Modules

Selected communication challenges

This section is comprised of situations that many physicians find difficult. There are two versions of most of the interviews. They do not illustrate a right and/or wrong way of interviewing, but are intended to illustrate responses that range from physician-centred to more patient-centred approaches. The differences might seem subtle but as you will observe, you can have a marked influence on the clinical outcome of the interview.

The communication challenges interview examples include:

  • Sexual history
  • Interprofessional conflict
  • Boundary crossing
  • Ethical dilemmas
  • Cross-cultural interviewing
  • Breaking bad news

Sexual history

MCC role objectives

Communicator

  • Use appropriate non-verbal communication (positioning, posture, facial expression) (1.2)
  • Elicit patient information through active listening and the appropriate use of open and closed questions, as well as using clear language appropriate to the patient’s understanding (2.1)
  • Identify the personal and cultural context of the patient, and the manner in which it may influence the patient’s choices (3.2)
  • Provide information using clear language appropriate to the patient’s understanding, checking for understanding, and clarifying if necessary (3.3)
  • Effectively present information about clinical encounters and management plans to patients and their families (5.1)

 

Professional

  • Practice the profession with due regard for basic human rights (the right to privacy, freedom from discrimination, autonomy) (3.6)

Introduction

This is a topic that makes many physicians uncomfortable and is one of the most culturally laden aspects of any society. Sexual customs and taboos are ingrained in us and some people respond to “different” sexual practices and orientations with strong emotion. Physicians raised in more conservative cultures may have difficulty dealing with topics like abortion, homosexuality or sexual violence.

While we might adapt our actions to the local context, attitudes often remain because they form an important part of an individual’s moral approach to life. Does this mean that, as physicians, we have to give up our beliefs and adapt to the beliefs of others? How can we find common ground if our beliefs are at odds with those of our patients? To address these issues, read the “Attitudes” section of the Observation Guide. You can also review the self-assessment exercises in Module 2. Honesty, self-awareness and genuine respect for people help the physician to be non-judgmental and to be patient-centred when discussing topics relating to sexuality.

There are two basic types of sexual history. One is part of a general interview and consists primarily of screening questions. This is usually done during the first visit with a new patient and can consist of a form or checklist to fill out. Even if a form is completed, it is wise to explore the topic briefly to make sure there are no issues the patient might want to bring up. The second type of sexual history is when a patient comes with a sexual problem or the physician has reason to explore this topic because of a related health issue. In these cases, the context is quite different and the amount of information obtained is usually greater and specific to the problem.

Regardless of the situation, the major barriers involved for the physician are likely to be:

  • Discomfort with the topic
  • Difficulty in finding appropriate words and phrases to use in the conversation
  • Making assumptions about sexual orientation, level of activity, practices or attitudes
  • Focusing on the sexual orientation of the patient rather than risk behaviour
  • Difficulty in remaining non-judgmental

Such barriers make it more difficult for the physician to explore the topic and for patients to respond completely and honestly. There are three interviews that illustrate a general approach to obtaining the sexual history of a new male or female patient. The physician uses some of the words and phrases that might be useful in these situations. The interview with the woman has two versions — one is a basic screening and the other is more detailed. The basic interview with the male patient is also more detailed and is related to Module 1. There are two other examples of patients presenting with a sexual problem as the main complaint. Each has two versions, reflecting both physician-centred and patient-centred behaviours.

Sexual history, female

  • Version 1

  • Doctor: Okay. I think we’ve covered most of what we need to discuss. I know your past health, your current situation. We’ve talked a little about your work and your family. Do you have anything you’d like to add with regards to those areas?

    Patient: No I think we’ve covered it all.

    Doctor: Good. Now to complete your personal history, I need to ask you a few questions about sexual activity, if you don’t mind?

    Patient: Sure.

    Doctor: First, are you currently sexually active?

    Patient: Yes.

    Doctor: Could you tell me a little about your partner or partners whether men or women or both?

    Patient: Just one partner now, my husband.

    Doctor: You said now, so you’ve had other partners in the past?

    Patient: Well, before we got married I had several… several boyfriends. I had sex with some of them but that was a long time ago.

    Doctor: Okay. You told me earlier that you’re on the pill. Do you also use condoms?

    Patient: No.

    Doctor: Okay. Have you ever had any infections, unusual discharges, or pain in your pelvic area?

    Patient: No.

    Doctor: Have you ever been treated for sexually transmitted infections?

    Patient: Oh no, nothing like that.

    Doctor: All right, I think those are all the questions I have for you at this time. Do you have any questions about what I’ve asked you or any other questions?

    Patient: No, I can’t think of any.

    Doctor: All right, thank you.

    Patient: Thank you.

  • Version 2

  • Doctor: All right. I think we’ve covered most of what we need to talk about. I know your past health, your current situation, and we’ve talked a little about your work and family. Is there anything else you’d like to add?

    Patient: No, I think we’ve covered it all.

    Doctor: To complete your personal history, I need to ask you a few questions about sexual activity if you don’t mind?

    Patient: Sure.

    Doctor: First, are you currently sexually active?

    Patient: Yes.

    Doctor: Could you tell me a little bit about your partner or partners whether men or women or both?

    Patient: Just one partner now.

    Doctor: And you’ve had other partners in the past?

    Patient: Well, I’ve had several girlfriends in the past but I’ve been with Jeanne for a long time now.

    Doctor: So you’re a lesbian?

    Patient: Yes.

    Doctor: Have you ever had sexual relations with men previously?

    Patient: No.

    Doctor: Now with anyone who’s sexually active I’ll ask about practices and precautions. Are you or your partner currently seeing anyone else?

    Patient: No we’re quite faithful to each other.

    Doctor: Do you practice safer sex, for example, protection during oral sex or making sure toys are clean?

    Patient: Yeah we know all about that we’re very careful.

    Doctor: Have you ever had infections, unusual discharges, pain in your pelvic area?

    Patient: No.

    Doctor: Have you ever been treated for sexually transmitted infections?

    Patient: No nothing like that.

    Doctor: Okay, I think those are all the questions I have for you right now. Do you have any questions about what we’ve talked about or any other questions?

    Patient: No I can’t think of any.

    Doctor: All right, thank you.

    Patient: Thank you.

Commentary on: Sexual history, female, versions 1 and 2

Note how the physician bridges to the sexual history part of this new patient interview. The timing is such that he already knows quite a bit about the patient and can adjust his vocabulary and approach to how the patient might be expected to respond. The differences in age and gender between physician and patient, which could prove embarrassing, are handled sensitively. The physician is matter of fact and professional, indicating that this is routine for all patients, but still asks permission. In version 2, he responds to the patient’s cue, noticing there is some discomfort with the topic and explains why he needs the information. The physician thoughtfully uses neutral terms in asking his screening questions. For instance, he inquires about activity with men or women instead of asking: “Do you ever have homosexual relations?” As well, he asks “Do you use condoms?” and not “Do you practice safe sex?”

The important topics of sexual activity, contraception and sexually transmitted infections are screened in just a few questions. A final open question: “Do you have any concerns you want to talk about?” allows the patient to bring up issues of importance to her, such as sexual function. Note that in version 2, the sexual orientation changes some of the questions, but the physician is not judgmental and probes only to determine safer sex practices.

Sexual history, male

  • Doctor: Okay, I think we’ve covered most of what we need to talk about. I know your past health, your current situation, and we’ve talked a little bit about your work and your family. Is there anything else you’d like to discuss?

    Patient: No, I don’t think so.

    Doctor: To complete your personal history, I need to ask you a few questions about sexual activity, if you don’t mind?

    Patient: Yeah, I guess so yeah.

    Doctor: I can see that makes you a little uncomfortable? It’s all right. We do need to ask these questions to all our patients. It’s important for your health and for our ability to care for you as physicians but if you’d rather discuss this another time then.

    Patient: No, its okay we can talk about it.

    Doctor: Okay, so are you currently sexually active?

    Patient: Yes.

    Doctor: And can you tell me a little bit about your partner or partners, men or women or both?

    Patient: Well, that depends.

    Doctor: That depends?

    Patient: Yeah.

    Doctor: Do you mean that you have both women and men partners?

    Patient: Just for the record here, I’m faithful to my wife so I don’t sleep around with other women and I love my son. My family is really important to me.

    Doctor: So let me get this straight, your wife is your only female partner?

    Patient: Yes.

    Doctor: But you’re also having sexual relations with men, is that correct?

    Patient: Yeah.

    Doctor: All right, thank you for telling me, I appreciate your honesty. So do you have multiple partners?

    Patient: Yeah

    Doctor: And do you use protection, you use condoms?

    Patient: Sometimes.

    Doctor: Do you engage in oral or anal sex?

    Patient: Yeah.

    Doctor: And, with your wife, are you using condoms right now?

    Patient: No, we’re trying to have another child so.

    Doctor: I see.

Commentary on: Sexual history, male

In the interview with the male patient, the physician recognizes and acknowledges the patient’s non-verbal cues of discomfort with the topic. He gathers more information in this case since it might become important in later management (see Module 1). He uses more closed-ended questions, possibly because he feels that the patient might not wish to elaborate, at least in this initial interview. Note that he also chooses not to pursue at this time the obvious health implications of the patient’s sexual activity. While it is important to establish trust and confidence in the relationship, the physician must also consider and respond to the risks involved for the patient and others.

