links on conversation with the patient

# an old online textual source on dialogue between doctor & patient written by Dr.Linus Geisler. i’m typing out some of its chapters in subsequent posts.

# similar to that old text, are these engaging videos’ links: [my bookmarks are in reverse order i.e start with the bottom link]

• I*CARE – Basic Principles – MD Anderson Cancer Centerdisclosing error: without delay, preferrably by a senior, do not blame/excuse & don’t state the error but state the case is being investigated. signpost/opening shot. recap -narrate past & connect it with current. emphasize alligning with their emotions. enlist family member. follow-up strategy & summary.
• M. D. Anderson Flash Playerpearls in delivering bad news: behind emotionally charged questions are concerns that are useful to explore the crux. check for the patient’s emotional expressions. enlist for family support for the patient to digest easily. expressing one’s own regret helps take away the doctor’s responsibility of delivering bad news. don’t set up false hopes. supportive control helps the prospect of death reassurance that he would’nt abandon the patient helps impart hope to sustain in the patient.
• M. D. Anderson Flash Playerinstead of drastically disclosing bad news, consider the impact on the patient’s future: find out the patient’s understanding of his condition ask beforehand if its ok for him to listen to the diagnosis recaptulate the what/how the investigations were done reveal the results in small chunks explaining in lay terms acknowledge & empathise & EMPHASIZE with his emotions strategy & summary
• M. D. Anderson Flash Playerexample of revealing bad news
• M. D. Anderson Flash Playersummary to clearly recaptulate the treatment plan, address any doubts/anxieties, conclude with a clear next contract to evaluate the results
• M. D. Anderson Flash Playera good visualization mismatch table to identify under-prepared/over-concerned patients so as to explore their cause & devise a STRATEGY to increase compliance.
• M. D. Anderson Flash Playeracknowledging emotions
• M. D. Anderson Flash Playerlistening skills
• M. D. Anderson Flash Player
• I*CARE – Basic Principles Introduction – M. D. Anderson Cancer Center
  • When you have to break bad news though, you use the SPIKES variant of that CLASS protocol. When you have to disclose an error, then you use the CONES variant of the CLASS protocol. And then, finally, there’s a sort of a sub-protocol that we call the EVE, which we use inside any encounter when there are emotions present
  • ‘C’ is for Context meaning the physical setting, the physical context in which you hold the interview. It’s actually quite important to get that right at the start.
  • ‘L’ stands for Listening Skills, switching on your listening skills. And there are several of these that you can put into practice very easily. By far, the most important is silence. You maintain silence when the patient is talking. We also, as well as silence, we’ve got several strategies for responding when the patient starts talking to let the patient know that you are listening and to roll the interview along, to facilitate it. And of those techniques, repetition is the most important, repetition of one word. You repeat one word from their last sentence in your first sentence and that simply lets the patient know that they have been heard, that you’ve been listening, that the circuit is complete.
  • ‘A’ for Acknowledging Emotions and Addressing Emotions.
  • ‘S’ for Strategy where you outline your, as it were, your medical plan, your plan for medical management, the diagnosis, the treatment, what you’re going to do, and how you’re going to investigate it.
  • ‘S’ is for Summary
  • ‘P’ is for Perception. Find out their perception. Before you tell, ask. Find out what the patient knows or suspects or perceives about their condition. Then, another pivotal point is ‘I’ for Invitation. Get an invitation from the patient to go ahead and share the information if that’s what the patient wants. Having gotten that invitation then go ahead with the ‘K’ for Knowledge, giving the medical facts which starts at the level of the patient’s understanding as you heard it in their response to the ‘P’ for Perception. And then, the all important ‘E’ is for Emotions. It is very important that emotions are addressed at the time they occur, as they occur.
  • sudden deterioration in the patient’s medical condition or, of course, when you’re talking to a relative about bereavement, and a sudden, a death, or of course, when a medical error has occurred. These are all examples when you have to give the information
  • ‘O’ which stands for Opening Shot.
  • ‘N’ stands for a process that we call the Narrative Approach which is a usual way of explaining the chronological sequence of events
  • EVE sub-protocol, is something you must do at any point, at any moment in an interview where an emotion erupts.
  • The first ‘E’ is for Exploration. Find out more about what the emotion is and what’s causing it. ‘V’ is for Validation in which you show the patient that the emotion they have expressed is intelligible and understandable and/or ‘E’ is the third, the second ‘E’, the third point of the EVE protocol is for the Emphatic Response showing that you have seen the emotion and that you can understand its course or origin. It acknowledges and automatically validates as well
  • communication is a factor of just having the right personality. It isn’t. It’s not something you’re born with. It’s not basically intuitive. You can learn it. It’s a matter of tuition not intuition. The fact is that anybody can adopt these techniques or behaviors. You can practice them. You can learn them and you can teach them. And the quality of every clinical encounter when they are used is enhanced.