CORE Book of Consultation & Reflection (2nd ed.) PDF

2nd Edition, January 2024 The CORE BOOK of Consultation & Reflection Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice Skillslab Department Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department Second Edition, January 2024 EDITORS Anita Kaemingk (MSc Neuropsychology, Redesign Teams Skillslab & CORE, first author) Valerie van den Eertwegh (PhD, MSc Change Management, Coordinator Intervision in the Master of Medicine, co-author) THE REDESIGN TEAMS SKILLSLAB & CORE Femke Jongen (MD, Head of Skillslab) Ingrid Caubergh (MSc Health Sciences, Head of CORE) Hanneke Vermeulen (MD, Teacher Clinical Skills) Sandy Nelissen (MD, Coordinator of Simulated Patients Education) ACKNOWLEDGEMENTS Special thanks go to Jan van Dalen, pioneer in the teaching of consultation skills in the Maastricht medical curriculum, with MAASglobaal, the first Description of a Consultation, and the Dutch translation of the renowned book Skills for communicating with patients by J. Silverman et al. Geraldine Jansen, MD, General Practitioner, Teacher CORE Petra Kuijpers, MD, PhD, Cardiologist Franca Warmenhoven, MD, Teacher Clinical Skills Trudy van der Weijden, MD, PhD, Professor Family Medicine, School CAPHRI Albertine Zanting, MSc, Liaisons officer Internalisation and Diversity Rob Houtepen, Coordinator GRGE (Metamedica/HES) Student Taskforce Diversify Medicine, Maastricht University This book is a growth book, so please feel free to share your comments with us: [email protected]. COLOPHON The content of this CORE Book was developed for study purposes under the auspices of the coordinators Clinical Practice at the Skillslab Department, Faculty of Health, Medicine and Life Sciences, Maastricht University. Every effort has been made to ensure that the information in this book is accurate and sources are listed correctly. This does not diminish the requirement to exercise sound and clinical judgement. The editors cannot accept any responsibility for its use in practice. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright owner. When using any part of the content or materials, please mention the source correctly. ©2022 Anita Kaemingk en Valerie van den Eertwegh Illustrations: Anita Kaemingk The CORE Book of Consultation & Reflection – January 2024 2 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department Content INTRODUCTION PART I. STRUCTURE OF THE MEDICAL ENCOUNTER Phase 1. Clarification of the reasons for the encounter Phase 2. Extended history taking and physical examination Phase 3. Evaluation, explanation and plan PART II. BRIEF EXPLANATIONS OF CONCEPTS 1. CORE: Consultation & Reflection 2. Connecting with the patient 3. Safety & Trust 4. Reasons for the Encounter 5. Context: consultation & patient 6. Frame of reference 7. Constructive communication skills: Attentive listening, Questions, Summary, Reflection of emotions 8. A Biopsychosocial Approach 9. Health literacy 10. Empathy 11. Reassurance 12. Coping strategies & Problem Solving 13. Dealing with strong emotions: a tool 14. Communication during physical examination 15. Clinical Reasoning 16. Breaking bad news 17. Explaining & Education 18. Shared Decision Making 19. Health Promoting Behaviour & Motivational skills 20. Collateral History (Heteroanamnesis) 21. Recording the findings 22. Functioning & the ICF 23. Emergencies 24. Self-care PART III. TOPICS TO ADDRESS IN PHASE 2 Extended history  Targeted history of presenting complaint  Completing review of systems  Past medical history  Family history  Social history and environmental aspects  Lifestyle and stress  Intoxicants  Drug history  Allergies  Summary of extended history Physical Examination RECOMMENDED READING & REFERENCES The CORE Book of Consultation & Reflection – January 2024 3 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department The CORE Book of Consultation & Reflection – January 2024 4 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department Introduction From the very start of the Faculty of Medicine in Maastricht in 1976, medical students have been offered a structural and longitudinal course in consultation and reflection skills (first called Sociale Vaardigheden, Social Skills). Over the years the programme has developed into the robust and comprehensive training it is now, with simulated patients (SPs), group discussions and special training sessions which together are known as CORE: COnsultation and REflection. The three-year course offers a whole-task, semi-authentic learning environment in which students work on the complex integration of communication skills, medical knowledge, clinical skills and personal development while interacting with trained ‘patients’. At the heart of CORE education lie Simulated Patient Consultations, known as SPCs. CORE is part of the Clinical Practice practical training programme in the Medical Professional line. To acquire the skills needed to understand and perform an effective human-centred medical encounter, step-by-step learning is essential. This method of learning is guided by dedicated CORE topics and teachers, students’ personal learning goals, feedback from SPCs and fellow students, and group discussions. CORE is part of the programme Clinical Practice in the line Medical Professional and facilitates the blending of three longitudinal education lines: 1. Medical Professional 2. Critical Professional 3. Personal Development CORE offers a safe learning environment in which you are allowed to try things out and make mistakes. In fact, this basic attitude will determine how much you will learn from the programme and how much joy and personal development it will bring to you. We therefore invite you to consciously choose to The CORE Book of Consultation & Reflection – January 2024 5 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department follow each part of the CORE programme with a growth mindset (‘I can learn anything’), as opposed to a fixed mindset (‘I’m either good at it or I’m not’). Performing an SPC is not about succeeding or failing. It is about trial and error and about being open to learn from each ‘whoopsie, I got stuck moment’. In this sense, the word ‘FAIL’ is understood as ‘First Attempt In Learning’. CORE explicitly:  Invites you to adopt a growth mindset. This will support better performance and learning outcomes, as well as provide more enjoyment and a sense of well-being during the study.  Supports your individuality (personal assimilation of skills). This will reduce your uncertainty (which might interfere with learning and effective communication), enhance your flexibility (needed in medical practice where every encounter requires its own approach) and develop your authenticity (which is particularly helpful in establishing sound authentic therapeutic relationships). First-year students are often very ambitious and have high expectations of themselves (sometimes too high). They take on too much because they want to come across as an experienced doctor or because they want to conduct the 'perfect' How flexible is your mindset? consultation. However, there is no such thing as a perfect consultation. Learning Do the free test on IDRlabs consultation skills is a lifelong process involving acquiring, reflecting, adapting and polishing. During CORE in the Bachelor’s phase, we provide the tools and the space to practice this process of lifelong learning. THE CORE LEARNING PATH As can be seen in the figure, the CORE Learning Path consists of the five phases that you will go through each time you learn from your SPCs. You will prepare and perform an SPC. During this SPC you will experience confrontations both large and small (e.g. you ask the simulated patient something in a specific way and you notice that it doesn’t work out as you had hoped). By watching the recordings and giving and receiving feedback you will become aware of your own behaviour. You will collect alternative methods and tips from the SPs, the Core Teacher and your peers to try out in the next SPC. This is a The CORE Learning Path. CORE activities linked to the five phases of becoming a skilled communicator. Learning is optimised when the student feels safe and experiences sufficient mental space (cognitive and emotional). (Based on Van den Eertwegh, 2015 ) The CORE Book of Consultation & Reflection – January 2024 6 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department process of trial and error which allows you to make mistakes and experiment until it feels authentic and natural. Ultimately, the new and more effective way of communicating will be fully internalised and integrated into your clinical repertoire. The reason we introduce you to the CORE Learning Path is because research has shown that active knowledge and being aware of these five phases will make you a more effective learner, resulting in behavioural changes with a long-lasting effect. This type of learning by doing is also called experiential learning, and it is the scientific underpinning of the CORE programme. HOW TO USE THE CORE BOOK OF CONSULTATION & REFLECTION This document comprises three parts. Part I presents the medical encounter in three phases. The Maastricht 'three-phase model' is based on the acclaimed and widely-used Calgary-Cambridge framework [2, 3]. The outline is not meant to impose fixed rules, but serves to fuel learning goals on skills from a simple, basic level to advanced and more complex situations. Part II briefly explains several concepts in healthcare that affect communication with patients and planning of care. Some of these can be READING: applied in CORE education, others merely offer a sneak peek into some Calgary-Cambridge Framework Silverman, Skills for communicating themes from medical practice. They may serve as a basis for group with patients. Chapter 1 discussions or personal reflection. There are multiple resources available to learn more about each topic. Part III gives an overview of the medical content regarding history taking and physical examination that is addressed by means of clinical reasoning. In the first year the focus lies primarily on becoming familiar with the first and second