A sexual complaint

MCC role objectives

Communicator

  • Use appropriate non-verbal communication (positioning, posture, facial expression) (1.2)
  • Elicit patient information through active listening and the appropriate use of open and closed questions, as well as using clear language appropriate to the patient’s understanding (2.1)
  • Identify the personal and cultural context of the patient, and the manner in which it may influence the patient’s choices (3.2)
  • Provide information using clear language appropriate to the patient’s understanding, checking for understanding, and clarifying if necessary (3.3)
  • Effectively present information about clinical encounters and management plans to patients and their families (5.1)

 

Professional

  • Practice the profession with due regard for basic human rights (the right to privacy, freedom from discrimination, autonomy) (3.6)

The following interviews illustrate ways of dealing with patients, male and female, presenting with a sexual complaint. They also illustrate the impact that patient personality can have on an interview. Each has two versions.

A sexual complaint, female, version 1

  • Doctor: Hello.

    Patty: Hi.

    Doctor: Are you Patty French?

    Patty: Yeah.

    Doctor: Ok. Well I’m Dr. Novak nice to meet you.

    Patty: You too.

    Doctor: Is it your first time at the clinic?

    Patty: Yeah.

    Doctor: How would you like me to address you? Is Patty okay?

    Patty: Yeah, Patty is fine.

    Doctor: So Patty, what brings you in today?

    Patty: I think I might be pregnant.

    Doctor: You think you might be pregnant.

    Patty: Yeah.

    Doctor: And what makes you think that?

    Patty: Well, you know… we had unprotected sex and we didn’t use anything.

    Doctor: And when did this occur?

    Patty: About 18 hours ago.

    Doctor: So you had unprotected sex 18 hours ago. Can I assume you’re not taking the pill?

    Patty: No.

    Doctor: Were you using anything else like contraceptive or anything like that?

    Patty: No.

    Doctor: So in terms of having sex 18 hours ago, was it the first time with this partner?

    Patty: No, we’ve had sex before.

    Doctor: So previously when you have had sex have you used a condom?

    Patty: Yeah.

    Doctor: And this is a new relationship?

    Patty: No we’ve been dating like four months.

    Doctor: So in the last four months you’ve been having sex but last night you didn’t use a condom?

    Patty: No.

    Doctor: Though previously you did use a condom.

    Patty: Yeah, I didn’t really think about it.

    Doctor: And have you ever been on any sort of birth control?

    Patty: No.

    Doctor: Well the thing about using a condom is that a condom can prevent pregnancy and sexually transmitted infections, have you ever been in this situation before?

    Patty: No.

    Doctor: No. So do you have any ideas what you like to do with this?

    Patty: Well, I heard about this thing called the morning after pill.

    Doctor: The morning after pill, that’s what you’re interested in?

    Patty: Yeah, if it’s not too late.

    Doctor: Well, the thing about the morning after pill is that it’s good within 72 hours. So you’re well within the time limit, you can relax about that. But now I would like to ask you a few more questions about your health in general. Just to make sure that the morning after pill is the good option for you.

    Patty: Okay.

    Doctor: Are you on any kind of medications right now?

    Patty: No.

Commentary on: A sexual complaint, female, version 1

In this interview with a young woman, the physician utilizes a number of techniques. Can you find examples of summarizing, paraphrasing and gathering information? What kind of questioning style does he have? How would you describe his attitude toward the patient? Note how his body language and tone are gentler than with Jack. He is adjusting to his patient and trying to put her at ease. However, how would you assess his adjusting to the patient’s understanding, his gathering of information and making assumptions? These three areas are especially important in exploring the patient’s sexual practices. Is there anything in this interview that you might have done differently or any information that you would have tried to obtain?

A sexual complaint, female, version 2

  • Doctor: Hello.

    Patty: Hi.

    Doctor: Are you Patty French?

    Patty: Yeah.

    Doctor: My name is Dr. Novak, nice to meet you.

    Patty: You too.

    Doctor: How would you like me to address you, is Patty okay?

    Patty: Yeah, Patty is fine.

    Doctor: So Patty, what brings you in the office today?

    Patty: I think I might be pregnant.

    Doctor: Okay you think you might be pregnant and how do you feel about that?

    Patty: It’s not what I want. I really don’t want kids right now.

    Doctor: Well can you tell me what happened?

    Patty: You know, we had sex and we didn’t use anything, so I’m worried I might be pregnant.

    Doctor: You didn’t use anything?

    Patty: No.

    Doctor: Meaning that you had unprotected sex. You didn’t use a condom?

    Patty: No.

    Doctor: Are you in any sort of birth control at all?

    Patty: No.

    Doctor: And when did this happen?

    Patty: Like 18 hours ago.

    Doctor: 18 hours ago most nights some time.

    Patty: Yeah.

    Doctor: Is this a new partner or a regular partner?

    Patty: We’ve been dating like four months.

    Doctor: So you’re having sex in the last four months.

    Patty: Yeah.

    Doctor: And have you used any protection?

    Patty: Yeah we use condoms.

    Doctor: You use condoms but last night you didn’t use a condom?

    Patty: No.

    Doctor: Is there a reason for that?

    Patty: It was different.

    Doctor: It was different. And what do you mean it was different?

    Patty: He was behind me.

    Doctor: So when you say that he was behind you, was it vaginal sex from behind or anal sex that we’re talking about?

    Patty: It was anal sex.

    Doctor: Is it the first time you’ve had anal sex?

    Patty: Yeah.

    Doctor: And this is the reason why you didn’t use a condom?

    Patty: Yeah, I didn’t really think about it.

    Doctor: And what concerns you about having anal sex and being pregnant?

    Patty: Well I guess that I really don’t want kids right now.

    Doctor: So do you think you can get pregnant from anal sex?

    Patty: Well, yeah can’t you?

    Doctor: It’s highly unlikely. Well after you had anal sex did your boyfriend perform vaginal sex?

    Patty: No.

    Doctor: So strictly anal sex?

    Patty: Yeah.

    Doctor: You didn’t have vaginal penetration after that?

    Patty: No.

    Doctor: Well the good news is like in all likelihood you cannot get pregnant from having anal sex but if you want we can talk about what could happen in the future if you’re having unprotected sex. I think you’re aware that having unprotected sex can lead to pregnancy.

    Patty: Uhmm.

    Doctor: Vaginally.

    Patty: But not the other way?

    Doctor: No, not anally unless you’ve had like anal sex then followed it with vaginal sex unprotected then that’s a possibility. So chances are very remote that you’ll get pregnant that way. Now, I would like to do a physical to make sure everything is okay.

    Patty: Okay.

    Doctor: So generally speaking, how’s your health?

    Patty: Generally, I’m pretty healthy.

Commentary on: A sexual complaint, female, version 2

In this interview, the physician employs many of the techniques used in version 1, but with subtle differences. Once again he uses open questions, but instead of asking: “Why do you think that?” in response to her opening statement, he says: “How do you feel about that?” This change in one word allows the patient to tell her story more openly, which is especially important since the physician does not know her. He follows that question with another good open question: “Tell me what happened.” Compare the listening style with that used in the Jack Simpson interviews, especially with respect to responding to cues and use of silence/interruptions. What other techniques and styles does he employ to gather information? Note how he even subtly checks the gender of Patty’s partner. Repeating the patient’s words (“different,” “behind me”) is particularly effective in bringing out important information about the sexual encounter. He adjusts to the patient’s level of understanding in his explanation, treating her obvious naivety with respect.

A sexual complaint, male, version 1

  • Doctor: Okay Jack, now according to chart it’s been about three years since you last came in, so what brings you in today?

    Jack: Well, you know, I went to a hospital about six months ago. I had to walk into a place in Sudbury because some lady I met left me with a nice little present and, you know, I had to go in and get some stuff and get it taken care of. But, you know they told me that I should go in for a follow up exam. And so my mom’s been sort of on my case about it, so here I am.

    Doctor: Your mom has been on your case about?

    Jack: Just going in and having a follow up.

    Doctor: Just about the follow up.

    Jack: Yeah, yeah. She said, “You go in and get it checked out. They say you should go,” so finem whatever you want.

    Doctor: So your mom knows that you caught something from someone, some woman in Sudbury?

    Jack: Well I mean, I don’t tell my mother everything you know. Well look she knows that I had a bit of difficulty down there. We didn’t have to go into the specifics really.

    Doctor: And this was six months ago?

    Jack:     That was six months ago.

    Doctor: So what happened?

    Jack:     Oh it’s all cleared up now.

    Doctor: Oh it’s all cleared up?

    Jack:     Yeah. They gave me the stuff they give, you know, the tetra whatever.

    Doctor: The what?

    Jack: Tetra something they gave me.

    Doctor: Some sort of antibiotic?

    Jack: Yeah, yeah that’s what it was.

    Doctor: And you said it’s all cleared up.

    Jack: All cleared up. Good as gold.

    Doctor: Good, good. That’s good. So anything else bothering you?

    Jack: No, no I feel fit as a fiddle except, you know, sometimes my knees get a little bit stiff.

    Doctor: You mentioned that your mom was concerned.

    Jack: Yeah but she gets concerned right. She probably thinks I’m going to drop dead of a heart attack or something like that.

    Doctor: A heart attack. Now why would she think that?

    Jack: Oh well, you know it’s… it happened to dad, so she’s a little bit jumpy.

    Doctor: How old was your dad when he died?

    Jack: He was 70.

    Doctor: He was 70.

    Jack: I’ve got lots of time.

    Doctor: And when did this happen?

    Jack: That was a little bit over a year ago.

    Doctor: A bit over a year ago and he was 70. How old are you now, Jack?

    Jack: I’m 30.

    Doctor: You’re 30 and your dad died when he was 70 from a heart attack and your mom is concerned. Is there anything else happening, any pain in your chest, anything like that?

