Communication Skills

Guide
Family Medicine Clerkship
(MEDC4302)

By

Shastri Motilal
Lecturer in Family Medicine
MBBS. Hons, DM
 Agenda
Outlines
Breaking Bad news
Chronic Disease Counseling
Smoking Cessation/Behaviour Change
Informed Consent
Patient Centeredness
HIV pre-test counseling
Important Dos and Donts
 Breaking Bad News - SPIKES
Protocol
Setting
Introductions
Establish reason for visit (brief history)
Perception
Ensures pt. comfortable and how pt. has
been since last visit
Asks if pt. is alone or would like someone
present
Finds out what pt. knows already and
elicits fears/concerns
 Breaking Bad News - SPIKES
Protocol
Invitation
Informs pt. you would like to give news and find
out if they would like to know all details
Knowledge
MUST GIVE WARNING SHOT (indicates results are
serious or not what we would have hoped for)
Gives bad news in simple understandable
language
Use of silence to allow patient to assimilate info
Gives info in small chunks
Checks to see if pt understood what was said
AVOID giving false reassurances
 Breaking Bad News - SPIKES
Protocol
Explore emotions
Respond to pt. emotions and show empathy
(I can see you are upset, shocked or
worried. I know this must be difficult)
Give pt. time to express feelings
Strategy and Summary
Come up with plan of action. The next step
would be
Asks pt if any clarification is needed
Offer personal support (I am here to help
youyou can always contact me at.)
Plan follow up visit (I will like to see you
 Counseling a Chronic Disease (CD)
Patient
Introductions
Clarifies reason for visit
Explore Disease
Past Med Hx - How long have you had CD? Any
other conditions?
Drug Hx Names of medications AND compliance. If
pt. non-compliant explore why
Fam Hx Has anyone suffered from CD its
complications or any other condition
Social Hx Must asks about smoking, alcohol, diet
and exercise! (Do you exercise? If no why? Do you
smoke? Do you drink alcohol? Tell me about your
diet.)
 Counseling a Chronic Disease (CD)
Patient
Explore Illness (FIFE)
Feeling How do you feel about having
this CD?
Ideas So what do you understand by
CD?
Function Has this affected your daily
life? (work, home) If so how?
Expectation
Answers Whatmust
to above do you
bethink we
should do? and appropriate
personalized
 Counseling a Chronic Disease (CD)
Patient
Mutual and realistic decision making
We can look at ways to improve your
compliance by.
We can improve your diet by.
Would you be willing to start some
exercise? Maybe you can.
If the medicine is giving you side effects
we can consider changing it to..
I value you feedback on how we can help
you. What do you think about this plan?
Would you be wiling to try
Counseling a Chronic Disease (CD)
Patient
Summarize
Tell me what did you understand from
our talk today?. any other questions
or anything youre unsure about?
I would like to see you back on..to
review..
 Smoking cessation/behaviour
change 5As and 5Rs
Introduction and reason for visit
Ask How long have you been smoking?
What do you smoke? When do you
smoke? Have you ever tried to quit? What
happened?
Advise As your doctor I must advise you
that smoking is bad for your health and
you should try to quit as soon as possible
Assess-Are you willing to quit anytime
soon? If so do you have a date in mind?
 Smoking cessation/behaviour
change 5As and 5Rs
Assist
Pick a quit date
Inform everyone that you would be quitting
Get a partner in quitting
Get rid of smoking reminders from environment
Substitute smoking with a positive behaviour eg.
Exercise, chewing gum
Avoid situations that would encourage smoking
Discuss use of medications that may help quit
smoking (nicotine replacement, varenicline,
buproprion)
Arrange Summarizes and plans next visit date.
Promises personal support
 Smoking cessation/behaviour
change 5As and 5Rs
Relevance You have this condition which
smoking would make worse. All the more
reason to stop.
Risks In addition to above smoking is also bad
because it may cause.infections, cancer,
heart disease, etc it affects every organ in the
body
Rewards If you were to stop smoking, you
would save money, be able to smell/taste food
better, breathe better, be a role model, live
longer
 Smoking cessation/behaviour
change 5As and 5Rs
Roadblocks So the last time you
tried to quit what were the
roadblocks? Withdrawal symptoms?
Felt depressed? Unable to cope?
Friends encouraged you to restart?
Repetition Summarize. So what
you understand from our talk today?
I would like to see you again to see
how things are going on.
 Informed Consent
Introduction and clarify reason for
visit.
Diagnosis What is the condition
name and what it is (simple terms) or
What is the name of the planned
prodecure
Details of the procedure. How is it
done?
Benefits
Risks State most common and least
 Informed Consent
Alternative procedures Is there any
thing else we can do for this
condition? What are my treatment
options?
Refusal If you were not to have the
procedure done what would be the
consequences
 HIV Pretest Counseling
Introduction and clarifies reason for visit
Introductory information about the
antibody test
Information about AIDS and HIV infection
Exploration of motivations for being tested
Risk factors
The significance of a positive test
The significance of a negative test
 HIV Pretest Counseling
Exploration of the potential psychosocial
ramifications of testing positive
Discussion about confidentiality and
testing procedures
Education about AIDS prevention, risk
reduction (personalized advice) and
coping strategies
Consent to be tested
Summarize and Follow up
Ground Rules
 Dos
Always introduce yourself
Good day, I am Dr.______, Would it be
okay if I spoke to you today?
What is your name? How old are you?
Are you employed?

Always clarify reason for visit.

So why did you come to see us today?
 Dos
Always be patient centered
Explore Illness (FIFE)
Feeling How do you feel about.. ?
Ideas Acknowledge patients ideas and
opinions
Function Has this affected your daily life?
(work, home) If so how?
Expectation What do you think we should
do?
Entertain pts opinion on next step
Listen
 Dos
Use open ended questions (good for building
rapport)
So tell me more about that pain.
What do you understand by.

Use close ended questions to get specific

information (usually to get yes/no responses to
seek clarification)
Do you do any kind of exercise?
Have you ever suffered from a heart attack or stroke
Does the chest pain move down the left arm, neck or
shoulder?
 Dos
Use signposting to add direction to your
consultation
In order to help you today I would like to
ask you some questions that may appear to
be very personal? Is that okay?...... Are you
sexually active? How many sexual partners
have you had within the past year?
I would like to find out a bit more about
some lifestyle factors..do you smoke/drink
alcohol? Do you exercise?
 Dos
Always Summarize
Firstly summarize what the patient has said
Okay so far you explained you came today
because you had this chest pain that started 3
days ago, 7/10 in severity, not radiating
anywhere and relieved sometimes by
antacids..
Secondly ask patient to summarize at end
of consultation
Okay so tell me what you understood today
from what we just spoke about.
 Dont
Avoid giving the pt a lecture.
Counseling is a two way process
Involve patient in the process
Give personalized relevant advice
Example
You would not advise a hypertensive patient
who has never smoked to do not smoke
You would not tell a patient they must eat fruits
and vegetable everyday and observe a low salt
diet without first asking what is your diet like?
 Dont
Dont speak uninterruptedly. Give patient
chance
Dont interrupt patients when they speak
Dont use your cellphone or electronic
devices in the middle of your consultations
Dont use medical jargon that patients
cannot understand.
Dont tell patient they must or have to
do anything
 Thank you
Questions?