Building the relationship. Occurs throughout the interview Occurs throughout the interview Important in Specialist medicine Important in Specialist medicine.

Building the Building the relationshiprelationship

Building the relationshipBuilding the relationship

Occurs throughout the interviewOccurs throughout the interview Important in Specialist medicineImportant in Specialist medicine Important in General PracticeImportant in General Practice Poorly developed in medical studentsPoorly developed in medical students Media reports of patient dissatisfactionMedia reports of patient dissatisfaction

What are the objectives that we seek to accomplish in building the relationshipwith the patient?

Other consultation Other consultation modelsmodels

Byrne and LongByrne and Long PendletonPendleton NeighbourNeighbour Cohen-ColeCohen-Cole Keller and CarrollKeller and Carroll

Skills for building the Skills for building the relationshiprelationship

Non-verbal communicationNon-verbal communication Developing rapportDeveloping rapport Involving the patientInvolving the patient

Non-verbal Non-verbal communicationcommunication

Demonstrates appropriate non-verbal Demonstrates appropriate non-verbal behaviourbehaviour

Uses notes in a manner that doesn’t Uses notes in a manner that doesn’t interfere with dialogue or rapportinterfere with dialogue or rapport

Picks up patient’s non-verbal cuesPicks up patient’s non-verbal cues

Developing rapportDeveloping rapport

Acceptance of patient’s views and Acceptance of patient’s views and feelingsfeelings

Empathy and supportEmpathy and support SensitivitySensitivity

Involving the patientInvolving the patient

Sharing of thoughtsSharing of thoughts Provides rationaleProvides rationale ExaminationExamination

Non-verbal and verbal Non-verbal and verbal communicationcommunication

Usually work together to re-inforce one Usually work together to re-inforce one anotheranother

Telephone consultationsTelephone consultations Evidence that non-verbal communication Evidence that non-verbal communication

can make a lot of differencecan make a lot of difference ““Healthy friction”Healthy friction”

Use of notesUse of notes

Patients withhold their initial reply until Patients withhold their initial reply until eye contact giveneye contact given

Patients pause when doctor looks at Patients pause when doctor looks at notesnotes

Patients use body movementPatients use body movement Fluency deterioratesFluency deteriorates Doctors miss informationDoctors miss information

Developing rapportDeveloping rapport

Accepting responseAccepting response Empathy and supportEmpathy and support SensitivitySensitivity

Accepting responseAccepting response

Accept non-judgementally what the Accept non-judgementally what the patient sayspatient says

Acknowledge legitimacy of patient to hold Acknowledge legitimacy of patient to hold their viewstheir views

Value patient’s contributionsValue patient’s contributions At the root of trustAt the root of trust

“I think that I might have cancer, doctor; I have been getting an awful lotof wind lately…..”

Skills of accepting Skills of accepting responseresponse

Acknowledge patient’s thought by Acknowledge patient’s thought by restating / summarizingrestating / summarizing

Show understandingShow understanding Use attentive silenceUse attentive silence Acknowledge value to youAcknowledge value to you

“I’m so angry with him. How could he have left me alone like that; he didn’t even make a will”

“So, you feel angry about being left alone and about the will. I can see that must be upsetting”

“Yes, I am. Then I feel guilty about being angry withhim. Am I going mad, doctor?”

I am glad you mentioned these strong emotionsto me. Let’s discuss things further.

Acceptance is not agreement

Identification

Acceptance

Explanation

Avoids premature reassurance

EmpathyEmpathy

Understanding and sensitive appreciation Understanding and sensitive appreciation of another person’s predicament or of another person’s predicament or feelingsfeelings

Communication of that understanding Communication of that understanding back to the patient in a supportive wayback to the patient in a supportive way

Understanding patient’sUnderstanding patient’spredicament and feelingspredicament and feelings

IntroductionIntroduction ClarifyingClarifying Attentive listeningAttentive listening FacilitationFacilitation EncouragingEncouraging Picking up cuesPicking up cues

SummarizingSummarizing AcceptanceAcceptance Non-judgementalNon-judgemental Use of silenceUse of silence Patient as equalPatient as equal Offering choicesOffering choices

Communicating empathyCommunicating empathy

Non-verbal communicationNon-verbal communication

Verbal empathic statements: supportive Verbal empathic statements: supportive comments that link the ‘I’ of the doctor to comments that link the ‘I’ of the doctor to the ‘you’ of the patientthe ‘you’ of the patient

“I can see that your husband’s memory loss has been very difficult for you to cope with”

“I can appreciate how difficult it is for you to talkabout this”

“I can sense how angry you have been feeling about things”

SupportSupport

ConcernConcern UnderstandingUnderstanding Willingness to helpWillingness to help PartnershipPartnership Acknowledge patient’s coping effortsAcknowledge patient’s coping efforts SensitivitySensitivity

Involving the patientInvolving the patient

Sharing of thoughtsSharing of thoughts Providing rationaleProviding rationale ExaminationExamination

Sharing of thoughtsSharing of thoughts

Use of summaryUse of summary Checking understandingChecking understanding Sharing thinkingSharing thinking

“what I am thinking now is how to sort out whether this arm pain is coming from yourshoulder or your neck”

Providing rationaleProviding rationale

“How many pillows do you use at night?”

“Do you get breathless when you lie flat at night?”

“Do you have to prop yourself up on several pillows?”

ExaminationExamination

Explain whyExplain why Ask permissionAsk permission