Communication Skills for

Medical Interview

Dr. I Putu Adiartha Griadhi, S.Ked

Background
Why do we learn communication
skills ?
It is a unit of our medical practice
Hundred of thousand interview will be performed
during a professional lifetime
Way to help the patient, individual patient
A bridge from theory to application

Background
There are communication problems !
About 54 % of patients complaints are not elicited,
and 45 % patients concern are not elicited
In 50 % visit, patient and doctor are not agree with
the nature of the presenting problems
Doctor frequently interrupt the patient, doctor
centered close approach during gather information
Evade patients ideas and concern, doctor use
jargon, patient recall and understanding was poor

Background
Communication skills : the benefits
A good interviewing process : patient likely to tell their
stories broader issues
Patient satisfaction : acknowledging patient
expectation, nonverbal communication, amount of
information
Patient recall and understanding : increased 30 % by
signposting, good organizing, summarizing, repetition
Adherence : by asking patient beliefs, concern, their
illness
Outcome : psychosocial and physiological problems

Background
There is evidence that communication skills could
overcome those problems. We can teach and
learn communication skills

Communication Process
Think
What is the next relevant question??
Communicate
What is the disease ??
Can you describe
the pain ?
I can see that you
have been very upset
Feel
by her behavior
I understand her
problems
I can see the
dificulties

Broad types of communication skills

CONTENT SKILLS
How they do it the
ways they
communicate with
patient; how they
discover the history;
verbal and non verbal
skills they use; how
they develop
relationship with
patient; the way they
organize and structure
communication

PERCEPTUAL
SKILLS

What doctors
communicate the
substance of their
questioning and response

PROCESS
SKILLS
What they are
thinking and feeling
their internal decision
making, awareness

What will we learn ?

CONTENT SKILLS
We learn to ask apropriate questions and responses
based on the main complaint
We learn to organize patients information into sacred
seven and basic four format
It developed while studying system organ-blocks

PERCEPTUAL SKILLS
We learn to behave as a doctor and develop professional
attitude
We learn to give appropriate responses to the patient

What will we learn ?

PROCESS SKILLS
We communicate to the patient, avoide to become a talkable checklist
We learn to understand patients perspectives (illness)
We learn to give explanation and planning to the patient

PATIENT CENTERED INTERVIEW

Patient Centered Interview

INTERVIEWING STEP
Interview should have a
logical sequence based on
five basic task

Five-point plan

1. Initiating the session

2. Gathering
information
3. Building the
relationship
4. Explanation and
planning

Five basic tasks

Breaking the barier, enough
information, good relationship, clear
instruction and explanation.

5. Closing the session

Patient Centered Interview

Expanded framework

Five basic tasks

Five-point plan

2. Gathering
information
4. Explanation and
planning
5. Closing the
session

3. Building Relationship

1. Initiating the
session

1. Initiating the session

a. Establishing initial rapport
b. Identifying the reason (s)
2. Gathering information
a. Exploration of problems
b. Understanding patients
perspective
c. Providing structure to the
consultation
3. Building the relationship
a. Developing rapport
b. Involving the patient
4. Explanation and planning
a. Correct amount and type
b. Aiding accurate recall &
understanding
5. Closing the session

Patient Centered Interview

The Process Skills
1. Initiating the Session
2. Gathering Information

Initiating the session

Establishing initial rapport
Identifying the reason(s)

Establishing initial rapport

GREETING :
Hello, Im dr. Jones. Do come and sit down

CLARIFYING YOUR ROLE :

Hello, my name is Catherine. Im a student doctor working with dr. Ko. Im
learning how to interview patients. We might spend 15 minutes for this
interview. Would that still be alright?

OBTAIN Px/ NAME :

Hello, Im dr. Jones. Do come and sit down. Can I just check is it Mrs.
Mary? [pause] I dont think weve met before, what do you prefer that I call
you?

DEMO INTEREST AND RESPECT : our position, posture, eye

contact, our perception and attitude, sit at knee-to-knee angle.

