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• Cover
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Foreword
• Preface to the third edition
• Preface to the second edition
• About this book
• About the authors
• Acknowledgements
• Dedication
• Introduction
• An evidence-based approach
• A skills-based approach
• A unified approach throughout undergraduate, residency and continuing medical education
• A unified approach to communication skills teaching in specialist and family medicine
• A unified approach to communication skills teaching on both sides of the Atlantic and beyond
• Who is the intended audience for this book?
• Learners at all levels of medical education
• Facilitators and programme directors
• Medical education administrators, funding agencies and medical politicians
• How have we addressed style issues in a book intended for the European, North American and wider international market?
• 1 Defining what to teach and learn: an overview of the communication skills curriculum
• Introduction
• More effective consultations
• Improved health outcomes
• A collaborative partnership
• Plan of chapter
• Types of communication skills and how they interrelate
• Example 1
• Example 2
• Example 3
• The problem of separating content and process skills in teaching and learning about the medical interview
• Confusion over process
• Confusion over content
• Marrying content and process
• An overall curriculum of doctor–patient communication skills
• The Calgary–Cambridge Guide (as presented in the 1998 editions of our companion books)
• The enhanced Calgary–Cambridge Guides*
• Three diagrams: the framework of the enhanced Calgary–Cambridge Guides
• The basic framework
• The expanded framework
• An example of the interrelationship between content and process
• Calgary–Cambridge Guides: communication process skills
• CALGARY–CAMBRIDGE GUIDES COMMUNICATION PROCESS SKILLS
• Initiating the session
• Preparation
• Establishing initial rapport
• Identifying the reason(s) for the consultation
• Gathering information
• Exploration of patient’s problems
• Additional skills for understanding the patient’s perspective
• Providing structure to the consultation
• Making organisation overt
• Attending to flow
• Building relationship
• Using appropriate non-verbal behaviour
• Developing rapport
• Involving the patient
• Explanation and planning
• Providing the correct amount and type of information
• Aiding accurate recall and understanding
• Achieving a shared understanding: incorporating the patient’s perspective
• Planning: shared decision making
• Closing the session
• Forward planning
• Ensuring appropriate point of closure
• Options in explanation and planning (includes content and process skills)
• If discussing opinion and significance of problem
• If negotiating mutual plan of action
• If discussing investigations and procedures
• Calgary–Cambridge Guides: communication content
• The need for a clear overall structure
• Choosing the process skills to include in the communication curriculum
• The research and theoretical basis that validates the inclusion of each individual skill
• Underlying goals and principles of communication that helped in choosing the skills
• Skills and individuality
• Relating specific issues to core communication skills
• Summary
• 2 Initiating the session
• Introduction
• Problems in communication
• Objectives
• Skills
• ‘What’ to teach and learn about the initiation: the evidence for the skills
• PREPARATION
• ESTABLISHING INITIAL RAPPORT
• Greeting the patient and introducing yourself
• Clarifying your role and the nature of the interview
• Obtaining the patient’s name
• Demonstrating interest and respect, attending to the patient’s physical comfort
• IDENTIFYING THE REASON(S) FOR THE CONSULTATION
• The opening question
• New consultations
• Follow-up visits
• Listening to the patient’s opening statement
• Learning how to listen at the beginning of the consultation is the first step to an efficient and accurate consultation
• Listening rather than questioning allows doctors and patients to achieve more of their objectives for this part of the consultation
• What is the evidence to support listening?
• What are the specific skills of attentive listening?
• What are the advantages of attentive listening?
• Screening
• The balance between listening and screening
• Agenda setting
• Summary
• 3 Gathering information
• Introduction
• Problems in communication
• Objectives
• The content of information gathering in medical interviews
• The traditional medical history
• Origins of the traditional method
• Strengths
• Weaknesses
• The disease–illness model
• Definition of disease and illness
• Why doctors need to explore both perspectives
• An alternative template for the content of the information-gathering section of the interview
• The biomedical perspective
• The patient’s perspective
• Background information: context
• The process skills of information gathering
• Exploration of the Patient’s Problems
• Questioning techniques
• What are open and closed questions?
• When should we use open and closed methods: the open-to-closed cone
• What are the advantages of open questioning techniques?
• Why is it important to move from open to closed questioning techniques?