    Jack: No.

    Doctor: Any shortness of breath?

    Jack: No, no nothing like that.

    Doctor: What about sleep, are you sleeping okay?

    Jack: Yeah, yeah, yeah I sleep fine.

    Doctor: How many pillows do you use when you sleep?

    Jack: How many pillows, it depends on how many of the girl has.

    Doctor: Okay well generally when you’re sleeping alone.

    Jack: Oh when I’m sleeping alone just like one maybe, two I guess.

    Doctor: And any problems, I mean when you’re lying flat on your back, any problems breathing?

    Jack: No.

    Doctor: Is there anything else then, do you have any pain in your legs anywhere?

    Jack: No but like I said earlier sometimes my knees get a little bit stiff. That’s what I get for you know sitting and pushing gas pedals and clutches all day.

    Doctor: What do you do for a living?

    Jack: I’m a trucker. A long-haul trucker.

    Doctor: A long haul trucker, when did that start?

    Jack: Oh I started that about three years ago. Remember that’s the last time I saw you. I had that checkup then.

    Doctor: Right, you came in for a full checkup, right?

    Jack: Yeah, yeah you remember me.

    Doctor: And there were no problems then.

    Jack: No. Everything was fine.

    Doctor: Okay, good.

Commentary on: A sexual complaint, male, version 1

Jack’s reason for the visit is a follow-up on his sexually transmitted infection (STI), as suggested by the physician who treated him six months ago. This physician starts with appropriate open questions, but when Jack says his STI is all cleared up, the physician drops the topic (comes to premature closure). He then inquires: “Anything else on your mind?” It is a good open question, but it leads to a detailed, although not complete, inquiry into heart disease, using primarily closed questions.

Why do you think the physician chose not to inquire further into the STI?

  • He did not need to as it has been treated.
  • The physician does not understand the importance of follow-up on STIs.
  • The physician feels uncomfortable with the subject and/or Jack’s presentation.

Jack might leave satisfied, but has he received appropriate follow-up and counselling with regard to high risk sexual behaviour?

A sexual complaint, male, version 2

  • Doctor: Okay Jack, I’ve been looking at your chart. I see that you were last in about three years ago. Is that right?

    Jack: That’s right.

    Doctor: Okay. It’s been quite a while, so what’s been going on? What brings you in today?

    Jack: Oh well, you know, I’m just taking care of business, that’s all. I had a little thing happened in Sudbury about six months ago. This nice, nice woman gave me a wheel present and I had to go in and get it taken care of and they gave me antibiotics and they told me, “You know, you should really go in for a follow up exam.” And you know just so you know I told my mother that I’d been in there. So she’s been insisting that I go and get a follow up, so here I am.

    Doctor: Now when you say she gave you a little present, what do you mean by that?

    Jack: Oh well I don’t know what you want to call it, Clap, VD a little dose of something.

    Doctor: So sexually transmitted disease or infection.

    Jack: Well, I guess that’s the scientific term, sure.

    Doctor: How long ago was that?

    Jack: That was six months ago.

    Doctor: Six months ago.

    Jack: The stuff they gave me cleared it right up.

    Doctor: Do you remember what they gave you exactly?

    Jack: Tetra something, tetra…

    Doctor: Well some sort of antibiotics?

    Jack: Yeah, yeah that’s what it was antibiotics. You take it for 10 days.

    Doctor: And you took it for the full 10 days?

    Jack: That’s right.

    Doctor: And everything’s cleared up?

    Jack: All cleared up.

    Doctor: And where did you say this happened?

    Jack: Well I saw the doctor in Sudbury, so it must have been when I was in the Sioux, well I know for sure it was when I was in the Sioux.

    Doctor: And you mentioned something about you were supposed to get a follow up exam?

    Jack: Yeah, yeah that’s right. They said, “You know, you should really go in for a follow up, a complete follow up exam.” And I said, “Yeah sure that’s a great idea.”

    Doctor: But you didn’t do it?

    Jack: Well no, no like not right away. Like I got stuff to do in my life and the thing cleared up right away, so I wasn’t too worried.

    Doctor: Okay, so what exactly happened, Jack?

    Jack: Well what happens on the road sometimes.

    Doctor: Well, you tell me.

    Jack: Well, I met this nice woman in the bar and, you know, sometimes you meet people in the bar and you know exactly what they’re about and sometimes you meet people in the bar and you seem just a little bit different and this woman she was, well… we were having a nice time, you know, having a chat and she told me she was a grade 2 teacher.

    Doctor: So one thing led to another?

    Jack: That’s right. We went back to her place and I wasn’t counting on anything happening that night because I mean, you know how it is. You bank, you put some money in the bank, you draw it out later but she was good to go. She was good to go for sure.

    Doctor: Had you met her before?

    Jack: No, no that was the first time. Usually I’m a little bit more discerning but she was so hot.

    Doctor: Okay now can I ask you Jack, did you wear a condom at this point or no?

    Jack: Well, no like I’m not in the habit of doing that. I ride bareback. You see this is the thing. Most of the women I see are married, so they’re taking care of that on their own.

    Doctor: What do you mean when you say bareback?

    Jack: Well it means no condom.

    Doctor: So you’re not in the habit of wearing condoms?

    Jack: No just me in the open air. I like it nice and slick and shiny.

    Doctor: And have you had a problem like this before?

    Jack: No, never, never. Like I thought she’d be okay because she’s married. It’s the middle of the afternoon, so I have a lot of afternoon sex, yeah.

    Doctor: Okay, so generally you don’t wear condoms when you’re having sex, why is that?

    Jack: It’s not nearly as much fun.

    Doctor: So basically you had this meeting with this woman.

    Jack: Yeah, we had sex.

    Doctor: You had sex.

    Jack: Three times.

    Doctor: Okay, and what happened after that?

    Jack: Well I got this feeling in my penis. It started to be uncomfortable and when I took a leak, well it it’s not like I was pissing fire or anything like that but it didn’t feel good.

    Doctor: So there was some pain in your penis?

    Jack: That’s what I’m saying, yeah and then I started getting these little bits of stains in my underwear, so some of the white ones I had to throw out.

    Doctor: What sort of pain was it Jack? Was it a burning pain, a sharp pain? What sort of pain was it?

    Jack: Just like a mild sort of I guess you’d call it a burn, like I said it’s not like there were flames shooting out of my penis.

    Doctor: But there was some burning?

    Jack: Yeah, there was some burning.

    Doctor: You also said that your underwear was stained?

    Jack: Yeah exactly.

    Doctor: So there was some discharge?

    Jack: Yep.

    Doctor: What color was it?

    Jack: It was like green yellow stuff.

    Doctor: Was it thick?

    Jack: Possibly, yeah.

    Doctor: And how long was it before you went to see your doctor?

    Jack: Not awfully long, that’s not the sort of thing you want to mess around with if you’re in my position.

Commentary on: A sexual complaint, male, version 2

In this version, the physician keeps the focus on the reason for the visit: follow-up on Jack’s STI. The mother’s concerns do not come out. Is this important in this context?

Note how the physician obtains appropriate details of the sexual encounter. He asks three times about condom use. The physician is likely trying to send a message to Jack about the importance of safer sex practices.

Note how he clarifies Jack’s jargon and paraphrases into language that he is sure he understands. Throughout the interview, the physician is professional and non-judgmental. In contrast to the previous interview, how will the information obtained here lead to appropriate care? What do you think the physician should do?

Interprofessional conflict

MCC role objectives

Professional

  • Be respectful of colleagues (4.3)
  • Recognize personal limitations and respect the expertise of others (5.2)
  • Communicate with other health-care professionals clearly, in a timely manner, and with due regard to their point of view (5.4)
  • Be sensitive to, and do not abuse, the power relationships within the health-care system (6.4)

 

Collaborator

  • Demonstrate respect for team members without bias (e.g., bias related to gender, ethnicity, cultural background or health-care role) (3.3)
  • Use strategies to deal with conflict through negotiation and collaboration, while respecting the views and positions of others (4.2)

Entrustable professional activities

  • Lead and work within interprofessional health care teams (8)
  • Improve patient safety and the quality of health care at both the individual and systems level (10)

 

Critical competencies

  • Accurately elicits and synthesizes relevant information and perspectives of patients and families, colleagues and other professionals accurately (9)
  • Works with other health professionals effectively to prevent, negotiate and resolve interprofessional conflict (14)

Introduction

Patients are not the only people we communicate with in our professional life. Much of what we do involves interactions with other health professionals. One of the major differences between physician-patient and interprofessional communication is the power differential. Patients come to physicians for help because of the physicians’ expertise. Because of this differential, patients have less control over the conversation than they would in other situations. This is not the case between health-care professionals. Interprofessional communication frequently occurs around problems about patients or the functioning of the health-care system. When there are disagreements, they are often related to the different ways health-care professionals view the system or interpret their role. But poor communication can lead to the escalation of a minor issue into an emotionally-charged conflict. The power relationships among different professions are more uncertain and complex than between physician and patient. However, the principles of communication remain the same: active listening, being non-judgmental and gathering information.

Watch these next conversations between a physician and nurse. Note how many of the items on the Observation Guide apply here as well. There are two versions and the second one is divided into three parts to better illustrate person-centred behaviours.

Interprofessional conflict: Introduction, version 1

  • Doctor: Excuse me, are you Molly Brown?

    Molly: Yes, I am.

    Doctor: Hi I’m Dr. Green. I’m the attending. I haven’t actually met you but I need to talk to you if that’s okay with you?

