List of Contents
Chapter 1: Interviewing and Health history interview
Tutorial 1: Chapter 1
Chapter 2: Instructing and educating individuals
Chapter 3: Counseling
Tutorial 2: Chapter 2 and chapter 3
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Chapter 1
Interviewing and Health history interview
Objectives
• Define interviewing.
• Describe the best setting to carry out an interview
• Identify types of questions.
• State use of each type.
• Describe the essentials of an interview.
• Communication skills needed for the interviewer.
Interviewing is one of the best and most common methods of obtaining information in a face to
face situation. The interview provides a situation for specific application of the techniques of
dyadic communication (i-e communication between two persons).
Definition
Interviewing is the interchange of verbal and non-verbal communication between two persons
or more in intention of exchanging information and data relevant to the topics under
consideration.
Interview settings
The setting of an interview is crucial for its success, particularly in terms of privacy and rapportbuilding. It is important to carefully consider the physical environment to ensure comfort and the
removal of any barriers. A counseling interview should be held in the most inviting area
available.
Tools used in interviews
Although questions are the most
important tool used by the interviewers, but interviews are not just a series of questions.
Interviewers often use statements to elicit opinions, feelings, beliefs, and attitudes from the
interviewees. A productive interview typically includes a mix of statements and questions at
the right moments.
Questions can make dyadic communication more accurate. They give feedback and receive
feedback. The interviewer should use an appropriate question, he has to be careful about the
wording of each question he asks and the type of question he uses at the appropriate time.
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The wording of the questions
The wording of the question is important, words must be chosen carefully as words can influence
how a person answers. The questions should:
Only be interpreted in one way.
Be short and have simple vocabulary suitable to the level of interviewee.
Be applicable so that the interviewee can answer them correctly.
Types of questions
1) Open- ended questions:
Usually helps you to obtain general information, they begin with phrases such as:
"How do you feel about ……………….?"
"What symptoms brought you to the hospital?"
"Can you describe your pain……?"
After the person has expressed some ideas, the interviewer might also use statements as:
"Please tell me more about your pain".
"It is interesting. Could you tell me more?"
Such statements allow people to respond freely. It is through this type of questions and
statements you can obtain more information and personal feelings and attitudes may be brought
to light.
2) Simple direct (close ended questions):
These are focused questions that are answered by: Yes or No.
Or
Eliciting single or few words as answers.
Close ended questions are used as a follow up to open ended questions to clarify or explore
more specific points.
Close ended questions do not:
• Give room to discussion.
• Show the full range of opinions, feelings, or attitudes a person has on the subject.
Examples
"Does the pain go anywhere?"
"Where did you deliver your baby?"
Remember
Use Open-to-Closed Cone
Closed direct questions interspersed with open ended questions give the interviewers much
more information.
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Questions that should be avoided
1) Leading questions:
Leading questions will lead the person to give only one answer. They make people give onesided answers. They are dangerous to use in interviews because interviewers will always agree
and rarely reveals their true opinions. These may suggest to the patient the desired answers.
Examples
"You do not miss any doses of your medication, do you?"
"Do not you think that …………?"
"Isn't it true …?"
"Would not it be better if …?"
"Shouldn't you have…?"
2) Double- barrel questions/ Forced-choice questions:
They are formulated to limit the choice of answers. People being interviewed will almost
certainly make one of the choices given, although they may have a completely different opinion.
Double-barrel questions are two questions in one containing words as either,therefore, both & or.
Examples
"Do you eat fish or meat?"
(He/she may be eating neither!!)
"Would you prefer to deliver in a governmental or a private hospital?"
(She may prefer to deliver at home?)
"Do you use the hospital or the health center for routine check-ups?"
(He/ she may be using a private physician.)
3) Double- negative questions:
Double-negative questions are questions that use two negatives to indicate a positive statement.
Example
"Do not you think it is not a wise policy to have a doctor in every health center?"
4) Embarrassing or sensitive questions:
These are blunt questions that may offend or hurt the interviewee.
Example
"Did you ever have a venereal disease?"
5) Jargon-filled questions
Jargon-filled questions should never be used as the words may be unfamiliar to respondent either
technically or slang ‫ عامية‬.
Example
"Has a physician ever done for you an abdominocentesis?"
The medical term is a type of jargons used by doctors. Replace the technical word by saying:
"Has a physician ever stuck a needle in your abdomen and taken water out?"
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6) Complex questions:
Always simplify the question so that respondents can understand it and answer it correctly.
Example
"When we collect enough data on the problems of this district and the available resources in the
community, do you think that building a center is more preferable than organizing outreach
activities?”
7) Inappropriate question
These are questions that the respondents cannot answer correctly, because they cannot remember
or because of the language or that it requests an attitude that they have not thought about.
Example
"How many cigarettes have you smoked since you have started smoking?" (Impossible to
answer)
Essentials of an interview
1) Knowledge of the topic:
Read about the topic of your discussion.
It can be extremely frustrating to be involved in an interview with a person who knows nothing
about the topic under discussion.
2) Temperament (‫)مزاج‬
Appropriate temperament or disposition is essential. A well-adjusted, trained professional
interviewer avoids bias, prejudice, and bad temper. He also does not make value judgments
based upon his own past experience.
3) Listening and observing:
Active listening is crucial in interviews, as it involves hearing and interpreting spoken words and
silent language to understand the complete message being delivered. A trained interviewer
listens to all that is being said, observes non-verbal reactions, and interprets verbal and nonverbal messages in the context of the discussion.
4) Eye contact: Eye contact is essential
5) Good interviewer: A trained interviewer that should be on time, have an objective for the
interview, aware of all the prerequisites for effective communication (Establish a relation, build
rapport by matching person's representation system, mirroring body language, matching his
voice, his experiences ,identify preferred representation system, remove environmental and
personal barriers.(not accept phone calls during interview)
He should promote a relaxed atmosphere and make the interview comfortable, accepting the
person's frame of reference, his level of knowledge, past experiences and interest.
He should be direct, honest, respectful, polite, friendly and empathetic showing concern and
behave according to the culture.
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Communication skills needed for the interviewer.
• Talk and present his message clearly.
• Use open - to- closed cone.
• Reassure the interviewee.
• Use echoing and reflection.
• Listen actively and pay attention.
• Observe carefully and be alert to all communication cues both the verbal and nonverbal ones.
• Discuss and clarify.
• Summarize and repeat carefully.
• Give and ask for feedback.
Medical interviews
The medical interview is considered the most important clinical tool available to physicians. It
is a core medical skill and is the major medium of care
The functions of the medical interview (3 functions)
1. Build a relation with the patient and promote it:
The doctor-patient relationship stands as the cornerstone of all medical care. This will require
specific basic skills namely:
a. Non-verbal skills and behaviors.
Facial expressions (a comforting smile), can significantly impact the rapport between the patient
and the doctor. Paying attention to patients' facial expressions may give clues regarding things
they are not saying, as well as alert you to pain and severity of pain. Facial expressions may
allow you to see to what degree you are connecting with your patients.
Remember
Keep eye contact-Interpret patients' nonverbal messages- Be careful of your own nonverbal
messages and keep consistency between your verbal and non-verbal behaviors.
b. Show that you are empathetic.
This is the most important relationship skill.
 Use non-verbal messages:
(Empathetic look, attentive listening/ silence or a touch)
 Use reflection:
Respond to patient's feelings as soon as they appear.
Reflection refers to a physician's statement of an observed
feeling or thought of the patient. This reflection will function as facilitator and can give the
patient permission to talk more about his feelings and thoughts.
Examples:
Dr. “You look sad" , Dr. "You look upset to day".
Dr. “I can see that you are worried"
Student:" Hello. I am Ibrahim Kamel, a medical student. You seem to be in pain. Is there
anything I can do for you?"
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 Use legitimation (validation):
Here the doctor should let the patient know that the feelings expressed make sense to him and
that he/she is not alone when dealing with the situation. Legitimation allows the patient to feel
that his reaction is a common one...
Examples
Dr.:" I can really understand why you were upset".
Dr.: "Of course it is painful. Anyone will feel the pain".
Dr.:"I can certainly understand why you are upset under the circumstances"
Student: "I really can understand how painful it is"
 Indicate your personal support:
This will enhance rapport. Statements of personal support encourage patients to feel that their
doctor wants to help and that he cares.
Examples
Dr.:" Please let me know what I can do to help".
Dr.: "If you need to contact me for anything please do so"
 Build partnership:
Patients are more satisfied with physicians and are more likely to comply with the treatment's
plan and instructions or advice when they feel a sense of partnership with their doctors.
Example
Dr.: "We have talked about your problem. We can now work together to find some solutions".
 Be respectful to the patient and his problems:
Attentive listening- specific non-verbal signals- eye contact- genuine concern all are signs of
respect. This will help in building and maintaining a relation.
2. Determine and monitor the nature of the problem:
You have to assess and understand the patient's problems and appreciate the psychological
aspects of his illness (e.g psychological aspect of cancer patients). So, there is a need to obtain
accurate, sufficient and relevant information in a time efficient manner.
Gathering accurate data is the central task of patient's assessment.
3. Educate patients and implement the treatment plan:
Regardless of whether the focus of medical concern is acute, chronic care or prevention, patient
education facilitates optimum outcome. Achieving collaborative management depends on the
skill of education, self- management support and motivational interviewing.
The objectives of this function is the achievement of total agreement between the doctor and
his patient about the nature of the problem(s), the diagnostic procedures, treatment plan, the
enhancement of compliance/adherence, improved outcome of treatment and gaining patient's
satisfaction.
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The health history interview
Objectives
• Describe the components of the health history.
• Explain how to open the interview.
• Explain how to conduct the interview.
• Describe how to close the interview.
The health history interview is a conversation with a purpose that provides a situation for
specific application of techniques of communication between two persons.
