THE ART OF COMMUNICATION AND INTERVIEWING

 

 

 

 

Characters of process of communication:

Fear  may be expressed by momentary anger e.g. the patient may shout at the physician for being late  probably he is afraid of  being unavailable.

Patient may speak about the present by recalling the past.

Messages might hide ; but the patient passes remarks

Gradual shifts of conversations

Body languages

Repetitions

A.R.T.  OF   INTERVIEWING:

·  A =ASSESSMENT

Most  of the questions are open ended and non directive .  The patient describes, raises concerns and interests.

·  R =RANKING

Ares to pursue further by direct questions so that each of the ranked problem can be investigated thoroughly according to its importance regarding the patient.

·  T =TRANSITIONS

Interview should flow smoothly from one aspect to another and the patient should be at ease.

The best interview should be organised and structured to  elicit as much information as possible.

Developing an open and productive Communication:

You should develop specific techniques in asking questions approached  with sense of purpose comparison  and curiosity.

It should be friendly conversations and interrogation.

 

Personality characters of both the patient and physicians:

Physicians should understand his own emotions , thoughts and reactions.

Patients responses should be noted

Emotional  ( Laughing and crying).

Motor             = Facial ( Smiling, nodding, frowning, sneering..etc.).

Speech pattern ( Rate – volume and tone and what dose it mean?)

Bodily gestures ( Clenching fists, fidgeting,

Patient emotional response to illness.

 

 

 

 

 

 

 

TECHNIQUES OF COMMUNICATING:-

 

·  FACILITATION= Encourage the patient to ventilate  how?Repeat last word, question look, as what, give me example, please more verification.

 

 

·  OPEN ENDED QUESTIONS= To have none specific informations.

 

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·  DIRECT QUESTIONS = To have specific information.

 

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·  SUPPORT = By giving him/her interests and true will to help.

 

 

·  EMPATHY= is to sympathize with the patient and to find a solution..

 

 

·  REFLECTION= repeat , mirror, echo a portion of what a patient has just said.

 

 

·  SILENCE=Brief, chance to express and explore more.

 

 

·  CLARIFICATION= for further information ,clarify to the patient what is clear from his behaviour  and reactions.

 

·  CONFRONTATION=to call patient’s attention to his misbehaviour or good for depressed , inconsistent, and contradictions.

 

 

·  SUMMATION=Review information

 

 

·  INTERPRETATION= is a formulation of data , events and thoughts.

 

 

 

PHYSICIAN – PATIENT RELATIONSHIP – FACTS AND THEORIES:

 

Definition:

is a 2 person relationship in a social system

It transcends the traditional bed side manner.

The physician provides emotional support and legitimise the illness .

It is an important mediator of the therapeutic effect of every ttt program. (Placebo).

 

The Sick Role:

Societal Expectations or the Ground rules.

 

Exempted from normal social responsibilities.

 

Unblamable

 

Motivated to get well

 

Obliged to seek technically competent help.

 

Performance of the sick role:

Economic:

In case of hard financial aspects the patients are supposed to be reluctant to assume the sick role.

Patients who are injured on the job, this may intensify and prolong the sick role.

Students might be inclined to assume the sick role for fear of interpretation in their careers

 

Personal Experiences:

Proper time to assume the role for personal reasons and secondary gain.

 

Societal view of a particular illness:

This may affect the motivation for assuming illness role.

 

 

Personality type:

Habitual patterns of thoughts, behaviour and feelings of individuals

THERE ARE  8 TYPES OF PERSONALITIES CAN VISIT YOU   :

·  Dependent, Demanding individuals

Require a lot of reassurance and attentions , may enjoy their illness and sensitive to rejection.

·  Orderly controlling individuals:

Need to control their external and internal environment, they display intense fear of being helpless.  you should describe to them precisely, with little emotional reaction, they feel very threatened by the control that physicians assume over their lives.