phases of the Maastricht three-phase model. With time and progress, the student can take on more topics to work on. At the end of the third year, a student should be able to execute a complete consultation on a single medical problem following the three-phase structure with dedicated skills, also to break bad news and engage in shared decision making. The CORE Book of Consultation & Reflection – January 2024 7 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department The CORE Book of Consultation & Reflection – January 2024 8 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department Part I Structure of the Medical Encounter In CORE education (Consultation and Reflection), the Maastricht three-phase model is applied to give structure to the medical encounter. In the training of clinical communication skills, this model offers a comprehensive and transparent tool for both complaint-centred and follow-up consultations. It will help the medical student to smoothly combine the two pathways that are always present in a doctor-patient encounter: the patient-informed pathway and the medically-informed pathway [2, 4]. The three-phase model will promote a relationship of authentic contact and trust with the patient, while at the same time exploring medical hypotheses. The Three Phases Phase 1. Clarification of the reasons for the encounter Phase 2. Extended history taking and physical examination Phase 3. Evaluation, explanation, and plan Each phase is characterised by its own frame of reference; indicating which person is ’leading’ or talking the most during that phase. See Part II for more information. Phase 1. Frame of reference: patient Phase 2. Frame of reference: doctor Phase 3. Frame of reference: patient and doctor PHASE 1 Clarification of the complaint and the Reasons for the encounter. Frame of reference: patient Objectives: to connect with the patient and establish a relationship of trust; to compile spontaneous information about the complaints from the patient; to clarify the patient's care request and their feelings, ideas, concerns and expectations (FICE); making a consultation plan together with the patient. Patients usually come to see their doctor about three things, which together are the care request: 1) signs/symptoms/presenting complaint 2) feelings/emotions/concerns about these signs/symptoms 3) a reason, wishes and expectations for this encounter. Often patients will spontaneously tell you about their complaint (I have such a tummy ache), but not their problem (I want to know if this tummy ache will go away on its own or I am worried that I may have cancer). It is important to clarify your patient's thoughts and feelings regarding both complaint and problem in the early stages, as these will set the agenda for the medical history-taking. These processes are referred to as complaint clarification and clarification of the Reasons for Encounter (or care The CORE Book of Consultation & Reflection – January 2024 9 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department request). Complaint clarification is NOT the same as taking a history of the complaint (e.g., using the SOCRATES method, as discussed in Part III), but serves to jointly establish the chief complaint that this consultation will address. If necessary, ask clarifying questions such as 'What do you mean exactly by tummy ache?'). Is this the most significant complaint, or does the patient have other issues ('Apart from tummy ache, do you have any other complaints or issues you would like to discuss with me?'). By addressing this early on, you prevent the patient from saving a potentially more important issue until the end of the consultation when there may not be enough time to discuss it ('Doctor, I sometimes notice blood in my stool'). This is known as the 'doorknob phenomenon'. This is more commonly observed when the doctor did not inquire thoroughly enough at the beginning of the consultation or when the patient did not feel the setting was safe or open enough. The problem is how the patient experiences the presenting complaint and how it affects their daily life. For you as a doctor to effectively discover the problem behind the complaint, you should enable and encourage the patient to talk as freely as possible. Realise that the patient is the expert at this phase, because you did not know anything about the reason for the visit when the patient came in. By having an open approach and being interested in the patient’s experiences, the doctor tries to get to know the patient and their context, by asking themselves ‘who is this human being who is sitting in front of me’. At this point in the encounter, you as a doctor ask the patient to describe their problem in their own words and explore their Feelings, Ideas (i.e. what explanation does the patient have), Concerns, and Expectations. A helpful mnemonic is FICE. Ask in-depth questions about any aspect that is not yet clear, for example the statement ‘I am worried, doctor’ does not give any information about what kind of worries the patient has. You as a doctor are having a In-depth questions such as 'tell me what exactly is worrying you' are consultation with a 35-year-old necessary to clarify any vagueness. woman who has been suffering from insomnia for 2 months. The lack of sleep makes her very emotional, and it is becoming Phase 1 is concluded with a summary of the chief complaint and the difficult for her to perform her daily patient’s Reason for the Encounter, verbally connected as close as activities as CEO secretary. You want to ask possible with the patient's language (e.g. ‘You have had a headache questions about the four aspects of the for 2 weeks, and now you are worried that it might be a brain patient’s perspective, which are: 1. Feelings, 2. Ideas, 3. Concerns, 4. Expectations tumour, because your grandma had one too. Is that correct? For us to find an answer, we need to..…’). This will contribute to the Formulate a question for each of these feelings of trust in a patient as well as elicit the first medical aspects without using the four words hypotheses, initiate clinical reasoning, and determine the agenda of literally. 1..... the consultation with extended history taking about the chief complaint. 2..... 3..... To match the medical perspectives with the patient's perspective, The Reason 4..... for the Encounter (including FICE) will be addressed again in phase 3. Has every question and concern been addressed? This is what we call closing the consultation circle. Communication skills of the doctor in phase 1 (Note: The example sentences are for illustration purposes; please try to use your own words as much as possible.)  Making contact (make eye-contact)  Making the patient feel at ease (use a little chit-chat to break the ice)  Attentive listening and active silences ('Aha, and what did you do then when you could not sleep?') The CORE Book of Consultation & Reflection – January 2024 10 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department  Observing nonverbal behaviour ('I see you are frowning; can you tell me what’s on your mind?')  Exploring the patient's cues (‘You said “that will be difficult”, what do you mean exactly?’)  Empathic attitude (‘I feel your worries, it’s good that you have come to see me.’)  Identifying and reflecting emotions (‘I can see that this is upsetting Q What is the difference you.’) between summarising and paraphrasing?  Asking for the patient's expectations ('What would you like me to do Q Which one is mainly meant to check for you?' 'What specific expectations do you have regarding what I and structure the conversation, and could do for you?') which one is to show that you are actively listening?  Open-ended questions, or questions that encourage the patient to share information spontaneously (’What happened then? Can you tell me more about it?’)  Making more specific (asking questions about a specific content, and rephrasing), (‘So you said your wife helped you, what did she do exactly after you sprained your ankle?’)  Paraphrasing (reproducing a verbal message using different words)  Summary of reasons for the encounter ( 'So, if I understand you correctly, you have come to see the doctor today because you have had this headache for two weeks now and you have already tried…... It worries you, because a friend was suffering from headache too, which appeared to be a tumour')  Structuring questions and information ( ‘We just talked about your reason for the visit, now I like to ask you a few more in-depth questions about the complaint itself.’)  Making transitions ('Now I understand what led you to make this appointment, shall we turn to some other questions?') FICE: Making assumptions about the patient’s expectations is a common pitfall. Building phase 1 with FICE (Feelings, Ideas, Concerns and Expectations) will help keep an open mind. The CORE Book of Consultation & Reflection – January 2024 11 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department  Drawing up a consultation plan ('First I would really like to hear more of your story, then I will ask some more in-depth questions and I will do a physical examination, and then we will discuss the findings and some options available to us. Is that ok?') PHASE 2 Extended history taking. Frame of reference: doctor Objectives: to obtain specific information about the presenting complaint in a structured way. This includes targeted history-taking, review of systems and physical examination, considering and reconsidering medical hypotheses, and making a differential diagnosis (DD). Note: history-taking starts in phase 1 (more focused on the patient’s frame of reference) and continues in phase 2 (more focused on the doctor’s frame of reference). In this phase, the doctor is the expert. The patient’s signs and symptoms that were formulated in your patient’s language in phase 1 are now translated into a medical context. In order not to lose your patient's trust, it is important to guide them through the various topics and procedures, and explain why certain questions are asked. In the patient's eyes certain medical information will not always seem to be associated with the complaint, e.g. questions about swollen ankles in a patient who feels short of breath. Therefore, the doctor may explain why it is necessary to ask these ’seemingly unrelated’ questions. If indicated, history-taking is followed by a physical examination, again with friendly and clear guidance to make the patient feel as comfortable as possible. As a doctor you should remain alert to cues and information that may provide more clarity about the exact problem or context of your patient, as well as be mindful of diverse wishes, expectations, communication styles, etc. Communication skills of the doctor in phase 2 (Note: The example sentences are for illustration purposes; please try to use your own words as much as possible.)  