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Basic communication skills
Herni Suprapti
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the facto rs that inf luence
doctor-patient commun icat ion
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some bad news
a relat ive has jus t d ied fai led some exams
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First the setting or situation is clearly
important
Second
how you feel at the time will influence
what you say, and so will the attitude
of the other person
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The factors (patients) will influence
how communicate
Personality
Upbringing
Social class
Ethnic
Cultural background
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Reactions to illness include
Denial
Anger
Anxiety
Depression
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Factors influence doctor-patient
communication
Patient-related factors
Doctor-related factors
The interview setting
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Patient-related factors
Physical symptoms
Psychological factors related to illnessand medical care (e.g. anxiety,
depression, anger, denial)
Previous experience of medical care
Current experience of medical care
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Doctor-related factors
Training in communication skills
Self-confidence in ability tocommunicate
Personality
Physical factors (e.g. tiredeness) Psychological factors (e.g. anxiety)
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The interview setting :
requirements
Privacy
Comfortable surroundings
An appropriate seating arrangement
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Doctor-related factors
medical student
doctor
easier than others to emphathise andcommunicate with patients
other factors influence our behaviour
during a consultation (Table 2.1)
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impair communication
Tiredness
Anxiety
Preoccupation with other concerns
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The setting of the interview
Most consultations take place in
a hospital ward
the outpatient clinic the GPs surgery
Privacy is essensial
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The setting of the interview
A patient in a hospital bed
sensitive information
Mrs Smith in the bed next door can hear
every word through the curtains
the patient can be moved
avoid interruptions Lighting
Temperature
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arrangement of seats
can influence how people communicate
with each other and
give clues to how they perceive their
own and each others roles in the
encounter
t ti t li i / GP
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outpatient clinic / GPs
consulting room
chairs and desk or a table
three possible ways of arranging the
seating
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Arrangement (a)
patient and doctor facing each other
across a desk
is unlikely to make the patient feel at
ease or facilitate discussion
the doctor may feel in control of the
interview
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Arrangements (b) and (c)
more informal
more likely to facilitate good
communication
th di t b t th
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the distance between the
interviewer & the patient
Placing seats
too close
too far
4-9 feet
distance may change during the courseof the interview
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in a hospital bed
standing over a patient
draw up a chair so that you are on the
same levelas the patient
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Beginning an interview
h t d f l t
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what made you feel at ease, you
might have included :
a comfortable setting
being greeted by name and a handshake
being shown where to sit
the interviewers introducing themselves and
explaining the procedure
an easy first question the interviewer appearing interested in your
remarks
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An unsatisfactorybeginningis likely to
lead to an unsatisfactoryconsultation
as the following case illustrates
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How no t to beg in an interv iew
Mrs Francis, a shop assistant aged 31,
attended medical outpatients at her
local hospital
Here is her story :
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When I went into the room which was big andbare I felt lost. I didnt know where to sit, the
doctor had his head down and was wri t ing, thenu rse was on the telephone and there were some
medical students talk ing to each other. I waited
around and w anted to run out the doo r. After
what seemed l ike ages the doc tor told me to si t
down and asked what was wrong. I didnt knowhis name and Im not sure that he knew mine, Idbeen think ing about my problems and what I
wanted to tel l the doc tor bu t I forg ot i t al lhedidnt seem very interested anyway. Hope I donthave to go again.
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what was wrong with the way this
interview was conducted
help the patient feel at ease, and
begin to build up a relationship that
enables them to share the story of theirillness with you.
Beginning the interview involves greeting
the patient, introducing yourself andorientating the patient (Table 2.2).
Guidelines for conducting an
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Guidelines for conducting an
interview
Beginning the interview
The main part of the interview
Ending the interview
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Beginning the interview
Greet the patient by name (Good morningMr Ricardson) and shake hands
Ask the patient to sit down
Introduce yourself (I am Judy William, as a
medical student) Explain the purpose of the interview (I
would like to find out about your presentproblem)
Say how much time is available Explain the need to take notes and ask if this
is acceptable
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The main part of the interview
Maintain a positive atmosphere, warm manner, goodeye contact
Use open questions at the beginning
Listen carefully
Be alert and responsive to verbal and non-verbalcues
Facilitate the patient both verbally (Tell me more)and non-verbally (using posture and head nods)
Use specific (closed) questions when appropriate Clarify what the patient has told you
Encourage the patient to be relevant
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Ending the interview
Summarise what the patient has told
you and ask if your summary is
accurate
Ask if they would like to add anything
Thank the patient
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The main part of the interview
Questioning
Listening
Facilitating
are three of the key skills that enable us tocommunicate effectively with others
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medical students & doctors often
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medical students & doctors often
:
ask too many questions and do notallowthe patient to tell their story intheir own words
ask questions that are too long, toocomplicated and confusing
ask questions in such a way that theymay bias the answers given
ignore questions that patients may ask
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So it must be concluded that asking
questions is a valuable skill that needs
to be learnt
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Open and closed questions
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Open questions
obtain a great deal of information and also
allows the patient to tell their own story
sould be used as much as possible,
particularly at the start of the interview
e.g. would you please tell me how you have
been feeling in the past few days?
