The setting

Patients attending the general practitioner will either he seen al home or in the surgery. In hospital, although leaching may be w ard-based, most examinations take place in consulting rooms. Privacy is a key requirement for all clinical examinations, which can be difficult in a ward setting. If the patient can get up then it is preferable to conduct the examination in an office or a single room If a bed-bound patient has to be interviewed there may be no alternative to pulling the curtains at the beginning of the interview. This will obscure vision but not sound. Other patients may unavoidably be eavesdropping, so it is important to proceed by talking m as quiet a voice as possible to enable understanding and by avoiding discussing sensitive topics unnecessarily.

Good interview technique

Yields accurate history

Valid basis for physical examination, investigations and interventions

Better compliance

Establishes effective working partnership with the patient ( therapeutic alliance )

Increases patient satisfaction and trust

Revelation of potentially important information e.g. abuse, intimate family history, previous non-compliance

Fewer complaints, less likelihood of litigation

Fig, 1.1 Benefits of good interview technique.

TABLE 1.2 Assets valuable for obtaining a good clinical history

• Being empathic - having the capacity to put yourseff in somebody else's shoes, to understand and share the patients thoughts and feelings

• Being an attentive listener - the quality thai patients rate as the most important attribute in a doctor from their perspective

• Being articulate - recognising when to speak, what to say and how to express it

• Being a good nonverbal communicator - using body language appropnately and responding to nonverbal cues from the patient

• Being friendly-rather than businesslike

• Being interested in other people - and enfliusiastic if a student

The ambience, arrangement of furniture and relative positions of patienl anil doctor all matter in facilitating communication. The aim is to establish a comfortable, relaxed, quiet and friendly environment which enables rapport to develop and the patient to talk.

Ideally doctor and patient should be sealed about I metre apart on similar chairs which are positioned in such a way thai ihe doctor can observe the patient hut the patient can look away without awkwardness (Figs 1.2, 1.3 and 1.4).

The arrangements should allow the clinician lo write during the interview. Doctors develop a style of interviewing which suits iliem best. Some record detailed notes during the consultation, others take rough notes as aides-mémoire. whilst some write little or nothing at the time but record the content as soon as the patient has left. There are advantages and disadvantages with any technique. During training it is useful to take detailed notes while the patient is being seen. This enables the record to he more complete and accurate. However, it is necessary to learn how to do this without damaging rapport, and it is important to recognise that the consultation demands that full concentration is paid to the patient. Writing should temporarily cease, for instance, with the revelation of sensitive information or signs of distress or irritation.

Time

[n General Practice a consultation of 5-10 minutes is usually adequate because the family doctor will have seen the palienl on previous occasions The doctor will not only be familiar wilh the past and social history, but may also have cared for other members of Ihe family and household. In hospital the appointment time of new outpatients will depend upon the nature of" the speciality and ihe patient's prohlem. It may be as much as 2-3 hours in child psychiatry.

It is important to plan the consultation lo the time available. To fail to do so may result in other patients being kept waiting, thereby diminishing (he value of their consultations. When a problem arises that clearly requires much more than lite allocated time, il may be advisable to arrange a further consultation

Fig. 12 The desk as a defence mechanism, aiso the failure to give the patient full attention. It stethoscope and white coat and the illuminated viewing bo*.

Fig. 12 The desk as a defence mechanism, aiso the failure to give the patient full attention. It stethoscope and white coat and the illuminated viewing bo*.

Fig. 1.3 A more appropriate arrangement of doctor and patient designed to pul the patient at ease. Note the eye contact, the presence of the patient's mother, (he picture and Ihe 'cuddly toy'

Fig. 1,4 Appropriate arrangement of doctor and patient for a bedside interview.

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