• What is the evidence for the value of open and closed questioning techniques?
• Eliciting the patient’s narrative
• Attentive listening
• Facilitative response
• Encouragement
• Use of silence
• Repetition or echoing
• Paraphrasing
• Sharing your thoughts
• What is the theoretical evidence for facilitation?
• Picking up verbal and non-verbal cues
• Clarification of the patient’s story
• Internal summary
• Accuracy
• Facilitation
• Language
• Additional Skills for Understanding the Patient’s Perspective
• What is the evidence to support exploring the patient’s perspective of their illness?
• Anthropological and cross-cultural studies
• Outcome studies
• Satisfaction and compliance studies
• Understanding and recall studies
• Are patient-centred interviews longer?
• How to discover the patient’s perspective
• Picking up and checking out cues
• Asking specifically about the patient’s illness perspective
• Feelings
• Effect on life
• Putting The Process Skills of Information Gathering together
• The continuum of open to closed questioning techniques
• The complete versus the focused history in information gathering
• The effect of clinical reasoning on the process of information gathering
• More advanced hypothetico-deductive reasoning
• Schema-driven approach
• Pattern recognition
• How do these different clinical reasoning approaches influence the process of information gathering?
• Summary
• 4 Providing structure to the interview
• Introduction
• Objectives
• Skills
• ‘What’ to teach and learn about providing structure: the evidence for the skills
• Making Organisation Overt
• Summarising
• What is summarising?
• Why is internal summary a key skill in structuring the consultation?
• What is the evidence for the value of summarising in the medical interview?
• Signposting
• What is signposting?
• Attending to Flow
• Sequencing
• Timing
• Summary
• 5 Building the relationship
• Introduction
• Problems in communication
• Objectives
• Skills
• ‘What’ to teach and learn about building the relationship: the evidence for the skills
• Using Appropriate Non-Verbal Communication
• What is the difference between verbal and non-verbal communication?
• Why understanding non-verbal communication can make a difference in the consultation
• What is the research evidence that non-verbal communication makes a difference to the consultation?
• What then are the lessons for physicians?
• Reading the non-verbal cues of patients
• Transmitting your own non-verbal cues
• Use of notes and computers
• Developing Rapport
• Acceptance
• The accepting response
• Functions of the accepting response
• Skills of the accepting response
• Responding to overt feelings and emotions
• Responding to indirectly expressed feelings and emotions
• Acceptance is not agreement
• The problem of premature reassurance
• Empathy
• Understanding the patient’s predicament and feelings
• Communicating empathy to the patient
• Support
• What is the research evidence that rapport-building skills make a difference to the medical consultation?
• Involving the Patient
• Sharing of thoughts
• Providing rationale
• Summary
• 6 Explanation and planning
• Introduction
• Problems in communication
• Are there problems with the amount of information that doctors give?
• Are there problems with the type of information that doctors give?
• Can patients understand the language that doctors use?
• Do patients recall and understand the information that we give?
• Are patients involved in decision making and to the level that they would wish?
• Do patients comply or adhere to the plans that we make?
• Are there problems in the teaching and learning of explanation and planning in medical education?
• Are these problems improving with time?
• How does all of this relate to the growing field of health literacy?
• Objectives
• The content of explanation and planning
• The process skills of explanation and planning
• Communication process skills: the evidence
• Providing the Correct Amount and Type of Information
• Do patients and doctors disagree over the amount of information that should be imparted?
• The traditional view of the doctor–patient relationship
• An unbridgeable competence gap
• The emotional nature of illness
• Professional authority
• Why has modern research been misinterpreted as confirming the traditional stereotype of information giving?
• Early studies of recall of information
• More recent studies
• Confirmation of prejudices
• What recent trends in society have influenced medical information giving?
• Changes in society
• Changes in medicine
• Patient autonomy
• What is the research evidence to suggest that giving more information is helpful?
• Do all patients want more information?
• What skills can learners use to help gauge the correct amount and type of information to give to each individual patient?
