’s suggestion- doctor should make their own opinion explicit. o Reaching a shared decision- if patient has uncertainty, doctor should provide further information on issues. If agreement not reached, doctor should propose postponing decision and supply patient with additional information/materials. What are the difficulties involved in shared decision making? o Patients do not want to partake in decision making- misconception. o Despite being exposed to some information, patient will never have the same level of knowledge and understanding as the doctor. Patient only needs to consider the received information and their own preferences. o The disclosure of many treatment alternatives and risks increase the patient’s anxiety- misconception. Decreased anxiety. o Shared decision making is a time-consuming process- using decision aids increases duration of consultation by only 2.5min on average. Or Fisher What are some decision aids that can foster shared decision making? o Patient information leaflets, websites, videos, etc that explain benefits and risks of different treatment options in comprehensible way. o Team work in the shared decision making process- consultation planning, gathering all information and questions possible about treatment options to address if patient asks. o Option grids- two or three treatment alternatives can be compared to each other in a grid on a single page, based on patient’s most common questions (6-8 aspects). o Multimedia decision support materials- professionally valid texts or videos. o Photograms/animals of procedures. Benefits of shared decision making? Patient will be: o More informed, retain more information about disease and treatment options o More realistic about benefits/risk of particular treatment o More active participant in their treatment o Feel that their decisions are more in line with expectations and values o More satisfied with treatment decisions. Or Fisher 8. Suggestive communication in medical practice. What is suggestion? o Type of communication that triggers an involuntary response, or a message that the receiver involuntarily accepts and follows. o Suggestion can manifest in: § Verbal communication- the statements a doctor makes or even their questions have a suggestive effect. § Non-verbal communication- doctor’s gestures, facial expressions, posture, tone of voice. § Physical environment- well-functioning hospital information system conveys order and reliability. why are patients susceptible to suggestion? o Particularly effective in an altered state of consciousness. Deviance from ordinary, vigilant, rational, dominant state of consciousness. When dream, under influence of alcohol/drugs, accident, disease, surgery, etc. o Loss of reality control- minor problem may seem very serious for patient or vice versa. o Law of negative interpretation- individual tends to take everything personally and of all possible ways to interpret information, chooses most unfavorable. o Trance logic- diminished logical reasoning. o Literalism- literal interpretation of what has been said. People do not understand jokes, humor taken literally. o Change in the perception of time- time may expand and evens can seen longer. o Intensification of emotions- good or bad o Primacy of visuality in cognition- enhanced visual thinking can make metaphors more effective. How does the use of positive suggestion change doctor-patient communication? o Recommendations instead of prohibitions- instruct patients what they should do o Positive framing- choose 90% survival rate rather than 10% mortality rate. o Future orientation- talk about why all procedures are happening, long term goal. o Focus on the goal- doctor communicates a goal to be achieved, lets patient decide how to accomplish it. o Involuntary response- formulating an expression so that performing it almost automatically happens. o Tailored communication- do not use generalizations like most patients.. o Making use of environment- integrating environmental stimuli to achieve goal. o Avoiding uncertain expressions- “sleep well” rather than “try to get some sleep” What is rapport and why is it essential? o Developing a good interpersonal connection. Two people are attentive to one another, become attuned to each other and work together to achieve common goals. o Contact- address the patient, greet them, introduce oneself, clarifying role in therapeutic process, asking questions. Or Fisher o Pacing and leading- doctor first immerses in patient’s experience and empathetically lets patient know they understand what they are going through. Once relationship established, doctor can lead patient in desired direction. What are some effective techniques for suggestion in medical communication? o Reframing- placing patient’s feelings and thoughts in positive framework. o Yes-set- initially, doctor asks only questions which the patient will answer yes to and only then do they state the target suggestion, so it will likely be accepted. o Implication- a latent suggestion whose purpose is not openly formulated. “the next time you try to quit…” implies there is a next time o Repetition- repeat suggestion to amplify effect. o Double bind- physician offers a number of equally suitable alternatives and patient chooses one of them. Gives patients a sense of control. o Visual comparisons- visual metaphor helps achieve goals. “just imagine..” o Paradoxical suggestion- making proposal that is seemingly contradictory to goal. o Anchor- connecting suggestion with an object or event. What evidence supports effectiveness of suggestive communication? o In field of surgery can: § Effectively reduce pain- patient experiences less pain/less painkillers used § Decrease frequency and severity of surgery-related complaints and improve patient’s physiological parameters § Effectively calm patients § Reduce recovery time in hospital o In field of interventional radiology- half amount of pain. o In obstetric practice- facilitates childbirth, reduce pain, speed labor process o In intensive care- duration on mechanical ventilation shorter and recovery time reduced. o In emergency care- increases survival rate and reduces duration in hospital o In pediatrics- collaboration between ill child and doctor to perform treatments o In dentistry- reduces anxiety, improves relationship, makes difficult situations more manageable. Or Fisher 9. Communication with children. What are some challenges in communicating with child patients? o Emotions that affect care- children can induce a lot of emotions in doctor which can affect the relationship that forms, manner of communication and even their care. Sadness, pity, urge to help. o Physician should therefore constantly be aware of effects of their emotions to avoid mistakes, whether downplaying problems if child behaving in hostile way or overtreating child due to heightened parental concern. o Challenges in adapting to various age groups- common problem is that doctor does not communicate with child according to their age and level of knowledge. o Lack of child involvement- doctors communicate with parents while child is left out of discussion. Expectation