Most clinicians rate the patient's medical history as having greater diagnostic value than either
the physical examination or results of laboratory investigations. Two thirds of diagnoses can be
made on the basis of the history alone, provided that it has been taken efficiently. Accurate
history provides focus to physical examination, making it more productive and time efficient.
The components of health history
They usually include:
1. Chief complaint or reasons for attending:
It is the issue that the patient is presenting with. Some patients may have an actual complaint as a
headache, colic, chest pain, cough etc. However, others may attend to receive immunization,
have a routine checkup or to pick up contraceptives etc.
2. History of present illness:
The doctor has to further explore the chief complaint by obtaining a well characterized
description of the complaint: location, severity/quantity, possible causes, factors that aggravate
or relieve the symptom, and associated manifestations.
3. Review of systems:
It is a systematic, head-to- toe- questioning of presence or absence of symptoms. It is important
as the patient may only focus on the chief complaint and ignore other symptoms he has.
4. Past history:
It will cover past medical history (chronic and acute medical conditions), surgical history (type
of operation, when it occurred and the indication for operation, etc.), childhood illnesses
(chicken pox, rheumatic fever etc.), and obstetric history (number of pregnancies and deliveries,
birth interval, pregnancy outcome {abortion, still birth, and early neonatal deaths} cesarean
section, complications during pregnancy, delivery or postpartum, tetanus immunization etc.).
Gynecological history includes the onset of menstruation, date of last period, use and type of
birth control and sexual function, etc.
5. Medication history:
It includes medications prescribed by the physician, over-the counter drugs and herbal
products. It covers medication name, the dose, frequency, timing of medication administration
and side effects. Medication history will provide insight into the patient's current and past
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medications, adverse drug reactions and allergies as well patient's adherence to the medication
used (how many doses he missed, reasons for non- adherence and what does the patient do if a
dose is missed).
6. Health maintenance/ Immunization:
The dates and results of screening tests as Pap smear, mammograms, tuberculin tests and
information on diabetes and cholesterol screenings should be included. This part also provides
information on the patient's immunizations and their dates of receipt.
7. Family history:
A family history helps identify potential risk factors for a patient's current and future health,
including health information from immediate relatives, including parents, grandparents, siblings,
children, and grandchildren.
8. Personal and social history:
From this history the doctor will learn about the patient' life including his social background,
housing condition, his/her life style and behaviors, It should cover as well tobacco , alcohol and
substance use.
I-
Opening the interview
Opening of the health history interview in few minutes should cover:
1. Introduce yourself.
2. Establishing aims of the interview.
3. Obtain patient consent.
4. Establish initial rapport.
5. Establish patient comfort.
6. Remove barriers to communication.
Establishing Patient Comfort
This gives the patient the opportunity to tell him how he or she is feeling at the moment
physically or emotionally, and gives the physician important
information about the patient.
Bringing a cup of water, raising the head of the bed or helping
the patient to sit may be greatly appreciated. If the patient is
hot or cold, in pain, or thirsty, the physician should ask whether
he or she can do anything to help.
If the patient responds with an emotional response such as “I am scared that I have cancer, “the
physician should help the patient express and cope with these feelings.
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Remember (your position)
Where you are positioned relative to the patient is important.
It is intimidating (threatening/ frightening) to the patient
for you to stand over him/her. The patient should not be
able to look up to make eye contact. Always have a seat.
Then ask the patient why he/she is here.
If family members or others are present, introduce yourself
to all present and explain the purpose of the interview.
They should not attend the interview except if the patient
asked for their presence. If they will attend, they should
not interrupt or comment on what the patient is saying.
II-
Conducting main body of the interview
How to conduct your interview
A. Elicit the chief concern (complaint).
B. Ask about other complaints or problems.
C. Obtain additional data from nonverbal messages.
D. Elicit the patient’s perspectives.
E. Explore the impact of illness on the patient.
F. Clarify and direct.
G. Check and summarize.
A. Elicit the chief concern (complaint):
To elicit the chief concern use correct questioning style.
Use open-to close end cone approach.
The patient will express their major concerns and will appreciate that their major complaint
(from their point of view was not ignored). Open questions will help you to learn about
environmental and other risk factors that may influence the development of symptoms (life
context of the illness). Also it indicates the willingness of the doctor to listen to his patient.
Let the patient talk spontaneously and freely. What the patient says first may not be the only or
even the most important complaint. Let the patient describe symptoms in a non-directed way to:
Allow you to narrow the set of diagnostic possibilities.
Help you learn about important environmental and stress factors that may influence the
development of symptoms.
Reveal personal feelings and attitudes.
B. Asking about other concerns (complaints or problems):
C. Obtain additional data from nonverbal messages:
The doctor's non-verbal messages have a powerful effect on the flow of information. Your
patient will continue speaking when he feels that you are listening. Maintaining eye contact,
leaning forward, actively listening and observing carefully, watching for emotional cues and
interpreting correctly patients` non-verbal signs are all important communication skills for
gathering accurate information
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The physical appearance of the patient: his/her clothing, glasses, jewelry, makeup can give you
several messages about the patient's personality, physical and emotional status. Their facial
expressions, gestures and posture, patients` eyes will provide you with several messages that
can help you understand your patient and carry out an effective interview.
D. Elicit the patient's perspective: ideas, concerns and expectations (ICE Model):
Perspectives
Patient`s perspectives is made up of thoughts ,feelings, ideas concerns , expectations ,support
system and previous experiences, this influence the physical effect of an illness itself. Patients`
perspectives can be understood through directly asking the patient about ideas, concerns and
expectations (ICE Model). If you do not explore the patients’ ideas, concerns and expectations
you are treating the patient as a disease rather than a person
Ideas
This is about what the patient believes is the cause or effect of the problem. This is an
opportunity to clarify misconceptions, improve understanding and build rapport. Ideas may
include their thoughts about their condition’s nature, cause, or progression. The doctor should
directly ask the patient about what he/she thinks could be causing the symptom.
Concerns
Concerns will address the patient’s fears and anxieties surrounding the situation. Concerns can
relate to the seriousness of the issue, potential implications for the future or unpleasant feelings
and emotions. It is important to find out the patient's particular concerns about his problem in
order to treat it efficiently. Addressing concerns can help with adherence to treatment plan.
Use an open-ended question.
Expectations:
All patient- doctor interactions are influenced by the expectations of both parties, the doctor has
to elicit the patient's expectations, if the doctor knows what the patient expects and wants
whether this is therapeutic options (e.g. prescribing a medication), advice or referral, he will
easily satisfy his patient. Doctors should elicit what outcomes are the patients looking for or
what are their goals .This can be elicited directly by asking open ended question
E. Explore the impact of illness on the patient.
F. Clarify and direct.
G. Check and summarize: Checking and summarizing periodically will:
Help the doctor to review what he has heard and what to be explored next.
Allow the doctor the opportunity to check the accuracy of what he collected.
Provide the patient the opportunity to correct any misinformation given.
Reassures the patient that the doctor is caring and interested.
Promote trust
III-
Closing the interview
Before closing the interview ask the patient if there is anything else he or she would like to
discuss. Then summarize the important information that you have gathered and thank your
patient with a smile.
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Carrying out the health history interview
Components of interview
Opening of the interview
1. Introduced self properly.
Skills
• know who the patient is
• do not called him by his first name without permission
• Relax with a confident smile, maintain eye contact, shake
hands
• Introduce yourself and your role (e.g physician in charge)
• Sit upright utilizing non-verbal greetings.
problem-oriented interview aims to help the patient's with
2. Stated aims of the
interaction and the expectation specific problems
of the interview.
health promotion interview aims to get data baseline of
• The person's current and past health problems,
• Assesses current health risk factors (family history,
smoking, diet, exercise, drug substance etc.).
• Detect early evidence of disease (chest pain, weight loss,
change in bowel habits etc.).
• Informed consent is an ethical obligation , a legal
3. Obtain patient consent:
requirement and a necessary component
• To ask the patient permission to discuss their personal
health information prior to jumping into an interview.
• Patients may refuse the interview if he is too tired or he
does not want to be interviewed by a male or female
• Interviewers should respect these wishes and should not
force their patients into agreeing to the interview.
• Demonstrate interest by showing concern and attention
4. Established initial rapport
Appearing hurried, bored, exhausted, or distracted can
(Body posture, eye contact,
seriously undermine the relationship with the patient
listened actively etc.).
• Listen carefully and do not interrupt your patient.
• Focus on the patient and maintain eye contact.
• Be reliable and don’t make unrealistic promises.
• Show support: smile and touch when appropriate
5. Respond to patient's feelings • The use of reflection followed by legitimation statements
to maintain rapport
and emotional reactions
• Comment on observed patient feelings as frustration, and
sadness so patients feel they have been noticed
• quiet and private environment
6. Established comfort of the
• Bedrail should be lowered to remove physical barriers.
patient.
• nonverbal cues that indicate the patient is not in comfort
e.g An IV, oxygen mask, or emesis basin at the bedside,
facial expressions of the patient of distress
• position: have a seat and do not stand over the patient
• turn off a radio or TV
7. Removed barriers to
• If you use a computer during the interview, look to the
communication.
patient and enter information when he stops speaking
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Conducting interview
1. Indicated the time available
2. Informed the patient of
what will be carried out in
the interview.
3. Elicited the chief complaint
(used open-to-closed cone
approach / comments).
4. Asked about other
complaints or problems
5. Elicit the patient's
perspective: ideas, concerns
and expectations (ICE
Model):
6. Explored the impact of
illness on the patient
7. Clarified and directed to
know more about the
problem.
8. Checked and summarized
Closing the interview
• Indicating time let the patient consider what and how
much to say.
• e.g to ask routine questions or perform a physical
examination in new patient or discuss the results of lab
investigation in return visit.
• Decide about what kinds of information you want to
seek: For new patients comprehensive health history
• First use open- ended questions to open the interview to
help patient describe their problems
• Allow the patient to talk freely for 30-40 seconds. Do not
interrupt your patient
• After an initial nondirective phase the doctor must ask
progressively more focused questions to explore specific
diagnostic hypothesis. So he uses closed-ended questions.