Initiating the session

Establishing initial rapport
Identifying the reason(s)

Identifying the reason(s)

1. THE OPENING QUESTION : Use our favorite question
What can I do for You ? (New patient)
How are you getting along with the new pills? (Follow up px/)
2. LISTENING : Attentive listening skills
1. wait time shift from speaking to listening, 3 seconds
2. facilitative response `uh-huh`, `okay`, `go on`, `I see`
3. non-verbal skills eye contact, posture, movement, affect,
vocal cues, facial expression, environment cues.
4. picking up verbal and non-verbal cues listening and observe :
patients ideas, concern and expectation.

Initiating the session

Establishing initial rapport
Identifying the reason(s)

3. SCREENING :
Checking with the patient all they wish to discuss
So youve been getting headache and dizziness lately. Has
anything
else been bothering you ?
If the patient continues.
So youve also been feeling very tired and irritable and wondering if
you might be anemic. Anything else at all ?
If the patient stops.
So as I understand it, youve been getting headache and dizziness
but have also been feeling tired rather irritable and a bit low, and
your
concern is that you might be anemic, did I get that right?

Initiating the session

Establishing initial rapport
Identifying the reason(s)

4. AGENDA SETTING : structuring the consultation.

Priorities can be established and negotiated.
Shall we start with the new problems, the diarrhea, and then move
onto the problems you have with your medication.
Doctor agenda can be added :
Lets think about your headache. I wouldnt mind checking on your
blood pressure later on, if thats all right
Problem with time
Im not sure that we have enough time to do it all. How about

Gathering information
Exploration of problems
Understanding patients perspective
Providing structure to the consultation

Exploration of problems
1. STARTING THE PATIENT OFF :
Open ended question
Tell me about your headache?
Patients narrative : own word, from when it first start up to the present
Tell me about your headache from the beginning

2. ATTENTIVE LISTENING
wait time, facilitative response, non-verbal skills, picking up verbal and
non-verbal cues

Gathering information
Exploration of problems
Understanding patients perspective
Providing structure to the consultation

3. FACILITATIVE RESPONSE :
Encouragement : uh-huh, okay, go on, I see
Silence : brief silence or pause
Repetition or echoing : Pain on your chest?
Paraphrasing : restating in our word Kedengarannya anda
sedikit khawatir dalam menghadapi masalah ini
4. FURTHER OPEN QUESTIONS :
Tell me more about the pain
You mentioned breathlessness, tell me more about it

Gathering information
Exploration of problems
Understanding patients perspective
Providing structure to the consultation

5. CLARIFICATION OF PATIENTS STORY :

Could you explain what you mean by dizziness (open Q);
When you say dizzy, do you mean that the room seems to
actually spin around? (closed Q)
6. INTERNAL SUMMARY : explicit verbal summary
Can I just see if Ive got this right? You have had indigestion
before, but for the last few weeks you have had increasing
problems with a sharp pain at the front of your chest. Is that right?
[pause]

Gathering information
Exploration of problems
Understanding patients perspective
Providing structure to the consultation

7. MORE FOCUSED CLOSED QUESTIONING : interview shift to a

more disease-orientated focus, doctor needs to ensure that
valuable diagnostic data are not omitted traditional methods.
SACRED SEVEN BASIC FOUR
B7: Onset, Location, Quality, Quantity, Chronology, Modifying
factors, Concurrent complaints.
S4: Present Illness, Past history, Family history, Social factor
Be careful that your closed questioning is not too focused!

Gathering information
Exploration of problems
Understanding patients perspective
Providing structure to the consultation

Understanding patients perspective

IDENTIFICATION : discover and listen to the patients ideas,
concern and expectations
ACCEPTANCE : acknowledge the patients views and right to
hold them, without necessarily agreeing with them
EXPLANATION : explain your understanding of the problem in
relation to the patients understanding and reach mutually
understood common ground

Gathering information
Exploration of problems
Understanding patients perspective
Providing structure to the consultation

How to understand patients perspective

1. PICKING UP AND CHECKING OUT CUES
I sense that youre not quite happy. Is that right?
2. ASKING SPECIFICALLY ABOUT PATIENTS PERSPECTIVE
What concern you about the problem?
3. FEELINGS
Discovering and responding to patients feelings
4. EFFECT ON LIFE
An open question about how the symptoms and illness are
affecting the patients life.