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closed questions
Asking spesific (i.e. closed) questions
gives the patient little choice in the way
they answer and ussually elicits a yesor a no
Have you been feeling unwell today?
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Case example 2.2
A patients response to open and
closed quest ions
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Dr Yates I see from your notes that you h ave had som e chest pain. Do
you st i l l have the pain ? Mr Clark
No, not now
Dr Yates Was i t tight or d ul l ?
Mr Clark It seemed a very dul l pain
Dr Yates Did i t go dow n your arm ?
Mr Clark No, I dont think so
Dr Yates Did i t get worse wh en you exerc ise ? Mr Clark
No, it didnt
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Mr Clark is seen by Dr Vale :
Dr Vale I understand that yo u have had pain. Would y ou please tel l
me more about i t ?
Mr Clark Well, i t was in m y chest and it came on when I was s it t ing at
my desk. It was a funny d ul l pain that stayed in the midd le ofmy chest. Ive had it a few times recently, always when Imat work
Dr Vale Can you te l l me what br ings i t on ?
Mr Clark Well, I was thinking about that. Ive been very busy at work
recent ly, and it seems to happen when I feel worr ied aboutsometh ing
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the advantagesof using open
questions and
the disadvantagesof closed
questions
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Dr Vale obtained considerably more
informationby using open questions
than Dr Yates, who used closed
questions
open style question is preferable
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open style question is preferable
because :
more relevant information can be
obtained in a given time
the patient feels more involved in the
interview
the patient can express all the concern
and anxieties about their problems;
these may be missed if closedquestions are asked.
open questions : some
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open questions : some
disadvantages
the interview may take longer and be
more difficult to control
some of the information may not be
relevant
recording answers may be more
difficult
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closed style of questioning :
the information obtained is restricted tothe questions asked
the interview is controlled by the
interviewer who decides the content ofthe questions
the interviewer has little opportunity toexpress their concern and feelings.This may make them feel frustated
C
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Closed question
obtain specific information that the
patient has not given
when the patient is shy or withdrawn
when it is necessary to obtain a limited
amount of factual information in a
limited period of time
painful arm after a fall
P bi i
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Probing questions
help a patient to think more clearly
about an answer they have given
Probing questions may be used
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Probing questions may be used
to :
Clarify : What do you mean by that ?
Justify : What makes you think that ?
Check accuracy : You definitely took
three tablets a day ?
Q ti t b id d
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Questions to be avoided
Complex questions
Leading questions
The questions should be
easily understood asked in such a way that does not
influence the patients response
C l ti
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Complex questions
confuse both the patient and the
interviewer
Ex : Did your vomiting start yesterday
or today and have you had diarrhoea?
only one part of the question would be
answered
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3t f l di ti
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3types of leading question
Conversat ional: to open or stimulate conversation
e.g. Arent we having awful weather this year?.
Simple: influence the patient to agree with the
interviewers viewpoint and should not be used
e.g. You dont sleep well do you?.
Subt le: to influence the repondent
should be avoided
the wording of a question can
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the wording of a question can
influence the answer
a study of the frequency of headaches
in a group of individuals
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Do you get headaches frequently
and, if so, how often? the average response was 2.2
headaches per week.
Do you get headaches occasionally
and, if so, how often?
the average reponse was 0.7 headache
per week.
Li t i
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Listening
patients appreciate and respons positively
is one of the most obvious components ofthe communication process
active or effective listening is one of themost difficult skills to acquire
The first step is receiving the message from
the other person.
li t i
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listening
Listening involves
receiving information
being in tune with the speaker
responding appropriately
This is active or effective listening
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Pi ki
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Picking up cues
A patient may be unable or unwilling to
articulate their real concern and
feelings.
it is important that their verbal and non-
verbal cues are picked up.
b l
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verbal cues
Dr Stone Hello Mrs Fine, com e and sit down . How can I help today?
