professional skills- 2 part two 2010- 2011 by dr. aziza rajab assistant professor head of nursing...

Professional skills- 2part two

2010- 2011

By

Dr. Aziza RajabAssistant professor

Head of Nursing dep .

King Abdul Aziz University

Professional skills- 2 course contents

1. empathy, sympathy and empowerment2. Doctor-patient Relationship

building a rapport with patients3. How to Interview Patient4. Principles of taking medical history from patient.5. Who are the difficult / patients( angry, anxious,

demanding, fearful ), and how to deal with them.6. Strategies for effective consultation.7. Principles of Breaking bad news 8. How to apply the steps of breaking bad news in

clinical setting

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Lecture 1empathy, sympathy and empowerment

By

Dr. Aziza Rajab Dr. Hashim FidaAssistant professor Assistant professor

Head of Nursing dep. Family & community health King Abdul Aziz University king Abdul Aziz University

What are the importance of empathy and sympathy?

• Can not build rapport or gain trust without showing those feelings

• Back bone for establishing and solidifying helping relationship

• Help in developing mutual understanding• Guide us to build appropriate perceptions• Help us to understand the message

how to differentiate between empathy and sympathy?

• Sympathy is to identify and communicate that you understand the patients feelings.

( e.g. I understand what you are saying, I know how you are feeling)

• Empathy is to share his/her feelings ( e.g. I do feel exactly what you feel )

What is empowerment?

• Empowerment is helping others to trust themselves, to identify, know, and believe in them selves and their abilities

• Enable others to act independently for him/her self, choose and decide for them selves.

• Enhancing people’s creativity, cooperation, inspiration, and productivity.

How to be sympathetic? • Try to listen effectively,• try to understand and perceive things as they are • Try to accept the feelings and point of views without

changing them, stop them, or judge them, • try to pay attention • Try to be consistent • Try to reflect on the patients feeling verbally by

summarizing, paraphrasing to show your caring attitude to patient

• Try to be genuine and sincere in your relation with patient

• Try to Respect and accept patient feelings• Try to set limits ( I don’t have time now but we will talk

next visit)

What are the type of empathic responses that we should avoid?

1. Judging response: to evaluate another’s feelings:Tell patients in various ways that they should not feel

discouraged or frustrated, they shouldn’t worry ,they shouldn’t question their treatment by other health professionals.

Any message from you that indicate you think patient is wrong or bad, will make patient think and feel that you are not worth his trust and he cant build confidence for a helping relationship.

2 .Advising response: we can offer quick solution to another person’s concern with or without correct

perception to his exact needsThe best source of solution to the problem is always

within the patient him/her self.Rely on other for advise may keep patients dependent

this is against the empowerment idea we talked earlier When there are times when patients are not capable of

coping or understanding or deciding for a solution to their problem, you should walk them and direct them to

the solution without dictating it to them. It has to be and show that it is coming from them not you.

3 .Reassuring response: telling patients who is facing surgery do not worry, every thing will be fine, you will turn

out just fine.It may seems to be helpful but it is conveying that the

person should not feel upset , scared of the procedure, and concerned about the outcomes.

You should tell the patient with exact words what is the procedure steps briefly in understood words, explain the

risk in an honest words, state the expected outcomes, and the assurance part has to be in the part how practices, competent you are, how careful you will be, and how

common this procedure is, and that his fear is very normal to feel.

4 .Distracting response: changing the subject, or cutting off patient’s talk or feeling just because

we don’t know how to response to themWe might direct the communication to topics we

feel comfortable with such as medication regimens and so forth

These responses tend to convey to patients that we are not listening, or we don’t want to listen.

Lecture 2Doctor-patient Relationshipbuilding a rapport with patients?

By

Dr. Aziza Rajab Dr. Hashim FidaAssistant professor Assistant professor

Head of Nursing department Family & community health King Abdul Aziz University king Abdul Aziz University

Doctors’ Mission

Doctors’ primary goals are:• To treat and cure where possible• To bring relief in suffering• To help the patient cope with illness, disability

and death.

Doctor- patient relationship

• The doctor – patient relationship is built on : 1. Honesty2. Confidentiality3. Trust and reliability

How to enhance doctor- patient relationship?

Developing rapport to enable the patient to feel understood, valued and supported.

Encouraging an environment that maximizes accurate and efficient information gathering, planning & and explanation.

Using the verbal responses and non verbal behaviors appropriately

Involving the patient so that he/she understands and is comfortable with the process of interview and the consultation.

Increasing both the physician’s and the patients’ satisfaction with the communication.

Developing and maintaining a continuing relationship of trust & respect over time.

Why doctors Communicate?

Gain Mutual trust & respect

Exchange information

Ask your seniors

Do your share of work

Interview and consult patients

Conduct Seminar & workshops

with whom doctors Ccommunicate?

• patient

• family

• physician

• health care administrators

• Media

• psychologist

• nurse

• social worker

• Dietician

• Pharmacist

• others

Communication & Medical care

• Good communication should be established on admission between clients, family and the treating multidisciplinary team.

• Client & family are encouraged to participate and verbalize in the ward round discussion about:– Offered medical care & treatment – Rehabilitation – Follow- up/re-admission plans– Doubts & worries.

Communication & Medical care

Proper information to clients and family regarding services available and how they can utilize them.

Information should be made available on:– Health Education/ Counseling & Psychiatry. – Endocrine, Metabolic, Neurology & nephrology.– Cardiology, Respiratory, GIT & hematology.– Nutrition, Immunization & ambulatory care.– Infections & infection control.– Clinical pharmacy & therapeutics.– Hygiene and Safety.

We need to communicate to build a trust relationship with whom?

Patients & care-giversNurses & auxiliary staffColleaguesAdministratorsEvidence in courtReporting research findings Talking to the mediaPublic at large

How can doctors build a positive rapport with their

patients?

What is rapport?

Rapport is the ability to connect, the ability to trust, the ability to express feeling and thoughts, the ability to understand, the ability to accept the other as is without judgment, and the ability to exchange information honestly and freely during formal or informal interviews. It is the process of creating a goodwill between the interviewer and the

interviewee .