    Molly: Well, I’m just in the middle of my coffee break right now. So if it could wait that would be great.

    Doctor: You know what, I just got paged. I’ve got to go down to the ER something I’ve got to deal with right away. I’m going to be straight with you. I’ve had a complaint about you.

    Molly: I’m sorry?

    Doctor: Yeah. One of the patients down the hall reported that he heard some, what he thought was abusive behavior happening to Mr. Jones in 4A, so I need to talk to you.

    Molly: I’m sorry, Mr. Jones complained?

    Doctor: Yeah.

    Molly: Complained about me?

    Doctor: No, it was another patient who heard something going on. I just want to check this out with you because I have to find out what actually happened?

    Molly: Have you met Mr. Jones by any chance?

    Doctor: Actually, I have met Mr. Jones, yes.

    Molly: So who was the patient then the complaint?

    Doctor: You know what, I’m not going to tell you that. I just need to check with you what happened this morning. Can you tell me in your own words what happened?

    Molly: Well, like I said I was just trying to get Mr. Jones prepared for you guys to come around for grand rounds and well, if you had met Mr. Jones you’d have a pretty good idea what I was up to.

    Doctor: Yeah, I know.

    Molly: So have you seen him?

    Doctor: I’ll give you, Mr. Jones is difficult but what happened? What went down?

    Molly: I was just trying to get him clean up of all the urine that was all over him, the vomit, everything else that was going on and that’s really it. Look I don’t know what the problem is here, so.

    Doctor: Well, what I’ve been told is that this patient heard some verbal abuse and he thought he heard a slap but is that the truth? Is that what happened? Did you actually do something to this patient?

    Molly: I’m sorry, you’re coming in here accusing me of abusing somebody when you haven’t even…

    Doctor: I have been told this by another patient and you know all patients on this ward are my responsibility. I have to check this out and I really want to find out what’s happening. I thought I’d do you a favor and talk to you before I talk to your supervisor but that’s what I’m going to have to do if you’re not going to tell me what happened?

    Molly: Well, thank you very much for the favor. I appreciate that but I’m afraid that, you know all I was trying to do was get him cleaned. Look I don’t think you appreciate what kind of patient this man is.

    Doctor: Look…

    Molly: He’s just a…

    Doctor: I know he’s a difficult patient.

    Molly: I’m sorry, excuse me, do you mind if I finish?

    Doctor: Actually, you know what! I just need to hear in your own words, did you slap this patient? Were you abusive to him verbally? Did you swear at him? Is that what happened?

    Molly: Can I talk now?

    Doctor: I really like to hear what you have to say.

    Molly: Okay. So like I said all I was trying to do was get him cleaned up. I just, I can’t.

    Doctor: Some of these patients are difficult but we are not expecting them to be perfect when we walk through the door.

    Molly: I can’t believe that you…

    Doctor: Look! What happened? Do I need to report this? What’s going on here? Because if that patient is in danger because of the care of one of the personnel here that is my responsibility and I have to report that so I have to find that out.

    Molly: I am trying to tell you what happened but obviously, you’re not very interested in hearing my side of the story are you?

    Doctor: I am interested and I think you should just calm down because I need to get the facts before I report this and you’re obviously not in a great space; so let’s find out what really happened.

Commentary on: Interprofessional conflict, introduction, version 1

Why do things not go well in this version? Usually in a conversation one of the parties initiates and takes a more active role. In this case it is the physician who asks to speak to the nurse. But why does the conversation become confrontational?

The physician states several times that she wants to hear the nurse’s story.

  • How would you assess her listening style, especially in her use of interruption?
  • How would you assess her questioning style? Note how questions become focused very quickly, from “Tell me what happened.” to “Did you slap him?”
  • What happens when the nurse attempts to gather information about the accusation?

Note the difference in the power relationship. The physician says: “Can you tell me in your own words what happened?” and “I’m responsible for the patients on this ward.” The nurse retaliates with: “I’m trying to tell you.” and “Can I speak now?”, statements that patients would likely not make. The nurse’s emotions appear to be directed at the physician. Why?

  • Do you think that nurses feel any less responsible for patients than physicians?
  • Is the physician being judgmental?
  • Do you think the physician has already made up her mind (e.g., is not open-minded)?
  • Did the physician demonstrate interprofessional respect toward the nurse?

How would you assess the quality and quantity of information the physician gathered?

Interprofessional conflict: Introduction, version 2

  • Doctor: Excuse me, hi. Are you Molly Brown?

    Molly: Yes, I am.

    Doctor: Hi, I’m Dr. Green. I’m the attending and I’m wondering if you have a minute to talk to me.

    Molly: What’s this about?

    Doctor: Well actually I got a complaint about you from another patient regarding your morning care of a patient down the hall.

    Molly: Who?

    Doctor: Mr. Jones in 4A.

    Molly: Oh, you have to be kidding me.

    Doctor: Yeah, well, this patient told me that he thought he heard some abuse.

    Molly: Well, yes he’s right because that Mr. Jones is very abusive. I can’t believe what I have to put up with from that guy. I can’t believe that a patient would come in and complain about me when that man, I mean he comes in here his covered in vomit and this isn’t the first time. He comes in here every single week, every week.

    Doctor: Okay, I think we should just calm down.

    Molly: I’m sorry. Calm down.

    Doctor: Yes, we need to discuss this rationally.

    Molly: I am calm actually. I’m being rational. I don’t think you understand…

    Doctor: You know what, Molly?

    Molly: What!

    Doctor: Oh look, I’m sorry I should have shut the door and given us some privacy. Do you mind if I just shut the door and we can sit down and talk about this and find out what really happened, is that okay?

    Molly: Okay.

    Doctor: I’m just going to shut the door. Have a seat. Okay, let’s just start this again.

Commentary on: Interprofessional conflict, introduction, version 2

The physician again initiates the conversation. It sounds similar to version 1, where she says “I need to talk to you.” Here she says “I wonder if you have a minute.”

  • Is there a difference in tone between “need” and “wonder”?
  • Is asking permission an indication of respect?
  • What do these statements say about the physician’s attitude toward nurses?
  • What is the response this time?

Having set the tone and asked her opening question, the physician receives an unexpected emotional response from the nurse.

  • Is this related to the physician’s inquiry or to the situation with the patient?
  • Is the content relevant to the physician’s concerns?
  • Is the emotional nature relevant to the physician’s concerns?

The physician does three things to defuse the charged situation:

  • She apologizes
  • She changes to a less confrontational physical position (sits down)
  • She says: “Let’s start again,” giving the nurse an opportunity to regain self-control

Interprofessional conflict: Information gathering

  • Doctor: Let’s just start this again. I’m going to tell you exactly what I heard and then I’d love to hear your story. Is that okay?

    Molly: Yes.

    Doctor: So this patient came up to me a few minutes ago and said he heard some abusive language and he thought he heard a slap when you were giving Mr. Jones his morning care, this morning before rounds and he wanted to report it to me because he was afraid for this patient. It’s my responsibility to check…

    Molly: Afraid for Mr. Jones? The man lives on the street. I don’t think you understand what we have to put up with from this guy. This isn’t the first time he’s been here. He comes in about once a week. And he is, and I mean, he’s filthy, the man hasn’t seen a shower from the last time he was here and he’s verbally abusive. He’s abusive to everyone and I have to sit there and clean him up. Do you know what that’s like? The guy… And now this is the man that you’re coming to me and telling me saying I’ve been abusive to him? Do you have any idea what that’s like?

    Doctor: Does he swear at you?

    Molly: Yes. He swears at us and he knocks things out of our hands. He knocks things away and he’s, I mean, and I have to get him cleaned up so that you guys don’t see him. He vomits over himself. He’s defecated and we have to clean him up, so that you don’t have to deal with that. I don’t think you understand what that’s like. And he knocks things away, knocks things out of our hands. I have about eight other patients I need to deal with, right.

    Doctor: You sound really, really frustrated.

    Molly: Yes, I am I’m really frustrated. And I don’t appreciate on my coffee break being cornered about a guy like that after 25 years. You know what, why don’t you go ask the rest of the patients on my ward whether they think I’m being tough on them. Of course, I’m not because they’re respectable human beings. They’re sick. This guy isn’t sick. He’s just a drunk.

    Doctor: It sounds to me like this patient seems different than the rest of your patients.

    Molly: Yes, he is.

    Doctor: Did you treat him differently this morning than you treated the rest of your patients?

    Molly: The rest of my patients don’t try to hit me when I’m washing them. The rest of my patients are respectful. So sometimes you have to be a little more forceful with these guys, right.

    Doctor: Is it possible you may have hit Mr. Jones?

    Molly: I didn’t. I just had to make sure he wasn’t going to do it again. You know… I mean, after 25 years this guy, he comes in here, he’s drunk, he’s abusive and I, 25 years and look at me, this is great.

    Doctor: Okay Molly, I’m going to ask you a few things. It sounds like this patient was being difficult and physical himself. Did you actually use forcible behavior on him? Did you actually slap him or push him down?

    Molly: I was maybe a bit stronger than I should have been, yes.

    Doctor: Thank you for being honest with me. There’s something else I’m going to ask you, you’ve dealt with him before, you’ve met him before, what was different about today? What got to you more than usual or has this happened before?

    Molly: No, no. I’m just fed up with the waste of money and time when there isn’t enough in the system for the people who really do need it. People like guys like this they just abuse the system and I… I didn’t sleep. My son didn’t come home last night and I don’t know, maybe that was a bit of trouble too. I don’t know. I just… I’m so fed up of people abusing their bodies and then expecting other people to look after them. It’s just…

    Doctor: Do you think your behavior this morning was different than you usually exhibit with your patients?