Mrs Fine I thought Id come to see you, doctor, about my headaches
Dr Stone Perhaps yo u co uld tel l me more about these headaches
Mrs Fine Well, theyre really bad, and getting worse. They started
soon after my mother died and now theyre making me feeldizzy. Im really worried about them
Dr Stone Could you tel l me why y ou are worr ied about them ?
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Dr Stone has picked up one of theverbal cues.
The other cue is that Mrs Fine relatesthe symptoms to her mothers death,
and Dr Stone should go on to explore
her reaction, e.g. Could you tell memore about how you felt after your
mothers death?
Non verbal cues
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Non-verbal cues
a lot of information about ourselves and ourfeelings in our body languagethe way we
dress, our posture, gestures and facial
expressions
When you interview a patient, you can learn a
good deal by watching them enter the room
(their appearance, posture, gait, etc).
be sensitive to their body language duringthe interview.
non verbal cues :
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non-verbal cues :
Eye contact: difficulty in maintaining eye contact
feels depressed
embarrassed about what they are saying
uninterested in the conversation
excessive eye contact : anger & aggression
Posture:
the confident person : sit upright
the patient depressed : sit slouched with head
bent forward.
non verbal cues :
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non-verbal cues :
Gestures: the angry patient with clenched fists or the
anxious patient who wrings their hands or taps
their feet continously.
Facialexpressions:
sadness, anger & happiness
The way the voice is used:
tone, timing, emphasis on certain words andvocalisation other than with words.
(Paralinguistics.)
Demonstrating active
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g
listening
show the patient that you are listening carefully.
use of
eye contact posture (e.g. sitting slightly forward facing the patient)
nodding your head
saying hmm go on
active listening : asking questions directly related to
following on from the patients last statement.
Facilitation
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Facilitation
essential part of effective listening
the aim : to help the patient to talk as
fully as possible about problems
Ex : verbal facilitation :
Please go on and tell me more about your
pain.
Yes, I understand please continue.
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give the patient time to respond afteryou have spoken.
Non-verbal : adopting an appropriate
posture
lean slightly forward towards the patient
maintain eye contact
nod your head at appropriate times
Clarification
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ask the patient to clarify somethingthey have said.
This can be done in several ways :
Please tell me exactly when your
abdominal pain started.
Can you describe the pain in moredetail?
What do you mean by dizziness?
Reflection
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Reflection
what they have just said may help themto proceed with their story
particularly when they may be finding it
difficult to go on because of their
feelings
Helping the patient to be relevant
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Helping the patient to be relevant
your time as efficiently as possible.
helping the patient not to stray from the
main point of the interview.
interrupt at an appropriate point and try
to redirect the interview.
Helping the patient to be
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relevant
For example :
What youve just told me about your job
is interesting, but Id like to hear moreabout the headaches youve been having.
It would help me to know more about the
c i rcumstances that br ing on your chest
pain.
Silence
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Silence
make us feel uncomfortable
can be a temptation to rush in with another
question
Silences are valuable
giving the patient time to reflect on what has been
said
use them yourself to observe the patient, to reflect onthe interview so far and to plan the next stage
Summarising
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Summarising
summarise what the patient has told you
e.g. Id like to make sure that Ive
understood you correctly. You told me that.
Summarising serves several important functions :
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Summarising serves several important functions :
check the accuracy of the patients story : opportunity tocorrect any misunderstandings
review the patients story and deduce what else needs tobe explored, and it allows you to buy time if you getstuck and cant think of what to ask next.
help the patient to carry on discussing their problemsitis one method of facilitation.
help you to keep the patient on track.
let the patient know that you have been listening
carefully and are interested It is an appropriate way to close an interview
Ending an interview
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Ending an interview
Summarise what the patient has told you
Ask them to check the accuracy of what you
have said
Ask them if you have left out any information thatthey feel is important
Enquire if they would like to add anything
End by thanking the patient, e.g. Thank you for
talking to me; our time is now up.