• Do not use closed questions prematurely
• Use enough facilitative comments and behavior
• responding to patients ‘emotions by empathetic statements
• Begin surveying all what is bothering the patient shortly
after exploring the patient's chief complaint.
• Patient may have other symptoms that he did not mention
either because he thinks that they are insignificant or that
he is embarrassed to mention them
• Ideas: this is about what the patient believes is the cause or
effect of the problem
• Concerns will address the patient’s fears and anxieties
surrounding the situation
• Expectations : what the patient expects and wants
• Find out the impact of the problem on interpersonal
relations (with spouse, family members and on his/her
work and emotional stability.
• Use open ended questions rather than closed ones.
• You may need to interrupt your patient's flow of
information to clarify a point or direct the process.
• The clarifying questions to ask your patient what he or
she means by the problem stated (diarrhea, allergies)
• The directive questions to direct the process of
interviewing to know more about the problem.
• Use open ended facilitation. This will encourage your
patient to speak more.
• You have to check and summarize what you have obtained
periodically or when in doubt to avoid misinterpretation
• The checking comment and summarization invites the
patient to reconsider the information given.
• Assessed the patient's understanding
• Provided an opportunity for the patient to ask you question
• Summarized the information gathered
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Examples of questions used in the interview
Type of questions
Introduce yourself
Examples
Physician: "Good morning Haj My name is Ahmed Ali. I am the
doctor of this ward."
Medical Student: "Good morning, Set Om Ahmed. My name is
Ossama Ibrahim. I am a medical student."
Establish aims of the
Physician: "Good morning Haj My name is Ahmed Ali. I am the
interview:
doctor of this ward. I need to take a detailed history of your condition".
Medical Student: "Good morning, Set Om Ahmed. My name is
Ossama Ibrahim. I am a medical student learning how to interview
patients. The doctor gave me your name."
Obtain patient
Physician: "Good morning Haj. My name is Ahmed Ali. I am the new
consent:
doctor. I need to take a detailed history of your condition. It will only
take few minutes and this will not tired you."
Physician: "Good morning Haj I am Dr. Saad I need to gather a little
information about you in order to make sure I am providing the best
care for you. Can we now talk for a few minutes?"
Physician: "I’d like to update your medical file to ensure we have your
most current health information; do you have a few minutes to answer
a couple of questions?"
Medical Student: "Good morning, Set Om Ahmed. My name is
Ossama Ibahim. I am a student doctor learning how to interview
patients. The doctor gave me your name. Would you be willing to talk
with me for a few minutes?"
Establishing Patient
Physician: "Before I ask you about your illness itself, I want to check
Comfort
how you feel right now?"
Indicate available time Do not use the word only as in: "We only have 30 minutes today". This
is a negative statement. You can say:" We have 30 minutes together
today"
Elicit the chief
Example of open
concern (complaint).
Dr.: "What can I do for you today?"
Dr.: "Now, what kind of problems brought you to the hospital today?"
Dr.: "What kind of problems have you been having recently?"
Example of closed
Dr.:" Where is the pain?"
Dr.:" Is the pain sharp?"
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Facilitative comments and behaviors
Facilitative questions
Exploring the patient's ideas about
the disease
Addressing concerns
Elicit patient`s expectations
Explore the impact of the illness on
patient's general functioning and
social life
"Tell me more about your pain or go on": is a
facilitative comment.
A head nod indicating attention is a facilitative
behavior.
Attentive silence, eye contact, hand gestures and
posture will encourage your patient to continue
speaking (facilitative behavior)
Repeating the last few words the patient has said often
invites him to keep talking (Echoing)
Dr.: "What else?"
Dr.: "Could you tell me more?"
Dr.: "You say they only come during spring?"
Dr.: "Could you tell me what is causing your stomach
pain?"
Patient: "I really do not know that is why I came to
see you?"
Patient: " Well I don't know if cancer stomach runs in
families or not. My father had pain in the stomach and
he died from cancer."
Dr.: "I would like to know what concerns you most
about your headache".
Dr: “What worries do you have about these
symptoms?”
Dr.: "In what ways do you think I can be of most help
to you?"
Dr: “What do you hope to get from the consultation?”
Dr.: "I would like to know how this headache has
affected your life at home."
Patient: "Well once I return home, I immediately go to
my bedroom and avoid speaking to anyone. I darken
my room and bind my head and lie down hoping that
the headache goes. I yell at anyone who enters the
room."
Dr.: "I understand; lots of patients with severe
headache behave in a similar way. What about your
husband?"
Patient: "Well he is supportive. When I have a severe
attack, he takes the kids far away and let them do their
homework".
Dr.: "Did your headache affect your work?"
Patient: "Well I told you. I changed my job a month
ago. Everything is new and I have to adapt to new
things. Until now I am coping. Once I am deeply
involved in work I forget about the headache. Mind
you I vomited twice at work".
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Clarifying the information
Clarifying the terminology used by the
patient
Finding the chronology of the problem
Directing to find the cause of the problem
(life context of illness)
Check and summarize
Closing the interview and thanking the
patient
Dr.:"Mrs. Aida you say you have more
headaches now. Can you describe these
headaches to me?"
Patient: "They are usually affecting one side
of my head. They are so severe that I usually
vomit. I cannot tolerate noise or even light."
Dr.: "You say you suffer from allergies. Can
you tell me what you mean by allergies?"
Patient: "Well my eyes run and itch and I
sneeze a lot. My head aches."
Dr.: "Can you tell me when these headaches
started?"
Patient: "I have been having them all my life.
They started when I was 14 years old.
But they are worse in the last 6 months."
Dr.: "You say they are worse in the last six
months?"
Patient: "Yes. I got married and I am
working in a Bank from 8.0 Am-5.0 Pm. My
Job is not an easy one and my husband is a
very demanding person. After my marriage
my life is different. I cannot do my work
efficiently as before. My husband does not
help me at all. He claims that home duties are
the responsibility of the woman not the man.
Dr.: "Do you think that the burden of your
marriage and work are putting you under a
stress?"
Dr.: "Let me check to see if I understand
what you have just told me. You are allergic
since you were fourteen years old. These
allergies are worse this year."
Dr.: "What question do you have for me?"
Dr.: "Do you have anything to discuss or
add?"
Dr.: "Thank you for all the information you
have given me".
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Interviewing and Health history interview
Tutorial 1
Exercise I
Identifying types of questions
1. Do not you feel that exclusive breast feeding should be recommended?
Type:
2. Do you prefer to play basketball or football?
Type:
3. Please tell me about your views about the communication course?
Type:
4. Do not you think it is not right for a pregnant woman not to attend for antenatal checkups?
Type:
5. Have you ever thought of applying for social aid for the poor?
Type:
6. Are nurses overworked, or they are just inefficient?
Type:
7. Have you ever been told that your child have PEM or rickets?
Type:
8. Where did you receive your antenatal care?
Type:
9. How many eggs did you eat in the past year?
Type:
10. Can you tell me more about these headaches?
Type:
17
Exercise II
Identify the communication skills carried out in the following statements:
1) Hello, my name is dr Samir. Thank you for speaking with me today. This interview will
take about 30 minutes to complete. The purpose of this interview is to learn about your
experience with the disease from the time before you got a diagnosis up until today
Communication skills carried out are:
a. -----------------------------------------b. ------------------------------------------c. ----------------------------------------d. -----------------------------------------What communication skills are missing in this statement?
a. -------------------------------b. ------------------------------2) You said you noticed something was different and didn’t feel right. Could you please tell
me more about that?
What is the use of this question?
----------------------------------------------3) How did your symptoms affect your daily routine, work, family?
What is the use of this question?
----------------------------------------------4) Which outcomes are most important to you when it comes to your condition?
What is the use of this question?
----------------------------------------------5) Doctor is asking a patient if it is okay to take a blood pressure reading, and the patient
replies “Yes”.?
What is the use of this question?
------------------------------------------------6) “I can imagine how frustrating this is for you.”
What is the use of this statement?
--------------------------------------7) “Most people in your position would feel the same way. ”
What is the use of this statement?
-----------------------------------------8) "How are you feeling?" "Are you comfortable now?" "Do you feel well enough to talk
now?"
What is the use of this question?
--------------------------------------------18
9) Dr "What problems brought you to the hospital today?"
Patient "My chest feels really tight!
Dr: your chest feeling tight (repetition)
What are communication skills used?
a.--------------------------------------b.---------------------------------------10) Which terms of ICE are the following statements?
a. What were you hoping to get out of today’s appointment?” --------------b. “What do you think might be causing your chest pain?” -----------------c. “What are you most concerned about?” -----------------------------d. “Let’s start by getting a list of topics you would like to talk about today. What is most
important to you?” -------------------------------11) “I’m not sure I understand. Can you explain it to me?”
What is the use of this question?
--------------------------------------------12) During the past half hour we have talked about ---What is the use of this statement?
------------------------------------------Exercise III
Now let us examine the following dialogue and answer the following questions?
Dr.: "Now, what kind of problems brought you to the center to-day?"
Patient: "I am having terrible headaches".
-What information did the doctor receive? --------------------------------------Dr.: "Please tell me some more about your headaches?"
Patient: "Well they are really severe. But they come and go. They come on slowly and get worse
over several days. They come worse during this season. You know I have allergy."
-What is the use of the doctor `s question? -------------------------------------------Dr.: "What else?"
Patient: "They only started a month ago".
-What is the use of the doctor `s question? -------------------------------------------Dr.: "You say that your headache started a month ago?"
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Patient: "Yes. You know we are in the spring. Spring and autumn are the months that allergies
and headaches do occur."
-What is the use of the doctor `s question? -------------------------------------------Dr.: "What else happened during this month?"
Patient: "Well I changed my job a month ago. Everything is new and I have to adapt to new
things. Also I have to work at night".