How can we build a rapport?• Using therapeutic communication techniques• Use the non verbal body language ( time, space, touch,

smile, eye contact, dress, distance, location, expressions, grooming), and the verbal ( the way we talk and address each other, the tone, voice, words used), and the formality levels should be used appropriately as needed to enhance connectivity.

• Avoid being judgmental, labeling, and criticizing• Empower patients and lower their feeling of

powerlessness, helplessness, dependability.• Show sympathy and empathy as needed.

How do I know that there is a positive rapport between me and

the other party?• When the interviewer and the interviewee share a

similar world view or situational view• When we are not jugging the person but rather

trying to understand them more• When we are able to express and communicate our

thoughts and feeling without fear or criticism to the other person

• When we mutually are understood correctly.

What are the doctors attitude and behaviors that can damage a helping relationship and

obstruct you from building rapport?

1. Stereotyping: seeing a patient as a person with stereotype behavior, then ,most probably you as a doctor will fail to listen without judgment, and your judgmental thoughts will reflect in your behavior & words , and patient will not build trust, there won’t be no rapport.

we must see patient as an individual and accept him/her as is

2. . Depersonalizing :if we focus our communication on specific problems and cases only, without taking the patient and his culture, background, thoughts& feeling in account, then we are really not understanding the person as a whole, and trying to implement solutions that are inapplicable because we don’t have enough connectivity with patient to comprehend the big picture about his/her circumstances.

3.Controling : doctors usually try to run the show when it comes to diagnose and treat patients, they rely on what they know more to decide for care, rather than trying to understand more from the patient about his feelings and thoughts about the disease it self and their preferences of the treatment.

Increased levels of patients participation and control over the health care interventions, usually empowers patients, and gives positive results that includes improved health, less complications & general quality of life positive outcomes.

Lack of communication and poor doctor- patient relationship : why?

Clinicians focus often on relieving patients' bodily pain, less often on their emotional distress, seldom on their suffering.Some of them view suffering as beyond their professional responsibilities.If clinicians feel unable to, or simply do not want to, address the powerful issue of patient suffering, it is appropriate to refer the patient to another professional on the healthcare team who is more comfortable in this area.

Lecture 3How to Interview Patient

By

Dr. Aziza Rajab Dr. Hashim FidaAssistant professor Assistant professor

Head of Nursing dep. Family & community healthKing Abdul Aziz University king Abdul Aziz University

What is an interview?

Professional Interview in the medical field is an interpersonal communication method and process to gather or/ and exchange information by using therapeutic communication techniques.

It is one of the most common methods used in patients assessment

with whom and why to do Interview ?

The medical interview is the usual communication encounter between the doctor and the patient.It can be classified according to the purpose of the interview into 4 types:History takingBreaking bad newsConsultationsObtaining informed consent

What are the steps of the interview?

1. Determine the purpose of the interview ( job interview, patient assessment, …)1. Determine the objectives of the interview2. Pre- research the topic and the person3. Prepare the questions and the context4. Organize the interview (opening, body, and

closing)5. Record and document the interview

What are the differences between formal and informal interview?

• In the Informal interview: there is small social talks at the beginning to get self comfortable, oriented, and prepare to be ready for the real sensitive issues.

• In the formal interview: the interviewer takes more direct, focused, serious, and in-depth elaborative approach to patients concerns and complains.

What are the Components of effective interview?

1. Differentiate between therapeutic and non therapeutic communications

2. Establish rapport3. Prepare the environment, choose right time,

get client comfortably situated 4. Listen instead of just hearing5. Differentiate between empathy sympathy6. Avoid being superficial and routines, Get to

the sensitive issues

How therapeutic comm. Is different than social comm.

Therapeutic communication characteristics unlike the social interactions, must be :

1. Goal oriented, planned, and focused on specific objectives.

2. Leagal accountability and responsibility for the given information.

3. Credibility of information and good reputation of the informer.

4. Mutual understanding between all parties involved in the communication.

Strategies to conduct an interview?

1-Use open ended questions always that makes the person think and elaborate on the question, and encourage the patient to tell their own story, specially in the start, such as:

What exactly happened, how do you feel about it , why do you think this is the problem, can you explain to me this, can you talk more on this…

(this will be time consuming at the beginning of the interview and hard to control, but that is ok because you want to build trust and understand your patient well(

Strategies to conduct an interview? Cont.

2. Lower patients defensiveness by:- Asking proper type of questions such as the what?

and how?- Minimize the why question, it makes patients feel

that they need to give justifications always and that might intimidate them, and make them feel guilt and responsible for what ever situation they are facing

- Use silence to allow patient to finish answering before asking next question and to avoid feeling of being interrogated

Strategies to conduct an interview?Cont.

3. Use closed ended questions appropriately only when you need to establish factual details quickly such as :does it hurt you when you cough? The yes and no answer gives you the exact information that you need for understanding the problem , but they often will not allow patients concerns and anxieties to be expressed.

Strategies to conduct an interview?Cont.

4- use probing questions for clarification and verification of information:

( e.g. for clarification: exactly what do you mean by that? )

( e.g. for verification : did I hear you say that you do not take your medication at all?)

Strategies to conduct an interview?Cont.

5. Do not Use and avoid leading questions such as ( e.g. I think your pain increases at night ?)They specify the answer you expect to get, there is no

advantage of using it.

6- always listen and use silence and touch whenever needed to express sympathy and keep building trust

7- accept and respect patients

Strategies to conduct an interview?Cont.

8- summarize : always summarize to patients what has been discussed in brief and points ( e.g. so we can conclude from our session today that you agreed to control your diabetes by measuring blood sugar twice a day, eat seven small meals instead of three big ones, and walk at least half an hour daily, right? Is there something else?)

Critical thinking questions

1. What are the most important concepts doctors need to take in consideration in building a helping relationship with patients?