Keeping the patient feeling at ease ('Are you ok to move on to some more in-depth questions about the complaint itself?')  Attentive listening (‘aha, hmmm yes, I see…’)  Empathic attitude (’that must be difficult indeed’)  Identifying emotions  Observing non-verbal behaviour  Rephrasing (‘So, in other words, because your ankle feels different this time, you are worried it might be broken instead of sprained?)  Tangible questions that will produce specific information (often more closed than open-ended questions)  Structuring of questions and information  Explaining why certain topics/questions are relevant  Directive approach, leading attitude of the doctor  Clear, friendly and patient-centred guidance during physical examination ('My hands aren’t too cold for you? I will now first examine your foot when standing and then I will ask you to …')  Summary of extended history taking  Making notes The CORE Book of Consultation & Reflection – January 2024 12 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department Medical content in phase 2 Several topics should be addressed during this phase. Depending on the nature of the consultation (is this a new patient?), the presenting complaint, the care request, FICE, and the hypothesis/differential diagnosis, some topics will need more attention than others. Also, the order of these topics is not set in stone, but depends on the course of the interview. See Part III for more information. Topics to address in phase 2 (see Part III):  Targeted history of presenting complaint  Completing review of systems  Past medical history  Family history  Social history and environmental aspects  Lifestyle and stress  Intoxicants  Drug history  Allergies  Physical Examination Clinical reasoning: diagnosis at first sight or trawling? The CORE Book of Consultation & Reflection – January 2024 13 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department PHASE 3 Evaluation, discussion, plan. Frame of reference: both patient and doctor Objectives: to evaluate the obtained information, to formulate a working hypothesis, to explain the findings, to make a possible diagnosis (including duration, severity, prognosis), to explore and discuss the patient's questions and perspectives considering all the information, to discuss treatment options (including pros and cons), to agree together on a course of action (shared decision making) and to close the consultation circle (readdressing FICE). During this phase both the patient-informed pathway and the medically-informed pathway come together. Evaluation of the obtained information and clinical reasoning will lead the doctor to a conclusion. The doctor explains this to the patient according to the best of their knowledge, and the explanation should always be adapted to the knowledge and abilities of the patient. It is necessary to check if your patient understands what you are saying, what they should do and how to adhere, especially when dealing with a patient with low health literacy (see Health Literacy in Part II). It is important to close the consultation circle by addressing the FICE from phase 1 again, and checking if these topics have been covered satisfactorily. This includes the skill of saying no to certain wishes of the patient in a constructive way, ('Doctor, can you give me a prescription for antibiotics?') if there is no medical reason for such an intervention. In such cases, it is sensible to explore the reasons behind such requests. It also includes the skill of motivating the patient to do something difficult, e.g. to stop smoking (motivational interviewing). Communication skills of the doctor in phase 3 (Note: The example sentences are for illustration purposes; please try to use your own words as much as possible.)  Keeping the patient feeling at ease  Empathic attitude ('I understand your worry, it’s very good that you have come to see the doctor.')  Effective reassuring  Structuring ('Shall I first explain what I found during the physical examination? After this we can discuss the two options.')  Transferring information ▪ about the hypotheses (informing) ▪ in small quantities/steps ▪ giving most important information first  Adapting to the patient's level of comprehension ▪ Using appropriate language ▪ Using illustrations and drawing, writing down the most important words or sources ▪ Checking if the information is understood  Dealing with emotions ▪ Identifying and reflecting the emotions of the patient ('I see from your face that it really worries you.') ▪ Identifying your own emotions (especially if there is bad news)  Considering options for the future together with the patient, making a new appointment if the patient is too overwhelmed to process any more information  Shared Decision Making The CORE Book of Consultation & Reflection – January 2024 14 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department ▪ Explaining alternative options for the course of action (including doing nothing) ▪ Listing advantages and disadvantages and expected outcomes ▪ Communicating risk numbers ▪ Giving room to the patient to process all the information and to ask questions each time you’ve explained something ▪ Inventorying the patient's perspectives ▪ Inventorying the patient's preferences regarding options for medical interventions ▪ Making decisions together with the patient ▪ Formulating suggestions of what can be done to help the patient  Applying motivational interviewing techniques, e.g. when dealing with lifestyle issues  Making concrete appointments for follow-up  Summarising the main findings and follow-up steps together with patient  Closing the encounter (e.g. get up and guide patient to the door)  Making notes  Recording the patient's reasons for encounter, health history and physical examination in a standardised way. During the consultation, your patient may have questions. In general, it is important that medical students are conscious of their moving knowledge boundaries (‘at this point what do I know, and what don’t I know?’). For educational purposes and in Simulated Patient Contacts (SPCs), students are invited to say what they think out loud. Thus, SPCs also offer the opportunity to learn to cope with uncertainty and to explore their personal boundaries in explaining and shared decision making. This is of course subject to the context and with the reservation that your patient's story will be discussed with your supervisor (in CORE this is a fictitious GP). The CORE Book of Consultation & Reflection – January 2024 15 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department The CORE Book of Consultation & Reflection – January 2024 16 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department Part II Brief Explanations of Concepts Learning how to engage effectively in a doctor-patient contact is a matter of learning to understand the patient and the interaction, of acquiring skills and also the knowledge of a variety of topics that affect you as a doctor. Part II presents an introduction to a number of these topics, with tips for further reading and short teaser questions (DIY - do it yourself). Feel free to look further and to share other sources and other points of interest with your CORE group members. 1. CORE: CONSULTATION & REFLECTION Consultation A medical encounter involves much more than having a friendly conversation and asking the right medical questions that will lead to a diagnosis. A doctor needs to have the ability to translate patients' words into medical care and vice versa, and to offer support with or without a diagnosis. A consultation is effective (efficient, accurate and supportive) when both doctor and patient feel that both pathways have been addressed satisfactorily. This can be achieved where the communication promotes interaction rather than transmission of information. In general, people are reluctant to go to the doctor. They only do that when they believe they can no longer resolve their complaints on their own. When they do go, more than anything, they want to be taken seriously before confiding private details. The first job of you as a doctor is therefore to show genuine interest and build trust, starting the very first second that you call your patient in from the waiting room. At about the same time, your mind starts a process of clinical reasoning that will continue throughout the health interview. A very important skill is not to jump to conclusions, but to keep an open mind until the end. While trying to facilitate feelings of relatedness during (and preferably after) the encounter with skills such as active listening, structuring, and showing empathy, you also need to organise and interpret the information shared by your patient. Hypotheses and differential diagnoses need to be tested until a working hypothesis that serves further diagnostics or plans of action can be formulated. Other advanced skills, such as shared decision making or motivational interviewing, support the feelings of autonomy and competency in the patient. These basic human needs, relatedness, autonomy and competency, play a major role in every patient's wellbeing, as well as in the success or failure of any plan of action that the patient will go home with (Self Determination Theory ). Reflection On learning. Learning in CORE education occurs through reflection. During the whole process of preparing, doing and debriefing a consultation, it is important that you