-What type of information did the doctor receive? ------------------------------------------Patient: "The headache was so severe that I wished to die!!"
Dr.: "I am sure that the pain was unbearable."
-what communication skill did the doctor use? ----------------------------------------------Dr: "Is Headache intermittent?"
- What is the type of question? ---------------------------------------Dr.: "Now that you have told me about your headaches, I would like to know what else is
bothering you."
Dr.: "What other problems do you have?"
Dr.: "Are there any other thing you want to tell me?"
-What is the use of these questions?--------------------------------------Exercise IV
Script
Read the following dialogue:
Dr. Sobhy: "Good morning Mrs. Abeer. You are always on time. Your daughter Lyla looks just
fine. She is now 4 months of age."
Mrs. Abeer: "Yes, she is four months and fifteen days" Mrs. Abeer leans forward and smiles
Dr. Sobhy: "She is four months and half. What are you giving her now?
Mrs. Abeer: "Only my breast."
Dr. Sobhy: "Well it is best to keep breast feeding her as long as possible. But now she will need
other foods to help her to continue to grow well. You can introduce her to cereals. What types of
cereals do you have at home?"
Mrs. Abeer: "Well I have rice and wheat."
Dr. Sobhy: "Good, you can use either to make the first food for her. Do you know how to make
porridge? "
Mrs. Abeer: "Yes, I can. (Abeer smiles) My family loves the thick porridge I do?"
(Dr. Smiles)
Dr. Sobhy: "Excellent, but for Lyla you have to make it very soft first by adding water. As Lyla
grows older, you increase gradually the thickness of the porridge.
Question: What function(s) of the medical interview did Dr. Sobhy fulfill?
20
Chapter 2
Instructing and educating individuals
Objectives
• Describe instructing patients during physical examination and Lab investigations
• Explain importance of prescribing and instructing patients skillfully.
• Describe essentials in giving information and instructions related to patients concerns
• Describe how to share bad news with a patient.
• Describe the clinical significance of health education.
• Explain how people change.
• Describe how a doctor educates his patient about his illness.
• Explain how patient's education can be integrated into a medical encounter.
.
In every contact with a patient you may instruct, guide or educate him. Clinicians rely on the
third function of the interview namely educate patients and implement the treatment plan to:
Educate their patients for shared decision making.
Support patient self- management.
Motivate their patients for adaptive health behaviors.
The educational or informational giving function is the most inadequately carried out. Many
doctors have seen their role primarily as diagnosticians and treatment providers; and not as
educators. Many doctors underestimate their patient's desire for information.
Research indicated that patients often do not understand their doctors, are unable to identify
correctly all the critical information given, do not know the medications prescribed.
Patients' non-adherence is a major problem.
Instructing the patient during a physical examination
Before you start any physical examination, ask the nurse or your assistant or a family member to
help the patient undress. Then ask your patient to lie down on the bed if this is needed. Make
sure that your hands are not cold while you are examining him/her.
During a physical examination you have to be aware of health literacy issues. Ineffective
communications may lead to hostility, anger or even refusal to be examined.
Cultural, language and communication barriers together or alone may lead to mutual
misunderstanding between patients and their doctors. Ensure privacy, minimize noise, and do not
use any frightening words or medical/ technical terms that your patient is not familiar with. So
when you carry a physical examination avoid using terms as auscultation, percussion,
palpitation, rectal examination etc. These terms are unfamiliar words to your patient.
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In order that the patient can cooperate during the physical examination, the doctor should show
his/ her respect and his/her empathetic skills. He should explain each step of examination he
will do whether this is a chest, abdominal, rectal or vaginal examination.
He should make clear communications and use plain language: a language at a level that the
patient can understand.
In some instances the patient may remember information that he forgot to tell you during
taking his medical history. In these instances, stop examining your patient, listen attentively
and look straight at his eyes. Collect accurate and sufficient data about the added information.
Evaluate this new information according to its importance and relevancy to his /present
problem. Thank your patient and then complete your physical examination.
EXAMPLE
Giving instructions during a physical examination
Dr.: "Ok Haj Samy, let us examine you now. I want to listen to your chest. Can you take off
your shirt and sit on the bed."
Patient: "Fine."
Dr.: "Now, I will listen to your chest. Just relax and breathe normally. Good. Now take a deep
breath and hold….Good. Again take a deep breath and hold…. Perfect. Your chest seems ok!
Doctor pauses
Dr.: "Just lie down flat on your back with your arms near your body and your head on the
pillow. Good, now I need to feel your abdomen. Just relax.
Do you feel any pain here?"
Patient: "No."
Dr.: "What about here or here..?"
Patient: "None. I feel no pain”
Dr.: "Fine, you are doing very well. Now I will do my last examination. It is a little
uncomfortable but it is important for the pain you are feeling.
Doctor pauses
Dr.: "Please pull your trousers and underpants towards your knees. Good.
Now, I want you to lie on your left side facing the walls and your knees towards your stomach.
Good. Now I will insert a gloved finger into your back passage. Good!! You are doing very well!
You can get dressed now."
You can see that in this example the doctor avoided using medical terms and smoothly
carried out his physical examination.
22
Instructions related to investigations
After physical examination you may need to confirm your preliminary diagnosis. You will refer
your patient for laboratory investigations. Tell your patient what and why are these
investigations required and their importance.
Suggest several laboratories and indicate when they should be carried out. Give the patient the
list of investigations needed. It is advisable to give your patient a printed list rather than a
handwritten list.
Before the patient leaves your clinic, give him/her the date for the next appointment. You will
need to discuss the results of the investigation and the diagnosis you will make.
Prescriptions
Writing prescriptions require good written communication skills. These prescriptions are kept by
the patient and may even be used several times. All prescriptions should be readable, complete,
clear and specific. Patients may not be able to read badly written prescriptions and even
pharmacist fails to do that.
Example of bad and good prescriptions
CASE STUDY
The deadly handwritten prescription
El-Ahram 9 November 2019
A 24 year old man complaining of constipation consulted a doctor who prescribed laxative
Laxin 3 times a day. The prescription was badly written, the pharmacist interpreted the drug to
be Lanoxin a cardiac drug that is considered to be extremely toxic on the cardiac muscle if
administered beyond the safe dose (one tablet per day for five days, then stop for two days, then
resume the drug). The patient died as he took the wrong drug 3 times daily. He died as a result of
a careless doctor who wrote unclear prescription and a pharmacist who did not perceive the
seriousness of the situation and inquired about the main complaint of the patient before giving
the wrong drug.
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This case study indicates that:
The doctor who prescribed the medication did not properly educate his patient. The
patient did not remember the name of the medication.
The pharmacist did not inquire about the indication of the medication that he could not
read. He should have asked the patient: "Why did your doctor prescribe this
medication? Also, he should have revised the strength and dose of the medication he
gave which did not match the dose prescribed by the physician. The pharmacist should
have telephoned the doctor or asked the patient to go back to his doctor and write a clear
prescription.
The importance of using the computer in writing medical prescriptions to avoid bad
hand writing. Also, others recommend writing the prescription in two languages.
Information and instruction related to health concerns
Doctors should provide the patient with a well written list of important information and
instructions related to his/her problem and its management. This list can act as a memory aid to
ensure compliance, avoid medical errors and help patients play an active role in taking care of
themselves. It can as well empower their care givers.
Patient's instructions should be written clearly and in simple language. The physician should
avoid writing: jargon, medical terms, symbols or abbreviations.
After writing your list you have to instruct your patient orally. You have to:
• Use words and expressions that are clear to your patient.
• Use few words.
• State the message in a consistent way.
• Be real and say what you mean.
• Be polite and considerate.
• Make sure that he/she understood your message
After giving your instructions ask your patient to repeat what you have stated. Ask your patient
if he/she has any question and then thank him/her. As a doctor you may also allow your patient
to record your oral instructions on their mobile.
Breaking Bad/Sad News
Breaking bad news is often challenging because the three functions of the medical interview
(building relations, determining and monitoring the nature of the problem, educating and
implement the treatment plan) overlap and occur simultaneously. So breaking bad news is
difficult. In breaking bad news the patient should feel cared for and supported and should know
that he/she will not have to go through the coming difficulties alone.
Deficient training in communication skills leaves most doctors unable to give bad news
appropriately. When bad/sad news is broken insensitively, it can lead to negative results for both
patient (and family members) and doctor.
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For the patient it may lead to:
Unnecessary pain and suffering.
Misunderstanding of the condition.
Affecting the patient's decision making.
For the doctor it may lead to:
Decreased personal satisfaction.
Decreased professional satisfaction.
Tendency to avoid similar situations in the future.
What are the possible emotional responses of people told bad news?
Become silent.
Ask lots of questions
Look fearful and angry
Show disbelief.
Look sad or Cry
Show guilt.
Blame others.
How to share bad news with your patient?
To break bad news you have to carry the following NINE STEPS:
1. Prepare for the discussion.
2. Make an introductory statement.
3. State the news with clear, concise language.
4. Wait for the patient reaction.
5. Reflect the response of the patient back.
6. Legitimize the patient's reaction.
7. Explore the cause of the patient's reaction.
8. Provide realistic hope.
9. Begin collaborative management once the patient's stress response has subsided.
1. Prepare for the discussion
a. Make preparations as fully as possible (read about the disease, the check notes, test results,
time arranged for follow-up investigations or admission).
b. Decide what time you are going to speak to the patient. Allow enough time.
c. Think about what you are going to tell your patient.
d. Ask the patient ahead of results if he prefers having someone with him when he/she is told the
results of the test or procedure.
e. Select suitable room, arrange furniture appropriately and ensure privacy with no interruptions.
2. Make an introductory statement
a. Make a brief statement that implies that you will discuss an important subject.
Example
"We got the results of (biopsy or CT scan or blood test …etc.) and we have something to
discuss".
25
Or
"I want to talk about what it shows."
b. Wait a second or two until you have the patient's full attention.