2. What are the main obstacles in building a rapport in any interpersonal relationship?

Lecture 4

Taking History

By Dr. Aziza RajabAssistant professorHead of Nursing dep .

King Abdul Aziz University

What are the reasons for history taking?

• For understanding the patient holistically, and has a complete picture

• Serve as the mean to start building rapport, relationships and trust

• To gather detailed specific information • To identify the problem / problems• To make proper conclusions about patient’s

condition• To make accurate diagnosis about patient disease

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Where can we take history?

• In the out patient clinic when the patient comes for the first time or after a long absent from a periodic appointments.

• In the in-patient different hospital units, after the patient been hospitalized and arrived in the unit clerking or history taking is a must.

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Does history taking has a defined process or steps?

Yes in order to take history from any patient the following should be set up:

• Specify the patient name, room & bed number• Collect any medical forms, record, or equipment that will be needed

during the history taking process.• Situate patient comfortably to allow confidentiality and privacy for

the patient, and his information provided and shared with you.• Prepare your self to dedicate your full attention, time and focus on

the process of history taking and the patient • Be sensitive to patient and his needs by being conscious to your

verbal and non verbal communication techniques.• Introduce your self and explain clearly what and why are you doing

this• Get assistant ar a translator as needed

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What are the components of history needed to be documented?

1. Patient’s demographic data 2. Past medical history 3. Family medical history 4. Present complains5. Physical examination to review body

systems6. Laboratory and radiology investigations7. Differential and accurate diagnosis

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1. Patient demographic data

Age Name sex Marital status Occupation and, Nature of work, hazards Personal habits, smoker, drinker hobbies such as painting, carpenting, welding Address / type of residence Travel abroad where, when, length of stay

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2 -Past medical history Past medical problems chronic disease: (hypertension,

diabetes, anemia, renal failure….), duration & treatment. Number of times hospitalized , when was the last one and

why? Past surgical problems (number of surgical procedures,

where, when was each. Drug history, is he /she on any regular medications, names,

doses, routes, frequency. Immunization history, when what type (mumps, measles,

tetanus, rubella, poliomyelitis, T.B., smallpox, typhoid, diphtheria, flu…)

Any exposure to infections Sensitivity against any medication, food, materials.

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3 -Family medical history

Any family member has any chronic diseases (hypertension, diabetes, liver cirrhosis, renal failure, cancer, congenital anomaly, depression, psoriasis….)

Any family is sensitive to any thing Any family member has infection (hepatitis) Causes of deaths, ages, Nature and type of relationship with patient Presence of any violence, stress, abuse or

relatedness problems

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4 -Present complaints Ask what seems to be the problem now? The time of onset of the complaint The duration of the problem The severity of the problem What is done toward the complaints to relieve it before

arrival to the hospital ? Any medication or remedy was used? What are the exact sign and symptoms - Sign is what you can actually see on patient - symptoms is what the patient is feeling and complaining of

without you being able to see it.

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5-Physical examination to review body systems

Use the four major skills in performing physical examination:1- observation2- palpation3- auscultation4- percussionYou only need to know what are they for now but you will learn

to perform them in the future levels of professional skills.The aim is of using these specific techniques in physical

examination on patients is to reach to an accurate conclusion about patients diagnosis by the help and mean of these four steps.

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5-Physical examination to review body systems

• Respiratory system: in this system you will assess if the patient is present with or complains of the following:

Cough, Sputum, colour of sputumHeamoptesis/ blood in coughDyspnea/ difficulty in breathing short of

breath, gasping for air, chest pain,..Orthopnea , difficulty breathing at night

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5-Physical examination to review body systems

• Cardiovascular system: in this system you will assess if the patient is present with or complains of the following:

Chest pain Patients color, skin moisture, Palpitation Dizziness and headache Weakness, easy fatigueness Ankle swelling or edema bleeding Vital signs: pulse rate, blood pressure, respiratory

rate, temperature 59

5-Physical examination to review body systems

• Gastrointestinal system: in this system you will assess if the patient is present with or complains of the following:

Appetite, Diet, and eating habits Weight now, gain or loss, amount, and in duration of,

reasons for gain or loss Vomiting, diarrhea, colour, amount, consistency daily bowl motion habits Abdominal pain, tenderness, distension,

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5-Physical examination to review body systems

• Nervous system: in this system you will assess if the patient is present with or complains of the following:

Cognitive Mental status Consciousness level Fits or seizers Transient ischemic attack Loss of sensation or ability to move Loss of balance , gait, posture Speech abilities Attention, concentration, memory

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5-Physical examination to review body systems

• Urogenital system: in this system you will assess if the patient is present with or complains of the following:

Pain during micturation, blood, pus, …. Menstruation habits, duration of fllow, amount,

pain…. Pregnancies, number, type of deliveries,

complications Breast engorgement, pain, swelling, lumps.. Secondary sex characteristics normally present or

absent

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5-Physical examination to review body systems

• Musculoskeletal system: in this system you will assess if the patient is present with or complains of the following:

Joint pain, stiffness, swellingLimitation in movementsAbsence of movement Amputation / prosthetics /moving aids such as

chair, zim-frame, cane,Infection, gangrene, bleeding deformity.

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6 -Laboratory and radiology investigations

Usually the doctors will order three major types of investigation to confirm their diagnosis:

1- laboratory tests of blood, urine, sputum, or tissue biopsy in hematology, biochemistry, cytology, immunology, microbiology or other labs.

2- radiological examination such as x-ray, CT scan ultrasound,, MMRI, Tomography, echo, …

3-Electrocardiography or electro encephalography

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7 -Differential and accurate diagnosisWhat we gained form all the previous steps of history taking is to reach to an

accurate diagnosis by analyzing differential diagnosis.• Differential or working diagnosis: is to assess the why most likely,Why less likely, why least likely

• accurate diagnosis: always consist of Anatomical part + pathological part Renal + failure Brain + tumor Heart + failure Cervical + cancer Liver + cirrhosis

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Documentation of all the steps of history taking process doctors can develop a clear understanding of

causes and nature of the problem, and based on that they can make medical plans to manage and cure

patients.

