Otago Medical School Clinical Skills 2023 History Taking PDF

UNIVERSITY OF OTAGO Te Whare Wānanga o Otāgo ELM OTAGO MEDICAL SCHOOL Te Kua Hauora o Otāgo EARLY LEARNING IN MEDICINE Clinical Skills 2023 History Taking in Te Aurorotanga / Early Lea...

UNIVERSITY OF OTAGO Te Whare Wānanga o Otāgo ELM OTAGO MEDICAL SCHOOL Te Kua Hauora o Otāgo EARLY LEARNING IN MEDICINE Clinical Skills 2023 History Taking in Te Aurorotanga / Early Learning in Medicine (ELM) The Clinical Skills Module in ELM provides opportunities to build the foundational clinical skills used in a consultation with a patient. You will learn these through hands- on learning activities, tutorial-based discussions and independent learning. Our aim is that you leave ELM Clinical Skills able to use and develop your consultation skills further with the patients you work with in ALM. Table of Contents Introduction to the Consultation _______________________________________________ 4 Calgary-Cambridge Guides Communication Process Skills ___________________________ 8 Initiating the Session _______________________________________________________ 13 Preparation (based on CCG Skills 1-2) ______________________________________________ 14 Establishing Initial Rapport (based on CCG Skills 3-5) __________________________________ 15 Identifying the reason(s) for the consultation (based on CCG Skills 6-8) ____________________ 17 Negotiates the agenda (based on CCG Skill 9) ________________________________________ 20 The Disease-Illness Model ___________________________________________________ 22 Gathering Information ______________________________________________________ 24 Gathering information __________________________________________________________ 25 The Process Skills used in Gathering Information_________________________________ 27 Exploration of Patient’s Problems (CCG Skills 10-18) ___________________________________ 30 3 The Patient's Perspective ____________________________________________________ 37 The Content of the Medical Consultation _______________________________________ 40 History of the Presenting Complaint(s) – Exploration of the Patient’s Problems _____________ 41 Exploration of the Patient’s Problem(s) from the Patient’s Perspective ____________________ 46 Building the Relationship ____________________________________________________ 51 Building relationship ____________________________________________________________ 52 Using Appropriate Non-Verbal Behaviour (based on CCG Skills 25-27) _____________________ 53 Developing Rapport (CCG Skills 28-31) ______________________________________________ 56 Providing Structure ________________________________________________________ 59 Providing structure to the consultation _____________________________________________ 60 Making Organisation Overt (CCG Skills 21, 22)________________________________________ 61 Attending to Flow (CCG Skills 23, 24) _______________________________________________ 63 Closing the Session _________________________________________________________ 64 Closing the session _____________________________________________________________ 64 Forward Planning (CCG Skills 55,56) ________________________________________________ 65 Ensuring Appropriate Point of Closure (CCG Skills 57,58) _______________________________ 66 History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 2  Key Contacts Clinical Skills Convener Dr Ruth Barnett Otago Medical School Ground Floor, Sayers Building Email: [email protected] Clinical Skills 2 Lead Tutor Steve Tripp Otago Medical School Ground Floor, Sayers Building Email: [email protected] Clinical Skills 3 Lead Tutor Sarah Holborrow Otago Medical School Ground Floor, Sayers Building Email: [email protected] ELM Administrators Otago Medical School Ground Floor, Hunter Centre Phone 479 7140 Email [email protected] Who you should contact: Clinical Skills Convener, Dr Ruth Barnett With feedback or comments about the course [email protected] For enquiries about the Moodle page, guidebooks and resources [email protected] For leave bookings and for tutorial absences Your Clinical Skills Tutor For tutorial absences and for all other enquiries and concerns This Reference Guide is subject to change – please go to the Clinical Skills Moodle page for the most up-to-date version. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 3  Introduction to the Consultation1 The main aim of Clinical Skills in Te Aurorotanga / Early Learning in Medicine is that students develop the skills needed to carry out a basic clinical consultation. A successful clinical consultation requires: knowledge skilled communication skilled physical examination clinical reasoning These four aspects need to be integrated for an effective clinical consultation. They are linked and are not adequate if used in isolation. The outstanding clinical reasoning abilities of a doctor will be of little use if the doctor does not have the communication skills to elicit why the patient has come to see them or what concerns they have. The outstanding communication skills of a doctor will be of little use if they are unable to competently perform a physical examination, or do not have adequate knowledge to reach a diagnosis. In Clinical Skills, we use scenarios based on typical illness presentations to enhance your learning. In these scenarios the patient presents with a presenting complaint or problem for you to analyse. It should be noted that not all patients will present with illness, they may seem quite well and despite this still need the knowledge and skills of their doctor. The communication skills you learn in Clinical Skills can also be used in these situations. The Calgary-Cambridge Guide The Calgary-Cambridge Guide was developed in the 1990’s by a group of medical academics from both the United Kingdom and Canada in response to emerging evidence that the way to provide safe and effective medical care for patients is through a Patient-Centred Medicine approach. The Calgary-Cambridge team systematised the process of the medical consultation, breaking it down into identifiable and teachable skills. They revised their work in the early 2000s to include the content aspect of the consultation. The Calgary-Cambridge Guide that we use as the basis of our teaching employs an evidence-based stepwise approach to identifying and mastering the skills in the medical consultation. The Calgary-Cambridge Guide on the following pages is a summary of the skills that are used to take a history from a patient. You will learn some of these skills in subsequent weeks. Not all of the skills in the Calgary-Cambridge Guide are covered in ELM. You do not need to memorise the particular skill and number. You do need to be able to identify a skill and explain why it is useful in a consultation. The skills listed in the guide are ones that you will build on as you advance in your medical training. Every patient is unique with experience you will be able to use the skills with flexibility to allow you to modify the consultation for the patient you are seeing. 1 Kurtz S, Silverman J, Draper J. Skills for Communicating with Patients 3rd ed. Radcliffe Publishing Ltd, 2013 History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 4 The Calgary-Cambridge Guide and the Hui Process In Hauora Māori Week in Semester Two you will learn about the Hui Process, “a framework to guide clinical interaction with Māori derived from engagement and relationship building principles of Te Ao Māori.” 2 The “Hui Process” has been identified as containing four key elements: Mihimihi: initial greeting and engagement Whakawhānaungatanga: making a connection Kaupapa: attending to the main purpose of the encounter Poroporoaki: concluding the encounter You will learn more about these elements in Hauora Māori Week. The Calgary-Cambridge Guide that you learn in Clinical Skills can be integrated with the “Hui Process” to enhance the therapeutic relationship with patients, especially your Māori patients. Patient Pronouns and the Calgary-Cambridge Guide in ELM Pronouns We use pronouns every day. Pronouns are words like “I”, “you”, “he”, “him”, “her” and “they”. They take the place of using a person’s name. In the English language pronouns are often associated with a particular gender. For example in the English language we can use “he” for males and “she” for females and “they” for any gender. In Te Reo Māori pronouns are gender neutral. In many other languages and dialects such as Mandarin, Cantonese, Armenian, and Persian pronouns are gender neutral. There are various genders that a patient can identify with. Some of these are male, female, transgender, gender neutral, and non-binary. There are many others. Some people do not identify with the gender they were assigned at birth. They will use pronouns that fit their identified gender. It is important to get this right. Patient pronouns in the clinical setting It is suggested that all patients are asked about their pronouns so that the healthcare team is aware of the pronouns they should use. An ideal time to ask about pronouns is when a patient registers for healthcare. In registering a patient important information is obtained and this can include the patient’s name, gender identity, pronoun, title if used, date of birth, address, and phone number. This information is often obtained in a non-confronting way by filling out a form. Commonly used General Practice software has recently been updated to include information in patient records. Some patients will freely talk about their pronouns. If the health practitioner makes a genuine introduction that shows care and interest in the patient and continues to build on this in the consultation then the patient is more likely to share important things such as the pronouns 2 NZMJ 16 December 2011, Vol 124 No 1347; ISSN 1175 8716 Page 73 http://journal.nzma.org.nz/journal/124- 1347/5003/ ©NZMA History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 5 they use. An important part of Initiation of the Session in the Calgary-Cambridge Guide is establishing initial rapport. Asking some people about pronouns may not help the health practitioner to establish rapport and build the relationship. This may make it more difficult to provide the care the patient needs. Although some patients will know about pronouns they may not be ready to disclose the pronouns they want to use. They may still be trying to work this out. If they have not been able to build a trusting relationship with their health practitioner it may be difficult to talk about it. Not all patients will know what a health practitioner means by “What is your preferred pronoun?” Due to our aging population many of the patients that a healthcare professional sees are over the age of 80. These people were born in the 1930s and 1940s. They have had over 50 years of interactions with health professionals and will have an expectation of what will happen. They have learnt grammar at school and being asked about pronouns in the context