• Chunking and checking
• Assessing the patient’s starting point
• Asking patients what other information would be helpful
• Giving explanation at appropriate times
• Aiding Accurate Recall and Understanding
• Ley’s research into patient recall
• Categorisation: an example of signposting
• Labelling important information: another example of signposting
• Chunking and checking
• Repetition
• Language
• Making explanations or advice specific enough for the patient to understand or act upon
• Using visual methods of conveying information
• Achieving a Shared Understanding – Incorporating the Patient’s Perspective
• Tuckett and colleagues’ research into patient understanding
• The methodology of Tuckett and colleagues
• What does the research of Tuckett and colleagues show about the information given by doctors?
• What does the research of Tuckett and his colleagues show about the influence patients can have on their doctors’ information giving?
• What are the combined effects of patients’ and doctors’ approaches to patient involvement in information giving?
• Can doctors and patients more positively influence each other towards a shared understanding in information giving?
• Does the research of Tuckett et al. about recall fit in with previous work?
• Was correct sense made of the explanations?
• Were patients committed to the doctor’s view?
• What are the main conclusions of Tuckett and colleagues?
• Other work to support shared understanding
• What skills can we recommend to help learners achieve a shared understanding with their patients?
• Relating explanations to the patient’s perspective
• Providing opportunities and encouraging the patient to contribute
• Picking up verbal and non-verbal cues
• Eliciting the patient’s beliefs, reactions and concerns
• Planning – Shared Decision Making
• Theoretical concepts behind shared decision making
• The mutuality model
• The shared decision-making model
• From compliance to concordance
• The research evidence to support shared decision making
• Do all patients want to be involved in shared decision making?
• What skills can we recommend to learners to help them achieve shared decision making in planning?
• Sharing own thinking as appropriate: ideas, thought processes and dilemmas
• Involving the patient
• Offering suggestions and choices rather than directives
• Encouraging the patient to contribute their ideas and suggestions
• Exploring management options with the patient
• Risk communication
• Decision aids
• Establishing the level of involvement the patient wishes
• Negotiating a mutually acceptable plan
• Signposting position of equipoise or own preferences
• Establishing the patient’s preferences
• Negotiating differences
• Checking with the patient
• Options in Explanation and Planning
• If offering opinion and discussing significance of problems
• If negotiating a mutual plan of action
• Discussing and offering options in management and treatment
• Providing information on action or treatment offered
• Obtaining the patient’s view of need for action, perceived benefits, barriers and motivation
• Motivational interviewing
• Accepting patient’s views and advocating an alternative viewpoint as necessary
• Challenging and confronting patients
• If discussing investigations and procedures
• Summary: explanation and planning is an interactive process
• 7 Closing the session
• Introduction
• Objectives
• The process skills for closing the session
• ‘What’ to teach and learn about endings: the evidence for the skills
• What actually happens in the closing section of the interview?
• What behaviours earlier in the visit prevent new problems from arising during closure?
• What communication skills can we recommend in the earlier sections of the consultation that will aid efficient and satisfactory closure of the session?
• What behaviours during closure are associated with inefficient endings?
• What are the specific elements of closure itself (see Box 7.1)?
• Forward planning
• Contracting
• Safety-netting
• Ensuring appropriate point of closure
• End summary
• Final checking
• Summary
• 8 Relating specific issues to core communication skills
• Introduction
• Specific issues
• Breaking bad news
• Key skills of the Calgary–Cambridge Guides to apply with greater depth, intention and intensity
• Cultural and social diversity
• Common issues and barriers in cross-cultural communication and social diversity
• Key skills of the Calgary–Cambridge Guides that need applying with greater depth, intention and intensity
• Age-related issues
• Communicating with older patients
• Key skills of the Calgary–Cambridge Guides to apply with greater depth, intention and intensity
• Communicating with children and parents
• Key skills of the Calgary–Cambridge Guides that need applying with greater depth, intention and intensity
• The telephone interview
• Key skills of the Calgary–Cambridge Guides that need applying with greater depth, intention and intensity
• Patients with mental illness
• Uncovering hidden depression and assessing suicidal risk
• Key skills of the Calgary–Cambridge Guides that need applying with greater depth, intention and intensity
• The psychotic patient
• Key skills of the Calgary–Cambridge Guides that need applying with greater depth, intention and intensity
• Examples of specific phrasing
• The open-to-closed cone
• Empathy without collusion
• Combining advocacy and support with challenge
• Gathering information from others
• Interviewing the older patient with mental illness
• Medically unexplained symptoms
• Other communication issues
• Further reading
• References
• Index
• Author index