    Molly: Yes. I wouldn’t be doing this for 25 years. I’m a good nurse. I’m a very good nurse. I love my job. I love my patients.

    Doctor: And I absolutely appreciate that fact and I really respect you for being honest with me. It sounds like this was an unusual thing that hasn’t happened before but it’s my responsibility and yours too, to report any behavior that may compromise the safety of a patient.

Commentary on: Interprofessional conflict, information gathering

Note the quality and quantity of information gathered this time. The physician is non-judgmental and the nurse is less defensive.

Please refer to the Observation Guide for the following sections:

Among the techniques, find where the physician appropriately uses:

  • Explaining
  • Facilitating
  • Legitimizing
  • Summarizing

Among the styles, find where the physician appropriately uses:

  • Silence
  • Checking-in
  • Open-ended questions
  • Body language
  • Gathering the equivalent of biomedical (the incident) and psychosocial (personal) information
  • Integration of information

Among the attitudes, find where the physician appropriately uses:

  • Encouraging discussion and feedback
  • Being non-judgmental
  • Respecting the other’s viewpoint
  • Being empathic

Interprofessional conflict: Management

  • Doctor: Okay Molly, I just like to summarize what I’ve heard and let me know if I’ve got the facts straight here. You’ve had a pretty difficult morning with an extremely difficult patient, on top of that you haven’t had a lot of sleep, and you’ve had some issues with your son; perhaps you behaved in a way that was somewhat inappropriate to Mr. Jones, is that accurate?

    Molly: I guess so, yes.

    Doctor: Okay. And again, thank you for being honest with me. Now, we do have to deal with this. I’m wondering what you think? What would you like to do next?

    Molly: You know I’ve been a nurse for 25 years. Well you came in here you must have an idea what you want to do?

    Doctor: Well, the reality is we do have to adhere to hospital policy, so this incident does have to be documented. We both got to write it down and it has to be reported to your nursing supervisor. Now, we do have some options there. We could go together to do that or you could go on your own and I can follow up later. What would you like to do?

    Molly: I’ll go talk to her myself.

    Doctor: Great

    Molly: I mean, I’ll just go down,

    Doctor: Great. I’ll follow up later and if you do want to talk more about this please come see me. We’ll see where this leads, okay?

    Molly: Okay.

Commentary on: Interprofessional conflict, management

Here we see the techniques of negotiating and summarizing used to good effect in finding common ground. Asking the nurse for her input to the process shows respect, and the physician is honest about her responsibilities to other stakeholders, e.g., hospital policy. The problem and not the personalities are dealt with, and both parties retain self-respect.

The boundary crosser

MCC role objectives

Professional

  • Maintain the highest personal, professional and legal standards at all times (3.3)
  • Abide by the profession’s rules, regulations and ethical codes (4.1)
  • Report a colleague’s actions or behaviours as required or appropriate, using the applicable reporting mechanism (4.4)
  • Observe appropriate and/or legal boundaries in relationships with patients and health professionals (6.3)
  • Be sensitive to, and do not abuse, the power relationships within the health-care system (6.4)

Entrustable professional activities

  • Assess, diagnose and manage patients with acute, common and complex diseases across outpatient settings (2)

 

Critical competencies

  • Develops rapport, trust and ethical therapeutic relationships with patients and families (8)
  • Develops a common understanding on issues, problems and plans with patients, families and other professionals to develop a shared plan of care (12)
  • Demonstrates knowledge of and applies the professional, legal and ethical codes for physicians(21)

Introduction

How much self-disclosure is acceptable in a physician-patient relationship? Patients, who genuinely like and respect their physicians, often want to know a little about them. If you are an international medical graduate, they may be interested in your background. How much should you tell them? Will it be rude, or damage the therapeutic relationship, to refuse?

There is the potential for inadvertent or deliberate boundary crossing in every physician-patient interaction. The degree of risk depends on the context: patient and physician age and sex, the clinical situation and the local environment. As professionals, physicians are totally responsible for the ethical conduct of the physician-patient interaction. Physicians must not exploit the power of their position relative to patients, and must manage situations in which patients initiate the incident.

What happens in the scenarios here is quite clear: the patient is crossing the physician-patient boundary and the physician must deal with it. Everyone knows that one does not enter into an intimate relationship with a current or previous patient. There are, however, many less obvious situations which are considered possible boundary issues in Canadian practice. What do you think about:

  • Looking forward to a patient’s visit, either because you like them, or they praise your professional skills.
  • Making special arrangements to see a patient. This may be a compassionate and reasonable professional action, or it may not. Is this only once or a frequent occurrence? If it is a frequent occurrence, your actions must be justified by the patient’s needs. What is your motivation?
  • It might be difficult to maintain appropriate professional boundaries in a small community; however your code of ethics must nonetheless be respected. Are you or the patient attending the same events because you belong to the same sports club or do you attend as an excuse to meet? You might be put in a situation where you encounter your patients outside of the medical environment. You should therefore have a strategy in mind to help you maintain proper professional boundaries. Think of a situation where this may happen. What would be your response?
  • How comfortable are you with the cultural norms for personal space and touching, particularly in the physical examination? How do you assess the patient’s cultural expectations?
  • Do you know when you should or must report a disclosure of sexual abuse of a patient? Who do you contact? If you do not report and the issue becomes public, what happens? Please refer to the regulations of the medical regulatory authority in the province or territory in which you would like to practice.

The boundary crosser: Part 1

  • Doctor: Okay, Colleen, you said that you’re feeling anxious. Can you tell me more about that?

    Colleen: Sure. I get sort of panicky inside. My heart starts to race, my hands get all sweaty, I get tongue tied. I feel like I’m going to say something stupid but yeah.

    Doctor: Okay, do you feel tightness in your throat?

    Colleen: Sure yeah.

    Doctor: You have difficulty breathing?

    Colleen: No.

    Doctor: You don’t get short of breath?

    Colleen: No.

    Doctor: Okay, when this happens, what do you do?

    Colleen: Usually I feel like leaving the situation like this is really interesting because normally I feel like leaving the situation but I don’t feel like that right now.

    Doctor: Right now…? Okay. When you talk about situations, what sort of situations are you talking about?

    Colleen: Usually around men but I’m not feeling uncomfortable right now. I think it’s probably because you’re so nice.

    Doctor: Well, I’m a doctor.

    Colleen: I can tell.

    Doctor: That’s probably why.

    Colleen: Except don’t wear a tie or anything like that.

    Doctor: Well, sometimes.

    Colleen: Well it’s nice actually.

    Doctor: Ok, good. So let me get back to, are there any other symptoms? So you have tightness in your throat but do you feel like you flushed, your skin is flushed, do you feel warm, anything like that?

    Colleen: A little.

    Doctor: What about do you perspire?

    Colleen: A little bit. Yeah, I like…

    Doctor: So not a lot.

    Colleen: No

    Doctor: Anywhere in particular, chest, forehead?

    Colleen: No. You know I was just going to say I know it’s in style now for guys to shave their heads but white hair really suits you.

    Doctor: Good. Okay.

    Colleen: It’s very manly actually, so attractive.

    Doctor: So these situations that you’re telling me about, what sort of situations precisely, I mean how often do you run into them?

    Colleen: Well usually around men.

    Doctor: What do you do for a living?

    Colleen: I’m a teacher.

    Doctor: Are there men where you teach?

    Colleen: Well there’s a couple, yeah.

    Doctor: And you have problems?

    Colleen: Usually at parent-teacher meetings that sort of thing. I’m okay with the moms but not so okay with the dads. I have a question for you.

    Doctor: Okay.

    Colleen: I have tickets to go see the premiere of an Oliver Stone movie and well, I was wondering if you might like to join me or?

    Doctor: I still need some more information from you okay.

    Colleen: Oh sure.

    Doctor: So this started how long ago?

    Colleen: About six months ago.

    Doctor: Six months. And did it start all at once or was it a gradual thing?

    Colleen: Are you left-handed?

    Doctor: Yeah, I’m left-handed.

    Colleen: That is so sexy.

    Doctor: Now. All right, so let’s get back to six months ago. Now, I really need to ask these questions Colleen and you have to help me. Ok?

    Colleen: Okay.

    Doctor: So I need you to focus a little bit more alright. Good, thank you. So six months ago, it started six months ago what happened six months ago? Did anything change in your life?

    Colleen: Well, not really a change, I mean, we were separated for a bit but just…

    Doctor: So you…Who was separated?

    Colleen: My husband and I.

    Doctor: So you were married?

    Colleen: Yeah. You’re not married, right?

    Doctor: No, not married.

    Colleen: That’s nice.

    Doctor: So tell me what happened exactly?

Commentary on: The boundary crosser, part 1

It might seem contradictory to talk about physician control in a patient-centred interview. How does the physician respond to the patient in this version? Does he seem comfortable, in control of himself and the situation?

The physician uses a number of styles and techniques in this interview:

  • His questioning style uses both open- and closed-ended questions. However, note the change in the type of question as the interview proceeds. Why do you think this happens?
  • He repeats or reiterates a lot. Why do you think he does this? Is it to clarify or because he is uncomfortable?
  • What is the physician’s response to the patient’s personal questions and observations?
  • Note the non-verbal language of both speakers.
  • He indicates his attempts to control the situation twice: “We can talk about that later,” and “I need you to focus.” What is the result of those attempts?

What is the quality and quantity of information gathered by the physician? How successful is he in following his interview plan with this patient?