Gathering information
Exploration of problems
Understanding patients perspective
Providing structure to the consultation

Providing structure to the consultation

1. INTERNAL SUMMARY : focused on specific part of the interview,
summarize both the disease and illness aspect of patients story
Can I just see if Ive got this right? You have had indigestion
before, but for the last few weeks you have had increasing
problems with a sharp pain at the front of your chest. Is that right?
[pause]
2. SIGNPOSTING : progression form one section to another, explain
the rationale for the next question.
Since we havent met before it will help me to learn something
about your past medical history. Can we do that now?

Building the relationship

Developing rapport
Involving the patient

Developing Rapport
1. ACCEPTANCE : accepting response, acknowledging the patients
rights to hold their own views and feelings.
Example:
Patient says : I think I might have cancer, doctor. I feel so
tired, said the patient
Our expression :
Youre worried that tiredness might be caused by cancer
(restating)
or
I can understand that you want to get that check out (ligitimizing)
[stop] (Full stop, allow the patient to continue)

Building the relationship

Developing rapport
Involving the patient

2. EMPATHY : overtly demonstrating doctors sensitivity to the patient

so that they appreciate doctors understanding and support.
Empathic statement are supportive comments that specifically link
the I of the doctor and the You of the patient.
Example :
I can appreciate how difficult it is for you to talk about this or
I can see that you have been very upset by her behavior
3. SUPPORT : complete the empathic response
Concern, understanding, willingness, partnership, sensitivity

Building the relationship

Developing rapport
Involving the patient

Involving the patient

1. SHARING OF THOUGHT : patient and doctor understand each
other, interactive consultation.
What Im thinking now is how to sort out whether this arm pain is
coming from your shoulder or your neck. or
Sometimes it is difficult to work out whether abdominal pain is due
to a physical or is related to stress
2. PROVIDE RATIONALE : rationale for question or physical
examination

Explanation and planning

Correct amount and type
Aiding accurate recall &
understanding

Correct amount of information

1. GIVING EXPLANATION AT APPROPRIATE TIME: never give
information prematurely. Give it later after you have all the facts at
your disposal. Example : A mother of an asthmatic child says,
Could my daughter have some antibiotics?
Prematurely you say, I dont think so. The cold triggered her
asthma
But after you check the patient, you find that she has been hot and
sick. You feel has lost the mother confident and say
Ahdespite what I said there is a problem here that need
antibiotics
You should answer that question this way
That is a good question. We will come back to your question after

Explanation and planning

Correct amount and type
Aiding accurate recall &
understanding

Aiding accurate recall & understanding

1. ORGANIZE EXPLANATION : divide into section, logical sequence
There are three important things I want to explain. First I want to
tell you what I think is wrong, second, what test we should do,
2. LANGUAGE : reduction in use of jargon, explanation of jargon
when used, use shorter words, use shorter sentences
3. CHECK PATIENTS UNDERSTANDING : ask the patient to
restate in their own words; clarifies as necessary.

Closing the session

End summary
Contracting

End summary : summarizing the session briefly and clarify the plan
So, just to recap, I think your diabetes has crept out of control a
little over the last year, probably because of the weight that you
have put on, but hopefully we will be able to get your sugar back
to a satisfactory level if you can get your weight down to where it
was before. I will find you the diet sheet that I mentioned and then
well see you in two months and see how well youre managing. Is
that a reasonable summary o what we have agreed?
Contracting : contracting about the next step for both patient and
doctor
So, I will dictate a letter to the specialist explaining the problem
and fax it later today. If the test is abnormal, I will phone you
before your appointment. Would you call me after your
appointment and tell me what dr Jones has said?

Calgary-Cambridge observation guide

1.

Propose a frame work

2.

Describes individual
skills

3.

Concise summary of
the skills

4.

Labeling a specific
behavior

5.

More patient
centered

6.

Emphasize important
area

EVALUATION CHECK LIST

Thank You !
Any question :
e-mail : tadiarthag@yahoo.com
YM : tadiarthag