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Lecture 5 WHO ARE THE DIFFICULT PATIENTS AND

HOW TO DEAL WITH THEM

By

Dr. Aziza Rajab

Head of Nursing dep.

DR. HASHIM FIDA

FAMILY & COMMUNITY MEDICINEking Abdul Aziz University

68

Objectives

By the end of this session, participants will be able to:

• list the 4 categories of “difficult” patients and discuss strategies for dealing with each, and

• list the components of the “CALMER” strategy for dealing with difficult patients.

The term difficult patient The term difficult patient refers to a group of patients refers to a group of patients with whom a physician may with whom a physician may

have trouble forming a normal have trouble forming a normal therapeutic relationship.therapeutic relationship.

Difficult patient

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Dealing with emotional Patients

Get patients’ attention: lower your voice, move so they must turn in your direction.encourage them to sit down but let them control their emotions.Listen not just to the patients needs, but also for underlying issues/concerns and unexpressed expectations.

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Dealing with emotional Patients/2

The use of “uh- huh” and “um” has been shown to help patients settle down on their own. Feels like a lot of time, but really isn’t.Avoid arguments, use disarming statements.Consider rolling with the resistance and agreeing with the patient if possible. Take a step back from the demand and ask probing questions to find underlying concerns. This may change a rant into a conversation.

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Dealing with emotional Patients/3

• Don’t assume things, ask to find out

• Don’t get emotionally involved, keep your professional attitude.

• Don’t give false reassuring comments.

• Say no in a tactful manner to the patient’s unrealistic wishes & demands.

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Handling the Difficult Patient

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What are some typical problem behaviors?

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Problem Behaviors

• Multiple symptoms involving multiple body systems

• Vague and shifting complaints• Dependent, clinging behavior• Undue concern about minor symptoms• Excessive preoccupation with physical disease• Poor response to usual methods of treatment• Difficult to communicate with

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• Hostile, demanding, dissatisfied• High utilization of health care services• Manipulative [calculating], exploitative

[abusive], controlling• Seductive• Unrealistic expectations of care• Raises new problems as visit ends• Resistant to physician’s recommendations• Noncompliant with treatment program• Rambling, unfocused• Self-destructive

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Three Characteristics of Difficult Patients

• Underlying psychiatric symptoms• Vague, functional and changing complaints• Difficulty in forming normal relationships with

physicians

Malcolm, et al. (1977)

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Physician Emotions

• Transference v. Countertransference• Hatred of Patients• Typing of Patients

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Transference v. Countertransference

• Transference=feelings experienced by the patient toward the physician that recapitulate other important relationships within the patient’s life

• Countertransference=the analogous emotions experienced by the physician in this relation with the patient

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Hatred of Patients

• Hatred toward a patient is a natural phenomenon.

• The responsibility of the physician for the patient is similar to that of the mother toward an infant.

• Like the mother, it is okay to feel the hatred but essential to refrain from acting upon it.

Winnicott, 1949

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Typing of Patients

• Dependent clingers• Entitled demanders• Manipulative help-rejecters• Self-destructive deniers

Groves, 1978

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Dependent Clingers

Patients who have inexhaustible needs for medical attention

• Initial honeymoon period when the physician is likely to be praised and receive stroke from the grateful patient, who then goes on to steadily increase the demands made on physician time

Sohr, 1996

83

Dependent Clingers

These patients produce feelings of AVERSION on the part of the physician or treating team.

• The natural response is to put off seeing such a patient as long as possible and perhaps to send subtle messages to the patient that his presence is less than enthusiastically welcomed.

Sohr, 1996

84

Dependent Clingers

It is important for the physician to do the opposite of his inclination.

• Instead of putting off the patient’s appointment, the patient should be scheduled promptly and frequently.

Sohr, 1996

85

Dependent Clingers

The use of frequently scheduled but time-limited visits does the following:

• Encourages the development of a more useful physician-patient relationship

• Stabilizes the patient by setting limits on the time spent at any one sitting

• Gives the patient permission to come back to see the physician without the need to develop a new symptom

Sohr, 1996

86

Entitled demanders

Resemble clingers in their neediness, but rather than flattery and seduction, they use intimidation, devaluation and guilt-induction to place the doctor in the role of the inexhaustible supply depot.

• They appear less naïve about their effect on the physician than clingers and buttress their hold on the doctor by threatening punishment.

Sohr, 1996

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Entitled demanders

These patients arouse ANGER in the physician and sometimes FEAR of loss of reputation.

• Frequently, the patient will threaten litigation.

Sohr, 1996

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Entitled demanders

The recommended strategy is to acknowledge the patient’s entitlement to good medical care and request that the patient stop misdirecting his anger.

• Try to resist projecting your value system onto the patient—the APOSTOLIC FUNCTION=notion that the doctor knows how the illness is supposed to feel and how the patient should be handling it.

Sohr, 1996

89

Manipulative help-rejecters

These patients are ungrateful. Their demands are not threatening as with Entitled Demander. Instead, they seem to believe that nothing will help.

• Pessimistic, yet strangely content• When one symptom disappears, another

surfaces.

Sohr, 1996

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Manipulative help-rejecters

These patients first elicit ANXIETY that a treatable illness has been overlooked. Eventually, the physician becomes IRRITATED with the patient. Finally, the physician becomes DEPRESSED and full of self-doubt. They can make the physician feel INADEQUATE and GUILTY.

Sohr, 1996

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Manipulative help-rejecters

A reasonable management strategy for somatization includes frequent patient visits.

• Once the relationship is established, it becomes easier to employ “tincture of time” and to avoid unnecessary and invasive procedures.

• Seeing the patient on a regular basis decreases the patient’s need to develop new symptoms in order to see the physician.

Sohr, 1996

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Manipulative help-rejecters

These patients are sometime called “crocks.”• Need to create a situation where the patients

need not remain ill in order to maintain the relationship with the doctor.

• Share pessimism with the patient and say that the treatment may not be entirely curative.