 

·  Dramatising and emotional individuals:

Need for continuous reassurance that they are still attractive and won’t be abounded . Describe impressionistically and charming often behave covertly .

 

·  Long – Suffering self sacrificing

Endure  protracted pain , they  complaint of bad luck and disappointments and efforts of their physicians.  they are mostly guilty.

 

·  Guarded and  Suspicious:

Hypervigilant, overly concerned about being harmed and exploited and criticises.  hardly trust physicians blame others for their illness.

 

·  Superior and Special individual:

Behave as VIP , grandiose , snobbish and arrogance , proud of themselves and seek most emollient physicians.

 

·  Aloof and Seclusive individuals:

Shy, remote and detached. They postpone the time to meet the physician alone.  Respect their privacy and don’t too much intrude if they don’t like to.

 

 

 

 

·  Impulsive:

low frustration threshold and unable to delay gratification , they demand immediate relief of symptoms and act out aggressively.  They may throw things of the physicians.

 

 

 

The patient may view the illness as

 

·  A challenge

 

·  Inherent weakness

 

·  Threaten for destruction

 

·  Punishment

 

·  Strategy to cope with life demands.

 

·  Relief from societal responsibilities

 

·  Irreparable damage

 

·  Positive Experience in the appreciation of the meaning of life and provides atheistic values.

 

 

 

This reflects both personality types and patient view about illness .

Cognitive responses to illness:

Minimization:

Tends to ignore, deny, and rationalize significance of illness up to delusional denial of illness.

Vigilant focusing:

Brisk response to perceived danger signals.  Anxious rumination and exaggerations.

Behavioral Responses to Illness:

·  Tackling:

active attitude towards challenge of illness .  He uses the damaged part of his body as if it is present and in its optimum function.

·  Capitulation:

Passivity i.e. fully give up.

·  Avoidance:

flights into health and escape from sinking  i.e. mixed from both above.

 

 

 

¨ SOCIETAL EXPECTATIONS:

5 key aspects to the physician ‘s role:

1-  Technical competence:

High updated and technical skilled also  knowledgable.

2- Medical Role:

Universalism, the physician is liable to treat any patient even his enemy.

3- Functional Specificity:

Specificity of competence ( he chooses what he specifically skilled to do )

Specificity of scope of concern ( Skills and knowledge  is only directed to medical care).

4- Affective neutrality:

Treat equally.

5- Collectively oriented:

Aware by things going on..

 

 

¨ PATIENT’S EXPECTATIONS:

 

The doctor    1- Reliefs from the distress regardless of illness.

2- An unhurried setting and atmosphere.

3- Available  ” MY DOCTOR”

 

¨ PHYSICIAN EXPECTATIONS:

 

The patient perceived as good  when he fulfill  5

1- Suffering by his symptoms.

2- Presents objective symptoms and signs of treatable disease.

3-Cooperates in treatment processes .

4- No emotional demands on  the physicians.

5- Appreciating efforts.

The patient is perceived as bad or blamed if one of the previous 5 is not fulfilled.

the problems created mainly by the physician  due to  ineffective communication or deficient technical skills , knowledge and judgment.

 

 

 

 

I-  ACTIVITY – PASSIVITY:

The prototype is that infant parent relationship

The task is to define the illness.

The role – the physician is sufficient and the patient has no role .

The physician gratifies his own needs for technical skills

Clinical Applications: as in delirium, comatosed, anaesthesia and immobilized.

 

II- GUIDANCE-COOPERATION:

In most current medical practice.

The task is to define illness and prescribe ttt

The doctor is responsible and the patient helps.

The doctor is fully licensed to design .

The physician satisfies his needs of nurturing, protect and restore.

Clinical Applications: as in infections and convulsence.

 

III- MUTUAL PARTICIPATION MODEL:

This is a model of 2 adults interacting for business purposes.

It provides the framework for illness and ttt , the patients view integrated with the physician.