reflect on your own behaviour, feelings, thoughts and skills. Only by reflecting on what went right, what could have been done differently or more effectively, will you gain self-insight. This self-insight fuels your personal and The CORE Book of Consultation & Reflection – January 2024 17 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department professional development. Reflection is a skill you will work on and continue to improve throughout your life. On mindset. For a medical encounter to be effective and beneficial to both your patient and you as a doctor, it is paramount that you gain insight into your own motives, feelings, responses, views on healthcare, etc. and their possible differences with those of the patient. Being sensitive to your own cultural perspectives diminishes the risk of judging the other person (judgements obstruct effective healthcare). You are therefore encouraged to reflect on your own mindset, how this changes over time (also as a consequence of the extensive medical training programme), and the self-evident disparities with other people. On the societal context. A medical encounter is not only about the interaction between two or more individuals in the consultation room, but also with many bigger outside forces. For example, the organisation of healthcare in a particular country dictates many decisions for the healthcare professional. In addition, a patient’s problems may be closely linked to societal circumstances, such as housing, healthcare access, food and water security, or governmental policies. You are invited to reflect on these issues when considering the patient’s circumstances and plan of care. What is effective, what is possible, what are the costs, etc? EXAMPLE: Mrs. Kadir comes in with a nasty cough. History taking reveals that she smokes a packet of cigarettes a day. You, as a doctor, have learned that only giving the advice to stop smoking is not effective. Consequently, you try to help her quit by means of motivational interviewing and a referral to the MUMC Stop Smoking Clinic. However, this doesn’t work either. Digging deeper into her story reveals that she is suffering from chronic stress due to the devastating impact of the childcare benefits scandal. The unjust and discriminatory policies of the Dutch Tax Authorities have caused her to run up large debts and her daughter to be involuntarily put into foster care. Mrs. Kadir is in survival mode. She has no mental space left for health changes such as stopping smoking. 2. CONNECTING WITH THE PATIENT READING: Building a relationship Silverman, Skills for The billion-dollar question: what is the secret to effective healthcare encounters? communicating with patients. The answer to this question is quite simple. It is all about a careful execution of Chapter 2 and Chapter 5. the initial stage. Taking steps to develop a relationship of trust early on will set the scene for efficient and accurate information exchange as the interview unfolds. Many problems that arise during a consultation, or beyond (time issues, deficient history taking, treatment plans that don’t match with the patient, as well as the notorious non-adherence and dissatisfaction), have their source in neglecting or skipping the first stage. Attention to relationship building allows for more satisfaction and less frustration in both patient and doctor. So, investment in the first few minutes is rewarding. Often, medical students hope to feel a ‘click’ with their patient, and in the absence of this they may Eye contact: 1 minute video Connecting with patients: Stanford easily label the patient as ‘difficult’. It is important to realise that feeling a (Zulman & Verghese) click or feeling someone is a difficult patient are the experiences of the student (and often also doctors), but that these feelings are not necessarily mirrored by their patient. Patients definitely don’t see themselves as difficult, but may feel not being heard or taken seriously. You, as a future doctor, have the key responsibility of establishing a connection The CORE Book of Consultation & Reflection – January 2024 18 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department with the patient. If the conversation proceeds with great difficulty, it often means that the connection is falling short. However, it is never too late to improve such a conversation. You can say something like ‘I have the feeling that our conversation isn’t satisfactory for you or that it doesn’t feel good to you. Tell me again/in more detail why such and such is important to you.’ This is called metacommunication, i.e. communication about the interaction. In short, it is quite possible to foster a warm-hearted connection with the patient by your own actions (even if you don’t agree with the patient’s ideas). How to build a relationship  Before starting, take a minute to clear your mind, to relieve any muscle tension (which improves your nonverbal behaviour) and to prepare mentally for the next encounter. This will allow you to be fully present and not disturbed by other thoughts.  Engage your patient right from the beginning with smiles and eye contact.  Show genuine interest and curiosity about your patient.  Watch and listen for visual, auditory and kinaesthetic (touchy-feely) cues and respond to them.  Match the pace and tone of your patient’s speech and their language.  Match your patient’s body posture.  Try not to interrupt or talk over your patient.  Leave a silence when your patient is clearly thinking hard.  Summarise for them what they’ve just told you to demonstrate that you have listened and understood. On average, doctors interrupt patients just 12 seconds into their opening Disconnection statements. Many doctors fear that if they Being aware of behaviour that brings about, disconnection don’t interrupt their patients, the patients will go on for an excessive amount of time. This appears may help to prevent the accidental breaking of a connection. not to be true: patients speak for an average of On rare occasions, it can also be used to help the patient 92 seconds, and 78% finish in 2 minutes. These 2 recognise cues meaning ‘it’s time to leave’: minutes are well worth listening to, because the  Altering body position so that it no longer matches that patient will often present the most important cues for the doctor to explore. of the patient.  Starting to speak faster and louder than the patient. Check for yourself: When listening to a story a friend or family is telling you, after how many  Breaking eye contact by looking away. seconds do you feel an urge to interrupt?  Starting to look at the computer. Try to neglect this urge and continue  Handing over a prescription or patient information leaflet. listening …. (practice makes  Starting to stand up from the chair. perfect).  Walking to the door. 3. SAFETY AND TRUST 'I would like to be a doctor that patients will trust and feel safe with' is a much-heard response when medical students are asked 'What type of doctor would you like to become?' And indeed, trust and feeling safe constitute the foundation of every salutary therapeutic relationship. But what does this mean, and how can one create safety and trust? Safety can be defined as free from harm or hurt. It is a primary need of human beings; it may even take precedence over the need for food and water when in danger. There is a difference between being safe and feeling safe. An individual may be safe but not feel safe, or vice versa. This is an important The CORE Book of Consultation & Reflection – January 2024 19 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department distinction in healthcare and medical encounters. Before a patient will READING: the patient’s feelings share important private details, they need to feel safe in an environment Many patients feel anxious when that is in itself hostile to a patient's integrity. For example, undergoing a entering the consultation room, but medical procedure such as an operation involves physical risk, but seldom verbalise their emotions explicitly in the medical encounter. patients may feel safe (while at the same time feeling anxious) because Research shows that patients more they trust the medical staff. In addition, many people have experienced readily express their concerns when feeling unsafe in their lives, such as unsafe or even abusive childhood their GP shows verbal and nonverbal situations, violence, difficult living conditions, or adverse healthcare affect to the patient, but not when the GP asks direct questions. experiences. This can have a long-lasting impact on their lives, and may (Bensing, 2008. Patient Anxiety in the result in more disease and frequent healthcare encounters. Also, they medical encounter) may suffer from recurrent intense feelings of not being safe while they are effectively in a safe situation. The key to feeling safe is not being safe, but having sufficient knowledge about a situation and the people involved. A doctor can foster feelings of safety by regularly explaining what is happening or going to happen, by being genuine and open-minded, having an unconditional positive regard for the patient's story (meaning not judging the patient and/or their situation), by building trust and a collaborative relationship ('we're in this together'), and especially by refraining from paternalistic and authoritarian behaviour. It is also important to be attentive to signs of earlier experiences of feeling unsafe that may lead to defensive or emotional behaviour that impedes an effective consultation on the actual complaint, or lead to resistance to physical contact, which could impede medical procedures. Trust is something valuable that is given from one person to another, it has to be given and cannot be taken for granted. Trust can be defined as ‘choosing to risk making something you value vulnerable to another person’s actions.’. A delicate process thus. Trust is not the result of a personality trait of the receiver (the ‘nice doctor’) but something that is built up during the interaction between two people. A doctor may be perceived as trustworthy by one patient but not by another. A feeling of trust can be facilitated by the doctor by being sincere, reliable, competent, and caring.  