Empathy
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Empathy
means putting yourself in other persons
place
The doctor can demonstrate
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empathy by :
looking at the patient and adopting an
appropriate posture
indicating that you understand what is
happening to them, e.g.:
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Patient My father died from a heart attack seven
years ago whilst I was on holiday in France
Doctor
That must have been a distressing time for
you
doctor-centred style of
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communication
the doctor has taken the dominant role in a consultation
with a patient
paying little attention to the patients concernsand understanding of their illness
not involving the patient in decisions about
their treatment
Patient-centred consultations
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Patient centred consultations
many patients want to know more about
their illness and be involved in treatment
decisions
leads to greater satisfaction and
compliance with treatment
Doctor & patient-centred
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interviewing styles
Mrs Fraser works as a clerk in an office. She hasbeen referred to her local hospital by her GPbecause she has had a persistent cough andwheeze for the past 6 months. She has tried to
stop smoking but is finding this difficult. Hercough is worse when she is at work and she isworried that it is brought on by the airconditioning in the office. She is afraid that she
may have to leave her job, which she dependson to support herself and her three children.
Doctor-centred style
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Doctor centred style
Dr Eliot Your doctor says that you have a cough, how long have you had it for
and is there anything else wrong ?
Mrs Fraser Ive had it for 6 months and sometimes I wheeze
Dr Eliot
Do you smoke ? Mrs Fraser
Well Ive been trying to stop and now I only smoke two cigarettes in theevening
Dr Eliot Your symptoms are probably due to your smoking. I strongly advise you
to stop smoking. Ill arrange for you to have a chest X-ray and othertests and Ill see you in 1 months time
Patient-centred style
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Patient centred style
Dr Eliot Your doctor says that you have a cough. Please could you tell me more about it and aboutany other symptoms you may have ?
Mrs Fraser Well Ive had this cough for about 2 months now and sometimes I feel short of breath,
particularly in the morning
Dr Eliot Could you tell me if you bring up any sputum when you cough ?
Mrs Fraser Yes, sometimes I do in the morning but I think thats because I smoke, although I am trying
to cut down. Also, I wheeze particularly when Im at work and I think thats due to the airconditioning
Dr Eliot You seem to have two concerns. First, you want to stop smoking and I am sure that is
important for your health. Second, you are worried about your work. How do you think that Ican help ?
Mrs Fraser Well I would like some help to smoking and I wonder if you could write a letter to the doctor
at work because Ive had quite a lot of time off work recently. Im really scared that I will losemy job and get behind with the mortgage.
The features of a patient-centred
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consultation are :
Exploring the patients experience of illness
Allowing the patient to express their beliefs
about their illness, e.g. what caused it. Allowing the patient to express their concerns
about the impact of their illness on their life
Treating the patient as a partner when
discussing treatment
practising the principles of good
i i
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communication :
Helping the patient to feel at ease andadopting an empathic approach
Using open questions
Picking up and responding to verbal cuesby listening actively to what the patient is
saying
Picking up and responding to non-verbalcues
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Touch
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Touch
is a powerful means of communication that weuse to express a whole range of emotionstenderness, love, anger, etc.
touch can convey concern and empathy, and itcan have a therapeutic effect in itself
touch must be used appropriately and with dueregard to the sensitivities of the patient and toprofessional codes of conduct.
When should touch be used in the
d t ti t t ?
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doctor-patient encounter ?
Shaking a patients hand on meeting at the startof an interview is socially appropriate
Putting your arm around a distressed person tocomfort them
placing your hand on the arm of a patient who is
having difficulty expressing their thoughts and
emotions conveys empathy, and this often helpsthe person to continue
two general guidelines when
t hi ti t
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touching patients :
Try to assess the patients likely response tobeing touched; you can pick up clues from the
way in which they relate their story, their posture
and other aspects of body language.
If you feel uncomfortable about touching
patients, it is probably advisable not to do it
you might communicate your anviety to thepatient.
Communication during the physical
i ti
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examination
touching during a physical examination
Remember that the patient is likely to be very
conscious of their vulnerability and the power ofthe doctor as they lie on the couch waiting to be
examined. They may also feel embarrased and
anxious about what may be found. Try to put
them at ease.
guidelines :
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guidelines :
respect the patients sensitivity and modesty a blanket
Explain what you are going to do. Do they haveany concerns about this ?
Be careful not to instil anxiety at this stage byyour facial expressions, or by spending a longtime on one part of the examination withoutexplanation
Avoid causing discomfort if possible by watchingthe patients expressions or by saying, Pleasetell me if I hurt you.
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