The boundary crosser: Part 2

  • Doctor: All right Colleen, I need to be really honest with you right now. I’m feeling very uncomfortable and I think we need to set some ground rules in order for me to help you because I want to help you but I can’t if you keep making this a personal relationship or trying to as opposed to a professional one. You know…This is a doctor’s office and I’m a doctor and in order for me to help you, you can’t be, you know… crossing that line. Do you understand that?

    Colleen: Yes, I’m sorry. I just said something terrible.

    Doctor: I know, I know it’s fine and it’s something we need to explore because I think that’s part of the problem right now but if you find that you, you know… you can’t stop yourself from crossing that line then there’s a couple of things we can do. First, I could bring the nurse in. We could have her in the room or I could have you see another doctor maybe a female doctor or maybe I could just leave the room and give you five minutes and then come back and we can try again. How does that sound to you?

    Colleen: I’d rather you see me. I don’t want to be seen by anybody else.

    Doctor: Okay. I’m willing to talk to you as long as we’re on the same page here, all right.

    Colleen: Okay, sure.

    Doctor: So you understand what I’m saying?

    Colleen: Yes, I know. I’m sorry.

    Doctor: Do you understand what I’m asking?

    Colleen: Absolutely. I’m very, very sorry.

    Doctor: Okay, it’s okay. You don’t have to…you know…

    Colleen: I know but I just feel like…you know… I did it again.

    Doctor: Is this something you’ve done before?

    Colleen: Uhm.

    Doctor: Okay. So you see, this is the type of behavior we need to discuss in order for me to help you. Is that okay with you?

    Colleen: Uhm.

    Doctor: Okay, good. So let’s get back to what we were discussing, alright?

Commentary on: The boundary crosser, part 2

Here is one way of dealing with such a situation. The physician attempts to regain control of the interview:

  • The physician stops the usual physician-patient conversation.
  • He is honest about his own feelings, indicating self-awareness.
  • He is specific, indicating that she keeps trying to make this a personal situation.
  • He notes that in order to help her, the relationship must be entirely professional.
  • He then describes the professional dialogue, and checks for understanding.
  • He is respectful of the patient and presents several courses of action for her to consider.

Note that in his body language he draws an imaginary line, which represents a boundary neither should cross.

He then asks for feedback about her understanding in order to find common ground.

Ethical dilemmas

MCC role objectives

Communicator

  • Gather information about the patient’s concerns, beliefs, expectations, and illness experience (2.3)
  • Respect patients’ rights to be given complete and truthful information (3.1)
  • Identify the personal and cultural context of the patient, and the manner in which it may influence patient’s choices (3.2)
  • Establish a common understanding and negotiate agreement concerning diagnosis, management, and follow-up (4.1)

 

Professional

  • Know, and appropriately implement, current ethical and legal aspects of the consent and capacity process. (2.4) These include:
    • determination of capacity for differing contexts of consent (2.4.3)
    • principles of the “reasonable person” standard (2.4.4)
    • principles of full disclosure (2.4.5)

Entrustable professional activites

  • Assess, diagnose and manage patients with acute, common and complex diseases across outpatient settings (2)
  • Manage transitions of care (7)
  • Collaborate with patients, families and members of the interdisciplinary team (9)

 

Critical competencies

  • Develops rapport, trust and ethical therapeutic relationships with patients and families (8)
  • Develops a common understanding on issues, problems and plans with patients, families and other professionals to develop a shared plan of care (12)
  • Demonstrates a commitment to their patients, profession and society through ethical practice (19)

Introduction

There are frequent ethical implications in the decisions physicians make every day. Although not everything is an ethical dilemma, physicians must remain aware of potential issues and be prepared to deal with them.

Consent, which is viewed as being integral to human rights, is the most frequent ethical issue that physicians deal with in Canada. Consent is enshrined in laws and legal statutes which all practicing physicians must understand. Each case in the previous section illustrates some aspect of consent.

This section illustrates communication issues that arise from dealing with an ethical dilemma about consent. Again there are two versions, one more physician-centred and one more patient-centred.

Ethical dilemma: Version 1

  • Doctor: Let me just make sure I got the facts right that you told me about your illness. You wanted to come and see someone who had a fresh point of view, who didn’t know about your dialysis and thinking that you might want to stop it. You’ve had kidney troubles since you got glomerulonephritis at age 10. You had all kinds of problems growing up with drugs and then they finally took your kidneys out and put you on dialysis when you were 23, I think you said?

    Patient: 23, yeah.

    Doctor: And then you got a transplant at 25 and you were okay for a while but then that failed four years later and so now another round of dialysis and we’re four years into that?

    Patient: Yeah.

    Doctor: Have I got those timelines, right?

    Patient: Yes.

    Doctor: And now you’re thinking that you don’t want to wait for another transplant.

    Patient: That’s right.

    Doctor: Well, the consequences of that because you have no kidney function of your own are pretty obvious and pretty final.

    Patient: I will die.

    Doctor: Right and that’s not something that as physicians, that we’d like to hear because there is so much that we can do for you. I mean, chances are very good with everything that you’ve been through. I mean, depression could very well be an issue. I mean, I know you’ve seen some doctors and they said you weren’t depressed, then, but this is now.

    Patient: Yes, well I’ve seen two and one of them told me that I was acting out on my frustrations which might not be so far off because I’m definitely frustrated but really, I’ve seen so many and finally, one of them told me that I had a choice. That I could make that choice.

    Doctor: Okay. Well, I think the problem with choosing to die or kill yourself is something that we view with great difficulty because of the fact that you might not be quite rational about it. I mean, they’re… you’re not in this alone. There’s a lot that we can do for you. I mean, people with kidney problems come to us all the time and…

    Patient: I just want to let nature take its course here.

    Doctor: Well that’s equivalent to committing suicide and when we hear that, we say to yourself, “Are you really thinking straight?” because we’ve got counselors. We could get your family in to talk to them. They’ve got lots of experience. I mean, a new kidney might come up in the near future and then suddenly your life turns around and you might regret having made this decision when it’s too late. I really feel that you’re making the wrong decision here.

    Patient: You just want me to see more doctors, more psychiatrists, and I just don’t see the point.

    Doctor: Well, there’s so much that we can do to help you.

Commentary on: Ethical dilemma, version 1

The physician begins by stating why the patient has come, that is, to talk to someone new about her problem. The physician then summarizes. What information is included in the summary?

  • Medical
  • Psychosocial
  • Illness experience
  • Patient’s values and worldview
  • Integration of information

She checks in that her summary is correct, but the focus tells us where the physician’s interests lie. She makes this explicit by stating: “As physicians we don’t like to see …”

As physicians we are trained to help people and to cure them if possible. Dialysis and transplantation are two of many technological breakthroughs which have saved lives and which we are obliged to use as professionals. This would appear to be the physician’s worldview: “There is an awful lot we can do …”

  • Is there a clash of values between the physician and the patient?
  • Does the physician show empathy (understanding of the patient’s worldview)? Empathy can be expressed both verbally and non-verbally.
  • What is the physician’s non-verbal style?
  • Does the physician show evidence of self-awareness?
  • Does the physician do anything to validate the patient’s feelings or views?

When the patient clearly becomes irritated and tries to interrupt to make a point, the physician rides right over her points and ignores the patient’s non-verbal message. In fact, the physician rarely looks at the patient and appears caught up in her plans to fix things.

The physician openly doubts the patient’s rationality about depression and minimizes her past experience. Common ground is not achieved: “I really think you are making the wrong decision.” The physician does not respect the patient’s point of view and will therefore be unable to help her, despite genuinely wanting to do so, but on medical terms only.

Ethical dilemma: Version 2

  • Doctor: Did I get the timeline of this long illness in your dialysis, right?

    Patient: Yes.

    Doctor: Okay. I could see you’ve been through a lot.

    Patient: I really just don’t see the point of it anymore.

    Doctor: You said you were thinking about stopping your dialysis.

    Patient: That’s right.

    Doctor: And you understand the consequences of that?

    Patient: Yes. I will die.

    Doctor: And you appreciate that that’s an irrevocable decision?

    Patient: Yes.

    Doctor: A lot of times when people make decisions like this, they are depressed, and I know you’ve seen a couple of psychiatrists and they said that you weren’t and from what I can see of you, I think that you are understandably low but not depressed to the point that you can’t make decisions for yourself. So I agree with that, but still I think it’s something that needs to be thought about very seriously.

    Patient: And I have been for about six months now.

    Doctor: Have you talked to other doctors about this?

    Patient: Yes. I mean, I’ve seen so many and finally, one of them did mention that I had a choice. That I could choose not to continue the treatment.

    Doctor: That’s true and that might give you some sense of control over your life. You can refuse treatment, of course you can and that’s assuming and I believe this to be true, that you’re not clinically depressed. You do seem to understand the consequences.

    Patient: I do.

    Doctor: But because it isn’t an irreversible decision, I think that we all need to make sure that we’re making the right decision for you.

    Patient: This is why I’m here essentially.

    Doctor: Well, I’m glad you came. I think that sometimes a second opinion helps. I’d like to talk to you more about your life, about how this has affected your life. I want to talk to you about what you would have liked to do in the future if you could or maybe still can and I’d also like to talk to your doctors about your treatment. I mean, are there things that they could be doing to make things easier? I don’t know that yet. And I know that they’re busy a lot of the time. So maybe I could talk to them and then you and I could talk again, if that would be agreeable. I mean you have got a lot of time to make this decision.

    Patient: Yes, I suppose that’s true.