is clear for doctors to inform children on a level appropriate to their age and try to involve them in their own treatment. o Use of inappropriate communication methods- baby talk, deceive a child, threatening child with overly exaggerated consequences to get them to cooperate, getting child to do something by punishment or by implying punishment. o Challenges in relationship with parents- intense emotions and excessive (often insistent parental expectations) is source of difficulties in communication. A triadic relationship develops which leads to problems (when and to whom the doctor should speak, ask, inform). What can facilitate communication with children? o Preparing the child for examination- inform child where they will go, what will happen there, and what the purpose of it is. Use picture books. o Child-friendly environment- colorful scrubs, images on walls, toys on diagnostic equipment, games, books for children in waiting room, monitor in waiting room. o Connect- § Introduction- use name or nickname. Introduce themselves. § Pacing and leading- doctor enters world of child, generates conversation about this world, and only after relationship develops, does doctor begin to steer discussion toward topic of interest. § Yes- set- asking questions with yes answers § Familiarizing the environment o Taking the anamnesis- § Talk to child at eye level. § Personal information- in case of older children, should come from them. § Ask simple questions- open ended initially § Always ask one thing at a time. o Examination- § Proximity of parent- smaller children on parent’s lap, older next to them § Observation of non-verbal communication- see consequence of underlying disease § Build cooperation by asking for child’s help- exam with child’s cooperation and not against their will. Or Fisher § Double bind- outline two alternatives for child that are both equally good and prompt them to choose. § Playfulness- incorporate into exam § Use of analogies- help child understand tests (CT, ultrasound) § Tell-show-do method- show device you will use § Distraction- give task to do or talking about topic of interest § Praise- you are doing great! § Contracting- ask child to cooperate in return of small reward § Time delimitation- break down longer procedure into several shorter parts. § Give the child control- agree on sign ahead of time that enables this. o Informing the child- § Child has a right to be informed § Age-orientated information transfer- use simple, concise phrases. Encourage child to ask questions § Involving child in their treatment- more effective if child is cooperative. What characterizes communication with adolescents? o Provide opportunity for adolescent to talk to you without their parents present o Create a safe space- helps emphasize everything falls under doctor-patient confidentiality. o Doctor should inquire about important topics like smoking, alcohol, drugs, sex, depression, suicidal thoughts, eating disorders. o Adolescents may have a number of questions about sexuality and appreciate opportunity to ask. o If communicating about sensitive topics, doctor should remain professional and avoid moralizing. o Doctor retains their own style of communication, no baby talk. How should the doctor communicate with parents? o Build on the parent’s experience and help- parent’s observations are essential. Included in decision regarding treatment options. o Give parents the opportunity to formulate their questions and concerns o Be understanding with parents even if you disagree with them- convey emotional reflection, reframing, and normalization. o Handle the triadic situation well- do not forget to communicate with child. Or Fisher 10. Communication with older people. Communication with elderly having age-related mental disorders. What are some challenges in communicating with the elderly? o People around 60 count as elderly but not considered a homogenous group as spans 30+ years even though diseases of old age create a unified group (sensory impairment, dementia). o Polymorbidity is common- several somatic diseases and psychological disorders present simultaneously which can complicate diagnosis and treatment. o Several diseases treated with several medicines and their interactions and side- effects may be conflated with symptoms. o As time progresses, likelihood of cognitive and sensory impairments increase, making communication more difficult. o Some diseases render difficulties in speaking (stroke, Parkinson’s) o Health literacy levels may be lower on average o Social support may be diminished- problems in administering meds, creating diet, assistance. o Financial problems influence decisions regarding treatments o Difficulties in movement- less likely to visit doctor o Ageism- discrimination against older people. Stereotypes like elderly communicate complaints in long, convoluted way, go to doctor just to talk to someone, all have cognitive impairment which is why they do not understand doctor’s explanations. o Striving to conceal symptoms- due to social perception of symptoms (incontinence, mental decline), need to meet social expectations is high, do not want to lose their job, afraid to go to hospital, scared of being forced into nursing home, cultural factors. o Infantilization- treating adult as a child. o Triadic communication- if relatives interfere. How should the doctor communicate with elderly people? o Create a suitable environment- § Waiting room should have chairs suitable for older patients § Have handrails everywhere § If lighting in clinic is sufficiency and background noise is minimalized. o Plan on longer consultations- have more complaints and symptoms o Establish a partnership- entitled to receive patient information and participate in decisions relating to their own treatment unless restricted by law. o Uncover symptoms- doctor should actively seek to expose problems that patient may not have divulged. Creating safe space. o Communication aspects of sensory problems- inquire at beginning of consult. Provide information in written form if hearing/visual problems. o Provide appropriate level of assistance- independence and autonomy important. o Take cultural differences into account- may attribute symptoms to old age which are actually signs of treatable somatic disease. o Adequate assessment of age-related depression and risk of suicide. Or Fisher What methods can aid communicating with patients with dementia? o Clock test used to diagnose dementia. Asked to draw in numbers on circle and add dials to point at certain hour. o Time your visits- condition of people with dementia usually better in morning than in evening. o Cooperate with relatives- people living with patient know them best o Use yes-no questions more frequently- but not exclusively as open ended questions boost participation of person suffering from dementia. o Preserve dignity of patient- do not correct or engage in confrontation. o Make use of non-verbal communication- o Deal with one thing at a time- ask one short question at a time, repeat. o Deliver information in a way that is tailored to patient’s condition- concise