The Pearls of Communication, History Taking, and Physical Examination: The Road to Passing Clinical Examinations

By Mohamed Elbagir Khalafalla Ahmed

For doctors and medical students who wish to pass examinations, and above all, to gain competency in the practice of internal medicine, they must master the skills of communication, history taking, and physical examination.

However, in spite of the abundance of textbooks, very few of them offer practical information to improve these skills. Thus, this concise book offers the required up-to-date, detailed, and practical information that is needed to master communication, history taking, and physical examination.

Written by an experienced university academic and a senior examiner in a number of international examination boards, this book will greatly increase the chances of candidates to pass internal medicine exams. It simply gives students and doctors the passport for such success. Also, above all, it will provide enormous help to improve patient care, which is the ultimate goal in the practice of medicine.

• Language: English
• Publisher: Xlibris AU
• Release date: Feb 15, 2017
• ISBN: 9781524522292

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Copyright © 2017 by Mohamed-Elbagir Khalafalla Ahmed.

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Rev. date: 02/13/2017

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TABLE OF CONTENTS

Foreword

Acknowledgement

Chapter 1: Communication Skills and Ethics: Gaining Competency

Overview

How Effective Communication Makes a Good Doctor

Types of Communication

Important Steps of Effective Communnication

Protocols of Communication

Breaking Bad News

Summary Points

Dealing with Special Situations

References

Medical Ethics

Summary of How to Approach an Ethical Problem

Chapter 2: The Art of History Taking

Opening the Interview/Setting the Agenda

Setting the Stage

Common Mistakes During History Taking

Examples of History and Communication Stations

A Model for History Taking from Adult Patients

Chapter 3: The Art of Physical Examination

Common Mistakes

The Long Case

MRCP(UK) Part II Exam (PACES)

The OSCE (PACES) Clinical Stations

Remember the Causes of Clubbing

Then Examination of Specific Systems

1. The cardiovascular system

Hints for CVS Examination

The JVP and Carotids

Do the Hepatojugular Reflux (HJR) by applying gradual pressure below the right costal margin or mid abdomen if there is no tenderness, for up to a minute

Examination of the Arterial Pulses

Auscultation

Examination CVS Cases

Bacteria-Free Infective Endocarditis

Other CVS Problems

2. The Gastrointestinal System

General Considerations: for examination

Abdomen stations and short cases

Chronic Liver Disease

Liver Cirrhosis(Hepatitis B and C, Alcohol, Bilharzia) and Fibrosis

Examine hands (better after face)

Then examine abdomen

Causes of Hepatomegaly

Patient with distended abdomen(Ascites)

Quick brief notes: Summary

3. Examination of the Respiratory System

Examination for Pleural Effusion

Physical Signs of Collapse Compared to Fibrosis

Mixed Respiratory Conditions

Other Respiratory Examination Cases

Concise Summary of Some Respiratory Problems

4. Examination of the Central Nervous System

General Approach

Examples of Neurological Cases

Cranial Nerve Palsies

Cerebrovascular Accidents (CVAs)

Pseudobulbar vs Bulbar

Tips on how to perform CNS examination

Other Short Neurological Cases

A Patient with Multiple Sclerosis

Peripheral Nervous System

5. Rheumatology Problems at a Glance

Ankylosing Spondylitis

Rheumatoid Arthritis

Systemic Sclerosis / CREST

Systemic Lupus Erythematosis

Miscellanous Short Cases and Examples for PACES

Take home message:

DEDICATION

To all those who have strived to teach us the art of clinical medicine.

To the souls of the late Professor Daoud Mustafa Khlaid and the late Professor Siddig Ahmed Ismaeel and all who taught us over the years from whom I learned the highest quality bedside medicine and manners.

To our medical students everywhere and to our young colleagues and trainees who need such pearls to help them practice fine medicine and pass their examinations.

This book is dedicated.