3. State the news with clear, concise language
a. State the news as it is.
Example
"The sample taken shows you have cancer breast."
b. Avoid medical terminology as mass, or lesion or biopsy etc.
c. Try to be definitive as possible. If the biopsy reading concludes that your patient has cancer
avoid using phrases as:
"The sample taken shows that you are probably (or may) have cancer".
d. If you cannot be definite, be clear and honest.
Example
"I am concerned about the results of your sample."
(Pause)
"We need to take another one".
4. Wait for the patient reaction
Actively observe the patient for any emotional reaction.
a. If no reaction appears or if your patient says:
"I am not an emotional person. I usually take action."
Then move to the treatment plan but continue observing for emotional reaction.
b. If you are not sure of the patient's reaction you can say:
"Before we discuss how we deal with your problem can you tell me your reactions to what I have
just told you?
OR
"What does this news mean to you?"
OR
"What is in your mind now?"
c. If the patient emotionally reacts you can go to step 5.
5. Reflect the response of the patient back
Use reflective statements as:
"You seem sad".
OR
"This news is upsetting you."
6. Legitimize the patient's reaction
Use legitimizing statements as:
"Of course, you're upset. I would be too".
OR
"Many of my patients react exactly as you are doing now."
OR
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"I can understand why you are angry about your illness."
By legitimizing the patient's reaction, you will make him feel that he is not alone when he is
dealing with the situation. Moreover, the patient will feel that his reaction is a common one.
7. Explore the cause of the patient's reaction
It is important that the treating doctor understands the causes of the patient's reaction. Each
person has his own reasons. Take your time and gather a list of the biggest concerns the patient
will have.
Example
Dr.: "Most people get upset about a cancer diagnosis; but everyone has his own reasons. What
upsets you the most about having cancer?"
8. Provide realistic hope
This is an important step. Give as much positive, practical support and information as possible.
Remember that what is hopeful news for you might still be bad news for your patient.
9. Begin collaborative management once the patient's stress response has subsided
a. Ensure that the patient has enough time to let news sink in.
b. Address patient's concerns before starting the management plan.
Example
Dr.: "May I address your concern now and the next steps to treat your illness.
Do you need more time to take this news in?"
c. Check patient's understanding before she leaves.
d. Offer a follow-up appointment, a number to call, or addresses of helpful agencies.
Patient education
Health education can be defined as any designed combination of methods to facilitate voluntary
adaptation of behavior conducive to health. Patient education represents health education
centered in medical care settings but not necessarily limited to clinics or hospitals. It is initiated
by medical personnel to strengthen the motivation and ability of patients to adhere to prescribed
medical or self - care regimens, including preparations for hospitalizations and rehabilitation.
Patient education may as well include education to prevent the onset of the problem or disease. It
may be directed at family members as well.
Clinical significance of patient education
Patient education is often as important as any prescription or surgical procedure in restoring a
patient's health. Its clinical significance is well established. It can:
Reduce patient anxiety.
Decrease use of analgesics and other medications.
Increase patient's adherence.
Reduce duration of treatment.
Shorten hospital stay.
Decrease risk behaviors.
Improve patient's satisfaction.
Reduce morbidity and mortality.
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Patient education is not as simple as it may at first appear. Patient education and its key
component, behavioral change, are long term processes that require time, stamina (‫) تحمل قوة‬and
increasing confidence in the patient's ability to cause change. Many factors interfere with the
successful transfer of information from doctor to patient as anxiety, low health literacy, patient
misunderstanding, and use of technical language.
Patient education involves helping patients come to know, understand and accept their illness, to
recognize and acknowledge risk behaviors, to make informed treatment decisions, to adhere to
treatment plans and to cope with complications and relapse.
Patient education is more than just telling and explaining. It does not mean instructing or
advising your patient. Here you are only giving information. On the other hand, the most
important function of educating your patients is to help them change their unhealthy behaviors.
The most important role of patient education is to change behavior.
What do we mean by a behavior?
A behavior is an action that has a purpose, duration and frequency. In all communities there are
many behaviors that promote heath and prevent disease (preventive behaviors) and others that
can help in the cure and rehabilitation of patients (treatment behaviors). As a doctor you need
to understand for example why your patient smoke or does not adhere to the medical
prescription? To change his/ her behavior it is important to find how frequently he does this
behavior and for how long. A recently adopted behavior can be easier to change. An unhealthy
behavior that is frequently carried out will be among the priority list of behavior that requires
attention. As a doctor, you need to educate your patient and help him to change the unhealthy
behaviors.
How can we help people to change behavior?
This is done by understanding the three groups of factors that affect behavior and deal with the
most important factors that are amenable to change. These groups include:
• Predisposing factors
• Enabling factors
• Reinforcing factors
Predisposing factors
Predisposing factors include knowledge, perception, beliefs, attitudes and values. They provide
motivation for behavior. Knowledge and beliefs can be changed and both are important.
Example:
If the mother does not know about oral rehydration salt and its role in treatment of diarrhea and if
she does not believe in its benefits she will not be motivated to give it to her child.
• Doctor's explanations, pamphlets, booklets, health talk etc. can foster patients' awareness and
understanding.
28
• The doctor can clarify patient's beliefs, worries and personal motivations through group
discussions, role play and stories.
Enabling factors
They include patient's health related skills and income, availability and accessibility of
services, health resources, transportation and time available. It also covers laws, rules and
regulations as well as commitment to health. Enabling factors will help the person to adopt the
new behavior and to carry it skillfully.
A skill is a practice or a behavior that is carried out correctly or according to specific criteria.
The doctor can reinforce the skills by having patients go over them again and again and
providing immediate feedback.
Example
If the mother lacks the skill of preparing oral rehydration solution and in giving it to her sick
child, she either will not give the child the solution or she will prepare or give it wrongly. So, it
is important that doctors train their patients and build their skills. The training method depends
on the type of skill.
➢ Manual skills
Giving an injection or preparing oral rehydration solution is example of manual skills patients
should acquire. The health provider should demonstrate the technique and allow the patient to
practice it in front of him and give immediate feedback. The patient should practice the skill until
he masters it.
➢ Thinking skills
Diagnosing signs and symptoms of a disease or complications require thinking skills. The health
provider can rely on case studies in his training. In the case study he can incorporate pictures of
signs of the disease or complications that the patient has to diagnose these signs. He should give
immediate feedback. The doctor should allow the patient to practice the skill learned on other
patients.
Reinforcing factors
They include the attitudes and behavior of all persons around the individual whether in the
family, school, work or when they seek care in a health facility. These factors will play a role
after the behavior has been adopted. Patients can find support from the doctor, the nurse, a
spouse, family members or peers. Your behavior and attitude will reinforce the patients adopted
behavior
Example:
If the grandmother opposes oral rehydration treatment, the mother may not give it to her child..
29
How to be an effective educator
1. Elicit patient's base line understanding of his problem/disease
Dr.: " What is it that most concerns you about your symptoms?
Patient: "Well, I've been weak and dizzy and urinating a lot. My mother felt the same when she
first got diabetes."
2. Tell the patient the core message
The core message can be the diagnosis, or acute management, or chronic care etc.
Dr.:"Mr. El Sayed, the tests confirm that you have diabetes". (Diagnosis)
Dr.:"Mrs. Sameer, I'm sorry to have to tell you that I have some bad news for you today. Your
biopsy confirmed that you have cancer breast. But I want to tell you that there is a lot we can do
for you."
3. Ask the patient for his or her understanding of his/ her condition
Dr.: "Perhaps you can tell me what you already know about diabetes and its management before
I go into details about diabetes, its causes, and what can happen if we cannot control it."
4. Respond to the emotional impact
Dr.: "I see how upsetting this news is for you. I am here to help you. I am going to do everything
that can help you go through this. I want you to remember that there is a lot we can do to fight
this thing together."
5. Counsel the patient about details of the educational message
The doctor once achieved the above steps he can now elaborate on the details of the core
message. Use language consistent with the patient health literacy. So use terms that the patient
will understand. Use short sentences that clarify each point. Use visual aids as posters, pictures,
drawings, charts or graphics to communicate more clearly.
The doctor should stop frequently to check the patient's understanding and ask for questions.
6. Ask the patient to tell-back the core details of the message
Dr.:" I would like to make sure that I have been able to make this information clear.
Would you mind telling me back what we just discussed about the condition?"
How can patient education be integrated into the medical interview?
First visit
The objectives of this first visit are to:
Raise awareness and interest.
Define the problem.
Achieve acceptance and commitment to change.
Negotiate a plan.
Start with a trial.
30
Doctor's Tasks in the first visit
In the first visit, the clinician's task is to move patients from non-awareness of the problem to
trials or action. The doctor task is to state the diagnosis or problem and to agree on the
problem and commitment. He should use trigger questions or statements. The doctor should
speak clearly and avoid using medical jargon or pathophysiological detail showing concern and
respect. The doctor should deliver a brief, clear message about the diagnosis or problem that
contains specific statements:
The name of the diagnosis /problem.
General prognosis.
What might be done?
How can the doctor help the patient and offer support?
Your patient may express feelings or worries once he heard the diagnosis. As a doctor you can
respond to the patient's expression of emotion or gently use open ended questions to elicit them.
You can say:
"What do you feel about..?"
This trigger question assess and attend to feelings, worries and expectations.
Also expect that your patient to shut down once he/she heard your diagnosis and prognosis. The
patient withdraws into himself/herself to examine the meaning of your message. If this happens,
you need to wait for the right moment or even the next visit to provide the information he/she
needs before moving to the next stage.
In communicating with your patient do not lay out several problems or provide too many
details. Your patient will feel helpless. If the patient has several problems ask him where he
wishes to start and then tailor the amount and kind of information to the patient's choice
"Where do you want to start?"
This trigger question is a way to assess awareness and agree on priority problem
"What do you know about"?