sentences in simple way, information in smaller units. o Tell-show-do method- explain what will happen, show device used. o Chain method- after teaching first step, ask patient to perform it autonomously, then move on to subsequent step. How should the doctor react to delusions and hallucinators of schizophrenic patients? o Schizophrenia is chronic, severe mental disorder that affects way a person thinks, acts, expresses emotions, perceives reality, and relates to other. Symptoms include delusions, hallucinators, disorganized speech, disorganized behavior. Anosognosia related to frontal lobe changes. o LEAP model- listen, empathize, agree, partnership. o Recommended methods of responding to delusions and hallucinations. § Non-judgmental, active attention- asking right questions, paraphrasing. § Expression of empathy- emotional reflection and normalization. § Delay- if patient is talking about delusions and asks if we agree, delay. § Emphasizing areas of consensus- also point out where differ in agreement. § Opinion as hypothesis- the way I see it… § The need for respecting each other’s opinion- express that you respect their opinion and hope this will be reciprocated. Or Fisher 11. Cultural competence of the physician. Why is cultural competence necessary for a doctor? o Culture is a common set of values, traditions, beliefs, behaviors, forms of communication specific to certain race, ethnicity, religious or social group. o Culture significantly determines an individual’s notions about health, illness, healing and healers. o Western medicine itself is part of Western culture and reflects the current views and results of this era. o Cultural competence means doctors: § Are aware of importance of culture in prevention, early detection and treatment of disease § Respect other people’s culture § Understand challenges inherent in forming relationships and communicating with people of different cultural backgrounds § Know of and employ methods to answer challenges arising from differences. o Migration increased need for competence. We are all simultaneously members of different cultures and subcultures which need to be addressed. How does culture affect the doctor-patient relationship? o Differences in explanatory models of health and illness- views concerning causes of disease and treatment options differ within one culture. Notions of health and illness determine health behavior, attitudes, and prevention, appraisal of symptoms, when to seek medical attention, acceptance of explanatory models and therapeutic approach. o Cultural values and traditions- § Consumption of various foods and alcohol, and to sexuality and contraception. § There may be significant differences in communication between different cultures. Handshake, eye contact. § Present oriented vs future-oriented cultures. In present, prevention less significant. § Role of family may vary in different cultures o Patient preferences in doctor-patient relationship- § Western culture is more individualized, doctor is primarily in contact with patient only. § In collectivist cultures, community is more important than the individual. o Stereotypes, prejudices, racism- § A stereotype is a generalization concerning a group of people, underpinning belief that all members of group have same characteristics. § Prejudice is negative, hostile emotion, judgement, and attitude towards others based on stereotypes. Can manifest in emotions, ways of thinking, and behavior (avoidance, discrimination, aggression). § Contrast effect- people who do not meet stereotypical image of group. Or Fisher § Racism is hostility towards other races of humans and considering them inferior. o Language barriers- challengers may arise in communication. How do cultural differences affect doctor-patient communication? o Doctors usually keep more of a distance if patient’s culture differs from their own in a significant way. Less of a partnership, doctors rarely involve patients in decisions about treatment. o Patients exhibit a similar pattern of communication to doctors- disclose fewer symptoms, express feelings less, less friendly communication than in intracultural relationships. o Lower patient satisfaction and reduced compliance. Can impair therapeutic effectiveness. What methods can help bridge cultural differences? o Cultural competence in doctor-patient relationship- § Vital for doctor to raise awareness concerning culture’s prominent role in determining lifestyle and health behavior. § Culture specific questions to pose: What do you attribute these complaints and symptoms to? Have your tried any remedies to treat your symptoms? Do you have any concerns about the treatments I recommended? § Doctor should respect beliefs of patient. § It is not necessary to prove the patient wrong, sufficient for doctor to endorse their own opinion. § The doctor’s goal is to convince the patient to accept their recommendations. § Physicians should not have prior assumptions o Characteristics of culturally competent healthcare organization- § Culturally competent healthcare system provides both cultural and language services to reduce health inequalities. § Training- understanding cultures, focuses on cultural aspects of doctor- patient relationship and communication. § Collaborate with community helpers- act as facilitators between healthcare sector and community members. § Culturally diverse medical staff- reduces prevalence of stereotypes, increases respect. § Culturally competent health promotion- takes into account the value system and specific attitudes of target cultures. § Reducing language problems- Multilingual signs and patient forms Dictionaries Interpreters- should be from hospital, not family member. Or Fisher Exam topics list „B” 12. Communication about functional symptoms Why do people who are deemed healthy by their doctors receive so many diagnoses? o If a patients has complaints or symptoms that do not have an underlying physical cause, they can receive a variety of diagnoses. o Every discipline has own diagnoses for functional complaints- chronic pain, dizziness, fibromyalgia, irritable bowel syndrome, atypical chest pain, tension headache, etc. depends on expertise of doctor patients sees. o “functional” is used to describe complaints and symptoms bearing no organic cause, and “somatization” is psychosocial disturbances manifested in bodily symptoms. How do functional symptoms develop and what sustains them? o Somatizing patients keep seeking medical attention because they do not receive a clear explanation of what causes their symptoms. Develop conviction that they have a hidden, difficult to diagnose illness for which medicine has no cure. o Somatization is a process in which predisposing, triggering, and maintaining factors play a role. o Predisposing factors- § Anxiety or depression in family- increased risk of genetics, parents have direct (child-rearing) and indirect (setting example) effect on how child learns to cope with stress and resolve conflicts. § Traumatic experiences in childhood- divorce of parents, moving, abuse § Some personality traits- catastrophizing, pessimism, alexithymia (difficulty in identifying and expressing emotions) § Previous physical illness o Triggering factors- § Difficult periods, crises- divorce, unemployment, losing close relative § Micro-stressors of everyday life- low intensity but prolonged, repetitive, constant stress effects. § Stress is a bodily reaction. Prepares for fight or flight. Stress-related physical changes can produce symptoms that may be interpreted as illness. Increases concern. o Maintaining factors- § Increased self-observation- triggers vicious cycle. May interpret normal signs as severe disease causing anxiety which prompts even more attention to bodily complaints. Somatosensory amplification- increased anxiety creates new symptoms like indigestion, skin irritation, arrhythmia, muscle tension/pain. § Reduced activity- becomes more isolated. Lack of exercise induces or increases somatic complaints and self-observation. § Excessive medical examinations- tests show discrepancies causing anxiety. Increases conviction that there is some disease which doctors are looking for but cannot find. Or Fisher § Advantages of illness- person receives more attention, is exempted from tasks, and avoid difficult situations/conflicts solidifying sick role. § Ex: medical student disease- nosophobia, fear of illness. How can somatization be recognized? o Doctors diagnose by trial and error, performing tests and excluding everything that indicates physical illness. o If basic tests are negative and positive diagnostic criteria for somatization (not via exclusion) persist, can be deemed functional. o Symptoms are diverse, affect several organ systems at the same time. o Patient cannot identify symptom precisely and tries to describe physical place and sensation in metaphoric way. o The more unverified symptoms and complaints, more likely a psychiatric disorders (somatization, depression, anxiety). o Complaints do not align with diagnosis. Complaints and symptoms are not constant but fluctuate in time. o Symptoms appear and intensify in correlation with personal difficulties, stressful life events. Do not occur or rarely occur during sleep. o Symptoms persist for long time. o Patient arrives to doctor with list of complaints, has already undergone a number of tests, treatments, arrives with much documentation. o Patient did not cooperate with previous doctors, low adherence, discontinued treatments, switched doctors. o Patient spends a lot of time observing, measuring, documenting their condition o Patient assigns great importance to minor problems/deviations in results. o Patient’s emotional reactions are fickle or extreme, patient is anxious/depressed. What to do if the patient, in fact, has a rare and undiagnosed illness? o Diagnosis of somatization should not mean doctor has no additional duties towards patient. Should be followed by therapy. Follow up sessions necessary so doctor can re-evaluate patient’s complaints and if needed, modify diagnosis. What mistakes are to be avoided when treating somatizing patients? o Denying the reality of symptoms- making it up, blaming patients. o Collusion and giving pseudo-diagnoses- to “reassure” patient. Confirms patient’s belief that despite negative test results, there is physical illness. Symptoms may temporarily subsite due to placebo effect but then reappear. o Failing to provide further help, immediately referring patient to a psychologist or psychiatrist. Due to stigmatization associated with this care, most patients will not accept this line of treatment. o Prejudice against somatizing patients- doctors assume these patients are acting to avoid work. In reality, passed from one doctor to next. A negative attitude due to prejudice significantly complicates treatment of somatization, patient does not heal which causes frustration and feeds back into prejudice. o Diagnosis of somatization is stigma. Often diagnosed with depression or psychiatric illness which carries more stigma. How to treat functional symptoms within the framework of somatic medicine? Or Fisher o Somatization can be treated with reattribution. Functional symptoms are given a new meaning, novel interpretation. Patients need to realize symptoms are ordinary and not caused by physical illness. o Feeling understood- § Accept that symptoms are real § Emphasize how frequent these symptoms are § Exclude somatic disease § Get to know the patient’s viewpoint- ask patient what they think causes complaints. o Changing the agenda- provide framework of interpretation for complaints and symptoms by mapping psychosocial background. § Ask for permission- motivate patient to consider other causative factors. § Map psychosocial factors by posing questions- when symptoms appear, what exacerbates and alleviates, what family/work circumstances are, if they are anxious. o Making the link- § Place complaints into psychosocial context- emphasize that events are frequently associated with important life events and stress. § Explain how psychosocial problems can provoke bodily symptoms- body can react to emotions/thoughts. § Symptom normalization- not sign of disease, normal bodily reactions. § Distinguish between complaints of functional and somatic origin- a somatizing patient may also have a somatic disease. o Negotiating further treatment- § Tell the patient about the vicious cycle of self-observation § Call the patient’s attention to importance of being active § Solution-oriented thinking § Successive (step-by-step) problem solving. § Using social support § Recommend stress management methods to patient. § Treatment of anxiety and depression § Keeping a symptom diary § Negotiate periodic meetings with patients § Set clear goals What can be done if this approach does not work? o Refer to psychologist/psychiatrist. o Cognitive behavioral therapy is effective treatment- aim to change way patient thinks and behaves with regard to own symptoms. o Acceptance and Commitment therapy- goal is for patient to learn to live with uncertainty generated by symptoms. o Need to treat underlying anxiety and depression. Or Fisher 13. Communication with patients using complementary and alternative treatments. What are the boundaries of conventional medicine? o In addition to conventional medicine (Western), other approaches exist to treat and prevent disease. o Complementary medicine- supplementary methods of assessing health and treating and preventing disease. Used with conventional medicine. o Alternative medicine- used instead of conventional medicine. o Complementary and alternative medicine (CAM)- methods of assessing health, treating and preventing disease by means other than Western medicine. o Integrative medicine- conventional medicine and CAM working together o Holistic medicine- takes physical, psychological, environmental, social and spiritual dimensions into account regarding health preservation. o Types of CAM treatments- § Natural treatments, herbs, substances of animal origin, vitamins, probiotics, dietary supplements. § Reiki/magnotherapy- founded on energetic system. Based on unity of body and mind. Yoga, meditation, visualization. § Address musculoskeletal problems with manual