Sincere means being honest, saying what you mean and meaning what you say; your actions are aligned with your words.  Reliable means meeting the commitments you make, keeping your promises.  Competent means having the ability to do what you are doing or propose to do.  Caring means that you have the other person’s interests and needs in mind as well as your own when you make decisions and take actions. In addition, a doctor is also a representative of a system that might not always be well-disposed towards the patient. This system may include factors such as problems with healthcare providers, access to care, confidentiality and complaints procedures or social security. These may interfere with feelings of safety and trust, which should be present during the medical encounter. It is important to realise that a patient’s bad experiences and their emotional responses are not personal attacks on you as a doctor at the time you see this patient. Things that have gone wrong were not necessarily done wrong. Recognising and acknowledging these feelings will help relieve them, while becoming defensive will make them worse. The CORE Book of Consultation & Reflection – January 2024 20 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department 4. REASONS FOR THE ENCOUNTER READING: the patient’s agenda In general, people see the doctor with a certain physical or mental discomfort Recent research shows that or pain. They might have been experiencing this discomfort only recently or clinicians seldom elicit the patient’s agenda; when they do, for a longer period. The reason why a person has come in now (and not they interrupt patients sooner sooner or later) may disclose some information about the person’s actual than previously reported. problem with the discomfort. The problem is how the patient experiences the Singh Ospina 2018 Eliciting the complaint and how it affects daily life. This is strongly determined by the Patient’s Agenda personal significance attached to it by a patient. All participants in a medical encounter (patient, doctor, patient's companion, other healthcare providers) will have certain thoughts, concerns, wishes, expectations, and requests of this consultation. Often, these will differ and are left unspoken, or at an unconscious level. To avoid misunderstandings and discontent, and to be able to help your patient effectively, it is important for you as a doctor to clarify the concerns and expectations of your patient (and their companion), as well as to be aware of their own. Expectations may concern diagnostics, information or course of action. Wishes can also be negative (e.g. not another prescription or referral!). Clarification of the Reasons for the Encounter should provide answers to the following key questions: 1. What change would the patient like to achieve in relation to their current condition? 2. What are the patient's wishes and expectations about the way this change should take place and the role of the doctor in this process? 'Change' can be interpreted as being informed, getting a diagnosis, a treatment plan, support, or any other answer to the care request. 5. CONTEXT Context in healthcare refers to all aspects, circumstances and experiences of both patient and caregiver that are relevant to communication, disease or care planning. The consultation context is defined by factors that are related to the present encounter. They may concern the patient, the doctor, the consultation room environment, the medical specialism and the consultation itself. Some factors can be recognised by the verbal and non-verbal behaviour of the doctor and the patient. Some factors are easily detectable, e.g. multiple persons or a child in the consultation room. Other factors will be more difficult to recognise, such as if a message on the information board in the waiting room has upset the patient. Or did they have difficulty making an appointment? Are doctor and patient feeling tired or rested? Is the patient functionally illiterate? These contextual factors affect communication; when falling behind schedule and feeling rushed, you as a doctor will find it more difficult to maintain an attentive listening attitude. Or if the complaint needs urgent care, you as a doctor will not continue exploring the request for help but will act immediately in accordance with the ABCDE approach (see Emergencies). When a patient has had the same physical examination multiple times, there is less need for the doctor to explain the procedure again. If knowledge of the Dutch/English language is insufficient, you as a doctor must adapt your communication or ask for the services of an interpreter. The CORE Book of Consultation & Reflection – January 2024 21 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department The patient context refers to the whole set of factors that determine someone's health or feelings of health. These include psychological factors such as ideas about illnesses, past experiences and coping strategies (see Coping Strategies Neighbourhood and district are important social determinants in & Problem Solving), as well as social factors such as living circumstances, social someone’s health. class, education, social support, work and financial stability, and biomedical factors (see Biopsychosocial approach). These factors are important for history Q What do you know about your own neighbourhood or taking and planning care (see Shared Decision Making). district? 6. FRAME OF REFERENCE A frame of reference is a person’s set of habits, norms and values, their perspectives on health and disease, etc., i.e. the colour of the glasses through which one sees the world. The frame of reference of the patient is the set of beliefs and experiences concerning the complaint or problem, and the best way to deal with it, i.e. the patient's perspective. This is individually determined and can only be understood by exploring certain comments ('you hear so many stories’, ‘I'm worried’, ‘something must be going on’). Or by asking directly (‘are you worried?’, ‘what do you think is going on?’). The frame of reference of the doctor is the set of beliefs and experiences concerning health and disease, their perceptions of their responsibilities as a doctor, and the way in which these should be practiced, i.e. the doctor's perspective. This includes the colour of your view on the world (shaped by their own values, experiences, how they were brought up, etc.), and also their acquired beliefs about the medical model of history taking, examinations, diagnosis and therapies, with its significance for the practice of the medical profession. [8, 9] A medical encounter starts with the patient’s perspective (which may include the perspective of family and loved ones). This is probably easier when patient and doctor have a shared cultural background (e.g. same region of origin, similar education, same gender, same sexuality, same age, same social class). It gets harder if gender and cultural frames differ, which is a typical situation in medical practice. Without exploring this, i.e. without asking why people act or think the way they do (for example why the patient says 'no' to a certain therapy that seems the READING: Cultural Differences obvious choice in the doctor's eyes), the therapeutic relationship will be Nunez Mahdi, Intercultural compromised and all the previous good work in vain. Competence in Health Care (eBook available at the UM Library) EXAMPLES: 1. An international student in the Netherlands feels ill, her roommate drives her to the hospital, but they are refused at the door. 'Who is your GP?' they are asked in an irritable fashion. Both sides feel resentment. The students don't know that you need to go to the GP first to get a hospital referral. The hospital staff are ignorant of the fact that this is a typically Dutch procedure and that people from abroad wouldn't know this. Luckily, the roommate's GP is available and understands the situation. She quickly writes a referral letter for the student. The CORE Book of Consultation & Reflection – January 2024 22 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department 2. A 24-year-old woman has lost one child in giving birth to twins, the other child is hospitalised. The mother hardly visits her baby. The hospital staff are afraid that attachment between mother and child may become compromised and consider reporting this to an authority. The nurses are upset by the mother's behaviour. Eventually one nurse decides to simply ask the woman why she doesn't visit her baby. It appears that the mother has been so busy arranging a house of her own, taking care of her other children and making a safe place for her baby that she hasn't even had time for mourning the lost child. She thought she was doing her best for her baby. The mother is shocked by the nurses' concerns, she had no idea. From then on, she visits her baby regularly. The nurses start to feel sympathy and offer their full support. To be able to explore cultural differences a doctor needs to develop intercultural sensitivity and competence. These are the main steps: 1. Become aware of your own frame of reference, your blinded perspective. 2. Acquire knowledge about other gender and cultural perspectives. 