Mohamed Elbagir Khalafalla Ahmed MBBS MD MRCP FRCP FACP FAATM

Professor of medicine, January 2017

FOREWORD

Optimal patient care necessitates that doctors should be competent in key educational areas, mainly communication skills, history taking, and performing through physical examination. Acquiring such fundamental skills needs perfect teaching and reading good books. Actually, there are few books that deal with these fundamental issues in detail; hence, I have compiled those in this text using relevant clinical information, practical examples, and examination tips. These will be a great help to both medical students and postgraduate candidates.

In general, doctors taking a postgraduate examination should have fulfilled the following:

(1) Completed an adequate period of training after graduation (at least four years).

(2) Have been well-supervised during the period of training according to a well-structured, postgraduate training programme.

(3) Have gained adequate clinical experience and competency so that they are able to elicit comprehensive medical history and perform thorough physical examination in a skillful manner.

(4) Are able to deliver emergency medical care, and most importantly, comprehensive patients management.

(5) To fulfill that, they should be able to effectively communicate with patients, hospital staff, and colleagues using the well-recognised communication skills and ethical approaches.

To achieve that, medical students and doctors in training need a guide and help. Besides formal teaching and major textbooks, this modest endeavour will greatly help students and doctors to prepare themselves for postgraduate exams (also undergraduate exams) in internal medicine, and above all, will also improve patient care during clinical practice.

Thus, this book offers practical help in simple format, which is written by an experienced academic and teacher with over thirty-five years of experience in the field of internal medicine teaching and examinations worldwide.

ACKNOWLEDGEMENT

I sincerely thank the following for their kind permission to quote some of the contents used in this book. I would also like to extend my thanks to all those who provided me with excellent material which I included in this book which is intended to improve the skills of our students & doctors.

1. Travaline, John M.

2. Tom Ferris. site; www.bppuniversity.ac.uk/medicalseries

3. [e-mail]

4. Matt Green, Teresa Parrott, Graham Crook.

5. Denise M. Dudzinski, PhD MTS

University of Washington. [e-mail].

6. [e-mail]. www.depts.washington.edu/bhdept.

7. Brusch JL. Infective Endocarditis. P 79, 82-83. Medscape Drugs & Diseases.

http://emedicine.medscape.com/article/216650-overview. Accessed Apr 6, 2016.

8. Shaffrey, Chris.

9. Mac master university, Canada:

CHAPTER 1

Communication Skills and Ethics: Gaining Competency

Overview

‘The patient will never care how much you know until they know how much you care.’

Effective doctor-patient communication is a central clinical function in building a therapeutic doctor-patient relationship, which is the heart and art of medicine. This is important in the delivery of high-quality health care. Much patient dissatisfaction and many complaints are due to breakdown in the doctor-patient relationship.

Patient-physician communication is an integral part of clinical practise. When done well, such communication produces a therapeutic effect for the patient, as has been validated in controlled studies. When doctors use communication skills effectively, both they and their patients benefit.

• Doctors identify their patients’ problems more accurately

• Their patients are more satisfied with their care and can better understand their problems, investigations, and treatment options.

• Patients are more likely to adhere to treatment, and to follow advice on behaviour change.

• Patients’ distress and their vulnerability to anxiety and depression are lessened.

• Doctors’ own well-being is improved

• Doctors are less likely to be sued and go to court

From obtaining the patient’s medical history to conveying a treatment plan, the physician’s relationship with his patient is built on effective communication. In these encounters, both verbal and non-verbal forms of communication constitute this essential feature of medical practise. Although much of the communication in these interactions necessarily involves informationsharing about diagnosis and therapy options, most physicians will recognise that these encounters also involve the patient’s search for a therapeutic relationship.

Physicians should become competent in five key communication skills:

1. Listening effectively

2. Eliciting information using effective questioning skills (e.g., history taking)

3. Providing information using effective explanatory skills

4. Counseling and educating patients

5. Making informed decisions based on patient information and preference

6. Breaking bad news

How Effective Communication Makes a Good Doctor

Listening Skills

A doctor who patiently listens, and who is much interested to address the concerns of the patients, will be highly rated by patients. This skill will make the patients trustand be closer to the doctor. Below are summaries of some of the expressions raised by patients about their doctors.