methods- massage. § Healing systems and homeopathy § Western medicine uses many herbs in everyday treatment (chemotherapy, etc). § Two areas can be distinguished by adherence to or an absence of a scientific approach and practice. Why are complementary and alternative methods popular? o Promise of holism- deals with whole person, not one aspect. Focus on unity of body and mind, psychosocial aspect of disease o A preference for the natural- CAM thinks whatever is synthetic is harmful while anything natural is beneficial to health. o Promise of no side effects- CAM practitioners do not talk about risks involved. o Desire for quick and complete healing- due to increase in chronic patients who are older, medicine provides alleviation for symptoms, not cure. CAM assert they can heal patients who are chronically or terminally ill. o Philosophical congruence- western medicine gives biomedical explanations for disease (genetic, environmental). CAM focus on spiritual or emotional causes. o A number of CAM practices may have side effects and be toxic. Several CAM methods proven ineffective. Why do doctors and patients fail to talk about these issues with each other? o It is important for physician to know whether their patient is using CAM and if so, which treatments in particular. Can impair effectiveness of biomedical treatments, may be harmful. o Almost 2/3 of patients do not disclose to their doctor they are using CAM. Fear doctor would not approve. o Usually, doctors try to avoid talking about this subject too. Doctors disregard topic. Or Fisher How should the doctor speak with their patient concerning CAM treatments? o Conversation should be initiated by doctor- ask about employed treatments, especially in patients suffering from cancer or chronic disease. Important to indicate they are open to discussing this in future as well. o Expressing understanding by doctor. Creates trust. § Normalization- like you, many patients use this method § Emotional reflection- I see you are worried about this and are trying several methods to help you heal. o Providing reliable information on CAM treatments- reliable, scientifically- grounded information about treatments. o Useful supplements to medical treatment- § Acupuncture effective in treatment of some pain (lower back, neck, migraine prevention). § Acupuncture, acupressure, aromatherapy and massage not useful for side effects of chemotherapy like nausea. o Methods impairing effectiveness of medical treatment § High doses of vitamin C reduce effectiveness of chemotherapy and radiotherapy § St. John’s Wort, oregano, yucca- reduces level of active ingredients in chemotherapy drugs § Grapefruit, milk thisle, cat’s claw- increase side effects of chemo. o Remedies proven to be harmful § Vitamin B17- not useful in cancer treatment. Releases cyanide during digestion, worsens conditions of cancer patients § Gerson diet- coffee enemas lead to electrolyte disorders (potassium deficiency) and colitis. o Methods whose effectiveness is not clear yet § Ayurvedic medicine and traditional Tibetan medicine. Why is it beneficial to communicate about CAM treatments? o Helps patients make decision based on professionaly reliable information, reduce harmful effects of potentially misleading information, decrease patient uncertainty and distress. o Open communication ensures patient satisfaction and improves doctor-patient relationship. Or Fisher 14. Communicating about intimate issues. When should the doctor talk to patients about sexual issues? o When the doctor speaks with a sexually healthy patient about sexual issues- related to contraception, conception, artificial insemination, pregnancy, miscarriage, abortion, STD. o When sexual disorder is a symptom, sign, or consequence of disease- endemics like diabetes/hypertension can cause erectile dysfunction. Detection can help cardiovascular prevention. Sexual problems may be symptoms of neurological diseases, psychiatric disorders. o When a sexual disorder occurs as side-effect of a drug- antihypertensives and antidepressants cause sexual problems. o When sexual disorder occurs as result of surgical intervention- amputation, breast surgery, uterine removal, stoma. o When patient is seeking advice for sexual problem o Practitioners should address these issues with almost all of their patients. Why do patients and doctors often avoid sexual topics? o Patients are usually ashamed to speak about this topic and doctors often fail to ask. Doctors feel intrusive asking questions about their patient’s sexual life. o Both sides feel the other side will address it if needed. How should the doctor converse about sexual issues with their patient? o Doctor should initiate the conversation- note in advance that these are routine questions posed to everyone. Assure them disclosed information will stay confidential. o Doctor’s behavior and communication set an example for patient- doctor does not show perplexity or astonishment, have accepting, open attitude. o Basic issues regarding sexuality- are you in relationship, how often do you have sex, are you using any contraceptive methods, do you have any sexual problems, do you have any questions about sexuality? o Normalization and reframing contribute to reducing patient anxiety- physician should note that this is a common problem and many people struggle with this. Should provide positive frame for situation patient has experienced as negative. o Finding the right phrases- avoid vulgar, childish expressions and euphemisms. Use neutral terms related to sex life in patient’s mother tongue. o Importance of avoiding semantic confusion- same concept is used differently by participants of a conversation. Frigidity, premature ejaculation, sex life are all terms used that mean different things. Important to clarify what these concepts mean. If patient discloses a problem, doctor should ask them to elaborate. o Use questionnaires- international index of erectile function questionnaire. Female sexual function index. o Involve partner in treatment of sexual problems- improper communication can aggravate sexual disorders while proper communication contributes to healing. Partner’s reaction can be assessed with circular questions (map interactions). Partner should be included in consultations regarding the sexual disorder. Or Fisher How can the doctor help resolve sexual problems? PLISSIT model helps practitioners find optimal level of assistance- o Permission- doctor creates environment in which patient feels they can speak openly about sexual issues. Doctor confirms how natural and normal manifestations of sexuality are. Ex: masturbation (guilty habit), misconception that orgasm reached by stimulating clitoris is inferior to vaginal orgasms, men more proactive at initiating sex than women. o Limited information- number of sexual disorders can be treated with simple advice or patient education. Ex: afer menopause, natural lubrication often inadequate so use creams or lubricants, in older men developing an erection may take longer and need more intense stimulation, misunderstandings concerning pharmacological treatment of sexual disorders (think ED meds work on their on and do not need stimulation). o Specific suggestions- sensate focus exercises to relearn sexuality. First step is temporary prohibition of sex which frequently achieves the opposite, eliminating performance anxiety. o Intensive therapy- individual or couples therapy. What are the characteristics of communication with people belonging to sexual minorities? o Sexual orientation- persistent emotional and behavioral pattern that expresses which sex the individual is attracted to o Gender identity- how individual conceptualizes their own gender o Heterosexual- attracted to individual of the opposite sex o Homosexual- attracted to individual of the same sex. Lesbian and gay. o Bisexual- attracted to both sexes o Transgender- gender identity is not the same as sex at birth o LGBTQ+ used to list these o How common is same-sex attraction? 