Communication Skills for

Medical Interview

Dr. I Putu Adiartha Griadhi, M.Fis.

 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 patient’s complaints are not elicited,
and 45 % patient’s 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 patient’s 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??
What is the disease ??
Communicate

“Can you describe

the pain ?”
‘I can see that you
have been very upset
by her behavior’

Feel
“I understand her
problems”
“I can see the
dificulties”
Broad types of communication skills

We Think…
CONTENT SKILLS What doctors communicate –
the substance of their
How they do it – the ways questioning and response
they communicate with
patient; how they discover
the history; verbal and non
verbal skills they use; how
PROCESS SKILLS
they develop relationship
with patient; the way they
organize and structure What they are thinking and
communication feeling – their internal decision
We Talk… making, awareness

PERCEPTUAL SKILLS
We Feel…
 We learn 3 type of skills
CONTENT SKILLS
• We learn to ask apropriate questions and responses
based on the main complaint
• We learn to organize patient’s 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
 We learn 3 type of skills
PROCESS SKILLS
We communicate to the patient, avoide to become ‘a talk-
able checklist’
We learn to understand patient’s perspectives (illness)
We learn to give explanation and planning to the patient

PATIENT CENTERED INTERVIEW

 The Nature of Interview

INTERVIEWING STEP
1. Initiating the session
Interview should have a
logical sequence based on 2. Gathering
five basic task information
3. Building the
Five-point plan
relationship
4. Explanation and
planning
5. Closing the session
Five basic tasks
Breaking the barier, enough
information, good relationship, clear
instruction and explanation.
 Patient Centered Interview
Expanded framework
Five basic tasks
1. Initiating the session
Five-point plan a. Establishing initial rapport
b. Identifying the reason (s)
2. Gathering information

3. Building Relationship
a. Exploration of problems
1. Initiating the
b. Understanding patient’s
session perspective
2. Gathering c. Providing structure to the
information consultation
3. Building the relationship
4. Explanation and a. Developing rapport
planning b. Involving the patient
5. Closing the 4. Explanation and planning
session 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, I’m dr. Jones. Do come and sit down”
• CLARIFYING YOUR ROLE :
“Hello, my name is Catherine. I’m a student doctor working with dr. Ko. I’’m
learning how to interview patients. We might spend 15 minutes for this
interview. Would that still be alright?”
• OBTAIN Px/ NAME :
“Hello, I’m dr. Jones. Do come and sit down. Can I just check – is it Mrs.
Mary? [pause] I don’t think we’ve 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 you’ve been getting headache and dizziness lately. Has anything
else been bothering you ?”
If the patient continues….
“So you’ve 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, you’ve 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 wouldn’t mind checking on your blood
pressure later on, if that’s all right’
Problem with time
‘I’m not sure that we have enough time to do it all. How about…’
 Gathering information
Exploration of problems
Understanding patient’s perspective
Providing structure to the consultation

Exploration of problems
1. STARTING THE PATIENT OFF :
Open ended question
‘Tell me about your headache?’
Patient’s 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 patient’s 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 patient’s perspective
Providing structure to the consultation

5. CLARIFICATION OF PATIENT’S 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 I’ve 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 patient’s 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 patient’s perspective
Providing structure to the consultation

Understanding patient’s perspective

IDENTIFICATION : discover and listen to the patient’s ideas,

concern and expectations
ACCEPTANCE : acknowledge the patient’s views and right to
hold them, without necessarily agreeing with them
EXPLANATION : explain your understanding of the problem in
relation to the patient’s understanding and reach mutually
understood common ground
 Gathering information
Exploration of problems
Understanding patient’s perspective
Providing structure to the consultation

How to understand patient’s perspective

1. PICKING UP AND CHECKING OUT CUES

‘I sense that you’re not quite happy. Is that right?’
2. ASKING SPECIFICALLY ABOUT PATIENT’S 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
patient’s life.
 Gathering information
Exploration of problems
Understanding patient’s 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 patient’s story
‘Can I just see if I’ve 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 haven’t 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 : ‘
You’re 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 I’m 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 don’t 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
‘Ah…despite 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 I
examined your daughter.’
 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 PATIENT’S 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 we’ll see you in two months and see
how well you’re 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

 CHECK LIST PENILAIAN
STATION 1 // W aktu : 5 menit // Anamnesa THT
Nama Mahasiswa :................................. Paralel : ...........
NIM :................................. Putaran :...........

Instruksi: Berikan tanda √ pada kolom Check BILA mahasiswa melakukannya !