Sohr, 1996

93

Self-destructive deniers

These patients exhibit a form of suicidal behavior.

• It is not unusual for physicians to wish occasionally for such patient to die quickly.

• Many recommend a psychiatric consult for these patients to rule out depression.

• These patients are not necessarily aware of their death wishes.

Sohr, 1996

Sohr, 199694

StereotypeStereotypeMechanismMechanismPhysician Physician EmotionEmotion

StrategyStrategy

DependenDependent Clingert Clinger

Regression into Regression into dependency. dependency. Patient has Patient has inexhaustible inexhaustible needs.needs.

Feelings of Feelings of power initially power initially followed by followed by aversionaversion

Set limits Set limits before total before total destruction of destruction of the relationship. the relationship. Schedule more Schedule more frequent visits frequent visits and limit and limit interruptions.interruptions.

Entitled Entitled DemanderDemander

Unaware of Unaware of dependency. dependency. Terrified of Terrified of abandonment.abandonment.

Guilt, fear, Guilt, fear, angeranger

Never Never disparage disparage feeling of feeling of entitlement. entitlement. Redirect Redirect feeling of feeling of entitlement to entitlement to acknowledged acknowledged right to good right to good health care.health care.

Sohr, 199695

StereotypeStereotypeMechanisMechanismm

Physician Physician EmotionEmotion

StrategyStrategy

ManipulatiManipulative Help-ve Help-RejecterRejecter

Afraid to get Afraid to get well for fear of well for fear of losing losing relationship relationship with physician.with physician.

Anxiety that Anxiety that treatable treatable illness has illness has been been overlooked.overlooked.

Put limits on Put limits on unrealistic unrealistic expectations. expectations. Share Share pessimism with pessimism with patient.patient.

Self-Self-destructive destructive DeniersDeniers

Dependents Dependents who have who have given up. given up. May appear May appear to take to take pleasure in pleasure in their their destruction.destruction.

Frustration. Frustration. May with the May with the patientpatient’’s s death and death and experience experience guilt about guilt about such wishes.such wishes.

Realize that Realize that the patient the patient has given up has given up and may truly and may truly want to die. want to die. Order Order psychiatric psychiatric consultation.consultation.

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The CALMER Approach

• Physicians must understand how their own attitudes and behavior may contribute.

• The CALMER approach assists physicians in reducing distress associated with interactions with problem patients.

Pomm, et al. (2004)

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CALMER

C=catalyst for changeA=alter thoughts to change feelingsL=listen and then make a diagnosisM=make an agreementE=education and follow-upR=reach out and discuss feelings

Pomm, et al. (2004)

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Catalyst for Change

• Physicians should remind themselves of what they can and cannot control about the situation.

• Physicians cannot control the patient’s behavior, but they can control their own reaction and try to be helpful by offering practical advice.

Pomm, et al. (2004)

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Alter Thoughts to Change Feelings

• The only way individuals can control their reactions is to alter their thoughts about the situation.

• Physicians should identify which feelings they are experiencing in response to the patient and then ask how these feelings might be affecting the physician-patient relationship and the management plan.

Pomm, et al. (2004)

100

“What can I tell myself about this situation that

will make me feel less ?_______”

Pomm, et al. (2004)

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Listen and Then Make a Diagnosis

• As a result of a physician’s negative response to a difficult patient encounter, he/she may not accurately hear what the patient is trying to verbally or nonverbally communicate.

• By engaging in the first two steps, the physician will be better equipped to truly hear what patients are trying to communicate.

Pomm, et al. (2004)

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Make an Agreement

• Make an agreement with the patient to continue the physician-patient relationship.

• “So, after all we have discussed, it is my understanding that you would like to continue to see me, and we have agreed that we will work together to keep you as healthy as possible. Is that your understanding, too?”

Pomm, et al. (2004)

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Education and Follow-Up

• After the physician and patient agree to continue their relationship and work together, how they will accomplish this needs to be addressed as specifically as possible.

Pomm, et al. (2004)

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Reach Out and Discuss Your Feelings

• “How do I now feel about this patient and his/her behaviors?”

• Identify how they will care for themselves the next time a patient elicits these types of feelings.

Pomm, et al. (2004)

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CALMER

C=catalyst for changeA=alter thoughts to change feelingsL=listen and then make a diagnosisM=make an agreementE=education and follow-upR=reach out and discuss feelings

Pomm, et al. (2004)

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Objectives

By the end of this session, participants will be able to:

• list the 4 categories of “difficult” patients and discuss strategies for dealing with each, and

• list the components of the “CALMER” strategy for dealing with difficult patients.

Lecture 6

The Art of ConsultationBy

Dr. Aziza Rajab Assistant professor

.DR. HASHIM FIDA

FAMILY & COMMUNITY MEDICINEking Abdul Aziz University

CONSULTATION

• Definition• Models of consultation• Difficult consultations• Communication skills

108

Definition

Most text books describe interviewing as a diagnostic procedure which is a systematic process of data-gathering designed to identify problems and to arrive at a conclusion,leading ultimately to a treatment plan. This is only partly true.To achieve its maximum value, the consultation should be therapeutics. The most important skill of family physician is ability to

interview patient effectively as follow;

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1.To provide health care to all patients, regardless of their age, sex, socio-economic standing and disease status.

2.To treat disease and promote healthy lifestyles in individuals and communities.

3.To provide comprehensive, continuous care, bearing in mind the cultural, social, psychological and economic factors that influence health and disease.

4.To provide care either directly or through other members of the team, depending on the needs of the patient and the resources of the community.

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Models of consultation

1.Bio-medical model (hospital model).2.Bio-psychosocial model.3.Byrne and long model doctors styles.4.Balint model. 5.Pendelton model6.Stott an Davis.7.Neighbour model.

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Byrne and long model doctors styles.