1.7% of adult population considers themselves homosexual, 1.8% bisexual, and 0.3% transgender so proportion of those that classify as LGBT is 3.8% in total. Boundaries not clear cut. Kinsey scale- indicates degree of homosexuality (0 (heterosexual)- 6 (homosexual). o How is health status of LGBT community different than those of heterosexuals? § Some inherent risk factors and the prevalence of some diseases is higher in this group. HIV infection, syphilis, and gonorrhea more common. Due to HPV infection, colorectal cancer more common in homosexual men. § Homosexuality associated with smoking, being overweight, increased psychoactive drug use, depression, anxiety, suicidal ideation and suicide. § Lesbian women at higher risk of heart attacks, cervical cancer, breast cancer, and asthma. § LGBT individuals utilize healthcare services less often. Participate in gynecological screening less causing cervical and breast cancer. § Increased prevalence of psychological disorders due to “minority stress” Or Fisher o Does the doctor need to know their patient’s sexual orientation? Doctor should know their patient’s sexual orientation, similarly to other factors influencing health. Affects medical advice and determines screening methods. o What factors pose a challenge in communicating with LGBT community? § Doctors underestimate proportion of patients who are not heterosexual, have little knowledge of health problems people in LGBT group may have. § Fear of discrimination. Include posters in waiting room that include LGBT- related materials. o What aspects of communication should the doctor take into account? § Question of sexual orientation- should be included in documentation or during conversation (sexual anamnesis). § Providing open, accepting environment- word use- employ phrases that promote safe space. § If patient indicates orientation other than heterosexual, doctor should continue with specialized counseling. Safe sex, STDs, vaccinations, referral to screenings. o Communicating about incontinence- embarrassing, reduce sex life and increase social isolation. Or Fisher 15. Communication with tense, hostile people. Why can healthcare be considered a hazardous workplace? o Hostility and aggression in healthcare may arise for several reasons. o Aggression as a consequence of disease- addiction, personality disorders, psychosis, mental disability, and dementia increase likelihood. Symptoms of disease (pain) causes increased tension in patients. Can be caused by organic disorders (epilepsy, brain tumor). o Aggression as situational problems (frustrations, conflicts)- difficulty in navigating new environment, long waiting time, healthcare workers do not communicate properly, patient feels they are receiving unjust treatment. o Aggregation as a personality trait o Healthcare and social work constitute the second most dangerous area to work in. 75% of work-related violence occurred against healthcare and social workers. Verbal or physical aggression. Most common in psychiatric and emergency departments. Nurses most vulnerable. How can hostility and aggregation be prevented? o Placing emphasis on prevention of aggression rather than handling hostile situations already in progress. o Prevention at organizational and individual level. o Organizational-level prevention options- § Organizational risk assessment- listening to experience, suggestions, and opinion of workers, analyzing previous incidents, reviewing the design and facilities of an institution from the perspective of safety (admission located further from ward is security risk, leaving healthcare devices accessible). § Reducing risk- individual level prevention is establishing a security service. Can make it rule to have sufficient number of healthcare workers trained in preventing and managing aggression present during each shift (aggression management team). Technical options include closed-circuit TV network, alarms, panic buttons, portable personal alarms. § Security policy- provides regulations for employees. § Aggression prevention and management training- address psychological, legal, & ethical considerations, give knowledge on aggression prevention. § Informing patients of their rights and responsibilities- should also know about their legal responsibilities. § Complaints handling policy- within institution and beyond (patient rights representation). § Reducing work-related stress levels- make appointments to decrease wait times, doctors should be transparent. § Reviews- monitor technical equipment, assess the trainings, analyze extent to which implemented safety regulations improve security. § Relationship-level prevention options- respect for human dignity, being empathetic, adhering to rules of intimacy, respecting patient’s autonomy. How can threatening situations be detected in time? Or Fisher o Individual risk analysis- doctors should devote more attention to possibly aggressive patients. § Circumstances of entering health care institution- if brought in by police or ambulance from a fight, greater risk. § Signs to watch for in anamnesis- violence, crime or alcoholism in family. Behavioral disorders at school, childhood cruelty, criminality, self- destructive behavior. Use of psychoactive drugs, addiction. § Heteroanamnesis- relatives may indicate aggressive behavior of patient. § Diagnosis- mostly addicts or personality disorder patients. § If patient considered potentially hostile, individual aggression management plan should be developed. o Signs in communication that suggest escalating tension- § Gestures, tense posture, hyperactivity, increased level of arousal (fast breathing, dilate pupils, muscle tension), prolonged eye-contact, intense urge to speak, uncoordinated movement, impaired thinking, repeating signs of previous violent behavior, verbal threat. How can proper communication help manage hostility? o Strategies to avoid- § Asking patient to calm down. § Belittling the problem § Using a superior tone of voice § Criticizing or looking down on patient § Reacting aggressively. o Recommended methods- § Retain a helping perspective- apply anger management techniques. § Maintain adequate distance § Use a calm tone of voice § Stay polite § Try to maintain a one-to-one- stimuli from multiple people can feel threatening. § Exit the situation if necessary o Level one: evasion- let the first one go (first harmful word/sentence should be ignored). Give short, neutral responses. o Level two: assertive responses without confrontation. 