3. Develop skills such as observing, listening, asking, interpreting and connecting. [9, 10] 7. CONSTRUCTIVE COMMUNICATION SKILLS Communication is called constructive when it allows for substantive progress as well as improvement of the relationship between the interlocutors. Communication between a doctor and a patient is called effective when it contributes to achieving mutual objectives and when both parties are aware of the meaning of the information exchanged. Constructive communication skills not only address what is being said (the content), but also how it is expressed (the form). They include clarifying the reason for encounter (FICE), active listening, asking (in- depth) questions, exploring, summarising, reflecting emotions, structuring, informing, and discussing. The exact phrasing by the doctor matters, e.g. the right amount of intensity when reflecting a patient's emotion or repeating the patient's words. Attentive Listening Attentive listening is one of the most important communication skills of a doctor. It is both active and highly skilled. Listening attentively instead of moving immediately to a series of questions about the history allows the doctor to achieve more objectives, and it requires very little time. Full attention through active listening enables the doctor to signal their interest to the patient, to hear the patient’s story, to prevent themselves from making premature A helpful hypotheses and from chasing down blind alleys. It also reduces the likelihood of mnemonic for the key complaints arising later, means not having to think of the next question (which blocks communication skills is LSD: Listen, Summarise, your listening and renders the patient passive), enables the doctor to calibrate the Dig deeper patient’s emotional state and to observe more carefully as well as to pick up verbal and Formulate a few actions nonverbal cues. for each of the 3 skills that you would like to practice (verbal or non- Asking questions verbal behaviour).": Questions are verbal invitations from the doctor to the patient to share information L...... about a certain topic. An open-ended question is the best way to collect information, e.g. S...... ‘How do you feel about it?’, ‘How is this affecting you?’ or ‘What is your question for me?’. D...... The CORE Book of Consultation & Reflection – January 2024 23 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department READING: Attentive Listening Silverman, Skills for communicating with patients. Chapter 2 Attentive listening allows the doctor to achieve more objectives, while it requires little time. Nevertheless, other verbals such as testing questions (‘It is difficult?’), showing empathy (‘That must be uncomfortable’), or repeating the exact words of a patient can be sufficient to invite the patient to continue talking. In such cases the doctor's intonation and non-verbal behaviour will give direction. In- depth questions tend to be closed questions in reaction to what the patient has said, where open-ended questions would yield more information. The distinction between open, closed, and suggestive questions is rather artificial. The invitational aspect of a question depends largely on the context in which it is used and the intention with which the doctor asks the question (since the nonverbal intention better determines how the patient receives the message than actual words do). Both closed and suggestive questions can have an invitational effect depending on the situation and how much the patient will feel constrained by them. Nevertheless, suggestive questions should be used sparingly, as they may cause a patient to want to please the doctor instead of providing accurate information. Summary A summary includes several different communication activities, i.e., summarising, paraphrasing, and parroting. To summarise is to briefly rephrase the most important topics offered by the patient in the previous part of the consultation. To paraphrase is the reproduction of the content in your own words without fundamentally changing the content, the meaning or the message of the text. To parrot is the short, literal repetition of the patient's words. Parroting serves the purpose of letting the patient know that you are listening attentively. The function of parroting is therefore more limited than a proper summary. Often, a summary or paraphrase starts with something like: ‘If I understand you correctly, then you're saying..’ Try to find your own words for this. A well-constructed summary contains the following:  content: what the patient has said should be reflected correctly in the summary.  conciseness: what the patient has said should be reproduced briefly.  vocabulary: repeating the patient's own words will contribute to the patient's feeling of being heard. The CORE Book of Consultation & Reflection – January 2024 24 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department  checking: presenting the summary in an interrogative form, asking for a reaction, or enabling an invitational silence.  identifying and expressing the beliefs or cognitions of the patient, e.g. an idea about their illness, diagnostics or treatment options. Reflection of emotions A reflection of emotions or feelings is a verbal representation of the patient's emotions (or feelings) as seen by the doctor. It is important to use accurate Reflections of emotions words to reflect the nature of the feeling and the degree of intensity. often contain a limited variety of emotion words such as angry, Example: a patient tells you that he is not looking forward to having frustrated, afraid, concerned, happy, surgery, the doctor reacts with ‘I understand that is not a pleasant or sad. Often these words capture the prospect.’ Although this is a reflection of feelings, it is a poor one, feelings only roughly. To become more because neither nature nor intensity are correctly identified. A better proficient in describing another one's feelings, you need to expand your reflection would be, e.g. ‘You seem to be afraid of something, am I vocabulary. reading this right?’ Often sentences such as ‘I can imagine’ are used to show empathy. Q Look at The Mood Meter by Marc These are not reflections of emotions but merely a sign of sympathy or Brackett and this explanation in Dutch. Describe your mood at this very just a commonplace response, and possibly not true when used in moment. How many emotion reaction to the patient's story (is it possible to really feel the agony of the words from The Mood patient?). Such sentences can be turned into a reflection if they are followed Meter are suitable? by concrete phrasing of a feeling such as ‘I can imagine that you're anxious about the operation because of the painful procedures you have had before.’ When emotions intensify and the patient appears overwhelmed, a continuation of the consultation is only possible if attention is first given to this. See Dealing with strong emotions for tips. 8. A BIOPSYCHOSOCIAL APPROACH MORE INFORMATION in the e-module: The primary task of medical doctors is to enhance, restore, or safeguard Introduction to a Biopsychosocial health and functioning of individual patients, groups of patients or a Approach in the Medical Encounter population. But what is health? Health can be defined as ‘the active adjustment to loss and disease, while retaining a certain measure of autonomy’. In fact, your role as a future doctor is to contribute to your patients' dignity. This applies to every domain of health, whether it's acute care or occupational health, but it's most evident in chronic illnesses or palliative care where curing is not the issue, yet much can still be done for the patient. To genuinely support the dignity of your patients as a (future) healthcare provider, it's essential to learn to take a comprehensive view, a biopsychosocial approach. This increases the effectiveness of your consultations. What does a biopsychosocial approach involve? Health, disease and functioning are shaped by the continuous interplay of [13, 14]:  Biological factors, such as physical development and constitution, physiology, injuries, family history, genes, epigenetics, hormones, intelligence, temperament, medical comorbidity.  Psychological factors, such as thoughts, feelings, emotions, behaviour, personality, cognitions, insight, coping strategies, past experiences, resilience. The CORE Book of Consultation & Reflection – January 2024 25 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department  Social factors including environment, such as living conditions, poverty, family situation, education, job, pastimes, social support, war and violence, discrimination, sexual identity, norms & values, eating habits, ethnical influences, religious community, neighbourhood, noise and air pollution.  Factors that give meaning to life create added value or meaning to a personal life. Meaning to life is influenced by aspects such as age, past experiences, having children, meaningful tasks, life expectancy, social support, spirituality, religious beliefs, etc. On an individual level, it is the intricate interaction of these factors that affect medical complaints, their presentation, the course of a disease and adherence. One such factor may entail Health and functioning are shaped by an intricate vulnerability to a complaint (risk factors), but also trigger, maintain, worsen, or improve interaction of many factors the complaint (4 P's: predisposing, precipitating, perpetuating, protective). For See Functioning & ICF for more example, high blood pressure is a risk factor in cardiovascular disease (CVD) and diabetes information on functioning mellitus, but may also be the consequence of other factors. Exertion is a strong protective factor in blood pressure and many other non-communicable diseases, but also a risk factor for injuries. How the patient gives meaning to life at a specific moment in time will affect their choices. Feeling meaningfulness is not something a patient can work on, as is often mistakenly thought, but arises from fulfilment of their universal basic needs (the feeling of relatedness, autonomy, and competence [self- determination theory]). In this, the home or work situation is important (is there a supportive partner or employer?), but every healthcare provider also has an influence on this. For example, if you, as a doctor, take your patient seriously, even when their views significantly differ from yours, they will feel more connected to you, and thus, possibly more motivated to endure a challenging treatment. For most people, their views on health and illness, for instance based on a religion, are part of their sense of meaning. This should therefore be a fixed topic within a consultation. Some of the most intrusive factors in developing and perpetuating chronic conditions (leading to frequent healthcare contacts) are adverse childhood experiences, living in disadvantaged neighbourhoods, large debts, smoking and lack of exercise. Individuals that have