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Patient-centered

Use of patient’s knowledgeAnd experience

Doctor-centered

Use of doctor’s knowledgeAnd skills

Balint model

• The doctor as a drug• Elimination by physical examination• The child as a presenting complaint• Inappropriate referral

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Pendleton model

1.To define the real reason for attendance2.To consider other problems3.To choose "with the patient" the appropriate

action for each problem4.To achieve a share of understanding5.To involve the patient in management6.To use time and resources effectively7.To establish and maintain doctor-patient

relationship

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Stott and Davis model

1.Management of Presenting Problem2.Management of Continuous problem3.Modifiation of help Seeking behavior4.Opportunistic health promotion

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Neighbour model

1.Connecting (establish a relationship)2.Summarizing( physical. psycho ad social

diagnosis)3.Handling-over(management of presenting

problem)4.Safety-netting(anticipating care)5.House-keeping(taking care of yourself)

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Difficult consultation

10-20% of daily consultation are difficult. This difficulties are either due to;

1.Difficult patient2.Difficult Doctor3 .Difficult communication between the doctor

and patient

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Initiating the ConsultationEstablishing a supportive environment.Developing an awareness of the patient’s emotional state.Identifying as far as possible all the problems or issues that the patient has come to discuss.Establishing an agreed agenda or plan for the consultation.Enabling the patient to become part of a collaborative process.

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The Art of Consultationgiving the correct amount and type of information to each individual patient.Providing explanations that the patient can remember and understand & which relate to the patient’s illness framework.Using an interactive approach to ensure a shared understanding of the problem with the patient.Involving the patient and collaborative planning increase the patient’s commitment and adherence to plans made.Continuing to build a relationship and provide a supportive attitude.

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Closing the interviewConfirming the established plan of care.Clarifying next steps for both doctor and patient.Establishing contingency plans.Maximizing patient adherence and health outcomes.Making efficient use of time in the consultation.Continuing to allow the patient to feel part of a collaborative process and to build the doctor-patient relationship for the future.

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Questions to ask yourself after each consultation

Was I curious? Do I know significantly more about this person as a human being than before they came through the door?Did I listen? Did I make an acceptable working diagnosis?Did I explore their beliefs?

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Questions to ask yourself after each consultation/2

Did I use their beliefs when I started explaining? Did I share options for investigations or treatment?Did I share in decision-making? Did I make some attempt to see that my patient understood?Did I develop the relationship?  

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Lecture 7

PRINCIPELS OF BREAKING BAD NEWS Lecture 8HOW TO APPLY THE STEPS OF BREAKING BAD

NEWS IN THE CLINICAL SETTING

By Dr. Aziza Rajab

Assistant professor DR. HASHIM FIDA

FAMILY & COMMUNITY MEDICINEking Abdul Aziz University

.

What is Bad News?

•Any news that drastically alters a patient’s view of his or her future

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What is Bad News?

Any news that seriously and negatively alters

the patient’s view of his or her future .

Buckman

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Do You Tell?

• 50 – 90% of patients want the truth

• So the issue is not “do you?”

• Issue is “how?”

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The Goal

• Help the patient and family understand the condition

• Support the patient and family• Minimize the risk of overwhelming distress or

prolonged denial

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BREAKING BAD NEWS

WHY IS IT SO DIFFICULT TO DO?

WHAT IS THE SOLUTION?

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EMPATHY: THE FOUNDATION

BEING FOCUSSED

UNDERSTANDING FROM THE ‘INSIDE’

RESPONDING WITH CARING

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WHAT IS THE SOLUTION?

KNOWLEDGE• HOW TO TELL?• HOW MUCH TO TELL?• WHO TO TELL?• WHEN TO TELL?

SKILL “LI ST EN”

ATTITUDE• IMPORTANCE OF SELF AWARENESS

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Why Is It Difficult to Do

• Worry that the news will cause an adverse effect

• Worry that it will be difficult to handle the reaction of patient or family

• Challenge of individualizing the approach

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Why is this Difficult?

•Social factors

•Our society values youth, health, wealth•Elderly, sick and poor are marginalized•Sick and dying have less social value

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Why is this Difficult?

•Physician factors

•Fear of causing pain•Uncomfortable in uncomfortable situations•Sympathetic pain due to patient’s distress

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Why is this Difficult?

• Fear of being blamed• Physicians have authority, control, privilege

and status• When medical care fails patient• it’s physician’s fault• “blame the messenger”

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Why is this Difficult?

• Fear of therapeutic failure• Medical system reinforces idea that poor outcome

and death are failures of ‘system’• and by extension, our failure• “all disease is fixable”• “better living through chemistry”• We are trained to feel this way; “if only……”

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Why is this Difficult?

• Fear of medico-legal system

• Everyone has “right” to be cured;• If no cure happens, someone is to blame

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Why is this Difficult?

• Fear of not knowing

• “we don’t do what we don’t do well”• Good communication is a skill that is not

highly valued, therefore not taught

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Why is this Difficult?

• Fear of eliciting reaction• “don’t do anything unless you know what to

do if it goes wrong”• Not trained to handle reactions• Not trained to allow emotion to come out

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Why is this Difficult?

• Fear of saying “I don’t know”•

• We are never rewarded for lack of knowledge

• Can’t know or control everything

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Why is this Difficult?

• Fear of expressing emotions•

• Viewed as unprofessional• Suppressing emotions increases distance• between ourselves and patients

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Why is this Difficult?

• Ambiguity of “I’m sorry”•• Two meanings• “I’m sorry for you”• “I’m sorry I did this”• Easily misinterpreted

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Why is this Difficult?

• Fear of one’s own illness and death

• Cannot be honest with the dying unless you accept you will die

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What Do Patient’s Want?

•Studies show that 50-90% of patients with terminal illnesses want full disclosure

•Not everyone wants to know

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Why is it a critical skill?

The Patient’s Perspective

•Patients often have vivid memories of receiving bad news

•Negative experiences can have lasting effects on anxiety and depression

•Can facilitate adaptation to illness and deepen the patient-doctor relationship

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Why is it a critical skill?

The Physician’s Perspective

High degree of difficulty +

Physician anxiety=

High risk of performing poorly

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What do patients want?