3 ways to react to conflict: employ aggression, be submissive or passive, or be assertive (represent our own position at same time expressing understanding of other party’s viewpoint. § Expressing our understanding- Emotional reflection- make contact, first step of pacing-leading. Clarification- what happened and what they are referring to. Conveying attention and empathy- understanding is not agreement, simply an understanding of what other person is saying/feeling. Expressing regret- “I’m sorry”. Even if do not agree with patient. Or Fisher § An objective explanation of our own position- short, do not want to lead to new debates. § Solution-oriented communication- compromise acceptable to everyone. o Level three- assertive responses with confrontation- § An objective description of the situation- unemotional. § Stopping verbal aggression- first formulate the problem, then disclose what you would like to happen. § Guiding the conversation in constructive direction o Level four- offering other ways of handling complaints- turning to head of department. Or Fisher 16. Communication with depressed patients. Recognizing the risk of suicide. What are depression warning signs? Specifics of communicating with depressed people- o Misunderstandings surrounding notion of depression- depression is not the same as just being sad. It is an illness, persistent mood disorder. o A lack in detection- both patients and doctor focus on somatic or concomitant symptoms that are associated with depression. Weight change, loss of appetite, sleep disorders, pain). o Observing the patient’s non-verbal communication may help recognize depression. May neglect physical appearance, physical movements slowed down, facial gestures are expressionless, rigid face, avoiding eye contact, hand gestures reduced. Posture, shoulders and head are drooping. Speech slower, monotonous, response time is longer. Inhibition in expressing emotion. o Observing the content of verbal communication can help detect depression. Beck’s triad- negative views of oneself, about world, and about future. Feel helplessness and abnormal lack of energy, anergia. Inability to feel pleasure, anhedonia. Complaints surrounding sleep (wake up earlier, cannot go back to sleep). o Two question screening- have you been bothered by feeling down, depressed or hopeless in last month? Have you been bothered by having little interest or pleasure in doing things? o Applying depression screening questionnaires- Beck Depression questionnaire and patient health questionnaire, determine severity of depression. o Patient education- dispels misconceptions. Not a sign of weakness but requires therapy. A lot of sleep and inactivity exacerbates symptoms. o Using low-intensity psychological interventions- behavioral activation aims at breaking one of basic self-destructive cycles in depression, reducing activity which exacerbates disease. Patient should keep diary of mood and activities and observe correlations between them. Then asked to select some activities to be monitored or measured and prepare an activity plan and schedule these activities in daily routine. How can one recognize suicidal intent in another person? o Cry for help- preparation for suicide is a process so intent can be recognized in time. Can manifest as vague implications or explicit expressions. Before committing the action, a significant part of those with suicidal ideation visit their physicians. o The screening of suicidal ideation with a targeted question- ask directly, do you have any suicidal thoughts? Especially patients with psychiatric disorders (in background of 90% of fatal suicides). Other disorders with high risk of suicide include addictions (alcohol and drug related), schizophrenia, personality disorders. Increased risk in those mourning and high among the elderly. o Warning signs- makes references to committing suicide or talking about their suicidal thoughts. Previous suicide attempt, frequent absences from school or workplace, neglect of friends, acquaintances, previous interests, hobbies. Increasing alcohol/drug use, sleep disorders, distress, tension, impulsive Or Fisher reactions, risk-taking behavior, changes in mood, negative vision of future, hopelessness, feeling of isolation, neglect of basic needs, searching for information about ways to commit suicide. o Presuicidal syndrome- Ringer’s model § Constriction- at level of social interaction (reduced contact), level of behavior (decline in interests), level of emotion (persistent depressive, anxious, or tense state), or cognitive level (preoccupied with suicide). § Aggression towards oneself- manifests in self-harm, self-injury, verbal aggression. § Suicidal fantasies- implicit references or explicit communication of suicidal intent. What should the doctor do if there is risk of suicide? o Assess the risk of suicide- first stage is entertaining thoughts about death. Then suicidal thoughts appear and fantasies and preparations follow. § Suicidal ideation- doctor should ask open-ended questions regarding suicidal thoughts and if warning signs exhibited. § Suicidal fantasies- do you think about how? § Preparation for suicide- ask about what preparations have been made. Those who have taken steps are in life-threatening situation, require immediate medical assistance. o Take preventative measures according to extent of risk at hand- § Desperation, thoughts about death, no intent to commit suicide- physician should assess whether the patient is depressed (Beck’s scale) and treat appropriately. Use successive problem solving, patient chooses solution they think are realistic and start implementing in order of increasing difficulty. § Suicidal ideation, suicidal fantasies (without making preparations)- patient should be directed to psychiatric care. Useful for doctor to propose assisting the patient with making an appointment. Patient should be provided information leaflets about phone support services and sites of care. Doctor should offer their own help and regularly check up on their patient. § Making preparations- need immediate hospitalization. Patient should be convinced of need for doing this. Analogies can help persuade patient concerning the necessity of hospitalization. May have to do against will. Or Fisher 17. Communication with patients having anxiety symptoms or addictions. How can doctors identify signs of anxiety and help an anxious patient? o Anxiety disorders- independent of triggers and persist, not proportionate to underlying cause. Panic disorder, phobias, PTSD). o Nonverbal and verbal signs of anxiety- § Handshake- hands are cold and clammy, handshake is weak. § Flushing- patient’s face, neck, upper chest may turn red. § Dry mouth- change in voice, licking their lips often. § Sweating- armpits or palms. If severe also on forehead. § Blinking- increases § Respiration rate increases breathing becomes shallow- speech may