• My doctor attentively listens and does not ignore my feelings.

• The doctor I see is very encouragingand allows us to ask questions and request explanations.

• I felt that the doctor is very caring and gets to the bottom of my problem.

• We are lucky to have such a patient doctor who allows us to explain our problem without interruption.

The Partnership

It is a really a true quality when a doctor creates a sincere partnership with the patient by using listening skills, attending topatient’s concerns, and respecting thevalues of patients. This will facilitate the patients to openly discuss their concerns.

Also, allowing the patient to share opinions about the management of his disease is a top communication skill referred to as patient autonomy.

Other Qualities of a Good Communicator:

Has respect for her patient. Good doctors understand that a sick or injured patient is highly vulnerable. Being respectful goes a long way towards helping that patient.

Has the ability to share information in terms her patients can understand.

Doesn’t interrupt or stereotype her patients. It’s easy for all of us to interrupt when we know time is short or we are in a hurry, but a practitioner who is a good communicator knows that if it can’t be done right, to begin with, it will need to be done over.

Has the ability to effectively manage patients’ expectations. By helping the patient understand what the next steps will be, and what the possible outcomes and their ramifications might be.

A poor communicator will criticize, belittle, or disrespect the patient by saying:

‘You worry too much.’

‘You got upset over nothing.’

‘You’ve got to try to cooperate.’

‘I’d like you to be more responsible.’(Implies patient is irresponsible)

‘You’re just too lazy.’

Difficult Patients Situations in Medical Encounters

Silent patient

Rambling or talkative patient

Vague patient

Angry patient.

Depressed or sad patient

Denial

• Anxious patient

• Somatization

Types of Communication

A. Verbal: talking, using words. This is the most common.

B. Non-Verbal: very important. This includes:

a. Facial expression: smile, using lips, head nodding

b. Keeping eye contact but not gaze

c. Posture: bend to impress the other side

d. Distance: average, not too farand not too close

e. Touch: to comfort and to ease tension

Types of Questions Used in Communication:

1. Open-ended: Goodquestions that are answered by a statement, not answered by yes or no. Example:‘Tell me about the character of your pain.’

2. Closed questions: Not recommended, use minimally. ‘Do you have pain?Yes or No.’

3. Leading: You want the patient to answer what you have in mind. Do not use ‘your pain is stabbing, yes?’

4. Explanatory: Good. You request more information. ‘You say you are not feeling well. Tell me more about this.’

5. Compound or multiple: Not recommended. ‘Do you have pain, nausea, vomiting, or indigestion?’

Dealing with Emotions

This is a key communication skill. Doctors should sense and respond appropriately to patient concerns and emotions. This is achieved by:

Empathy: Sharing the patient feeling and providing support. It is caring, understanding, and supporting.

• Use empathy to communicate understanding and appreciation of the patient’s feelings or predicament, and overtly acknowledges patient’s views and feelings

• Provides support: expresses concern, understanding, and willingness to help; acknowledges coping efforts and appropriate self-care; offers partnerships

• Deals sensitively with embarrassing and disturbing topics and physical pain including when associated with physical examination

Barriers to Effective Communication

It is not always easy to communicate with patients for a number of reasons:

• Speech problems

• Spoken foreign language

• Time constraints on physician or patient

• Unavailability of physician or patient to meet face to face

• Altered mental state

• Psychologic or emotional distress

• Gender differences

• Racial or cultural differences

Communication and Patient Outcomes

Research on the effect of communication skills on patients has focused on three areas: patient satisfaction, patient concordance, and physiological outcomes. These three are, of course, closely connected. For example, the patient who has a clear understanding of the nature of their hypertension or diabetes and how to manage it, both through lifestyle and pharmacological means, is more likely to follow the recommended management plan accurately, resulting in better control. It has also been suggested that an effective doctor-patient relationship can be therapeutic in itself.