This trigger question is a way to assess the patient's understanding of his problem and clarify
knowledge, experiences with the diagnosis or its treatment. This will help the doctor to quickly
and efficiently provide the needed input. To help your patient to remember you should:
Use simple words.
Stress relevant points.
Summarize at the end of each main topic and at the end of your communication.
Record your instruction or provide a written document.
"What are you willing to do?"
This question will reveal the intentions of the patient to take action. It assess readiness to
change and build commitment. It will also open the way for constructive negotiation about
actions to be undertaken. The patient and his doctor have to come to some agreement about
31
actions to be done and expectations. If the patient is not ready to act, the doctor has to continue
in his persuasion and negotiation in the next encounters.
The doctor briefly describes and explains options and available alternatives. Also he explains
potential side effects and complications. The doctor may indicate his/her preference and advice
and provide specific recommendations. He should ask his patient for a decision.
"Which option do you choose?"
Asking the above question ensures that the patient can become actively involved from the
beginning in their treatment. The doctor should always show respect for the patient's right and
need to exercise a choice and he should ask for patient`s decision and start negotiating a plan for
a trial
In negotiating the plan for a trial, the doctor can steer (guide or lead) his patient toward
behaviors that are simple and easily to change and be performed. This is to maximize the
chances for success. The patient can perform the behavior needed skillfully. Then other
behaviors/skills can be addressed.
The doctor needs to help his patients understand and practice the skills needed during office
visits.
Examples of skills
Administer an insulin injection to self correctly.
Monitor ones' blood glucose efficiently.
Prepare oral rehydration solution according to guidelines.
"How do you want to go about it?"
By using the above question, the doctor can assess and reinforce skills and resources for
implementation. Knowing the resources available will help the doctor to train his patient to use
available resources.
The doctor can help his patients overcome their anxiety or embarrassment about admitting their
concerns by asking the question:
"What problems might arise?"
This question will reveal patients' anticipated problems and find solutions. Knowing the
patients' problems will help the doctor to find solutions with his patients. The doctor can start
problem solving process by asking about possible problems and obstacles
Anticipating problems and obstacles from the beginning can promote adherence and helps
prevention of relapse.
Support from the social environment is a powerful determinant of successful behavior change
and maintenance. Always as a doctor find out sources of help available to your patient and
mobilize this support. You can ask:
"Who or what might help you?"
32
The patient may be supported by a spouse, family members, and social groups. As a doctor, you
may need to identify, mobilize support and give those helping the patient additional
information, training in specific skills and special support. The attitudes and behavior of all those
around your patient will reinforce the adopted behavior.
Adoption and maintenance of behavior change
The tasks here are to reaffirm commitment and arrange a follow-up date. The doctor has to offer
his support. A statement as "I'd like to see you again in …" will indicate the doctor's continued
interest in working with his patient. The doctor has to arrange follow up date.
The follow up interval should be long enough to give the patient some experience with the trial
and produce measurable changes. At the same time, it should be short enough to provide timely
Before the patient leaves, the doctor should repeat the main points of the agreed-upon plan. He
may even ask his patient to summarize these points. This is important to ensure that the patient
understands the plans agreed upon and give him the opportunity to correct misunderstanding. For
example, the doctor to check and reaffirm agreed upon plan he can ask:
"Until we next meet, what will you do?"
Repeating the main points gives the patient an opportunity to rehearse them. Also, you will be
sure that your patient understood your plan.
Second and subsequent Visits
The objectives of these visits are to:
Continue to focus on actions carried out.
Help patients to reach maintenance of the behavior newly adopted and
Prevent relapse to the previous unhealthy behavior (e.g relapse to smoking behavior after
quitting smoking).
Assist those who moved to relapse to cope with it.
Doctor's Tasks in the second and subsequent visits
In subsequent visits, patients may still need to focus on the action. However, with more contact
with the doctor they will be able to move to the maintenance or prevent relapse to occur. The
doctor has two tasks in follow-up visits:
Build and reinforce maintenance of the adopted behavior. (main task)
Prevent relapse or assist in coping with it.
The doctor in subsequent visits will use trigger questions and statements when he is reassessing
the problem and patient's commitment, improving the management plan, and in discussing
follow up visits.
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Trigger questions and statements for second and subsequent visits
A. Reassess problem and commitment.
"Where do you want to start?"
"What has happened since your last visit?
"Today your findings are …."
"This means for you…."
"What do you now feel about …….."
"What are you willing to do now?"
B. Renegotiate an improved plan
"Your options are…."
"I recommend you …."
"Which option do you choose…?"
"How do you want to go about it now?"
"What problems might arise?"
"Who might help you?"
C. Reaffirm plan and follow up.
"I'd like to see you again in …."
"Until we next meet, what will you do?"
Doctor should stress successes and indicate the failures the patient experienced in trying to
implement his or her plans. The doctor will use these successes and failures in improving the
original plan or reconstructing new plans. He can carry the same steps carried out in the first visit
using trigger questions/ statements.
It may not be necessary to ask each of the questions/ statements, you should base your approach
on strategies that facilitate behavior change.
The second task in follow up visits is to prevent relapse or to assist the patient in coping with
relapse. The basis of relapse prevention is good maintenance counseling. This will cover:
Eliciting successes and failures.
Reconstructing plans.
Reviewing all the processes of behavior change.
Addressing relapse and failures directly.
As a doctor you have to understand that patients develop feelings of shame, guilt and inadequacy
when they relapse. You have to provide an enormous boost to their ability to cope with relapse.
Explain that one learns from one's failures and mistakes.
34
Chapter 3
Counseling
Objectives
• Define counseling and the purposes of counseling.
• Discuss the key qualities of an effective counseling relationship.
• Discuss the specific skills needed in counseling.
• List the steps of the process of counseling.
• Enumerate important points to be done by the counselor during the counseling sessions.
Definition of counseling
Counseling is a process, based on a relationship that is built on empathy, acceptance and trust.
Within this relationship, the counselor focuses on the patient's feelings, thoughts and actions
without judging him and then empowers him/her to cope with his/her life, explore options, make
his/her decisions and take responsibility for those decisions.
During counseling a person with a need and the counselor meet and discuss in such a way that
the person gains confidence in his/her ability to find solutions to his/her problems. This personal
communication has the task and opportunity of approaching the person as a whole in both verbal
and non-verbal expressions.
The opportunity offered by counseling consists in making the individual aware that he is
responsible for himself/herself, that he/she has the ability to understand himself/herself and can
be able to change himself/herself. It can reduce confusion.
Purposes of counseling
Counseling is one of the most frequently used method to help individuals, couples and families
to think about their problems, understand their causes, take correct decisions and act
appropriately to solve their problems .Solutions are selected and chosen by the individual and not
by the counselor.
Key qualities of an effective counseling relationship
The key qualities of an effective counseling relationship include:
The counselor and patient /client work as a team.
Objectives, activities and possible solutions are planned together.
The counselor encourages the patient/client to actively participate in the treatment
process.
The patient/client feels valued and understood by the counselor.
The patient/client realizes there are decisions he/she can make to improve his health and
is helped to make these decisions.
35
Skills needed in counseling
These skills are five skills namely:
1. Attitudinal skills.
2. Listening skills.
3. Reflecting skills.
4. Probing /action skills.
5. Problem solving /problem management skills.
1. Attitudinal skills
• Greeting patient while standing.
a.Respect
• Calling him/her by his name according to the culture.
• Bringing him/her a chair.
• Maintaining an eye contact.
• Listening to him/her
• being open and friendly
b. Warmth
• Warmth in a culturally appropriate way encourages patients to
openly discuss their problems and explore possibilities for change
of behavior.
• Understanding the feelings and experiences of the patient from
c. Empathy
his/her point of view. (Seeing the world through his/her eyes)
• Setting aside our own beliefs, attitudes and judgments.
• Communicating this understanding to the patient.
• Empathy involves the following characteristics
A. Open mindedness: Ability to set aside your own beliefs, attitudes
and values in order to consider those of the other person.
B. Imagination: Ability to picture another's background, thoughts
and feelings.
C. Commitment: A desire to understand another.
D. Knowing and accepting who you are: This will help you to
develop empathy for others.
• Empathy is hindered by the followings
A. If the person has different values, social principles or standards
you may find it difficult to be empathetic.
B. Prejudice and negative attitudes towards others.
C. Labels i-e categorizing people as members of a group rather than
individuals.
D. Stereotypes or giving individuals the characteristics of a group to
which they belong.
• The consistency or harmony between what you say verbally, and
d. Genuineness
your nonverbal behavior. It reflects honesty, transparency and trust
• Counselor self-disclosure: The counselor shares relevant personal
e. Self-Disclosure
feelings, experiences, or reactions to client/patient.
• Client/ Patient self-disclosure: the patient talk about his problems,
helps him to understand his own self better, create mutual trust and
promotes relationship.
inconsistencies between what is said and what are done by the patient
f. Confrontation
36
The most important counseling skill.
There are verbal and nonverbal components to listening. Listening also
includes being silent for some time.
• Use of minimal encouragers as "Mm-hum", "Yes", "really", "Aha".
• Acknowledge the person's feelings as: "I can see you are really angry".
• Avoid interrupting the patient unnecessary.
• Ask questions if you do not understand.
• Repeat back the main points of the discussion in fewer words to check
if you have understood the patient correctly.
• Look friendly and welcoming
b. Non-verbal
• Maintain eye contact in a culturally acceptable way.
behavior:
• Use open postures without crossed arms or legs.
• Demonstrate attention e.g. nodding, leaning towards the patient.
• Relax, keep it natural.
• Gives the patient time to think about what to say.
c. Silences
• Gives the patient space to experience his feelings.
• Allows the patient to proceed at his own pace.
• Gives the patient freedom to choose whether or not to continue.
• Provides the counselor time to absorb what his patient has said.
• Help patients to clarify for themselves their problems and feelings.
3. Reflecting
• Are valuable in building a relationship with patients by communicating
skills
trust, acceptance and understanding.