experienced war and violence or have lost their home and family may present with other syndromes. EXAMPLE: Mr Claramita is 58 years of age and was born in Heerlen. He has knee problems. It was established that his medial meniscus was injured (biomedical). Mr Claramita has a lot of pain when walking and is afraid that it might get worse ( emotion). He thinks that it is best not to strain his knee (thought, cognition), and becomes less and less active The CORE Book of Consultation & Reflection – January 2024 26 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department physically (behaviour). With a heavy heart, he decides to leave his indoor football club for which he has been active for over 30 Getting it sharp: What is the difference years (coping strategy, social). Furthermore, he is not able to between a patient’s context, a patient’s frame continue his work as an upholsterer (meaningful day job), he of reference and the biopsychosocial factors loses his customers and is starting to have financial problems influencing a patient’s life and health? (stress). All the stress (biopsychosocial) makes him easily Try to indicate the differences between upset and angry (emotion), and he argues a lot with his wife these three concepts in the case of and daughter (behaviour). The pain in his knee seems to get Mr Claramita. worse and his back is starting to bother him as well. Feeling ashamed of his situation (emotion), and unable to talk about it (insight, coping strategy), he prefers to sit on the couch with a can of beer (coping strategy), becoming more and more withdrawn (loneliness, social support). He has never been slender (‘It runs in the family, doctor, there’s not much I can do about it’), but now he has rapidly put on 20 kg. When he wakes up in the morning he feels exhausted because of sleep apnoea (biomedical), he gets depressed (comorbidity) and develops metabolic syndrome (comorbidity). His depressed mood (emotions) makes him apathetic: he is simply unable to make the initial decision to get off the couch to do something (behaviour). All the well-meant encouragement of his family and friends is in vain. This makes them feel hopeless as well and makes him feel even more of a loser (feelings). BPS in practice He would like to be able to work again in some way. Besides, Applying BPS is done easily with a comprehensive anamnesis. There are also his daughter is pregnant. When he thinks of becoming a various BPS systems with different grandfather, he would like to be in much better shape so he purposes. We'll mention three. could babysit for his grandchild (meaningful tasks). 1. The International Classification of For you as a doctor to offer the patient (and their loved ones) Functioning, ICF. significant relief, it is important to identify those aspects of their See paragraph condition that the patient could be helped with most at a certain Functioning. point in time. This means that you must possess complex skills 2. Positive Health such as careful history taking and clinical reasoning, but above all, See the DIY in this unconditional, sincere interest in your patient. Inviting open paragraph. questions and active listening will often stimulate the patient to 3. The Rainbow Model disclose cues that are important to them and possibly relevant for (The Dahlgren-Whitehead the doctor to explore. To support the patient's feelings of model of health deter- autonomy and competence, advanced skills in shared decision minants) E.g. this making and motivational interviewing are of added value. RIVM-interpretation. You will also need to develop good skills to effectively collaborate with other healthcare professionals in the healthcare chain, from practice assistants, paramedics, medical specialists and psychologist to social workers and occupational health physicians. This is even more important when your patient has limited:  resistance (the ability to cope with setbacks),  resilience (the ability to recover from setbacks), or  self-reliance (the ability to take care of oneself even in the face of adversity; see also Health Literacy). The CORE Book of Consultation & Reflection – January 2024 27 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department Obviously, in Mr Claramita’s case only prescribing a painkiller is suboptimal care. The main goal could be to support him in breaking out of the The Positive Health movement downward spiral and to enhance his resistance and resilience. For instance, puts BPS into practice using the it may be a good idea to start with his sleep apnoea, followed by his mood, Spider Web as a conversation tool. fitness and family support system (e.g. with psychoeducation and an Fill out your own spider web to see your health exercise programme), and continue from there. balance. Appreciate that the factors in Mr Claramita's story may occur in a variety of different cascades. Perhaps he was employed and was made redundant first, which subsequently led to gloominess and inactivity, causing a decline in his physical fitness and a gain in weight, eventually leading to joint problems, and so on. 9. HEALTH LITERACY One in four Dutch citizens has limited health literacy (approx. 3.5 million adults). This means that they struggle with finding, understanding, evaluating, and using health information. Individuals with limited health literacy skills experience poorer health, utilize healthcare services more frequently and have greater difficulty navigating the healthcare system. Furthermore, they find it challenging to actively engage in discussions with healthcare providers during consultations and have difficulties assessing different treatment options. They are also less capable of managing their health and illness at home, generally experience poorer health outcomes, and have a shorter life expectancy. For you as a future healthcare provider, this means that you must be able to communicate with patients in such a way that they understand you and can take action based on your information. In short, to become a 'health-literate doctor'. What is health literacy? We distinguish between health literacy skills at the individual level and at the organizational level. Individual health literacy consists of three How do you recognize that your skills: patient has limited health literacy? 1. Functional - such as reading and writing, calculating, A significant indicator is their √ level of searching the internet; also called basic skills. education: up to vocational education level 1 2. Interactive or communicative - such as reading or less than 10 years of education in their country of origin. Other signs include: comprehension, abstract reasoning, distinguishing primary √ Difficulty in telling a chronological story. and secondary issues, reflection. √ Avoidance of reading and writing situations. 3. Critical - such as applying information, organising, thinking √ Becoming uncomfortable or angry when too ahead, prioritising. many questions are asked. √ Arriving late or on the wrong day. In everyday life, this means that people have difficulty with, See this checklist (Dutch) for more indicators. among other things: Taking medications correctly Formulate three questions that you can ask a patient to explore Navigating their way in the hospital their health literacy. Conducting online searches (digital skills) Understanding (invitation) letters and emails The CORE Book of Consultation & Reflection – January 2024 28 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department READING: Health Literacy www.hrsa.gov health-literacy www.gezondheidsvaardigheden.nl Bates' Chapter 2 Making a drawing supports clarifying the medical problem to the patient. Comprehending brochures, websites, forms, and package inserts Engaging in conversations with healthcare providers Understanding and implementing explanations and advice Health literacy of organizations indicates the extent to which organizations, such as a general practice or hospital, enable people to find, understand, evaluate, and use information and healthcare services. A "health-literate organization" is one that is accessible and understandable to everyone, regardless of their level of health literacy. Large Numbers  Limited health literacy is not the same as low literacy or limited basic skills, although there is overlap. In the Netherlands, approximately 18% of adults are considered to have low literacy, which is around 2.5 million people. However, individuals with a low level of education more often also have limited health literacy compared to those with a medium or high level of education, at 38% and 23%, respectively.  In Europe, the numbers of people with limited health literacy are even larger than in the Netherlands, they vary from 25% to 72%. In healthcare practice, this translates to huge numbers of consultations.  Maastricht University Medical Centre (MUMC) has calculated the Watch this video on number of consultations with patients with low basic skills: more than health literacy. The numbers of 500,000 consultations per year (outpatient, emergency care, and low literacy and limited health literacy may differ between countries. What remote consultations), and more than 20,000 admissions or day could be reasons for these differences? treatments.  Add to that the consultations outside the hospital, including visits to Q How about your neighbourhood? Do you think that its level of health literacy general practitioners, youth doctors, elderly care specialists, or is higher or lower than the country’s occupational health doctors. Also, consider that both the number of average? Why do you think so? Why people with limited health literacy is larger, and this group visits a would it be important for a doctor to know? doctor more frequently. The CORE Book of Consultation & Reflection – January 2024 29 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department Temporarily reduction of health skills In addition, a patient's ability to care for themselves may be undermined temporarily (reduced self- reliance or resilience). This can be seen, for instance, when an individual is suffering from conditions such as depression, from stress (for instance due to huge financial debts or being overwhelmed with demands), from grief (e.g. over the death of a loved one or loss of work), or from trauma (which is a mental and physical response to a deeply distressing or disturbing event). 