Che Bo- Sco Che Bo- Sco

No Item Observed No Item Observed
ck bot re ck bot re
1 Memulai wawancara 6 Keluhan Utama
(10)  Menyapa pasien ..... 0,5 ..... (5) teridentifikasi
 Menjelaskan diri siapa ..... 1 .....  Bersin-bersin ..... 5 .....
 Menanyakan nama pasien ..... 1 .....
 Menunjukkan perhatian ..... 0,5 .....
Identifikasi problem pasien 7 Riwayat Penyakit Sekarang
 Pertanyaan pembuka openQ ..... 2 ..... (16)  Sejak 3 bulan lalu ….. 2 …..
 Mendengarkan pasien ..... 1 .....  Hidung ….. 1 …..
 SKRINING problem px/ ..... 3 .....  > 5 x paroxismal ….. 2 …..
 Menentukan agenda ax/ ..... 1 .....  Setiap hari, selama 3 ….. 2 …..
2 Menggali Informasi bulan
(23)  Meminta pasien bercerita ..... 5 .....  Saat bersih2 kamar ….. 2 …..
 Mendengarkan px/ ..... 4 .....  Bersih2 – tambah berat, ….. 3 …..
 Respon aktif thd px/ ..... 3 ..... istirahat – ringan
 Open question dahulu ..... 3 .....  Tersumbat, rinore, ….. 4 …..
 Closed question kemudian ..... 2 ..... gatal, batuk kering,
gangguan aktivitas
harian
 Pengaruh penyakit thd ..... 2 ..... 8 Riwayat Penyakit terdahulu
kehidupan (10)  Keluhan yang sama ….. 3 …..
 Penyimpulan2 ..... 2 ..... sebelumnya
 Beri tanda pindah topik ..... 2 .....  Riwayat alergi makanan ….. 4 …..
3 Membangun Hubungan Baik  Riwayat Asma ….. 3 …..
(10)  Penerimaan ..... 2 .....
 Empati ..... 2 .....
 Dukungan ..... 2 .....
 Membagi pengetahuan ..... 2 ..... 9 Riwayat Penyakit dalam
 Memberikan alasan ..... 2 ..... (15) keluarga
4 Explanation and planning  Anggota keluarga dg ….. 5 …..
(5)  TANYA pengetahuan px/ ..... 1 ..... sakit sama
 Jmlh dan jenis info TEPAT ..... 1 .....  Riwayat alergi ….. 5 …..
 Info tersusun dengan baik ..... 1 .....  Riwayat asma ….. 5 …..
 Bahasa sederhana ..... 1 .....
 Memastikan pasien ..... 1 .....
mengerti dg bertanya
5 Mengakhiri wawancara 10 Riwayat pengobatan
(2)  Memberi penyimpulan ..... 1 ..... (4)  Tidak berobat ke dokter ….. 2 …..
 Perjanjian tentang langkah ..... 1 .....  Konsumsi obat-obat ….. 2 …..
selanjutnya bebas

(√)Global Rating Score. Terlepas dari nilai, KESAN ANDA mahasiswa ini □LULUS □GAGAL

Nilai = (-------- +--------) x 100 = ............. Observer : (..........................................)

50 50
 CHECK LIST PENILAIAN
STATION 2 // Waktu : 5 menit // KIE Pasien
Nama Mahasiswa :................................. Paralel : ...........
NIM :................................. Putaran :...........

Instruksi: Berikan tanda √ pada kolom Check BILA mahasiswa melakukannya !

Bo- Sco Bo- Sco

No Item Observed Check No Item Observed Check
bot re bot re
1 Memulai wawancara 6 Faktor Risiko
 Menyapa pasien ..... 1 ..... teridentifikasi
 Menjelaskan diri siapa ..... 1 .....  Obese --- 5 ---
 Menanyakan nama pasien ..... 1 .....  Merokok …. 5 ….
 Menunjukkan perhatian ..... 1 .....
Identifikasi problem pasien 7 Penjelasan Penyakit
 Pertanyaan pembuka ..... 1 .....  Etiologi ..... 5 .....
 Mendengarkan pasien ..... 1 .....  Derajat Penyakit ..... 5 .....
 SKRINING problem px/ ..... 1 .....
 Menentukan agenda ax/ ..... 1 .....
2 Menggali Informasi 8 Penjelasan Terapi
 Meminta pasien bercerita ..... 2 .....  Modifikasi gaya ..... 10 .....
 Mendengarkan px/ ..... 1 ..... hidup : rokok,
 Respon aktif thd px/ ..... 1 ..... diet rendah
 Open question dahulu ..... 1 ..... garam, olahraga
 Closed question kemudian ..... 1 .....
 Pengaruh penyakit thd ..... 1 .....  Pengobatan ..... 10 .....
kehidupan teratur
 Penyimpulan2 ..... 1 ..... 9 Modify Risk Factor
 Beri tanda pindah topik ..... 1 .....  Hindari Rokok ..... 5 .....
3 Membangun Hubungan Baik  Mengatur berat ..... 5 .....
 Penerimaan ..... 2 ..... badan
 Empati ..... 3 .....
 Dukungan ..... 2 .....
 Membagi pengetahuan ..... 2 ..... 10 Prognosa ..... 5 .....
 Memberikan alasan ..... 2 .....
4 Explanation and planning
 TANYA pengetahuan px/ ..... 3 .....
 Jmlh dan jenis info TEPAT ..... 2 .....
 Info tersusun dengan baik ..... 3 .....
NILAI = --------- X 100 =
 Bahasa sederhana ..... 3 .....
100
 Memastikan pasien ..... 3 .....
mengerti dg bertanya
5 Mengakhiri wawancara Observer,
 Memberi penyimpulan ..... 2 .....
 Perjanjian tentang langkah ..... 1 .....
selanjutnya
(............................................)

(√)Global Rating Score, Terlepas dari nilai, KESAN ANDA mahasiswa ini □ LULUS □ GAGAL
Thank You !
Any question :
e-mail : adiarthagriadhi@gmail.com
Phone : 081999636899