• Help the counselor to gain information about the patient and his views
of the situation.
• Help the counselor to check his perception of what the patient
communicates.
• Listening for both verbal and nonverbal communication of feelings.
a. Reflecting
• Reading body language and reflecting what we see if feelings are not
feelings
verbally expressed.
• Introducing ways of reflecting feelings respectfully:
"It sounds like…," or "May be you are…,"or "You seem …"
b. Restating / Repeat the content and feelings of the message using slightly different
Reframing words. So:
• Be tentative and respectful: ("I hear you saying…"or "It sounds like “
• Use your own words to communicate your understanding of what your
patient is saying.
• Use slightly different words that have the same meaning. Do not just
repeat what your patient said.
• Rephrase both content and feelings.
c. Affirmation Is the expression of sincere appreciation by the counselor of the patient's
efforts and strengths in coping with his life challenges? Affirmation is an
important skill as it is an effective way of communicating a supportive
and caring attitude.
d. Summarizing This is an important skill as it organizes, clarifies and highlights the
most important areas, feelings or themes of what your patient is
communicating.
2. Listening
skills (active
listening)
a. Verbal
behavior
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Listening and reflecting skills should come before and after
probing or action skills.
a. Asking questions Use questioning to seek further information to understand the
patient's experience, assess the nature of the problem(s), and work
(clarifying).
together.
There are two basic types of questions to be used to invite others
to talk and to do more clarification namely open questions and
probing questions. The latter is a type of closed questions.
b. Interpretation or Making a statement about the counselor's understanding of what
patient is communicating.
making
Interpretation is different from reflection.
statements
In interpretation you are including your thoughts. So do not state
them as facts. You are adding your understanding to what the
patient has said.
When you are interpreting or making statements:
• Keep them short and specific
• Focus on facts and feelings.
• Include verbal and nonverbal messages.
• Check for validity and verification.
• Make sure that your patient confirms what you say.
Confrontation in counseling means that the counselor is
c. Confrontation
facilitating a process of self-confrontation for his patient.
or challenging.
• To invite patients to challenge the defenses that prevents them
from managing problems.
• To help patients focus on themselves and their own
inconsistencies or discrepancies.
• To help patients become more aware of themselves. Awareness
will lead to change.
In carrying confrontation
• Be respectful and empathetic.
• Use warm body language.
• Be specific and give examples.
• Confront the behavior/action not the person.
• Confront one thing at a time.
• Supplying data, opinion, facts, or answers to questions.
d. Information
sharing and
• Always ask what your patient already knows and build on it
• Check that your patient wants information before giving him
education
• Make sure that the information is relevant.
• Provide small pieces of information at a time.
• Present the information as an option
• Information should be shared with warmth, respect and caring.
Managing
problems is only possible if the counselor and the
5. Problem solving
patient have lots of time together. This cannot be done in one
/problem management
session. You have to realize that those around your patient could
skills
be part of the problem.
4. Probing /action skills
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Examples of statements used in counseling
Attitudinal skills
Warmth
Example
dr in a smile and appropriate tone of voice "Hello Mrs Sabry I am glad you could come today.
Can I help you?"
Empathy
To empathize is to see with the eyes of another, to hear with the ears of another and to feel with
the heart of another. It is the ability "to put oneself into another's shoes"
Example
Patient: "When I had the abortion, I cried a lot and I was just not feeling good. I spent most of
my days in bed."
Counselor: "It sounds that you were looking forward to have a child. It was a great loss to you
not to complete your pregnancy".
Genuineness
Example
Patient: "You seem to understand me so well. Thanks I feel much better now."
Counselor: "I am happy that I have been helpful. Yet I do think that we still have to work
together more."
Confrontation
Example
Counselor: "You said that you did not love your father. Now you are saying you love him. What
exactly do you mean?"
Reflecting skills
A. Reflecting feelings
Example:
Patient: "I am a widow. I have five children. They are all dependent on me. I do not have a
permanent work. I cannot afford paying for the medicine you have just prescribed. I do not know
how to comply with the treatment you are recommending!!"
Counselor: "It sounds that you are really bitter."
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B. Restating / Reframing
Start a restating statement with phrases like:
• "In other words …"
• "Do you mean…"
• "You sound…"
• "I gather…"
• "It sounds as if..."
• "So basically, what you are saying is…."
• "I am not sure that I understand you correctly…"
Example:
Patient: "I am angry with my son. He does not study. He has started to smoke and he comes late.
He has joined recently a group of bad kids. I just want to bang his head. He makes me just mad.
Really I want to kill him."
Counselor: "It sounds like your irritation and frustration with your son has reached a climax."
C. Affirmation
Affirmation is useful because:
• It strengthens the counseling relationship.
• It encourages the client/patient in the choices, knowledge or behavior he/she has done.
• It improves self- esteem.
➢ When you want to convey affirmation always focus on the patient.
Example:
Say: "You should be proud of yourself for attending for your checkup."
Do not say: "I am so proud of you for attending to day".
Examples of statements that convey affirmation:
• "You have taken a big step to day, I am sure you feel satisfied."
• "It is great that you recognize the risk and you want to do something before it gets worse."
• "You really have some good ideas of how you might solve your problems."
• "I appreciate the effort you have made to see me today despite how low you are feeling."
Pay attention to your body language, your tone of voice and your facial expression.
D. Summarizing
• Draws together important points.
• Clarifies important issues.
• Reviews the session, briefly describes the most important points and says what could be
covered next session.
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Types of summaries:
There are two different types of summaries that you can make as a counselor:
i. Summaries that are offered during the session: these will keep you focus on important areas in
counseling
Example
"So, in the past few days you have been very tired and weak. You cannot sleep at night. Is that
correct?"
ii. The detailed summary offered at the end of the counseling session. It reviews the session,
then prioritizes and focuses future counseling.
Example
"Today we have spoken about importance of spacing for your health, and the health of your
infant as well as your family. We have also discussed the different methods that are available for
family planning. In the next session we will review these methods and you will decide which of
them may be suitable for you."
An important part of summarizing is asking for feedback. This is important to assess whether
you have understood the client/patient or not.
Probing /action skills
A. Asking questions (clarifying).
Open Questions
These are questions that invite others to talk. They lead to a conversation or a dialogue. They
encourage longer explanatory answers.
Example: What are your main concerns?
Probing Questions
These are closed questions that start with how, who, when or where. The purpose of these
questions is to get more concrete information or to clarify
Examples:
• How did you react to your test results?
• When was your first checkup?
• Who was the first one you shared with him/her your news?
In counseling we can use as well hypothetical questions and Nth-degree questions. These
questions are variations of the two basic types of questions.
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Hypothetical Questions
These are questions involving a pretend situation. The purpose of them is to help your
client/patient think of other possibilities or scenarios that allow him/her to visualize possible
outcomes or behaviors.
Example:
If you tell your father about being physically abused by your teacher, how do you think he would
react?
Nth degree Questions
These types of questions help define and prioritize a patient/client agenda. They are appropriate
at the beginning of the counseling session. It may encourage him/her to be specific about
describing sensitive issues.
Examples:
• What is the worst thing that could happen?
• If we could deal with one thing today, what would be most important to you?
Unhelpful Questions to avoid
Closed questions that have a yes or no answer or those that start with did or are. These
questions are not good for exploration.
Either/or questions can be leading.
Multiple questions are confusing.
Leading questions will compel the person to respond in a way which is seen to be
acceptable to the counselor.
B. Interpretation or making statements.
Example:
Patient: "I am always tired. I have no energy at all. I go to work because I need the money.
I have a very demanding boss. Nothing I do pleases him. When I get home from work my
husband starts nagging me and my kids are all over the place. The house is in a mess. All I feel
like doing is climbing into my bed and shut my ears and eyes and sleep."
Counselor: "You just want to escape by sleeping." (Interpretation)
C. Confrontation or challenging.
What does the counselor confront?
 Discrepancies in content or statements.
Example:
Counselor:" Earlier you have said that your husband was considerate, but just now you are
saying that he treats you poorly."
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 Discrepancies between verbal and nonverbal messages.
Example:
Counselor:" You have been crying since you arrived and told me that your husband divorced
you, yet you keep insisting that you do not care".
 Issues that are being avoided.
Example:
Counselor:" You have been talking about your concerns about diabetic complications, yet you
did not tell me why you are not complying with the treatment prescribed."
 Self-defeating attitudes and beliefs.
Example:
Counselor: "I am wondering why you already have decided that you will not be able to reduce
your weight. You should congratulate yourself for coming to day for consultation."
 Harmful or illegal behavior.
Example:
Counselor:" You said at weekends you hang around and smoke some weed. Are you aware of
the harm you do to yourself?"
 Distortions from reality.
Example:
Counselor: "You have made the choice to not breast feed when your baby is born. Have you
thought of the cost of infant formula?"
 Unrealistic expectations.
Example:
Counselor: "We discussed your concerns about this pregnancy, yet you did not attend regularly
the antenatal checkups."
Problem solving /problem management skills.
Important skills in problem solving.
• Provide the patient with skills to cope with the problem to feel stronger & more able to deal
with it.
• Help the person to decide about realistic and attainable objectives that may be successfully
achieved.
• Help the person to draw up a plan of action. The person should feel that the actions chosen
will help him to reach the objectives developed.
43
• Both counselor and his patient need to talk about how effective the action plan has been. They
should discuss new problems that might occur and their possible solutions. The counselor
provides support as they both work together the steps of problem management again.
• The patient should come up with his own options.
• The patient should realize the advantages and disadvantages of each option.
This can help him focus on realistic outcomes.
• In exploring alternatives with patient, counselor has to help him to make distinction between
what they have control over and what they cannot change.
• The counselor has to help his patient walk through outcomes of different choices.
The counselor is not responsible for solving the problem, just helping his patient approach it and
explore options. The patient is the one who decides about his own options.