11 tips for clear communication: 1. Normalize limited health literacy and low literacy. For example, ask, "We know that many people have difficulty filling out forms. How about you?" 2. Do not assume basic knowledge of the body. 3. Be mindful not to overestimate patients' comprehension level. 4. Use short sentences and simple words (ask questions that start with 'how' and 'what' instead of closed yes-no questions). 5. Stay on message without going off-topic: stick to the core of your message. 6. Be as concrete as possible, avoid jargon, abstractions, and figurative language. 7. Use images, create drawings, or show a video. 8. Repeat the key points (limit them to a maximum of three). 9. Employ the teach-back method: "There's a lot to take in, just to make sure that I've explained things clearly, what will you tell others at home?" 10. Utilize supportive educational materials (including digital resources) 11. Routinely offer help with paperwork. 10. EMPATHY Watch the 3-minute video One of the most frequently recurring learning goals of medical students is to 'be of researcher Brene Brown on empathic'. And indeed, in contrast to older generations who firmly believe that empathy versus sympathy being attentive to the patient's emotions (not to mention their own) would compromise the necessary professional distance, clinical empathy appears to be a Q What are the differences between empathy and fundamental key in the quality of medical care. sympathy? What is empathy and how can you learn to be empathetic ? Empathy is a person’s ability to recognise and share the emotions of another person, and the willingness to show it (understand, feel and act upon it). It is a foundation stone of trust and compassion, both of which are necessary for the better fulfilment of medical tasks and their consequent better health outcomes. It is often mistaken for sympathy, pity or just friendliness. As with trust, being actively empathetic is not merely a personality trait, but something people can learn and develop throughout life. You can develop this by reading novels, watching movies and reading patient’s stories. Several types of empathy can be distinguished:  Cognitive empathy: understanding something of the pain or happiness of the other person; this is a rational process. READING: Empathy Silverman Chapter 5  Affective empathy: feeling something of the pain or happiness of the other Building the Relationship. person; this is an emotional process.  Social empathy: doing something to show that you care; this is a process of the human need to establish equal and altruistic stable relationships). The CORE Book of Consultation & Reflection – January 2024 30 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department Professional empathy is a balanced combination of these. Too much or too little of any of these types of empathy can indeed compromise the professional position and be exhausting. In developing sound Q Can you be ‘against’ empathy? Read: Paul Bloom, ‘Against Empathy’ professional empathy, it is helpful to understand your own balance. Is or watch: BBC, Darkside of Empathy it easy for you to show that you care, or do you prefer to keep such Q How much empathy do you need and what emotions to yourself? Do you feel someone else’s pain or happiness about compassion and anger? as if it is yours, or does it just make you shrug your shoulders? Can Q Does a high level of empathy make you a good person and a low you picture what the other person is going through, or is this a big blur level a bad person? for you? Showing empathy in a medical encounter can be done in many ways. For example, by making eye contact (or other respectful nonverbal behaviour that fits with your patient’s culture), smiling, providing a tissue, putting a hand on the shoulder, showing interest, not interrupting, listening, conscientious execution of the medical role, rephrasing the patient's words, talking about their social life, sending a personal message on special occasions such as the birth of a child, etc. Most empathetic communication happens nonverbally. In practicing verbal expressions of empathy (e.g. 'I can appreciate how difficult it is for you to talk about this'), at first these may feel unnatural or phoney to you as a student but may become internalised and more genuine over time. This is important, because in real life, an empathic reaction will only be effective if it's authentic, not simulated. Patients (and people in general) automatically feel whether or not a reaction is natural and meant from the heart. Some examples of empathic reactions:  'Can you tell me what is bothering you so much, and why this is so important to you?'  'I can see that this worries you, would you mind telling me more about this?'  'That's quite something, thank you for sharing. We'll find an answer to this Reading novels and together.' patient stories increases empathy and awareness of a When practicing verbal empathetic responses, it's important to choose words patient’s life. Think back on a that resonate with you as an individual. Also, try to use as few standard phrases story you read about a person as possible to prevent them from becoming clichés, and realize that sincerity is with an illness. key. Q What do you remember most from it in terms of how the event touched the person’s life? Was it 11. REASSURANCE life changing? Did you notice any development in this person’s There are few jobs as ambivalent as that of medical doctor. Keen interest in the perspective? problems of the human body and excitement for any extraordinary clinical Q How will this insight picture are counterpoised by deep concern for the human being that is burdened affect your skills by it. Most medical students choose their study because they want to help people, as a doctor? to cure people. Yet, dealing with patients means also dealing with suffering and anguish, and often with the impossibility of offering a cure. On top of this, doctors frequently need to inflict more pain on the patient as part of diagnostics or treatment. Being able to reassure a patient is understandably one of the most desired skills in a doctor's toolbox. This is re-emphasised by patients who ask questions such as ’Is this serious?’ and ’Can you help me?’ Reassurance is tightly connected to trust and empathy, and can be found in many behaviours, nonverbal The CORE Book of Consultation & Reflection – January 2024 31 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department as well as verbal. And as with trust and empathy, a heartfelt 'show-don't-tell' approach is much more fruitful than just telling the patient not to worry. In fact, only 40 seconds of compassion may already lead to a decrease in anxiety. There are both effective and ineffective ways to reassure a patient. Ineffective ways include the commonplace (‘Don't worry’), wishful thinking (‘We'll make you better’), refuting without foundation too early in the encounter (‘It is probably not as bad as you think’), ignoring the emotional content of the patient's words, sticking to a solution-driven approach (‘If the pain returns you can take a paracetamol’), and referring a patient for diagnostic tests that are not indicated but only for reassurance’ sake (this may actually have the adverse effect of increasing stress). Effective ways of reassurance take the patient's concerns unconditionally and seriously. For instance, recognising and acknowledging the patient's feelings (‘I see that this headache makes you anxious, it must be hard to deal with it’), conscientious history taking and physical examination (‘Let's take a closer look at it and get down to particulars’), being specific (‘It's not a brain tumour’), and re-addressing the Reason for Encounter (‘I think we have covered all aspects of your complaints, you were worried that your headaches might be caused by a brain tumour, but I don't see any signs of that’). 12. COPING STRATEGIES & PROBLEM-SOLVING Illness, complaints and treatments cause distress in everybody’s life. The way individuals try to deal with a stressor is called coping. There are many different coping strategies and styles. Examples of coping styles include problem-focused, which addresses the problem causing the distress; emotion-focused which aims to reduce the negative emotions associated with the problem; meaning-focused, in which an individual uses cognitive strategies to derive and manage the meaning of the situation; social coping (support-seeking) in which an individual reduces stress by seeking emotional or instrumental support from their community. Examples of coping strategies are:  Active approach: trying to analyse and solve the problem. The CORE Book of Consultation & Reflection – January 2024 32 Faculty of Health, Medicine and Life Sciences Bachelor of Medicine: Clinical Practice, CORE Skillslab Department  Social support: seeking consolation and sympathy from others.  Avoidance: denying or avoiding the problem.  Palliative approach: focusing on things other than the problem (in the extreme this can lead to addictions).  Passive reaction: ruminating or self-blaming.  Emotional expression: showing frustration, tension or aggression.  Soothing approach and wishful thinking: telling yourself that the problem will disappear or that other people are suffering more. Coping strategies affect the doctor-patient relationship in several ways. First, both doctor and patient have their own style when dealing with their own illness (doctors too fall ill sometimes). In a medical encounter, these personal styles colour the expectations (also subconsciously) about what the encounter should deliver for both parties (and a third party, the patient’s companion). This may cause misapprehension when these expectations differ. In addition, healthcare providers also have preferred coping styles when dealing with a person in need or a distressed patient. Promin

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