be fragmented, might pause often to breathe deeply or sigh. § Behavioral repertoire narrows- anxious patient is restrained, inhibited. § Movements aimed to reduce anxiety- pace up and down, tap fingers § Speech is characterized by stereotypes that provide safety § Sentences are either very short or extremely long. Masks distress. § Disturbances in speech- disruptions, wrong word order, leaving out or repeating words, stuttering, incomplete sentences. Mahl scale- indicates level of anxiety based on incidence of 10 signs of disturbances. § Incongruent communication- force fake smile, laugh when not appropriate, want to appear calmer than they are. o Assessing anxiety with a questionnaire- State-Trait Anxiety Inventory (STAI) or Hamilton Anxiety scale. o Options for reducing anxiety- § Revealing the cause of anxiety- beneficial if anxiety is reactive. § Providing information- worrying about an uncertain, unpredictable, threatening future. Alleviate by informing them of expected waiting time, events before examination, what will happen. § Ensuring control- asking for permission, offering options, discussion of therapeutic options. § Distraction- in children but maybe for adults too. Changing topic of conversation. § Control of respiration- vicious cycle of shallow breathing and gasping for air. Causes dizziness due to increased CO2 causing further anxiety. To break cycle, breathe slowly and evenly. How can a doctor spot warning signs of addiction in patients and what can be done to help them? o Early detection and treatment is important as common cause of mortality and work disability. o Anamnesis and physical examination- medical history characterized by frequent accidents and injures, being absent from work/school, BP fluctuations, GI symptoms, anxiety, depression, attempted suicides, sleep disorders, sexual dysfunctions. Not smell of alcohol on breath, characteristics of speech, traces of Or Fisher injuries/injections, shaky hands, sweating, dilated or constricted pupils, bloodshot eyes, inflammation or ulceration of nasal mucosa, rapid HR. o Screening with questionnaire- § Two-question screening- in last year, have you drunk or used drugs more than you meant to? Have you felt you wanted or needed to cute down? § CAGE questionnaire- if answers yes to questions, suspicition. Cutting down- have you felt need to cut down on drinking? Annoyance by criticism- have people annoyed you by criticizing? Guilty feeling- have you felt bad/guilty about drinking. Eye-openers- have you had drink first thing in morning to steady nerves/get rid of hangover? § AUDIT questionnaire- alcohol use disorders identification test. 10 questions that map level of alcohol consumption (1-3), alcohol dependence (4-6), adverse effects of consumption (7-10). § ASSIST questionnaire- alcohol, smoking, and substance involvement screening test. First question asks about types of psychoactive substances used throughout life. 2nd in last 3 months and how often. 3-7 explores severity of substance abuse, 8 asks if patient injected drug. Out of 39. Low score 26)- strong likely hood of dependence already present. Has effects on health, social, legal, financial and relationship. Need addiction treatment. Excellent effectiveness (sensitivity 95-100%, specificity 79-93%). o Helping addicts- 5As and 5Rs method, motivational interview and stages of behavioral change model. § FRAMES model- Miller and Sanchez. Feedback- informing patient of physical/psychosocial consequences and symptoms of alcohol consumption. Responsibility- emphasizing patient’s own responsibility Advice- doctor should clarify that they recommend quitting Menu- doctor should suggest several good options for implementation of change. Empathy- should pervade whole conversation. Self-efficacy- doctor should reassure patient that they are capable of change, augmented with genuine compliments. How should the doctor react to delusions and hallucinators of schizophrenic patients? o Schizophrenia is chronic, severe mental disorder that affects way a person thinks, acts, expresses emotions, perceives reality, and relates to other. Or Fisher Symptoms include delusions, hallucinators, disorganized speech, disorganized behavior. Anosognosia related to frontal lobe changes. o LEAP model- listen, empathize, agree, partnership. o Recommended methods of responding to delusions and hallucinations. § Non-judgmental, active attention- asking right questions, paraphrasing. § Expression of empathy- emotional reflection and normalization. § Delay- if patient is talking about delusions and asks if we agree, delay. § Emphasizing areas of consensus- also point out where differ in agreement. § Opinion as hypothesis- the way I see it… § The need for respecting each other’s opinion- express that you respect their opinion and hope this will be reciprocated. Or Fisher 18. Breaking bad news. What counts as bad news? o Significant negative impact on how the patient or their relatives envision their future. Receiving diagnosis of chronic disease, loss in body function, or serious, irreversible damage to health following an accident. o Diagnosis of incurable, terminal, life-threatening disease. Does it need to be said? o Adults in possession of their faculties have the right to information regarding their illness and condition. o Doctor should ask patient if want to know the information and in what form. Who should deliver the bad news and when? o Who should break the news? The doctor treating the patient, the attending physician who first learns about the test result that makes the diagnosis certain. o Who should be informed? The patient should be informed, as well as the relatives the patient agrees to inform. Always need consent. o When should the patient be informed? Delivering bad news is a process. List many possibilities for symptoms before testing. If the test result confirming the diagnosis comes in, talk to the patient as soon as possible. o Where should the bad news be disclosed? Preferably in doctor’s office, not in hallway or during rounds as others may be privy to information. How should the diagnosis of severe, incurable disease be communicated to patient? SPIKES- o Setting up (preparation)- § Get prepared for the patient, review medical history, tests results. § Prepare written material to give to patient- Leaflet, tissue § Get time, but not interrupted. Plan course of conversation. § Ask patient if they wish to have relative present. o Patient Perception (mapping patient’s knowledge)- § Question about the psychological state of patient. If complaints of increasing and new symptoms, suspects illness to be more serious. § Questions about how much they know about the current state. o Invitation to break the news (request consent)- § Find out how detailed they want to know about the bad news § Double bind and normalization can be used. § Some patients want me to tell them the information, while others are only interested in main points. o Knowledge (sharing information)- § Simple to understand wording, short, straightforward wording. § Gradual disclosure- information should be communicated in cascade, smaller portions. Go on