The physician is professional specialist with skills , the patient is perceived as expert and concerned.

The physician leads but not order, the patient monitor and participate.

It fulfils needs for discovery , and mastery over anxiety.

Clinical Applications as in cases of D.M and D.S.

 

IV-SOCIAL INTIMACY :

2  close friends

 

STRESSES ON THE PATIENT – PHYSICIAN RELATIONSHIP:

I- DIFFICULT PATIENTS:

The difficult patient is the one who raises problems in relationship.

1-Covertly self destructive:

covertly suicidal, defeat the physician attempts to save lives

endanger a sense of futility in the physician who may act with overt anger or covert wishes that the patient would die.

Exampified by those with severe emphysema and continuous smoking

2-Uncooperative patient:

question treatment.

Refuse testing and treatment

Request another opinion

Demands that hospital make concessions to their needs

don’t get well

 

3- Somatizing patient:

Have a long standing recurrent physical  c/os  without significant underlying disease or physiological abnormalities.

Psychologically their symptoms are stemmed to serve them!!  How?

 

Intrapsychic conflict: The alteration of guilt through suffering secondary                                            to chronic pain.

Problematic Interpersonal relationship: Refusal of sexual relations                                           because of recurrent headache.

Social or Environmental Problems:  Not returning to unpleasant jobs                                       because of continuing symptoms stemming from work related                                        troubles.

The difficult patients are perceived by physicians as not truly patients on scientific bases , so they lead to physicians’ frustration and anger.  They are seeking with their physicians a key source  of the respect, affection, concerns sympathy and love that they are not getting from parents, spouses , children or close friends .  They are somatoform disorders

Somatization disorder

Conversion disorder

Hypochondriasis

Psychogenic pain disorder

Factious disorder

Malingering.

4-patients with chronic Cognitive Impairment ( Chronic Organic Brain Syndrome):

Those are uncooperative , negativistic and fail to perform mental state examination.

Those patients may be dehumanized.

 

5-Physicians as patients:

induces more stress .

They choose physicians with whom they may not lose equality.

custom issue

treating physicians may be reluctant to ttt physicians

treating physician may fear criticism of his knowledge.

 

 

DIFFICULT CLINICAL ISSUES:

 

1-PAIN:

development of rapport and trust between the patient  in pain and physician may be impeded due to

Underprescribing as the physician fear to turn the patient to an addict

If it is not functional may not take attention, respect, interest and reacts with resentment, anxiety .

 

2-DYING:

Helping this patient to accommodate to death , the physician usually avoid, the physician may uncomfortably about informing the patient .

 

3- The patient with CONSENT

The informed consent refers to patient right to choose .

 

4-SEXUALITY;

Physician fear asking about sex aspects so he leaves unclosed data.

 

TRANSFERENCE AND COUNTERTRANSFERENCE:

 

I- TRANSFERENCE:

Unconscious projection presents feelings about attitudes linked to important people in the patient ‘s early life ( Parents and siblings )onto someone  ( the physician).  When intense it introduces distortion that interfere with effective working alliance between physician and patients.

Patient may reactivate an infantile need for none demanding gratifying omnipotent parent.

Repressed negative feelings

Negative transference reactions(hostility, suspiciousness, and competitiveness).

 

II- COUNTERTRANSFERENCE:

Physicians misperception of and inapporpiate  behaviour toward patient. stemmed from unconscious emotional determined responses  ( Unconfident doctor since childhood, thinks that all patients are revising him;  doctor wants all patients love him and he seeks to do ultimate impossible help to them; doctor wants to alleviate the childhood pain …etc.

 

It is expected when?

the doctor has intense feelings ( anger, guilt, sexual attraction ) toward patient.

Feels drowsy, bored , unconcerned , unable to empathize, vulnerable to criticism from the patient.

becomes inattentive to the patient.

Argues  with the patient

Dreads from the patient visits.

Feels that the patient is unappreciating