Process of counseling
The counseling process covers four steps namely:
1. Identify the need.
2. Prepare for counseling.
3. Conduct the session.
4. Follow-up.
Actions to be carried out by counselors
(A) Before you start your counseling
Check any information that can help you: background history, investigations and screening tests.
Plan to see the client four to six times.
(B)In the beginning of your counseling
Ensure privacy (use screens/curtains) and provide comfortable seating.
Remove personal and environmental barriers: Minimize distractions (as noise, visitors
dropping in, receiving phone calls, looking at the computer or checking your diary etc.).
Sit forward and at the same level as your client/patient, maintain eye contact, and nod
at appropriate moments.
Establish a relationship and building rapport and trust.
Work out with your client/patient why he/she is with you today and what he/she expects
from talking to you.
Adhere to appropriate ethical principles and ensure confidentiality.
(C) During all your counseling sessions
Listen carefully and do not interpret or analyze.
Clarify/ reflect /summarize the problems.
Help the client/patient to understand his/ her feelings.
Explore the problem and find solutions.
Guide the client/patient to decide on intervention.
Help the client/patient to plan his /her own solutions when he/she is ready.
The client/patient needs to decide what will work best for him/her. You only help him/her
to draw a plan of action.
Monitor the actions done and provide support.
44
Tutorial 2 (chapter 2 & 3)
Instructing and educating individuals
Exercise I
Breaking bad news
Compare Case study 1 and case study 2 using the check list of steps of breaking bad news
CASE STUDY 1
CASE STUDY (2
Consultant: "We get the biopsy Dr. Samy looked at his watch. He is ready now for his patient
results back. (The consultant
Mr. Salah. He has read his file and checked the results of the
looks down and frowned). I
biopsy. He asked his nurse to admit his patient and stressed
need to talk to you."
that once his patient comes in no one is allowed to come in.
When the patient came in, he shakes his hands and asked him
Mrs. Salma: "Uh oh, that
to sit on the chair in front of him. He removed all barriers.
sounds bad.
Consultant: Maintaining eye contact: "We get the sample
Consultant: "Well the biopsy
results back. I need to talk to you."
shows that you have breast
cancer".
Mr. Salah: "Uh oh, that sounds serious."
Mrs. Salma: "Oh no! I cannot
believe this!"
Consultant: "Well the sample shows that you have lung
cancer".
Consultant: "It's Okay. We
Mr. Salah: "Oh no! Not me!! (He cries)
have a lot we can offer you. We
Consultant pauses to give the patient a moment to express
will talk now about your
options. But first I do not want tearfulness.
you to feel scared. I am going to Consultant: "This is really upsetting news."
have you speak. The most
important thing is that we have Mr. Salah: "Of course you have just told me I have lung
cancer!"
a lot to offer you."
Consultant: "Yes, most of my patient gets really upset when
they hear the word cancer."
Mr. Salah: " I' am sorry. I did not mean to snap at you. But it
is really terrible news."
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Consultant: "Well I understand your feelings. You know
people get upset for all different reasons when they receive a
diagnosis of cancer. What upsets you the most?"
Mr. Salah: "Well I have a family. I have four children. My
wife does not work. I' am the only breadwinner. I am worried
about them. I am worried about the expenses of the treatment
and the hospital".
Consultant touch the patient's shoulder
Consultant: "Well, we can help you by meeting part of the
hospital expenses. Also here are addresses of two nongovernmental agencies that can help."
Mr. Salah: "Thank you".
Consultant:" Have you got any other concerns?"
Mr. Salah shakes his head
Consultant: "Would you like to discuss the treatment
choices of your condition now?"
Mr. Salah: "Well I have to discuss the situation with my
family. Also I would like my wife to be with me next time."
Consultant: Checks his notes:" Well can we meet on next
Sunday at 10.O 'clock?"
.
46
Check list of steps carried out in breaking bad news
STEPS
CASE STUDY 1 CASE STUDY 2
YES
1. Prepared for a discussion
- Selected a suitable room (ensured comfort & privacy)
- Allowed enough time
2. Made an introductory statement
3. State the news
- with clear, concise language
- Avoided medical terminology
4. Actively observed the patient for any emotional
reaction
If not sure asks about what the news mean to the
patient
5. Reflected the response of the patient back
6. Legitimized the patient's reaction
7. Explored the cause of the patient's reaction
8. Provide realistic hope
9. Addressed patient's concerns before starting
management plan
10. Checked patient's understanding
47
NO
YES
NO
Counseling
Exercise II
Counseling dialogues
Dialogue 1 (in Family planning Unit)
Patient: I don't want any more children. A friend of mine has an Intra Uterine Device and she is
very pleased with it, so I would like one too.
Doctor: Yes, we have Intra Uterine Device here. It's nice to have a client who knows what she
wants. The nurse will see you soon to put it in.
Question: Is this dialogue good or bad? Why?
Dialogue 2
Patient: I hate this diet.
Doctor: How many Kg have you lost?
Patient: 5 kg. And I try so hard, but I just can’t do it. I do diet all day, but then my husband
comes home and wants a big dinner. And then we sit together and watch TV, and he wants
ice cream. And so, of course I eat it with him.
Doctor: Why don’t you let your husband take a walk with you after dinner? And try eating
yogurt instead of ice cream? (What does the doctor do now?----------------------------- )
Patient: I tried yogurt before with him and we both didn’t like it. Also, I don’t think he will
want to go walking every night. He’s tired after work.
Doctor: Try Fruity Delight Low-Fat Yogurt. Its great, and don’t be so quick to give up on
his walking. Will you at least give it a try?
Patient: Okay.
Dialogue 3
Patient: I hate this diet.
Doctor: You hate it? How come?
Patient: I try so hard to cook like I am supposed to and eat what I was told. But my husband
refuses to eat that way. Then he complains that I’m too fat! I have to give up what I like to eat,
and then it still doesn’t work.
Doctor: I can see why that would be frustrating. (skill demonstrated is-----------------------)What do you think would help? (What does the doctor do here?------------------------------)
Patient: I don’t know. Sticking to this diet is so hard. I don’t know what else to do.
Doctor: What do you think the problem is?
Patient: Well, I do diet all day, but then my husband comes home and wants a big dinner. And
then we sit together and watch TV, and he likes to have ice cream. So of course I eat some ice
cream too.
Doctor: What would you do to change this situation to feel better about it? --------------Patient: I really do want to lose weight. Not just because my doctor says so, but I don’t like
how I look, and I don’t have much energy anymore.
Doctor: What will happen if you don’t change anything?
Patient: I’m not sure. I guess I’ll keep gaining weight
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Doctor: And what if you do? How will that make you feel?
Patient: Awful. I hate being frustrated all the time.
Doctor: Can you accept things staying the way they are?
Patient: No! I’ve just got to lose some weight.
Doctor: Well, tell me one thing you can do when you leave here to get you started?
Patient: I need to talk to my husband. I don’t think he knows how bad I feel about my weight
and he telling me I’m fat doesn’t help.If I can just get him on my side, the battle would be half
over.
Doctor: So, do you feel that you could talk to your husband about it?
Patient: Yeah, I think I could. He and I talk about a lot of things, so I think he `ll listen.
Doctor: That’s great. So when are you going to talk to him?
Patient: Tonight, when he gets home from work.
Comment on this dialogue-------------------------------------------------Dialogue 4
Fill in the blank: the counseling skill demonstrated and purpose of skill
dr Hi Nora, thank you for taking the time to come and meet with me today.
skill demonstrated---------------------purpose of Skill--------------------------dr : Is there a specific reason for your visit?
Patient: Yes, I’m here because about 6 weeks ago I was in a really bad car accident
dr: Oh dear, I’m really sorry to hear that, that must have been extremely scary for you
skill demonstrated---------------------purpose of Skill--------------------------Dr Can you tell me a little more about what happened?
Patient : Luckily there was a truck driving behind me who saw the whole thing and he ended up
stopping traffic and calling Emergency
skill demonstrated---------------------purpose of Skill--------------------------Dr: So how has your recovery been since the accident six weeks ago?
Patient : I really just don’t feel like myself.
Dr Right, in what way do you feel different than from before the accident?
skill demonstrated---------------------purpose of Skill--------------------------Patient: I’ve just been kind of tired. Like I want to sleep a lot. I don’t feel like going out.
Dr: That is understandable; you’ve been through a very frightening experience. I want you to
know that I’ve experienced a similar thing in my life, so I do understand that it is really
challenging, but I want to help you get through it
skill demonstrated---------------------purpose of Skill--------------------------Dr :So since the accident, you just haven’t been feeling like yourself, you’ve been feeling tired
and down. Can you tell me a little more about that?
Patient : I’ve just been really scared to drive anywhere by myself mostly. I haven’t been wanting
to go to work
49
skill demonstrated---------------------purpose of Skill--------------------------Dr: But coming here today is amazing and clearly demonstrates your strength.
skill demonstrated---------------------purpose of Skill--------------------------Dr : So if you could kind of imagine yourself, maybe three months down the road, what would
you like to be feeling and thinking?
skill demonstrated---------------------purpose of Skill--------------------------Patient: I think that I want to feel confident in my ability to drive and also just my ability to get
through this and to feel more comfortable driving
Dr So your goals are to feel significantly more comfortable and confident with driving again in
comparison to how you’re feeling at the moment.
skill demonstrated---------------------purpose of Skill--------------------------Dr: So looking at some of your goals, like feeling more comfortable and being able to go to friends, what
might be a small step you could take in order to reach those goals?
Patient: I do not know
skill demonstrated---------------------purpose of Skill--------------------------Dr: Do you think you might be able to try some very simple breathing exercises, and some
mindfulness practices that help to reduce the feelings of anxiety when you get into the car.
Patient: Yes, definitely.
Dr Great, I can tell you’re really motivated and demonstrating a lot of strength and a positive
attitude towards wanting to achieve your goals.
skill demonstrated---------------------purpose of Skill---------------------------
50