For themselves…• more time to talk • and show feelings

From the doctor…• more information, caring, hopefulness, confidence• a familiar face Strauss 1995

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What do you do?

•What have you have found helpful in making “bad news” visits go as well as possible?

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Six Step Protocol

• -arrange physical context• -find out what patient knows• -find out what patient wants to know• -share information• -respond to patient’s feelings• -plan follow-through

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Arrange physical context

• Always in person, face to face• NEVER on telephone• Assure privacy• Verify who is present• Verify who should be present

• ASK

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Arrange physical context

• Remove physical barriers• Sit down• patient-physician eyes at same level• appear relaxed, not casual • (avoid ‘open 4’)• Touch patient (appropriately)• above the waist, handshake, shoulder

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Find out what patient knows

• Not just knows, but understands

• Use open questions• closed questions excellent for history-

taking• prevent discussion

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Find out what patient knows

• Listen effectively to response:• tells understanding, ability to

understand• Repeat back what patient says• Do not interrupt• Make encouraging cues• Maintain eye contact

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Find out what patient knows

• Tolerate silences

• Listen for “buried question”• question asked while you are speaking

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Find out what patient wants to know

• Ask!!• Do not allow families to run interference

• If patient chooses not to know now, may ask later

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Share the information

• Plan agenda • know beforehand what information has

to get across• eg diagnosis, treatment,

prognosis, support

• Start by aligning with what patient knows

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Share the information

• Allow patients to ‘get ready’• Impart information in small packets• best case retention = 50%• Speak English, not “Doctor”• Verify message is received

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Respond to feelings

• Acknowledge emotions• strong emotions prevent communication• identify and acknowledge them

• Learn to be comfortable with silence and with emotion

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Respond to feelings

• Range of normal reaction is wide• give latitude[ freedom] as much as

possible• stay calm, speak softly• be gentle, yet firm• stick to basic rules of interview:• question-listen-hear-respond

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Respond to feelings

• Distinguish between adaptive and maladaptive behaviors

• Adaptive Maladaptive• anger rage• crying collapse• bargain [agreement] manipulation• fulfilling an ambition impossible “quest”• fear anxiety/panic• hope unrealistic hope

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Respond to feelings

• Respond with empathic responses• “it must be very hard to…”• “you sound angry (afraid, depressed)…”

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Respond to feelings

• In the face of true conflict: act, don’t react

• If you cannot change behavior, get help

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Planning follow-through

• Have plan of action• Make certain patient’s understand what is

fixable and what is not• Always be honest• Patient leaves with contract:• what will happen, who to call, how

to call, when to return

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S etting up the interview

P erception of the patient re their illness

I nvitation from patient to share info

K nowledge and Information conveyed

E motions responded to empathically

S ummary and Strategy for follow-up

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1 .Setting up the interview

• Anticipate [expect] the possibility of bad news, and arrange a follow-up visit after significant scans, biopsies etc.

Avoid telephone Private setting, sitting down Turn off beeper, no interruptions Ensure adequate time

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1 .Setting up the interview

Lab reports, X-rays present Support person present , if desired Review the condition, basic prognosis and

treatments before the visit HOPEFUL TONE

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Assessing the patient’s

2. Perception

• ASK then TELL• Important if the patient is not well known to you OR

if visits to consultants have occurred • “Assess the Gap” between what the patient knows

and the diagnosis• “What have you already been told about might be

going on?• “What is your understanding of why the CT scan was

ordered?”168

Obtaining the patient’s

3. Invitation

• Preferably before the visit• Easier if patient is well- known• Listen to patient cues• “Are you the sort of person who likes to know all the

details of your condition?• “Would you like me to discuss the results of the CT

scan with you?”

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Giving

4. Knowledge and Information• Align yourself with the patient’s understanding and

vocabulary• Start with a warning shot: “I’m afraid that the scan

shows that the problem is fairly serious.”• Give diagnosis simply, avoid euphemisms [use of

alternate word for a unpleasant word • ] or excessive bluntness[word used to hide the real

thing]

• Provide information in small chunks• Check frequently for understanding170

Giving

4. Knowledge and Information

• Align yourself with the patient’s understanding and vocabulary

• Start with a warning shot: “I’m afraid that the scan shows that the problem is fairly serious.”

• Give diagnosis simply, avoid euphemisms or excessive bluntness

• Provide information in small chunks• Check frequently for understanding

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Giving

4. Knowledge and Information

• Check for knowledge or experience with condition

• Allow for pauses, use repetition• Will usually want basic but clear information

re treatment plan and prognosis BUT

• Tune into patient readiness to hear more, and know when to stop

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Respond to

5. Emotions empathically

•Observe for and allow emotional reactions•Kleenex handy, use of touch

N aming the feeling “I know this is upsetting”

U nderstanding “It would be for anyone”

R especting “You’re asking all the right questions”

S upporting “I’ll do everything I can to help you through this”.

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6 .Summary and Strategy for follow-up

• Summarize discussion• Clear follow-up plan re: referral, tests, next

contact (in <48 hrs)• Provide written summary or brochures• Refer to community resources• Invite support person for next visit if not

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6 .Summary and Strategy for follow-up

End on note of hope and partnership AFTER: document well assess your own reaction

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Six Steps for Breaking Bad News

S etting up the interview

P erception of the patient re their illness

I nvitation from patient to share info

K nowledge and Information conveyed

E motions responded to empathically

S ummary and Strategy for follow-up

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SPIKES

• S = Setting up the interview

• P = Patients Perceptions

• I = Invitation to ascertain how much the person wants to know

• K = Knowledge and information giving

• E = Emotion management

• S = Strategy and Summary summarising the key points

(Taken from Baile et al. 2000 and reproduced by kind permission of AlphaMed Press)

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How Should Bad News Be Delivered?