    Doctor: I mean, I won’t try to talk you out of it but I would like to talk with you about it if you’re willing?

    Patient: Actually, I appreciate that a lot because I get most people trying to talk me out of it.

    Doctor: I won’t do that but let’s talk again soon, okay. How about if we make an appointment for next week?

    Patient: Sure.

    Doctor: Good.

Commentary on: Ethical dilemma, version 2

After a summary similar to that in version 1, the physician checks in again then acknowledges the illness experience with a simple empathic statement: “You’ve obviously been through a lot.” No more needs to be said. The statement is sincere and the patient knows that she has been heard and understood.

The physician then explores in some detail the ethical issue of capacity:

  • She summarizes previous psychiatric consultations.
  • She is honest about her opinion (she agrees the patient is not depressed).
  • By doing so she validates and respects the patient’s point of view.
  • She acknowledges ethical rules concerning refusal of treatment, but:
  • She also makes it clear that in life and death decisions, the level of capacity the patient requires might be higher than in less critical situations.
  • She does this by clarifying and contextualizing the consequences of such a decision.
  • Does the patient both understand and appreciate the consequences of such a decision?

The physician validates the patient’s point of view (“Of course you have the right to refuse …”) and then bridges to a management mode with “But …”

  • Recognizing the patient’s ambivalence about the decision, she states her position as a professional: “We all need to make sure it is the right decision for you.”
  • She indicates her need for more information in order to fully understand the patient.
  • She attempts to find common ground: “I would like to talk more with you.”
  • The patient responds that she has been heard and understood: “I appreciate that. Most others try to talk me out of it …”

What is the major difference between the first and second interview? It is the physician’s attitude.

In the second interview, the physician gives control to the patient and accepts that the patient has the right to control her life: “Knowing you can stop dialysis may give you a sense of control.” She does not attempt to use her expertise in a paternalistic way to “fix” the problem. Rather, she enters into a professional dialogue with the patient.

Cross-cultural interviewing

MCC role objectives

Communicator

  • Initiate an interview with the patient by greeting with respect, attending to comfort and to the need for an interpreter if applicable, orienting to the interview, and consulting with the patient to establish the reason for the visit (1.1)
  • Use appropriate non-verbal communication (positioning, posture, facial expression) (1.2)
  • When appropriate, facilitate collaboration among families and patients, while maintaining patient wishes as the priority (1.5)
  • Gather information about the patient’s concerns, beliefs, expectations, and illness experience (2.3)
  • Indentify the personal and cultural context of the patient, and the manner in which it may influence the patient’s choices (3.2)
  • Provide information using clear language appropriate to the patient’s understanding, checking for understanding, and clarifying if necessary (3.3)

Entrustable professional activities

  • Assess,diagnose and manage patients with acute, common and complex diseases across outpatient settings (2)
  • Collaborate with patients, families and members of the interdisciplinary team (9)

 

Critical competencies

  • Develops rapport, trust and ethical therapeutic relationships with patients and families (8)
  • Develops a common understanding on issues, problems and plans with patients, families and other professionals to develop a shared plan of care (12)

Introduction

Some feel that competent cross-cultural communication requires a detailed knowledge of every culture, something that is clearly not possible. The position taken here is that, with basic knowledge of the techniques of patient-centred interviewing, relatively little additional knowledge and skills are required to perform a cross-cultural interview. This is because of the considerable overlap of the two models: in both, physician self-awareness, willingness to relinquish power and find common ground with the patient, and appreciation of the distinction between disease and illness are central to the physician-patient interaction. (Hanson et al., 1996)

Barriers to cross-cultural communication

  • Belief that one must know the details of each patient’s cultural values and beliefs.
  • Belief that it takes too much time, especially if one must work with an interpreter.
  • Belief that the medical model is the only valid model of health care.
  • Beliefs about others that are based on our own cultural experiences. We may not be aware that these beliefs can be a barrier to effective communication.

The physician’s explanatory model

The physician has two cultures:

  • His/her own social/ethnic background (e.g., born Canadian, Chinese, South African)
  • The medical culture learned in medical school and subsequent practice

Often we do not think about either of the physician’s two cultures as contributing to a cross-cultural encounter. We think of the medical knowledge and skills we learned as being “without culture” and therefore neutral and objective. But in fact, western medicine is grounded in social values and beliefs, as are all human activities. The western model of medicine is therefore a culture. The second explanatory model of the physician is his or her personal history. This is part of us all, but especially evident in international medical graduates. We all try to live in the seemingly culture-neutral medical world, but our personal background influences all that we do and say. If we are not aware of this in working with patients, misunderstandings are certain to occur.

Since the patient is seeking the physician’s help, and the physician is the one with professional expertise, it is the responsibility of the physician, not the patient, to recognize the differences in points of view and to not make assumptions.

The patient’s explanatory model

While the physician’s model is disease-oriented, the patient’s model is illness-oriented. A patient does not know that their gall bladder is inflamed and full of stones; they just know that they have a pain in the belly. Perceptions of illness are culturally determined and different for each person. They provide the meaning of what is going on: how we decide we are ill, why we think we are ill, how we cope with illness, and when we decide we are no longer ill. These beliefs may differ in the same individual over time. For instance, a patient may have a relatively western approach to an illness until the stress of end-of-life issues result in a reversion to original values and traditions. Think about the patient in Module 2 with this in mind.

Determining a patient’s explanatory model of illness

  • What do you call this illness? What do you think caused it?
  • Why did it happen at this time?
  • How does the illness affect you?
  • How bad is it? How long do you think it will last?
  • What kind of treatment do you think you should have?
  • Have you tried any treatments already?

As you can see, this is a variation on the patient-centred method. It is important also to realize that the physician answers the same questions about the patient’s problem, but from his or her own biomedical and cultural perspective. You may “know” that the causation of the belly pain is gallstones while the patient “knows” it is due to something else. Failure to openly acknowledge any differences between the patient’s and your model will make it difficult to negotiate common ground.

Psychosocial and acculturation issues

This additional information may be particularly important in working with patients who are from a non-Canadian background. Again, most of this should be part of any good patient-centred interview.

  • Family structure (here and in home country)
  • Decision-making process (individual and/or family)
  • Size of community here (confidentiality may be an issue in small ethnic communities)
  • Education and current functional status in Canada
  • Type of primary culture (avoid stereotyping)
  • Age at immigration/length of time in Canada
  • Degree of interaction and integration into Canadian social structure
  • Understanding of the Canadian health care system
  • Language fluency

Using the Observation Guide, note the techniques and styles used by the physician in both interviews. How does the interviewer need to change his approach when working with interpreters?

Cross-cultural interviewing

  • Version 1

  • Doctor: Hi, I’m Dr. Welsh.

    Anna:   Hi, I’m Anna Lopez and this is my cousin, Maria Lopez.

    Doctor: Hi, Maria.

    Maria: Hello.

    Doctor: So what can I do for you today?

    Anna: Well, we came in today because my cousin, Maria has diabetes and I don’t think that she’s taking very good care of herself. Also she doesn’t speak English.

    Doctor: Okay, so you’ll be able to translate for us?

    Anna:   Yes.

    Doctor: Perfect, so you say she has diabetes?

    Anna:   Yes.

    Doctor: Okay, and how long had she had it?

    Anna:   She’s had it for about eight months I think.

    Doctor: Okay, and you said she’s not doing really well?

    Anna: Well it’s just that she has medication but she’s not taking it every day or she’s not taking the prescription as she should be.

    Doctor: Ok, and why isn’t she taking her medication?

    Anna:   Well, I think that she thinks that she feels well.

    Doctor: Excuse me. Excuse me. Excuse me, please. Could you just tell me what’s going on?

    Anna: Yes, I was just saying that she doesn’t take her medication every day and she should take her medication. She should take better care of herself.

    Doctor: Okay, and what was she saying?

    Anna: Well she was saying that she feels better and she doesn’t think she needs to take her medication and she doesn’t like to take the pills.

    Doctor: With some blood tests that question can be easily answered and then from there we’ll know how to proceed.

  • Version 2

  • Doctor: Hi I’m Dr. Welsh.

    Anna: Hi, I’m Anna Lopez and this is my cousin, Maria Lopez.

    Doctor: Hi, Anna. Hi, Maria.

    Maria: Hello.

    Doctor: What can I do for you today?

    Anna: Well, I brought Maria in today because she has diabetes and I was wondering if you could talk to her about that. Also she doesn’t speak English.

    Doctor: OK, so you’ll be able to translate for us?

    Anna: Yes.

    Doctor: Perfect. If you don’t mind, I would like to establish a few ground rules so that we’re all comfortable with how we do this.

    Anna:   Sure.

    Doctor: Perfect. So, I would like to speak directly to Maria, so I could establish a connection with her but I don’t want you to feel like I’m ignoring you and you on the other hand, I’m going to ask you to translate as exactly as possible what I say to Maria and do the same when she speaks to me.

    Anna:   Sure, I understand.

    Doctor: Could you translate, please.

    Anna:   Of course.

    Doctor: Is that okay with you?

    Anna:   Yes.

    Doctor: So, Maria your diabetes, how long have you had it?

    Anna: Eight months.

    Doctor: And are you taking any medication for it?

    Anna: Yes, she takes Diabeta.

    Doctor: Did you bring any in with you today?

    Anna: No, she doesn’t have it but listen, I’m afraid that she doesn’t take her medication. At least she doesn’t take it every day and I don’t think that she’s taking very good care of herself.

    Doctor: Excuse me. Excuse me. Please, could you just tell me what’s going on?