Patient Satisfaction

Patient satisfaction has been linked to a partnership relationship between doctor and patient where there is a human connection, and the doctor demonstrates empathy, a non-judgemental attitude, and warm non-verbal communication. A patient-centred approach, in which the patient’s perspective, including beliefs, fears, and expectations, is actively integrated into the consultation, and is also associated with increased satisfaction. A patient-centred approach leads to a greater understanding of the patient’s reasons for seeking help.

Researchers have identified that the single most powerful predictor of patient satisfaction is the amount of jargon-free information the patient receives on diagnosis, causes, prognosis, and possible treatments. Appropriately delivered and timely information helps patients to cope with the uncertainty of illness, and participate in the management of their illness.

Clinical competence also, not surprisingly, leads to patient satisfaction, although some studies have suggested patients are unable to objectively assess technical competence except in glaring examples, and tend to infer it from the doctor’s interpersonal skills. Paling suggests that patient trust is a function of perceived competence and caring.

Adherence

Non-concordance rates with prescribed medication have been estimated to be between 30–60per cent in a range of studies with the most significant determinants of concordance being the patients’ understanding of the illness, the rationale of the treatment, their understanding of the drug regimen, and their relationship with and trust in the doctor. Eliciting the patient’s knowledge, beliefs, and concerns about their illness also increases adherence to treatment regimens.

Symptom Relief and Physiological Outcomes

A number of different studies have demonstrated an association between doctor-patient communication and physiological measures such as:

• Resolution of chronic headache

• Post-surgical recovery and decreased length of hospitalisation

• Post-myocardial analgesia

• Blood pressure and blood sugar measurements

• Improved symptoms and function of patients with rheumatoid arthritis and peptic ulcer disease

• Perceived health status and daily functioning

• Duration of sore throat

• The possibility of improved survival rates from breast cancer

Important Steps of Effective Communnication

• Intiating the interview by making rapport with the patientThis is done by:

(a) greeting the patient;

(b) introducing yourself: mention your name and grade;

(c) secure patient comfort, privacy, and welfare;

(d) calling the patient by his/her pfeferred name.

• Using appropriate and clear language by avoiding the use of medical and scientific terms that are difficult for the patient to understand. Examples: Do not say the cancer has metastasized to the bone;better say ‘I am sorry that your tumour has spread to the bone.’

• Use body language that is non-verbal:

To be interested in the patient, maintain eye contact and do not be distracted by looking at the notes or the door. Frequently use facial expressions including smiling and head nodding. This will leave a positive impression on the patient.

• Discuss and agree on what you will be discussing with the patient (the agenda).

Mention to the patient what you will be discussing and ask him/her if they have anything to add.

Agreement:

Always summarise and agree with patient on what has been discussed. Make sure the patients accept the information, whether it is a diagnosis or a management plan. This will lead to improved patient complaince.

• Be open-minded and supportive:

Patients will feel comfortable and trust the doctor if the latter has a flexible and supportive attitude. Listen and listen so that you can grasp the feelings and concerns of the patient.

• Give informative account of the patient’s condition:

Avoid talking too much about details of diagnostic tools and drug therapy. Be practical and provide the necessary information that will make the patient reassure and well informed. Patients like the doctor who tells them about practical issues when it comes to drug therapy and its side effects. Explain to them whatthey do if anything go wrong. This will reduce stress and improves psychological status and hence improves the quality of life.

• Be honest, admit, and apologise when mistakes occur:

By doing so, patients will be in a better way not to sue you or your foundation.

The comments cause of litigation is ineffective communication. Thus, good communication and open discussion with apology will lessen the anger and concerns of the patients, and will decrease the chances of litigation.

• Use empathy and listening skills:

Again, I emphasise the importance of listening to the