• ABCDE Mneumonic• A-Advance Preparation• B-Build a therapeutic relationship• C-Communicate well• D-Deal with patient and family reactions• E-Encourage and validate emotions

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Advance Preparation

• Familiarize with the facts of the case, consultant opinions, prognosis and treatment options

• Arrange for appropriate environment and time where there will be no interruptions (silence beeper and cell phone)

• Mentally rehearse how you will deliver the news• Prepare emotionally

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Advance Preparation

• Familiarize with the facts of the case, consultant opinions, prognosis and treatment options

• Arrange for appropriate environment and time where there will be no interruptions (silence beeper and cell phone)

• Mentally rehearse how you will deliver the news• Prepare emotionally

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Build a Therapeutic Relationship

• Determine what the patient wants to know• Have family or other supporters present

based upon patient preference• Introduce yourself to everyone present• Foreshadow the bad news• Assure the patient that you will be available-

schedule a follow-up meeting

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Communicate Well

• Find out what they know• Speak clearly-avoid euphemisms like “growth”• Allow silences-proceed at the patient’s pace• Assess understanding• Summarize and make followup plans

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Types of Ambiguous Communication

• Jargon and technical language• Euphemisms• Evasion [ dodging]• Conflicting information• Percentages and statistics• Obfuscation [to make somebody confused]

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Example

• Physician: As you may remember, when we first started chemotherapy, we told you that we would check blood and x-rays before each cycle. I have looked at your scans today and there are signs that things are progressing, so we do not think that you should have any more chemo

• Patient: So what happens now?

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• Physician: Well, we just want you to come back and see us if you develop any further problems with your breathing and we will treat those symptoms

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• The researcher met with the patient after this conversation and his interpretation of what the physician told him was “Well it’s good news, really…the doctor thinks things are progressing so I don’t need any more chemo and to just come back if my breathing starts up again-getting breathless you know”

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Deal with patient and family reactions

• Assess and respond to emotional reactions• Be empathetic-I’m sorry that I couldn’t give

you better news• Avoid criticizing colleagues

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Encourage and Validate Emotions

• Offer realistic hope• Offer referals as needed• Use interdisciplinary services to enhance care• Take care of own needs and others affected

by the news

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Other Pointers

• Avoid telephone notification• Be a good listener• Respect preferences

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In a meeting

• Find out who everyone is• Determine what they know• Determine what they want to know• Tell• Respond• Plan future meetings

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Ten Important Needs of Families of Critically Ill Patients

• Be with the patient• Be helpful to the patient• Be informed of changes in condition• Understand what is being done and why• Be assured of the patient’s comfort• To be able to ventilate emotions• To be assured that their decisions were right• Find meaning in the dying of their loved one• To be fed, hydrated and get rest

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Ten Important Needs of Families of Critically Ill Patients

• Be with the patient• Be helpful to the patient• Be informed of changes in condition• Understand what is being done and why• Be assured of the patient’s comfort• To be able to ventilate emotions• To be assured that their decisions were right• Find meaning in the dying of their loved one• To be fed, hydrated and get rest

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Death Notification

• Prefer to be told by the physician• Ask the family members what they know about the

situation• Bridge from what they know with a brief description

of what happened• Give information about the resuscitative efforts • Conclude with the victim’s response, the statement

of death and an assessment of the cause of death

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BREAKING BAD NEWS: CONCLUSIONS

1) BAD NEWS CANNOT BE CONVERTED TO GOOD NEWS

2) KNOWLEDGE OF NORMAL PSYCHOLOGY WILL HELP INFORM THE PROCESS

3) SPECIFIC SKILLS (LISTEN) CAN BE LEARNED AND APPLIED

4) SELF AWARENESS AND THE ABILITY TO DEAL WITH PERSONAL STRESS IS ESSENTIAL TO GOOD COMMUNICATION

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2nd lecture(how to break bad news)

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Case Scenario

• During morning clinic, you receive a phone call from the radiologist at your local hospital.

A chest x-ray carried out on Mr. Ahmed shows features highly suggestive of lung cancer.

You remember that Mr. Ahmed is a 50 year old in your practice area.

What problems confront you and how could they be dealt with?

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Case scenario

• 30-year-old lady delivered a baby with down syndrome 8 hours ago. The pediatrician told you as an intern to tell her husband about the diagnosis.

What points would you like to consider in discussing this request with him?

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Aims: breaking bad news

• Enhance the psychosocial adaptation of patients and their relatives.

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Principles: breaking bad news

• The most appropriate persons.

• Details of the patient and all necessary information.

• What information is to be conveyed and in what order?

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Principles: breaking bad news

• Terminology.

• Privacy.

• Appropriate setting

• Timing.

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Principles: breaking bad news

• Respect and absolute attention.

• Active listening

• Empathy

• Honestly and accurately.

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Principles: breaking bad news

• Check out understanding.

• Patient reactions

• Body language.

• Relaxed, unhurried.

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Principles: breaking bad news

• Explanatory leaflets.

• Avoid unnecessary distress and minimize misunderstanding.

• Avoid overload patient with information.

• Summarize the information.

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Principles: breaking bad news

• Questions.

• Support.

• Early follow up.

• Time for your own felling.

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Practical and Role play

• Two volunteer student

• Scenario

• Role play

• discussion

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conclusion

رضي سنان بن صهيب يحي أبي عن : صلى الله رسول قال قال عنه الله

: وسلم عليه اللهالمؤمن)) ألمر له عجبا كله أمره إن

: خير إن للمؤمن إال ذلك وليسوإن له، خيرا فكان شكر سراء أصابته

)) له خيرا فكان صبر ضراء أصابتهمسلم رواه

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Breaking Bad News

clinicians are responsible for delivering bad news, this skill is rarely taught in medical schools, clinicians are generally poor at itbreaking bad news is one of a physician’s most difficult duties.

medical education typically offers little formal preparation for this task.

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THE PAST AND THE PRESENT

Hippocrates advised concealing most things from the patient.

Older physicians, who trained duringthe 1950s and 60s, were taught to "protect" patients from disheartening news.

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BREAKING BAD NEWS/2

any news that drastically and negatively alters the patient’s view of his or her future.

it results in a cognitive, behavioral, or emotional deficit in the person.

receiving the news that persists for some time after the news is received.

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