of healthcare will not always make sense to them. The therapeutic relationship and pronouns Every patient is unique. A skilled medical practitioner adapts every consultation for the patient they are seeing. A consultation with a patient is not “one size fits all”. If we treat the patient as an individual, are caring and respectful, build a trusting relationship, challenge our own assumptions, and are aware of unconscious bias this will help to create a safe environment for a patient to share important things that they may not yet have shared with other people. A patient’s pronoun may be one of those things. When a health practitioner is interacting with a patient they will use the person’s name or call them “you”. They will not need to use a gender defining pronoun when talking with them. They may need to use a pronoun if they are reporting findings or referring a patient. Gender neutral pronouns are used if the health practitioner is not sure what pronouns to use. In primary care health practitioners who have their name on the door are advised to add their pronouns beside their name. In the Dunedin School of Medicine many students in ALM have put their pronouns on their name badges. A patient who knows about pronouns will see the use of pronouns and understand that the health practitioner is aware of gender diversity. This may be an invitation to that patient to talk with the health practitioner about their own pronouns. Pronouns in ELM Clinical Skills The Clinical Skills Team is aware of the importance of the correct use of a patient’s pronouns. We have recently consulted with doctors and other clinicians who work specifically with gender diverse communities. We asked if we should be teaching medical students to ask patients about their pronouns in ELM Clinical Skills. Interestingly, they had been asked the same question by postgraduate doctors doing their training in General Practice. They do not think that we should routinely ask questions about a patient’s pronouns. They think that we should be creating a safe and welcoming environment for a conversation about pronouns to take place. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 6 In ELM Clinical Skills we teach students how to interact with a patient using Calgary Cambridge as a framework for the consultation. When you begin ALM we want you to be able to take a history and carry out a basic physical examination with a patient. The Clinical Skills Team believes that the skills that you are developing in ELM Clinical Skills will enable you to find out about a patient’s pronoun if it is important for the patient to share this. In ELM Clinical Skills we are not suggesting you ask every patient their pronoun. We do want you to be aware that there is a range of pronouns that patients use. This includes “he/him” “she/her” or “they/them” or a mixture of these. Our aim is that in every clinical scenario in Clinical Skills the patient’s gender is identified and the patient’s pronouns are clarified. In tutorials you will be told the patient’s name, their identified gender, and pronoun before you begin your interaction. We will give you practice reporting findings on people with a range of gender identity. The Calgary-Cambridge Guide and Calgary-Cambridge Guides Communication Process Skills The list of skills that follow is a summary of the skills we use in a consultation with a patient. We will be learning about most of these skills in ELM Clinical Skills. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 7  Calgary-Cambridge Guides Communication Process Skills3 Initiating the session Preparation 1. Puts aside last task, attends to self-comfort 2. Focuses attention and prepares for this consultation Establishing initial rapport 3. Greets patient and obtains patient’s name 4. Introduces self, role, and nature of interview; obtains consent if necessary 5. Demonstrates respect and interest; attends to patient’s physical comfort Identifying the reason(s) for the consultation 6. Identifies the patient’s problems of the issues that the patient wishes to address with appropriate opening question (e.g., ‘What problems brought you to the hospital?’ or ‘What would you like to discuss today?’ or ‘What questions did you hope to get answered today?’) 7. Listens attentively to the patient’s opening statement, without interrupting or directing patient’s response 8. Confirms list and screens for further problems (e.g., ‘so that’s headaches and tiredness, anything else?’ or ‘do you have some other concerns you would like to discuss today?’) 9. Negotiates agenda taking both patient’s and physician’s needs into account Gathering information Exploration of patient’s problems 10. Encourages patient to tell the story of the problem(s) from when first started to the present, in own words (clarifying reason for presenting now) 11. Uses open and closed questioning techniques, appropriately moving from open to closed 12. Listens attentively, allowing patient to complete statements without interruption and leaving space for patient to think before answering or go on after pausing 13. Facilitates patient’s responses, verbally and non-verbally, e.g., by use of encouragement, silence, repetition, paraphrasing, interpretation 14. Picks up verbal and non-verbal cues (body language, speech, facial expression); checks out and acknowledges as appropriate 15. Clarifies patient’s statements that are unclear or need amplification (e.g., ‘Could you explain what you mean by light-headed?’) 16. Periodically summarises to verify own understanding of what the patient has said; invites patient to correct interpretation of provide further information 17. Uses concise, easily understood questions and comments; avoids or adequately explains jargon 18. Establishes dates and sequence of events 3 Skills for Communicating with Patients, p22-25 History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 8 Additional skills for understanding the patient’s perspective 19. Actively determines and appropriately explores: Patient’s ideas (i.e., beliefs regarding cause) Patient’s concerns (i.e., worries) regarding each problem Patient’s expectations (i.e., goals, what help the patient had expected for each problem) Effects – how each problem affects the patient’s life 20. Encourages patient to express feelings Providing structure to the consultation Making organisation overt 21. Summarises at the end of a specific line of inquiry to confirm understanding before moving onto the next section 22. Progresses from one section to another using signposting, transitional statements; includes rationale for next section Attending to flow 23. Structures interview in logical sequence 24. Attends to timing and keeping interview on task Building relationship Using appropriate non-verbal behaviour 25. Demonstrates appropriate non-verbal behaviour: Eye-contact, facial expression Posture, position, movement Vocal cues, e.g., rate, volume, intonation 26. If reads, writes notes or uses computer, does so in a manner that does not interfere with dialogue or rapport 27. Demonstrates appropriate confidence Developing rapport 28. Accepts legitimacy of patient’s views and feeling; is not judgemental 29. Uses empathy to communicate understanding and appreciation of the patient’s feeling or predicament; overtly acknowledges patient’s views and feelings 30. Provides support: expresses concern, understanding, willingness to help; acknowledges coping efforts and appropriate self-care; offers partnership 31. Deals sensitively with embarrassing and disturbing topics and physical pain, including when associated with physical examination Involving the patient 32. Shares thinking with the patient to encourage patient’s involvement (e.g., ‘What I’m thinking now is....’) 33. Explains rationale for questions or parts of physical examination that could appear to be non sequiturs History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 9  34. During physical examination, explains process, asks permission Explanation and planning Providing the correct amount and type of information Aims: to give comprehensive and appropriate information to assess each individual patient’s information needs to neither restrict nor overload 35. Chunks and checks: gives information in assimilable chunks; checks for understanding; uses patient’s response as a guide to how to proceed 36. Assesses patient’s starting point: asks for patient’s prior knowledge early on when giving information; discovers extent of patient’s wish for information 37. Asks patient what other information would be helpful, e.g., aetiology, prognosis 38. Gives explanation at appropriate times: avoids giving advice, information, or reassurance prematurely Aiding accurate recall and understanding Aims: to make information easier for the patient to remember and understand 39. Organises explanation: divides into discrete sections; develops a logical sequence 40. Uses explicit categorisation or signposting (e.g., ‘There are three important things that I would like to discuss. First...’; ‘Now, shall we move on to...?’) 41. Uses repetition and summarising to reinforce information 42. Uses concise, easily understood language; avoids or explains jargon 43. Uses visual methods of conveying information: diagrams, models, written information, and instructions 44. Checks patient’s understanding of information given (or plans made), e.g., by asking patient to restate in own words; clarifies as necessary Achieving a shared understanding: incorporating the patient’s perspective Aims: to provide explanations and plans that relate to the patient’s perspective to discover the patient’s thoughts and feelings about the information given to encourage an interaction rather than one-way transmission 45. Relates explanations to patient’s perspective: to previously elicited ideas, concerns, and expectations 46. Provides opportunities and encourages patient to contribute: to ask questions, seek clarification or express doubts; responds appropriately 47. Picks up and responds to verbal and non-verbal cues, e.g., patient’s need to contribute information or ask questions, information overload, distress 48. Elicits patient’s beliefs, reaction and feelings regarding information given, terms used; acknowledges and addresses where necessary Planning: shared decision making Aims: to allow patients to understand the decision-making process to involve patients in decision making to the level they wish to increase patient’s commitment to plans made 49. Shares own thinking as appropriate: ideas, thought processes and dilemmas 50. Involves patient: History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 10  Offers suggestions and choices rather than directives Encourages patient to contribute their own ideas, suggestions 51. Explores management options 52. Ascertains level of involvement patient wishes in making the decision at hand 53. Negotiates a mutually acceptable plan: Signposts own position of equipoise or preference regarding available options Determines patient’s preferences 54. Checks with patient: If accepts plan If concerns have been addressed Closing the session Forward planning 55. Contracts with patient regarding next steps for patient and physicians 56. Safety nets, explaining possible unexpected outcomes, what to do if plan is not working, when and how to seek help Ensuring appropriate point of closure 57. Summarises session briefly and clarifies plan of care 58. Final check that patient agrees and is comfortable with plan and asks if any corrections, questions, or other issues More detail about the Calgary-Cambridge Guide is found in Skills for Communicating with Patients and Teaching and Learning Communication Skills in Medicine, by Suzanne Kurtz, Jonathan Silverman and Juliet Draper (published by Oxford: Radcliffe Press). Both of these books are available on Close Reserve in the Medical Library. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 11 History Taking using the Calgary-Cambridge Guide The diagram below from the Calgary-Cambridge Guide is an outline of what happens during a consultation with a patient. The five sequential steps in the middle of the diagram that form the “medical” part of the consultation are supported throughout by providing structure and building the relationship. According to the Calgary-Cambridge Guide, Initiating the Session is the first of 5 sequential steps that take place during a medical consultation. The second task is Gathering Information and the fifth and final sequential task is Closing the Session. The third sequential task is Physical Examination. You will learn the fundamental skills of physical examination in ELM and develop these further in ALM. The fourth sequential task is Explanation and Planning. Explanation and Planning is covered in the Advanced Learning in Medicine Programme). In this reference guide we focus on the following components of history taking: Initiating the session Gathering information Building the relationship Providing structure Closing the session From: Kurtz S, Silverman J, Benson J, Draper J. Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides. Academic Med. 2003;78: p806. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 12  Initiating the Session Initiating the session is the first of the five sequential steps that take place during the medical consultation. You will use the skills listed below to initiate the session. Initiating the session Preparation 1. Puts aside last task, attends to self-comfort 2. Focuses attention and prepares for this consultation Establishing initial rapport 3. Greets patient and obtains patient’s name 4. Introduces self, role and nature of interview; obtains consent if necessary 5. Demonstrates respect and interest; attends to patient’s physical comfort Identifying the reason(s) for the consultation 6. Identifies the patient’s problems of the issues that the patient wishes to address with appropriate opening question (e.g. ‘What problems brought you to the hospital?’ or ‘What would you like to discuss today?’ or ‘What questions did you hope to get answered today?’) 7. Listens attentively to the patient’s opening statement, without interrupting or directing patient’s response 8. Confirms list and screens for further problems (e.g. ‘so that’s headaches and tiredness, anything else?’ or ‘do you have some other concerns you would like to discuss today?’) 9. Negotiates agenda taking both patient’s and physician’s needs into account From: ‘Calgary-Cambridge Guides Communication Process Skills’ Initiating the session is especially important as it sets the scene for the rest of the consultation. At the start of a consultation first impressions are formed by both the doctor and the patient. A medical consultation is not a “chat”. It is much more. The patient has come to the doctor for a reason and has usually given thought to what they need from the doctor. The doctor’s task is to find out why the patient has come, and to use their skills of communication combined with their medical knowledge and their ability to build a good professional relationship to address what the patient needs. The four main objectives during this phase are: 1. Preparation 2. Establishing initial rapport 3. Identifying the reason(s) for the consultation 4. Negotiating and Agenda setting History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 13 Preparation (based on CCG Skills 1-2)4 “We are not empty handed when we walk into a room to meet a patient. We carry our own culture and beliefs, conscious and unconscious assumptions, needs, emotions, expectation and skills as physicians or trainees, as well as our level of presence or distraction on that particular day.”5 Your patient needs your full attention. When you are seeing patients in practice it can be easy to be distracted by what happened with the last consultation, the other patients in the waiting room, or your own personal issues. It is helpful to begin a clinical consultation with the understanding that this encounter is highly significant for the patient and that they deserve your full attention. Recognising your own needs and attending to them before seeing the patient means that you can give your patient the attention they need. When you are a medical student, you may be distracted by your tutor and peers watching you, or you may be distracted by needing to remember specific medical knowledge. This distraction can affect your ability to give the patient your full attention and this can affect the consultation. It is also important to be aware that you make conscious and unconscious assumptions about patients. Use this awareness to constantly challenge those assumptions. An adult may bring a child to see you. You may assume that the adult is the child’s parent when in fact the adult is the child’s grandmother. Questions to ask yourself before seeing the patient are: Have I put aside previous tasks and am I ready to turn my attention to this patient? Have I checked the patient’s notes and results, and do I have a reasonable understanding of what has previously been wrong with them? Have I completed my preparation and am I ready to greet them with my full attention? Am I prepared to challenge my assumptions? 4 Adapted from: J. Silverman, S. Kurtz, and J. Draper, Skills for Communicating with Patients 3rd edition (Oxford: Radcliffe 2013), p.38 5 Dobie S. Reflections on a well-travelled path: Self-awareness, mindful practice and relationship-centred care as foundation for medical education. Acad Med 2007;82(4):422- 7 History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 14 Establishing Initial Rapport (based on CCG Skills 3-5) Make a genuine introduction Introduce yourself using your full name Clarify your role Checks patient’s name Checks patients age only if necessary Clarify nature of interview Gain permission to continue Demonstrate interest and respect throughout Attend to patient’s physical comfort throughout Make a genuine introduction Welcome the patient with a smile. Be genuine. Show them you are interested in them. If you are comfortable with offering a handshake then you could do this. Introduce yourself and clarify your role Introduce yourself with your first and last names. While using your first name only may seem friendly the patient needs to know who they are talking with. Using both of your names can help you take on the role of medical student and signals to the patient that you are professional. It makes sense to clarify your role as medical student at this stage. The patient needs to know where you fit in the healthcare team. Check the patient’s full name Clarify the patient’s name if you know what their name is or ask them their name if you do not know. Clarify the nature of interview, and check for permission to proceed Explain why you are interviewing the patient. If the interview is a learning opportunity for you as a student, then explain clearly that you are practicing your consultation skills and check that the patient is ok with this. Example when practicing in class: “Hello, I’m Sione Alatini (puts out hand and shakes patient’s hand while continuing). I am a second-year medical student here at the Otago Medical School. “Hello Sione.” “What is your name?” “I’m Ronald Trotter. Just call me Ron.” “Thanks Ron. Is it ok if I interview you today in front of my tutorial group so I can practice my consultation skills?" “Yes, Sione that would be fine.” History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 15 Example when working in General Practice: when you have been told who you will be meeting: “Hello, my name is Maia Jones. I am a second-year medical student working with your GP. “Hello Maia.” “I want to check that I have the right person. Are you Alison Dowie?” “Yes, that’s right – I’m Alison Dowie.” “What would you like me to call you?” “Oh, Alison will be fine.” “I am here to learn about what happens in General Practice.” “That sounds like a good thing to learn about.” “Yes. I’m learning a lot. The receptionist told me you are happy for me to speak with you so I can practice my consultation skills before you see Dr Smith. Is that still all right with you?” “That is just fine Maia.” Example when working in General Practice: when you are uncertain whether you have seen the patient before: “Hello, my name is Andrew Phillips, and I am a second-year medical student.” “Hello Andrew.” “You seem familiar to me, but I can’t recall your name. Have I met you somewhere before?” “Yes Andrew, I’m Mary Murphy. You met me last week when I was here with my partner who has angina”. Demonstrate respect and interest, attend to patient’s comfort Throughout the consultation you need to show respect and interest. You will show this through the communication skills you use and the questions you ask. The patient should feel welcomed by you in a safe clinical environment where there is trust between you and they feel able to work with you to get the best outcome. Use a professional respectful attentive posture. If you sit in the chair with your back well supported and with both feet on the ground this will help to steady you if you are feeling nervous. If you need to cross your legs cross them at the ankles. A leg crossed high on the thigh may look like a barrier to the patient. Sit close enough to the patient to show your interest. Do not sit so close that you make them uncomfortable by invading their personal space. Throughout the consultation you need to pay attention to your patient’s physical comfort. You will use your skills of observation to do this. Consider the environment you are in. Is the lighting all right - not too dark or too glaring? Is the room warm enough? Is the room private? Is the patient comfortable sitting? Would they prefer to be lying down? Are you sitting or standing in a way that helps you communicate well with your patient? Are you sitting at an angle rather than sitting directly face to face which can appear confrontational? History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 