2. Summarising skills
The best way of finding out if the doctor has found out the real reason for the patient attending is to periodically summarise the doctor's understanding of the reason for the patient's attendance.
What do we need to elicit?
When should you elicit?
What signals can the patient give that more information can
be elicited?
How should we elicit?
· ideas
· expectations
· concerns
· feelings
· effects of symptoms, treatment e.t.a.
Think!!
What does this problem mean to this person?
E.g.
How does a back strain affect a doctor, labourer, or a mother of three small children?
It is time to think of the folk model of why people come to see us:
· what has happened
· what has happened
· why has it happened to me
· why has it happened now
· what will happen if I do nothing about it
· what should I do about it
1. There may be points that you require clarifying
2. Act on your hunches
The patient may give signals that they have some more information for you:
a. May interrupt you
b. Patient may demonstrate speech censoring
c. The use of:
· Deletions
"It's no better" (What's no better)
"Something will have to be done" (What about whom)
· Distortions, turning actual behaviour and events into abstract concepts
" I feel a failure" (what have you failed and what feelings are you feeling)
· Generalisations
"I don't like hospitals" (all hospitals and why)
d. Patient may demonstrate features suggestive of internal speech
(1) Speak the patient's language!
(2) The patient is always right ( to start with)
Use the patient's statement to continue the dialogue in the direction the patient has chosen, but later change it in the direction you want
(3) The patient always goes first
Try and find out what the patient feels is going on.
Avoid
"what do you think is going on"
and try
" I have a few thoughts as to what might be going on, I imagine you have some, what are your ideas?"
(4) Explain why you are asking
So that the patient is clear what you are thinking of
(5) Don't interrupt internal speech
(6) Use open questions
Compare
"do you want an antibiotic?"
"Is there any treatment that you feel might help?"
" It is sometimes difficult to know whether an antibiotic will help here"
Try using conjecture.
"I was wondering whether……….."
My friend John
e.g. "I once had a patient who………."
(7) Encourage the patient to talk especially if censoring is going on
Use:
Echo. Echo back the last significant statement
Checking. Summarise what the patient has said so far and check if it is correct.