    Anna: She was just saying that she doesn’t take her medication everyday only when she’s not feeling well.

    Doctor: And what were you saying?

    Anna: That she needs to take her medication and that she needs to take better care of herself.

    Doctor: Okay. So we’re going to have to get a little bit back on track. If you could just translate my question and her answer and try not to intervene, please.

    Anna: Okay.

    Doctor: Perfect, thank you. So, Maria, why aren’t you taking your medication every day?

Breaking bad news

MCC role objectives

Communicator

  • Respect patients’ rights to be given complete and truthful information (3.1)
  • Effectively communicate in challenging situations (delivering bad news, addressing anger, confusion, medical error, misunderstanding and media interviews) (3.5)
  • Establish a common understanding and negotiate agreement concerning diagnosis, management, and follow-up (4.1)
  • Disclose patient information only when legally permitted (6.1)
  • Adhere to provincial or territorial requirements for obligatory disclosure of patient information (child abuse or abandonment, reportable communicable diseases, duty to warn threatened individuals) (6.2)
  • Transmit information to third parties (insurance companies, government agencies) truthfully and in a timely manner (6.3)

 

Professional

  • Know and communicate to patients the limits of professional confidentiality (reportable conditions, duty to warn) (2.3.2)
  • Maintain the highest personal, professional, and legal standards at all times (3.3)

Entrustable professional activities

  • Assess, diagnose and manage patients with acute, common and complex diseases across inpatient settings( 1)
  • Manage transitions of care (7)
  • Collaborate with patients, families and members of the interdisciplinary team (9)

 

Critical competencies

  • Seeks appropriate consultation from other health professionals, recognizing the limits of one’s own expertise (5)
  • Conveys relevant information and explanations accurately to patients and families, colleagues and other professionals (10)
  • Develops a common understanding on issues, problems and plans with patients, families and other professionals to develop a shared plan of care (12)

Introduction

Breaking bad news is among the most difficult tasks a physician faces. We might be concerned about the emotional response of the patient — and ourselves. We might feel that we have failed the patient in some way and therefore feel guilty or helpless. We might be unsure of what the patient knows already and how much they want to hear. Concerned family members might make requests or demands that are difficult to fulfill. We might have had little or no training in how to break bad news, have had to do it infrequently or never before. Lacking a logical approach and appropriate words, we might appear clumsy, uncomfortable or insensitive. Failure to deal with these issues might result in a conversation with a patient at a critical moment in their life that is less effective than it could be.

Here are two articles that provide structured approaches to breaking bad news. They describe acronyms one can use to remember all of the things one should do. However, it is important not to apply these rules in a rigid manner. It is particularly important when breaking bad news to tailor your words and behaviour to the patient’s needs. Perhaps the one constant rule should be: plan ahead, if possible. Think about the situation, the patient and what you might, or might not, say and do.

You can read the articles before or after watching the interviews:

  • Challenge 1

  • Doctor: Hey, Henry come in, have a seat.

    Henry: Hi doc, how are you?

    Doctor: I’m alright, how are you doing?

    Henry: Not bad I guess.

    Doctor: How’s your wife?

    Henry: She’s okay. She went to see her specialist last week and he said that she’s stable.

    Doctor: Oh that’s good.

    Henry: Yeah.

    Doctor: And did you take her in?

    Henry: Oh yes. I drive her, I always do.

    Doctor: Yeah, right. Well, that’s actually one of the things I want to talk to you about today Henry.

    Henry: Yeah, I was afraid of that. You know that test really wasn’t fair.

    Doctor: Henry… I have the results of your driving assessment and I know how much this means to you. So that’s why I wanted you to go see an independent professional company for your test. Unfortunately, they only confirmed my fears about your driving. They said that unless there are some positive changes with your Parkinson’s you really shouldn’t be driving, Henry and I know this is the last thing you want to hear but I agree with them.

    Henry: Yeah but I’m a careful driver, doc honestly. I drive slowly and we only have to go to the drugstore, the grocery, the doctors. You know I can’t take Shirley to the buses it’s half a mile away I’m her husband I got to drive her so I can look after her properly.

    Doctor: I know you’re careful Henry but it’s your reaction to another driver or something unexpected that worries me and you have to admit your vision isn’t as good as it used to be. You don’t want to be hurt in an accident. You don’t want Shirley to be hurt in an accident or anyone else hurt.

    Henry: No, no of course I don’t, but you know, they say that older drivers are safer than those young yahoos driving around you. Can’t we get another medication or can you give me a larger dose or something?

    Doctor: I do understand Henry but unfortunately, in our province this is one of those situations where I’ll have to report it to the Ministry and they will probably take away your license.

    Henry: But you can’t tell other people about my Parkinson’s, can you?

    Doctor: I’m afraid Henry that this is one of those situations where I have to break patient confidentiality and you know I wish it could have turned out better but, I do have some ideas on how to keep you moving without you being the driver.

    Henry: I can’t afford taxis you know that. I mean, you know where we live.

    Doctor: There are a lot of senior groups in your area that are able to help you and they’re not very far away and I put together this list of contact names and numbers that you could reach them and get a hold of them and they’ll be happy to help you.

  • Challenge 2

  • Doctor: Hi, are you Helen Sebastian?

    Helen: Yes that’s me.

    Doctor: Hi, I’m Dr. Alvarez. We haven’t met before but I’m one of the residents here. We actually changed our rotation yesterday, so I would be looking after you now.

    Helen: Okay, nice to meet you.

    Doctor: You too.

    Helen: You know, there have been so many doctors in and out, I don’t really know who my doctor is. I was hoping to go home soon and I think they finished all the tests.

    Doctor: Yes, the tests are in and that’s actually what I wanted to talk to you about. Now, I see from your chart that you’ve had some bloating and some bowel problems for the last six months, is that right?

    Helen: Yeah. You know, I really didn’t think much about it but I checked in with my doctor about it and she thought that given my history I should.

    Doctor: So you had an operation two years ago, what did they tell you about that?

    Helen: Well, they said that I had ovarian cancer and that they were able to get it all and I’ve been feeling quite good actually.

    Doctor: Okay, so you had about two good years I guess, a year and a half or so, right?

    Helen: Yeah.

    Doctor: Okay, Helen, sorry is it okay if I call you Helen?

    Helen: Please do.

    Doctor: If you don’t mind my asking, is there anybody at home with you?

    Helen: No, I’m divorced and my children live out of town, why are you asking?

    Doctor: I see. Well, the tests are in and we can discuss them now. There’s no real easy way for me to tell you this but the news isn’t very good. You see the CT scan and the ultrasound they didn’t give a definite reason for your bowel problems but the laparoscopy did and I’m afraid the cancer has infected on. Now, were you worried about that possibility?

    Helen: Well, I had… You know I had wondered and sometimes I felt a little scared but I don’t understand, I mean, they said that they got it all. Did they lie to me, because I feel good?

    Doctor: No, I don’t think they lied. They honestly thought that they got it all but you need to understand that this is the nature of ovarian cancer and sometimes it acts like this.

    Helen: I mean… How bad is it? Is there treatment like chemo or something?

    Doctor: Well there are drugs used sometimes, yes but Helen, I’ll be completely honest with you, there is no cure for this. The drugs that are used are very toxic and this is something that you would have to sit down and discuss.

    Helen: So are you saying that, I mean, what about another operation? You know the last time, they said that they could get it all so what about that?

    Doctor: Helen, I’m really sorry to have to explain this to you but the cancer has spread throughout your abdomen and right now we don’t have a cure nor the ability to operate it. Now, is there anybody that you would like to have by your side like a friend or a clergyman? We also have support staff on site.

    Helen: I think I just need to be alone for a few minutes, maybe a bit later I could talk to somebody.

    Doctor: I understand. Is there anything I can do for you right now?

    Helen: No, I just need a minute.

    Doctor: Okay I’m going to leave now but I’m going to come back with the social worker. I believe that it’s important that you have someone to talk to. Is that okay with you?

    Helen: Yeah.

Commentary on: Breaking bad news, challenges 1 and 2

The first interview illustrates the more common kind of breaking bad news situation. The news is not life threatening nor life-ending, although it is definitely unwelcome and disturbing to both physician and patient. The tone of this conversation shows two people who clearly have an ongoing physician-patient relationship. While the situation is not life-threatening, it represents a loss of freedom and independence. It may result in a profound emotional response from the patient, and perhaps a sense of guilt or helplessness in the physician.

Mandatory reporting 

There are a number of situations (e.g. suspicion of child abuse, and communicable diseases, etc.) in which a physician is legally required to report the patient condition to a third party. When a patient has a medical condition that makes them unfit to drive, a physician must be prepared to discuss this with the patient and may have a duty to report. Provincial and territorial reporting obligations vary, physicians must know how to have these conversations and where to find the appropriate resources. We recommend reviewing the following resources:

In cases of mandatory reporting, only the relevant information can be disclosed. The patient should be informed of the disclosure, and with the patient’s permission, a discussion with family is encouraged. You must clearly document the details of the discussion.

Those interested in finding out more about evaluating fitness to drive can read Determining Medical Fitness to Operate Motor Vehicles and consult DriveABLE.

The second interview is the classic kind described in the literature: a terminal illness in a patient unfamiliar to the physician. Also, the physician is a relatively inexperienced resident and is clearly uncomfortable. Compared to the first interview, he uses many more of the behaviours and techniques suggested in the literature. While his approach lacks finesse, his honesty and compassion are evident. What other behaviours suggested in the literature does he use? How successful are they? Which behaviours would help the physician communicate more effectively?


 

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