16 Identifying the reason(s) for the consultation (based on CCG Skills 6-8) The next phase of the consultation involves establishing the issue(s) the patient wants to discuss, and then deciding on the order in which to address them. Patients have often given a lot of thought to what they want from a consultation, and they will have their own ideas about this. They may come with a handwritten list of symptoms, they may have come to discuss a specific treatment, or they may come needing medical documentation. It is important to understand that patients will often have more than one issue they want to discuss, and that the issue or complaint they mention first may not be the one they are most concerned about. Sometimes patients will offer an initial problem to discuss, and only mention other more serious or embarrassing problems later in the consultation. To have a plan for the whole consultation, rather than blindly following the first “lead”, you need to ascertain as many reasons as possible for attendance, and then negotiate with the patient the order in which to address them. The skills required in identifying the reason(s) for the consultation are: Asking an open question to begin the interview Listening “actively” and encouraging the patient to complete and expand on their opening statement Confirming the patient's list Screening for further problems Agenda setting The opening question to identify patient’s concerns Start the consultation with an open question that allows the patient to speak freely without any limitations or assumptions about their agenda. Here are some example opening questions: “Why have you come to see the doctor today?” “How can I help you today?” “What do you want to see the doctor about today?” History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 17 Listen attentively to opening statement, without interrupting or directing the patient’s response Active listening happens when you use non-verbal communication to show the patient you are genuinely listening. You will encourage the patient to say all they want to say, and you will show the patient you are interested in what they are saying. Do not interrupt the patient. Research in 1995 by Stewart (Stewart M. Effective physician- patient communication and health outcomes: a review. CMAJ, 1995; 1523(9): 1423-33.) found that physicians interrupt patients an average of 18 seconds into the patient’s description of the presenting problem. If patients are not interrupted, they are more likely to present more of their problems to the doctor. Interestingly the length of the overall consultation is not altered significantly. If the doctor allows a patient to finish their opening statement, they are less likely to bring up new concerns later in the consultation which means that the doctor can use time more efficiently. Even minimal interruptions on the part of the doctor at this stage can significantly impact on what the patient tells the doctor. If the doctor interrupts the patient to ask them to talk more about one symptom, it leads the consultation away from the direction that the patient may have been taking and can therefore restrict their options. If the doctor interrupts at the beginning of the consultation, then the doctor may carry on without identifying the patient's main concern. The doctor may then start testing different hypotheses (or considering a differential diagnosis) before the patient has had a chance to tell their whole story. Interruption at the beginning of the consultation can break the patient's flow and may mean they do not tell the doctor everything they want to say. It is best to resist any temptation to explore part of their story or clarify anything at this stage. The skills required for active listening are: Use of silence: Allow the patient time to go on after pausing. Give them time to think about what they have just said. Non-verbal skills: Use a professional attentive posture. Use appropriate eye contact. Your facial expression should show that you are interested and concerned. Your voice should also show an interested and caring attitude. Picking up verbal and non-verbal cues: Be aware that patients may often express their concerns, ideas, and expectations using non-verbal communication or indirect comments. Watch the patient and listen attentively to pick up these cues. At a later point in the consultation check out and clarify these cues. Facilitative responses: This type of response will encourage the patient to complete and expand their opening statement. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 18 Several techniques are helpful when listening to the opening statement: Use silence and wait attentively to allow the patient to think at their own pace and enable them to recall information. Use “minimal encouragers” such as “go on”, “uh-huh”, “OK”, “yes”, “I see”, to encourage the patient to continue. More about skills used to facilitate communication can be found in “The process skills used in gathering information” on page 23. Confirm the patient’s list After you have listened attentively to the patient’s complete opening statement you need to confirm what the patient has told you. When you confirm the list, you are showing the patient you have heard them, and you are also checking that you have understood correctly. This is an opportunity for the patient to put you right if you are on the wrong track. Your next step will be screening for more problems. Without good confirmation of the list the patient may feel you are dismissive of what they have just told you. Screen for further problems It is important not to assume that the patient has told you all that they want to discuss. After confirming the list, you need to ask the patient if there is anything more they want to talk about. If you use the phrase “anything more” this is inclusive of what the patient has told you and lets the patient know you are interested in everything they want to tell you. The screening is a two-way dialogue. You are listening to your patient all of the time, showing that you are interested in everything they have come to see you about. If you haven't got it all keep asking questions and confirming the list with the patient until they indicate that you have an accurate appreciation of what they have been telling you. Examples of confirming the list and then screening for more problems When the patient has completed their opening statement, you will confirm the list and then screen for more. “You said you have been feeling tired and dizzy lately. Is there anything more that you wanted to talk about?” When the patient replies with another problem you will need to listen until they stop again. You will then repeat the screening process by confirming the list of the problems including the additional ones and then ask if there is anything more. “You are tired and dizzy, and you've also been very worried about your partner who has been quite unwell. You’re wondering whether the worry has caused your symptoms. I will talk with you more about that. Do you have any more concerns?” Continue the process. Eventually the patient will say something like “No, that's all.” History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 19 Negotiates the agenda (based on CCG Skill 9) At this stage of the interview if there is more than one problem the patient has presented with you will usually need to work with the patient to decide which problem to discuss first. Both the patient’s agenda and the doctor’s agenda will need to be considered. The patient may have come expecting particular problems to be assessed. This is part of the patient’s agenda. You will have medical knowledge that helps you prioritise the important problems. This is part of the doctor’s agenda. Usually, the patient’s agenda takes priority. Sometimes the doctor’s agenda takes priority especially in cases when the patient has presented something like chest pain that needs to be dealt with promptly. You will usually negotiate the agenda by finding out what is most important for the patient and begin with that. “Which of these symptoms is concerning you the most?” “Well, probably I am most worried about the dizziness, and of course my partner.” Your reply will include what the patient has said to you. “Would it be all right if we discussed your dizziness and tiredness? We could then talk about your concerns with your partner, and lastly discuss your new symptoms with needing to pass urine more often.” If the patient has a very long list, they wish to discuss then you will need to be talked about this openly. “There are eight things here you want to deal with. I’m not sure we’ll be able to do all of that today. I wonder if it we can work out what is troubling you the most and deal with them today and maybe you can make another appointment so we can talk about those other things?” If your agenda takes precedence over the patient’s agenda, you can tell the patient what you want to talk about first and give them your reasons for why you want to do that. “You’ve told me about that central crushing chest pain that lasted 20 minutes last night and your athlete’s foot. I really think we should talk about that chest pain first because it sounds as if it was pretty bad.” “That would be fine. But I do need more cream for my feet.” Although the patient may be more concerned with her athlete’s foot a doctor will be more concerned about the central crushing chest pain lasting 20 minutes that happened last night as this could be life threatening. It makes sense to prioritise the chest pain. Acknowledging all of the patient’s concerns and setting the agenda helps the patient to feel secure about the direction of the interview. This helps to give the consultation structure. Providing structure is an important part of the consultation and is discussed further in this reference guide on page 54. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 20 Before moving on to the gathering information part of the consultation, you should consider your objectives for this phase and ask yourself: Have I established a supportive environment for the patient? Have I discovered all of the problems that they wanted to discuss? Have I developed a mutually agreed plan for the consultation that we are now going to proceed with? History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 21  The Disease-Illness Model The Calgary-Cambridge Guide for the medical consultation has been developed from the work of Professor Ian McWhinney at the University of Western Ontario, who developed the disease-illness model. This approach requires the doctor to gain an understanding of the patient as well as their disease and is patient centred. Patient-centred medicine involves understanding the meaning of the illness for the patient while interpreting it with a medical frame of reference. It considers both the disease (biomedical cause of un-wellness in terms of pathophysiology) and the illness (the individual patient's unique experience of un-wellness). The doctor's agenda refers to the information the doctor needs to gather about the patient's symptoms, the examination the doctor needs to perform, the tests or procedures the doctor needs to consider, and the differential diagnosis the doctor needs to make. The patient's agenda refers to the patient’s illness experience - their ideas, concerns, expectations, the effects of the illness, and their feelings about what is going on for them. Patients can have illness without disease. A patient grieving the recent loss of a partner may feel very low in energy and motivation and may be forgetful and tearful. They do not have a “disease”. They do have significant symptoms. Patients can also have disease without illness. A patient can have hypertension and feel completely well. The goal in a consultation is to integrate the biomedical content (the disease framework) with an understanding of what these symptoms mean for the patient (the illness framework). To do this the doctor gathers information about the patient’s disease and their illness. An experienced doctor will weave back and forth between the patient's perspective and the biomedical perspective as they gather information. They will listen and enquire about physical symptoms that might reveal evidence of underlying disease. They will listen and enquire about the patient's perspective on their illness. The doctor will then integrate the two aspects to gain a more complete understanding of the patient’s presentation, and then proceed with explanation and planning using a shared understanding and decision-making process. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 22 The Disease-Illness Model is well conceptualised in the following diagram: The Disease-Illness Model. After Levenstein et al. (1989) and Stewart et al. (2003). From: J. Silverman, Kurtz, and J. Draper, Skills for Communicating with Patients 2nd edition (Oxford: Radcliffe 2013), P.65 History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 23  Gathering Information Gathering information is the second of the five sequential steps that take place during the medical consultation. You will use the skills listed below to gather information. From: Kurtz S, Silverman J, Benson J, Draper J. Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides. Academic Med. 2003;78: p80 History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 24 These are skills you can use to gather information: Gathering information Exploration of patient’s problems 10. Encourages patient to tell the story of the problem(s) from when first started to the present, in own words (clarifying reason for presenting now) 11. Uses open and closed questioning techniques, appropriately moving from open to closed 12. Listens attentively, allowing patient to complete statements without interruption and leaving space for patient to think before answering or go on after pausing 13. Facilitates patient’s responses, verbally and non-verbally, e.g. by use of encouragement, silence, repetition, paraphrasing, interpretation 14. Picks up verbal and non-verbal cues (body language, speech, facial expression); checks out and acknowledges as appropriate 15. Clarifies patient’s statements that are unclear or need amplification (e.g. ‘Could you explain what you mean by light-headed?’) 16. Periodically summarises to verify own understanding of what the patient has said; invites patient to correct interpretation of provide further information 17. Uses concise, easily understood questions and comments; avoids or adequately explains jargon 18. Establishes dates and sequence of events Additional skills for understanding the patient’s perspective 19. Actively determines and appropriately explores: Patient’s ideas (i.e. beliefs regarding cause) Patient’s concerns (i.e. worries) regarding each problem Patient’s expectations (i.e. goals, what help the patient had expected for each problem) Effects – how each problem affects the patient’s life 20. Encourages patient to express feelings From: ‘Calgary-Cambridge Guides Communication Process Skills’ During the Gathering Information part of the consultation the doctor takes the medical history and gets as much information as possible to allow them to understand the symptoms that the patient has been experiencing. It is important to understand the medical and the context of these symptoms, the impact they have had on the patient’s life, the patient’s feelings, ideas and beliefs, and concerns about the symptoms, as well as the patient’s expectations of the consultation. Calgary-Cambridge recognises two components that enable gathering information from a patient. These are the: Process skills for exploration of the patient’s problems Content to be discovered History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 25 The Process Skills are the techniques used to gather the information. The Content is the biomedical, patient perspective, and background information that the doctor needs to gather. This is demonstrated in the diagram below. Gathering Information Process Skills for Information Gathering Patient narrative Question style: open to closed cone Attentive Listening Facilitate response Picking up cues Clarification Time-framing Internal summary Appropriate use of language Additional skills for understanding the patient’s perspective Content of Information Gathering History of the Presenting Complaint The Biomedical perspective (disease) The Patient’s perspective (illness) Sequence of events Ideas and beliefs Symptom analysis Concerns Relevant systems review Expectations Effects on life Patient is encouraged to express feelings Background information Past medical history Drug and allergy history Family history Personal and social history Review of systems Adapted from: Kurtz S, Silverman J, Benson J, Draper J. Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides. Academic Med. 2003;78: p807 History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 26  The Process Skills used in Gathering Information The Calgary-Cambridge Guide outlines the skills needed when gathering information from a patient. These Process Skills are summarised below: Encourages patient to tell story in own words. Uses open-ended and closed-ended questions appropriately. Listens attentively, with no interruption, leaves space for patient to think. Facilitates patent's responses, verbally and non-verbally (encouragement, silence, repetition, paraphrasing. Picks up verbal and non-verbal cues, checks out and acknowledges Clarifies patient's statements that are unclear or need amplification Periodically summarises to verify own understanding, invites patient to correct. Uses concise, easily understood questions and comments, avoids jargon. Establishes dates and sequence of events. Questioning Styles Before going into detail about the specific skills required in the information gathering phase of the consultation you need to understand the impact of the type of questions you ask. The patient comes to the consultation ready to tell their story. It is easy to assume that they will tell their story whatever the doctor says or does. However, this is not true. The doctor’s words and actions have a profound influence over the story a patient tells. The nature of the doctor’s questions can steer the patient away from one aspect of their story and limit their ability to elaborate in some areas. If you are aware of the effects of the different questioning styles, then you can use these with skill in the consultation. There are three main styles of question which are explained on the following pages. These are: Open questions Closed questions Leading questions 1) Open questions Open questions often start with what, when, where, how and why, encouraging a response that can provide a range of information. They do not limit the response to a “yes” or “no”. They can direct the patient to a specific line of inquiry and give the patient freedom to elaborate. Open questioning techniques tend to open up the consultation and it makes sense to use them when you start to gather information. For example: “Tell me about that cough” “What’s been going on with that cough?” History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 27 An open question or statement like “Tell me about that cough” directs the patient to talk about the cough and allows the patient freedom with their reply. When you need more specific information about the cough you can ask a question that is still open yet more specific such as: “When do you cough?.” This is more directive in exploring the cough symptom, and the question is still open, giving the patient opportunity to elaborate. Open questions will encourage the patient to tell their story in their own words and will prevent the doctor from “stabbing in the dark” with closed questions. 2) Closed questions Closed questions generally lead to a one-word answer, usually “yes” or “no”, that do not encourage elaboration and tend to close off the consultation. For example: “Do you have a cough?” “Do you cough at night?” “Do you get pain with your cough?” “Do you bring up phlegm with your cough?” These answers tend to be limited to yes or no and do not allow the patient the opportunity to give more detail. Closed questions can be helpful. If a patient answers with “Yes” to a closed question it can be followed up with an open question to find out more. For example: “Do you have a cough?” “Yes, I do.” “Tell me about that cough.” Once you have heard the patient’s story you may need to ask closed questions. Closed questions allow the doctor to use their biomedical knowledge and ask specific questions about the symptoms which are important diagnostically and may not have already emerged from the patient's story. These closed questions enable a patient to provide detailed and relevant information. Whenever the patient answers “Yes” to a closed question it must be followed up, usually with an open question or statement. A doctor may follow up with the closed question “Do you have fever?” in a patient who talks about their red swollen foot that could have gout or be infected. A doctor may ask “Have you lost weight?” when the patient has told their story about indigestion and a sensation of food sticking in their oesophagus. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 28 3) Leading questions A leading question presupposes a particular answer. If a doctor asks a leading question the patient can be put in a difficult position. As the patient may not want to contradict the doctor they may agree even if this is not correct. For example: “So, this has been going on for a week. That’s right, isn’t it?” “And that was the most troublesome thing?” “You didn’t have any pain, did you?” Open to Closed Cone The process of moving from an open questioning style to using closed questions, is known as “Using an open to closed cone”. The cone diagram shows the wide-open mouth of the cone that captures as much information as possible (with open questions). Gradually the questions become more specific, and finally closed (at the bottom of the cone). These closed questions can be essential. A medical interview usually contains a number of open to closed cones, as different topics are discussed. One of the most common mistakes made in consultations is to move to close the cone too quickly by using closed questions too soon. The following example shows a move from open to closed cone questioning from the doctor: “Tell me about this pain” Open and directs patient to talk about the pain. “You said the pain came on this morning while Open and directs the patient to talk you were walking up the stairs. Can you tell me about the episode of pain this morning. more about that?” “What does that pain feel like?” Open and directive. “You said the pain seemed to be in the centre of Closed. your chest. Did you feel it anywhere else?” “Was there any pain in your neck or arm?” Closed. Note that the “Open to Closed Cone” process is used many times within a consultation to explore the many things the patient tells the doctor. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 29 Exploration of Patient’s Problems (CCG Skills 10-18) CCG Skill 10. Encourage patient to tell their story in their own words The patient wants to tell you their story. They are likely to have prepared what they want to tell you. Start with a carefully worded open question, and then listen carefully to the patient’s story. Prompt the patient only if necessary. In this example the doctor is gathering information about both the disease and illness. We have information about the cough, the phlegm, the pain, and the worry about pneumonia. Doctor: “Could you tell me about your cough?” Patient: “Well, it probably started about 3 weeks ago, and at first I just noticed that I was coughing first thing in the morning. At first there was no phlegm, then a couple of weeks ago I started bringing up some phlegm.” Doctor: “Then what happened?” Patient: “I kept bringing up phlegm every morning and at first it was yellowy, but now it is green and thick and I'm bringing it up every time I cough.” Doctor: “And what else is happening?” Patient: “And now I've started to get pain, here on the side of my chest every time I cough. When that started I got quite worried because I thought I might have pneumonia.” CCG Skill 11. Use open and closed ended questions Start by asking open questions that encourage the patient to tell their complete story from the beginning. Continue with open questions to get an understanding of both the disease and illness aspects of the patient’s presentation. Use your biomedical knowledge and knowledge about the patient’s perspective to guide the questions you ask. As you find out more from the patient you will move from open to closed questions. Closed questions will help you to fill in gaps when there is information you need to gather that the patient has not told you. The most common mistake is to move to closed questions too early. This can lead to the patient being asked a long list of questions and can stop them telling their story. CCG Skill 12. Listen attentively This requires the same skills as CCG Skill 5 (wait time, non-verbal skills, facilitative responses and picking up on patient cues), to allow the patient to tell their story without interruption. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 30 CCG Skill 13. Facilitate patient's responses A facilitative response involves both verbal and non-verbal communication skills. The main focus in this section is on verbal facilitative skills, with some discussion of specific non-verbal skills. See the section “Building the Relationship” on page 46 for more information about non- verbal facilitative skills. The following facilitative skills can be used to enable the patient to say more about a topic: encouragement silence repetition (mirroring or echoing) paraphrasing sharing your thoughts. Encouragement Neutral facilitative comments like, “uh-huh”, “go on”, “I see”, as well as nodding the head or an interested facial expression will encourage the patient to continue their story. Silence A verbal encourager is often followed by a period of silence to allow the patient to elaborate. If a patient is finding it hard to put into words what is going through their mind, then a longer pause will be necessary to enable the patient to do this. Silence from the doctor enables the patient to do that. Silence can show the patient that the doctor has time for them and is not rushing the interaction. Repetition When the doctor repeats the last few words or key words that the patient has said, it encourages them to keep talking on the topic. It is slightly more directive than using silence or an encourager because by repeating these words the doctor directs the patient to talk about that more. Repetition can be called mirroring or echoing. Patient: “And now I’ve started to get pain, here on the side of my chest every time I cough. When that started, I got quite worried because I thought I might have pneumonia.” Doctor: “You got worried.” (Repetition) Patient: “Yes. A friend of mine had something similar and ended up in hospital for 6 weeks with pneumonia.” Using repetition may feel unnatural and awkward however it works well for patients. It is a very effective of way of showing a patient that they have been heard. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 31 Paraphrasing The doctor restates in their own words the content or feelings of the patient's message. Doctor: “So, a friend had pneumonia and ended up in hospital?” (paraphrase of patient’s concern) Patient: “Yes. I don’t want to be sick for weeks – our oldest grandson is getting married in 3 weeks, and I have to be better by then.” Doctor: “You’ve really got to get better soon because your grandson is getting married in 3 weeks.” (paraphrase of content) This is an effective technique and loses its effectiveness quickly if it is over-used. Sharing your thoughts When the doctor explains why they are asking a question, the patient can understand the reasoning, and this encourages them to elaborate. Doctor: “You’ve got this pain in your chest and you’re worried about pneumonia. I really need to ask you some more questions to work out what is causing that pain.” History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 32 CCG Skill 14. Pick up verbal and non-verbal cues, check out and acknowledge It is important to pick up both verbal and non-verbal cues, check them out to ensure that you have interpreted them correctly and acknowledge them. This demonstrates that you have heard and understood the patient. In most medical interviews the patient may give one or more cues, and if the doctor does not respond to them the patient is likely to bring up the same issue (such as underlying stress or worry about the significance of a symptom) a second or even a third time. You will find more information about this in “The Patient's Perspective” on page 33. CCG Skill 15. Clarification of the patient's story Clarify any statements that the patient makes that are unclear. The patient may give you information that is very general or use a technical term that has a very specific meaning for you as someone with medical training, while to the patient it means something quite different. If it is not clear you will need to ask the patient to explain or give examples of what they are talking about. Doctor: “You mentioned indigestion. What happens when you get indigestion?” Doctor: “You said you have rheumatism. Can you tell me about that?” These open questions encourage the patient to talk about the problem and helps the doctor find out what the patient means. The purpose of clarifying what the patient has said is to help the patient tell you what is going on and to make sure that you are both talking about the same thing. CCG Skill 16. Periodically summarising In a “periodic summary” the doctor gives a short summary of the information gathered so far. This summary can occur anywhere in the consultation. A summary lets you organise the information and can help you to remember it. A summary improves accuracy because it gives the patient the opportunity to either correct or confirm what you have learned from the consultation. Summarising accurately shows that you have been listening. Summary for confirmation of specific information A summary may be made at the end of a chunk of information. An advantage of this is that it confirms that the doctor has the correct information. It is also a way to help the doctor remember important information and can help them work out what to ask next. Doctor: “So, you tried taking cough mixture for that cough. Are you taking any other medications?” History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 33  Patient: “Well yes. There’s the cilazapril for blood pressure and I take a pill for my thyroid as well.” Doctor: “So that’s the cough mixture, cilazapril and the thyroid pill.” “What is the thyroid pill called”? Patient: “It’s thyroxine. I’ve been on it for years.” In making a summary of the medications the doctor recognised that they needed more information about the thyroid pill so asked another question. Summary as facilitative opener If the patient or doctor are “stuck” a summary can act as a facilitative opener and get the consultation going again. The doctor can make a summary and then pause and listen attentively. The patient is often then able to continue their story. Doctor: “So, this all started three weeks ago with a cough and now you’re coughing up thick green phlegm and you have pain on the side of your chest when you cough. You’re worried that you might have pneumonia. Patient: “That’s right. And I’ve been really breathless too. I had to sit up in bed all night last night and I’m sure I had a fever.” Summary for clarification It can be useful to make a summary to be sure you have the story correct. In this case the doctor wants to be clear about when symptoms started. Doctor: “So, about six weeks ago you got a cough. And you’ve been coughing green phlegm and been breathless with a fever too.” Patient: “That’s right. I have had a cough but only for three weeks. The phlegm went green yesterday. And the fever and breathlessness really only started last night.” You make a periodic summary as often as it is needed. There is no set place for where these summaries should occur in the consultation. Summarising is a useful technique. It is important not to summarise too often as it can disrupt the flow of the consultation. The patient does not need to hear an exact summary of what they have told the doctor. They need to hear enough so that they know the doctor has understood what they are saying. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 34 CCG Skill 17. Appropriate language use It is important to use concise easily understood language. Avoid jargon or overly technical medical terms. It is helpful to use the same language that the patient uses. Some patients, such as health professionals or patients who have a long-standing medical condition, may be very familiar with medical or technical language. Other patients will have no knowledge or understanding of medical terms. It is important when talking with the patient to match their level of understanding and use the language they are familiar with. CCG Skill 18. Establish dates and sequences of events A full exploration of the sequence of events should include enough information to write a short story or make a movie about the patient’s presentation that includes details about three aspects: any precipitating event(s) the onset of the event in detail what has happened in detail since the onset It is important to get clear and detailed information about the sequence of events. You will need to consider: Onset ▪ Day, date, and time of onset. ▪ When the patient was last completely well especially if the onset is not well defined. ▪ Duration – how long the symptom(s) have been present. This gives an indication of onset. ▪ Mode of onset - sudden, rapid, or gradual. Precipitants – event(s) that occurred before the onset of symptoms. Time course – what has been happening from when symptom(s) first started until now. ▪ How long symptoms last if they are intermittent. ▪ Frequency – how often symptoms occur. ▪ Pattern –if there is a pattern. Symptoms may be static, deteriorating, random, worsening. ▪ When any exacerbations and remissions have occurred. ▪ Recovery –what the recovery period is like. Establish a timeline for the patient’s story and other information gathered early in the consultation. It is helpful to make a note of specific dates if the patient knows these. Sometimes it is helpful to ask the patient to tell you what has been happening starting at the beginning. A clear timeline plays a significant role in reaching a diagnosis. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 35 Consider these two patients who each present with flu-like symptoms, headache, and rash: Patient A became unwell yesterday with flu-like symptoms that started at lunchtime. They never get headaches, but they have had a headache that has been getting progressively worse since lunchtime yesterday. They now have a rash which started 30 minutes ago and is spreading. Patient B became unwell yesterday with flu-like symptoms that started at lunchtime. They have had headaches for years and need a repeat prescription for their regular medication to prevent this. They also have a rash that they get intermittently. It has been worse in the past month, and they need more ointment for that. Both patients have flu-like symptoms, headache, and rash. Meningococcal meningitis must be excluded as the cause for these presenting symptoms in each patient. The sequence of events for Patient A with the very recent onset of flu-like symptoms and worsening headache with the appearance of a rash makes meningococcal meningitis much more likely. The sequence of events for Patient B who has had flu-like symptoms for a day, headache for years, and a rash for a month makes meningococcal meningitis much less likely. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 36  The Patient's Perspective Understanding the patient's perspective requires additional skills from the doctor. Additional skills for understanding the patient’s perspective 19. Actively determines and appropriately explores: a. Patient’s ideas (i.e. beliefs regarding cause) b. Patient’s concerns (i.e. worries) regarding each problem c. Patient’s expectations (i.e. goals, what help the patient had expected for each problem) d. Effects – how each problem affects the patient’s life 20. Encourages patient to express feelings From: ‘Calgary-Cambridge Guides Communication Process Skills’ There are several skills you can use to explore the patient's perspective on their illness: by picking up on information or cues given by the patient by directly asking for the patient's ideas, concerns, expectations, and the effect the presenting problem has on their life by encouraging the patient to express their feelings Patients often tell doctors their perspective. Studies show that while patients do volunteer this information some doctors do not actively explore this information. You must gain an accurate appreciation about the patient’s experience of their illness. If this is not achieved the consultation may not be successful. When the patient gives you information in their story about their illness experience you must listen actively and encourage the patient to give you more information while you try to understand the importance of this for the patient. Some patients do not openly volunteer their own ideas and feelings about their illness and give this information indirectly through verbal or non-verbal cues. As we discussed in the reading for initiating the consultation, it is important to use the skills of active listening, while observing the patient's non-verbal communication so that you can follow up on these cues. Research shows that while doctors tend to pick up and respond to informational cues, they are not as good at picking up cues of an emotional nature. This may be because the doctors have been preferentially listening for information about the disease. You need to be constantly alert and actively thinking about picking up on all cues that the patient gives in the consultation. Non-verbal cues from the patient may include looking anxious or showing worry in their body posture, their facial expression, and their tone of voice. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 37 Verbal cues may include the use of emotionally laden words like “worried”, “anxious”, “frightened”, “dangerous”, “important”, “serious”, or “stressed”. These words may be repeated if the patient does not feel that the doctor has heard them. If the patient uses these words you must follow up on them. The patient may hesitate mid-sentence or hold back from saying something important or sensitive. It is important to recognise this and give the patient space to say what they need to say. You may need to encourage them to continue with a gentle prompt. “What were you going to say?” “Tell me what you’re thinking about.” The questions we can ask in gathering information about the patient’s perspective are inherently empathic and help to build rapport. More detail about this can be found in “Building the Relationship” on page 46. As well as following up on cues that the patient gives, it is can be necessary to ask direct questions to explore their perspective further. CCG Skill 19. Actively determines and explores: patient's ideas, concerns, expectations, and the effects of the illness on their life Here are some examples of ways to ask about ideas, concerns, expectations, and effect on their life: Ideas “Have you any ideas about what is causing this?” “So what do you think might be happening?” “Have you got any thoughts about what could be going on?” Concerns “Is there anything in particular you are concerned about?” “What was the worst thing you thought it might be?” “You said you were worried. What are you worried about?” Expectations “What were you hoping the doctor might do for you today?” “When you made the appointment, what were you thinking I might do for you?” “Did you have any plan for how to approach this?” “You said you thought your ankle might be broken and the doctor might do an X-ray. Was there anything else you thought the doctor might do?” Effects on life “So you said you were so sick you couldn’t go to work. What else has it affected?” “You’ve got a lot going on. How is this affecting you?” “What impact is this having on you?” History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 38 CCG Skill 20. Encourages patient to express feelings It is often easier to focus on the disease rather than explore a patient’s feelings as this may seem intrusive. However, the patient's feelings about their illness are often an important indicator of their health beliefs and coping style. A patient may reveal their feelings about a problem using words like “scared” suggesting they are fearful, or they may express other feelings such as relief or concern. This may be given openly or through non-verbal cues. You need to notice when the patient talks about their feelings and acknowledge the patient's feelings explicitly. This is called "reflecting feelings" or "validating". This is also covered in more detail in the section on “Building the Relationship” on page 46. Here are some examples of skills that could be used to encourage the patient to express their feelings. Picking up and checking out verbal cues “You said you felt miserable. Could you tell me more about how you’ve been feeling?” Repetition of verbal cues “Angry…?” Picking up and reflecting non-verbal cues “I sense that you are very tense – would it help to talk about it?” “You sound sad when you talk about John…” Direct questions “So how did that leave you feeling?” “What’s that been like for you?” Using acceptance, empathy, concern, understanding to allow the patient to know that you are interested in their feelings “I can see that must have been hard for you.” History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 39  The Content of the Medical Consultation We have been discussing the Process skills used to gather information from the patient. The process skills are the skills we use to enable the patient to tell us what we need to know. The process skills are “how we gather information”. We also need to know in detail the information that needs to be gathered. This is the Content of the consultation. The content is “what information we need to gather”. Content gathered in history taking Patient's Presenting Problem(s)/Complaint(s) History of the Presenting Problem(s)/Complaint(s) o Biomedical perspective o Patient’s perspective Background Information: o Past Medical History o Medications o Allergies and Adverse Reactions o Family History o Personal and Social History o Physical Activity History In this guide our emphasis is on taking a patient’s medical history - the first three areas listed above. The Clinical Skills programme over the next two years will gradually also equip you with knowledge about specific body systems including fundamental skills in physical examination. Patient’s Presenting Complaint(s) This is the list of problems that the patient initially presents with. We ask about the Presenting Complaint(s) during the “Initiating the session” part of the consultation when we: summarise the presenting complaints screen for additional complaints negotiate the order you will address the presenting complaints History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 40 History of the Presenting Complaint(s) – Exploration of the Patient’s Problems We use medical knowledge to explore the patient’s presenting problems or complaint(s). This can be organised into the following sections: Biomedical Perspective ▪ Sequence of events ▪ Symptom analysis ▪ Associated symptoms Patient’s Perspective ▪ Ideas ▪ Concerns ▪ Expectations ▪ Effect on life ▪ Feelings – the patient is encouraged to express feelings at any stage in the consultation Exploration of the Patient’s Problem(s) from a Biomedical Perspective Sequence of events Before analysing the symptoms in detail, it is important to get the whole story and understand the time sequence. Once you have a clear picture of the sequence of events you should have enough information to write a short story or make a movie about the patient’s presentation that includes details about three aspects: any precipitating event(s) the onset of the event in detail what has happened in detail since the onset There can be some overlap between the sequence of events and symptom analysis. Onset and timing may be part of both the sequence of events and symptom analysis. You will need to consider: Onset ▪ Day, date, and time of onset. ▪ When the patient was last completely well especially if the onset is not well defined. ▪ Duration – how long the symptom(s) have been present. This gives an indication of onset. ▪ Mode of onset - sudden, rapid, or gradual. Precipitants – event(s) that occurred before the onset of symptoms. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 41  Time course – what has been happening from when symptom(s) first started until now. ▪ How long symptoms last if they are intermittent. ▪ Frequency – how often symptoms occur. ▪ Pattern –if there is a pattern. Symptoms may be static, deteriorating, random, worsening. ▪ When any exacerbations and remissions have occurred. ▪ Recovery –what the recovery period is like. Symptom analysis This involves the thorough analysis of each symptom gaining exact details. Here are some examples: “I've lost such a lot of weight recently” Important information to gather: how much weight has been lost over what time-period the weight has been lost the part of the body that has lost weight any associated symptoms patient's feelings about the weight loss (such as anxiety or delight) patient's ideas (what they think caused the weight loss) patient's concerns about the weight loss patient's expectations (what they think the doctor might do) effect the weight loss has on the patient’s life, including daily activities whether any other factors could have contributed (such as change in diet or physical activity) “I've been feeling hot lately, like I've got a fever” Important information to gather: when it began relationship to time of day fluctuation over time duration what it feels like? (how hot? have they checked?) aggravating factors alleviating factors any associated symptoms patient's feelings about the possible fever (such as anxiety) patient's ideas (what they think is causing the possible fever) patient's concerns about the possible fever patient's expectations (what they think the doctor might do) effect the possible fever has on the patient’s life, including daily activities and extent of disability History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 42 There are many methods that can be used to help you to remember how to analyse symptoms. WWQQAA and SOCRATES are two that we suggest. WWQQAA Where: the location and radiation of a symptom When: when it began, fluctuation over time, duration Quality (what): what it feels like/ description of the symptoms Quantity (how much): intensity, extent, severity, degree of disability Aggravating factors (precipitation and exacerbating): what makes it worse Alleviating factors (relieving): what makes it better Adapted from: J. Silverman, S. Kurtz, and J. Draper, Skills for Communicating with Patients 2nd edition (Oxford: Radcliffe 2013), p.70 WWQQAA is very useful for analysing any symptom including pain. A drawback of WWQQAA when you are learning is that there are several things you can ask about each letter. WWQQAA does fit very well with clinical reasoning. As you become more experienced you will use more clinical reasoning in your questioning and WWQQAA is helpful as it is less of a checklist. You may not need to use all aspects of WWQQAA. SOCRATES (originally a check list for pain that can be modified to explore other symptoms) Site: where the pain is located (localised versus generalized) Onset: speed of onset and any associated circumstances Character: described by adjectives, such as sharp/dull, burning/tingling, preferably using the patient’s own words Radiation: does it go anywhere else? Associated symptoms: such as fever, visual aura of migraine, nausea Timing: duration, course, pattern such as episodic or continuous, variation by day/week or day/night Exacerbating and relieving factors Severity From: MacLeod’s Clinical Examination 11th edition; G. Douglas, F. Nicola, C. Robertson, Eds (Churchill Livingstone 2005), p. 3 History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 43 SOCRATES is a very useful checklist to analyse pain. It can be modified to analyse other symptoms. You may not need to ask all aspects of SOCRATES. A drawback of the mnemonic ordering of SOCRATES is that it does not involve clinical reasoning if used in order as it separates attributes that can link well together such as site and radiation. Another drawback is that the way SOCRATES can influence the way you ask questions. It can prompt you to use language it uses such as “radiate” and “character” that are not words we commonly use. It also combines the two attributes “exacerbating and relieving” in the letter “E”. This can lead you to ask about the two attributes in one question which is not recommended. Quantity/Severity Assessing the quantity/severity It is useful to find out how bad a symptom is. This is Quantity in WWQQAA or Severity in SOCRATES. You can assess quantity or severity simply by asking the patient “How bad is it?” and they will tell you. You can also do this by asking the patient about the effect the symptom has on their function, or what they are able to do. Severe pain can affect mobility. Severe swelling can prevent use of a limb or stop a person from putting on clothing. If the patient has a rash you might want to ask how big an area it covers to work out the extent of the problem. The pain scale The pain scale is particularly useful if you want to compare levels of pain. You do not have to use the pain scale to assess severity if you have found out how bad the symptom is by asking the patient about this. You may use the pain scale to find out how bad the pain is now in comparison with what it was like when it started. If you use the pain scale it is important to explain it to the patient before you ask the numbers. It is also important to acknowledge and interpret what the patient has told you. In the pain scale “zero” is no pain at all, and “ten” is the worst pain the patient can imagine. Doctor: “That pain sounds pretty bad Steve.” Steve: “Yeah, and it is getting worse.” Doctor: “I’d like to use the pain scale to compare what it was like when it started with what it is like now.” Steve: “Ok.” Doctor: “In the pain scale zero is no pain at all and ten is the worst pain you can imagine. What number would you have given the pain when it started?” Steve: (Thinking aloud…) “Mmm… when it started… zero is no pain, ten the worst... It would have been a 2.” Doctor: “What number would you give the pain now?” Steve: “It is more like an 8 now.” Doctor: “Wo-oh. 2 when it started and 8 now. That really is getting worse.” Steve: “Yeah. It’s bad” History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 44 Associated Symptoms The symptoms a patient has can either be general symptoms, or symptoms specific to a particular body system. Symptoms often do not happen in isolation. When a patient presents with a symptom it is important to inquire about the other symptoms that might be related. The doctor uses their medical knowledge and their ability to “think like a doctor”, using their clinical reasoning to guide the questioning about these associated symptoms. Associated symptoms include both general symptoms such as a change in energy, mood, appetite, weight, sleep patterns, or temperature; and specific symptoms related to a body system. Each body system has its own list of possible symptoms that may be part of a presentation related to that system. You will learn these as you learn each body system in ELM. The following is an example of the use of exploring the associated symptoms for a patient who presents with cough. The doctor has fully explored the presenting symptom and has just given a short summary. Doctor: “You said you’ve had this cough for three weeks and it isn’t getting any better. And now you are coughing up heaps of yellow stuff and you’ve got that pain in your chest. I’m just going to ask you some more questions to find out more about what has been going on. Associated symptoms (General): What’s been happening with your weight? What has your appetite been like? How’s your sleep been? What about your energy levels? Have you had a fever? Associated symptoms (System specific): Have you had any shortness of breath? Have you had any wheeze?” The first five questions about Associated Symptoms are about general symptoms while the final two are about system specific symptoms related to the respiratory system. For more information regarding the general symptoms refer to the General Symptoms Reference Guide available on Moodle. As you progress through ELM you will have opportunities to learn the associated symptoms that are related to each body system. You will also learn the associated symptoms that occur with common health conditions. History Taking in ELM Reference Guide: Calgary-Cambridge Guide to the Consultation 45 Exploration of the Patient’s Problem(s) from the Patient’s Perspective The patient’s perspective on their illness and their presenting problems can explored by finding out about: Ideas: the patient's beliefs about what has caused their illness, how it relates to previous illness, and their general ideas about health Concerns – their worries about what the symptom means for them Expectations - what they hope to achieve from their visit to the doctor Effects on life - the effects of the illness and its symptoms on their life It is also important to encourage the patient to express their feelings about what is going on. This can be done at any stage in the consultation when it seems appropriate. Background Information All patients come with their own personal context. They all have a past that includes a medical history. They all have a family with medical history, and they all live in a community. Each of these areas will potentially have some bearing on the complaints they present with and need to be explored. This background information is part of traditional medical history taking and is considered under the following headings: Past medical history Medication Allergies and Adverse Reactions Family history Personal and social history including physical activity history Past Medical History This refers to any previous significant illness, long term health problem, or hospital admission.