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Part 1
Clinical Examination
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Chapter 1
The Medical Interview
Good communication between doctor and patient forms the basis for excellent patient care and the clinical consultation lies at the heart of medical practice. Good communication skills encompass more than the personality traits of individual doctors â they form an essential core competence for medical practitioners. In essence, good communication skills produce more effective consultations and, together with medical knowledge and physical examination skills, lead to better diagnostic reasoning and therapeutic intervention. The term âcommunication skillsâ, when applied to medical practice, describes a set of specific skills that can be taught, learned and assessed. A large evidence-base shows that health outcomes for patients and both patient and doctor satisfaction within the therapeutic relationship are enhanced by good communication skills.
In this chapter the medical interview as a whole will be considered and then the way in which communication skills should be approached in different types of assessment encountered by students and trainees reviewed.
There are a number of different models for learning communication skills in use throughout the world. They are generally similar and all emphasise the importance of patient-centred interview methods. This chapter is based on the CalgaryâCambridge model (Fig. 1.1) which has been widely adopted in Europe and the USA and with which the authors are familiar as a means of teaching and learning and as a framework for assessment (Silverman et al. 2005). Like all clinical skills, communication skills can only be acquired by experiential learning. This may take the form of small group learning with role play, the use of actors in simulated learning environments or, for more experienced learners, in recorded real consultations with subsequent feedback.
Effective Consultation
Effective consultations are patient-centred and efficient, taking place within the time and other practical constraints that exist in everyday medical practice. The use of specific communication skills together with a structured approach to the medical interview can enhance this process. Important communication skills can be considered in three categories: content, process and perceptual skills (see Table 1.1); these mirror the essential knowledge, skills and attitudes required for good medical practice. These skills are closely interrelated so that, for example, effective use of process skills can improve the accuracy of information gathered from the patient, thus enhancing the content skills used subsequently in the consultation.
Table 1.1 Categories of communication skills
| Content skills | |
| What the doctor communicates | Knowledge-based: appropriate questions and responses; accurate information gathering and explanation to patient; clear discussion of investigation and treatments based on knowledge |
| Process skills | |
| How the doctor communicates | Skills-based: verbal and non-verbal communication skills; relationship building; organising and structuring the interview |
| Perceptual skills | |
| What the doctor is thinking | Attitude-based: clinical reasoning and problem-solving skills; attitudes towards the patient; feelings and thoughts about the patient; awareness of internal biases |
Structure
Providing structure to the consultation is one of the most important features of effective consultation. Process skills should be used to develop a structure that is responsive to the patient and flexible for different consultations. Six groups of skills can be identified and each will be considered below.
Sequential in the consultation:
- initiating the session
- gathering information (including from physical examination)
- explanation and planning
- closing the session
Throughout the consultation:
