Calgary-Cambridge Guide to Communication in the Physical Examination

Original Editor - Mariam Hashem

Top Contributors - Mariam Hashem, Merinda Rodseth, Kim Jackson, Ewa Jaraczewska, Shaimaa Eldib, Tony Lowe, Tarina van der Stockt and Olajumoke Ogunleye  

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (15/01/2021)

Introduction

Communication is defined as a set of procedures for improving outcomes of care To become more effective you have to focus on specific and numerous skills, not just some vague notion of improving communication in general. Learning to communicate effectively is a little like learning to play professional tennis. To become masterful you have to focus on various skills and strategies, not just the overall game and, like athletic skills honed to a professional level of competence, physician-patient communication skills will atrophy if you stop paying attention to them. (rephrase). It is a learned skill rather than a personality trait. experience alone can be a poor teacher. While it is an excellent reinforcer of habit, it tends not to discern very carefully between good habits and bad.

To be able to understand is not the same as to be able to do. If you really want to enhance skills, five elements are necessary:1 • Systematic delineation and definition of skills to be learned. • Observation of learners performing the skills (live or on videotape). • Well-intentioned, detailed, descriptive feedback (preferably with videotape). • Practice and rehearsal of skills. • Repetition (i.e., a helical, reiterative model rather than a linear, once and done model).

Initiating the Session • establishing initial rapport • identifying the reason(s) for the patient’s attendance Gathering Information • exploration of problems • understanding the patient’s perspective • providing structure to the consultation Building the Relationship • developing rapport • involving the patient Explanation and Planning • providing the correct amount and type of information • aiding accurate recall and understanding • achieving a shared understanding: incorporating the patient’s perspective • planning: shared decision making • options in explanation and planning if discussing opinion and significance of problems if negotiating a mutual plan of action if discussing investigations and procedures Closing the session

ith medical students, residents, and practising clinicians. If we work to enhance communication skills in medicine, the prize on offer is substantial. That prize includes:

• More effective consultations with respect to accuracy and common ground, efficiency, supportiveness, collaboration, and reduced conflicts and complaints. • Improved outcomes in terms of patient and physician satisfaction, understanding and recall, adherence to treatment plans, symptom relief, and physiological outcomes.

Good communication is an essential practice that has shown to improve the patient's willingness to engage in the treatment.

Clinical examination is facing a challenge concerning its accuracy and importance. The advancement in research has proven low reliability and validity of many clinical tests with higher rates of accuracy associated with imaging and scans. However, when the subject is approached from cost-effectiveness and availability point of view the perspective changes. Access to advanced medical diagnostic tools geographically and the affordability of such tests differed from a place to another. Therefore, clinical examination is still a valuable tool in clinical practice.

Despite being the golden standard, laboratory testing and imaging if misused could be harmful and could be contributing to overdiagnosis, leading to further psychological and behavioural harms. The power of careful hands performing systematic physical examination still surpasses the technological era

A thorough and effective physical examination is considered to be an art that is not only important for proper diagnosis but also builds the patient-healthcare relationship. Lack of physical examination is perceived by the patients as insufficient attention . Interpersonal aspects and good communication increase the patient's satisfaction.

A study by Hinchliffe and Lavin found the physiotherapist's communication with the patient to be a key factor in patients satisfaction and compliance with the treatment.

Unline the subjective history taking, where the patient plays an active role, during the physical examination the patient's role changes. The clinician can make this process easier by guiding the patient's throughout, knowing that patients start the examination with some uncertainty. Your patient needs to understand the process and follow your train of thought. This is achieved by providing a structure, to signpost.

Signposting: refers to informing your patient what you are about to say or do to help them feel less anxious and give them a sense of control. By providing a concise summary of the last step and the following step of the assessment,

Example:

Following the subjective history taking of an MSK condition, the clinician can signpost by saying:

With all the information you have given me, I have a couple of ideas what might be the cause of your discomfort. We will now move on to a physical examination to try and narrow down the underlying structures responsible for your symptoms. I firstly want to assess how you move in general and then simultaneously check for the possible involvement of your vertebral joints, muscles, and nerves in your back pain. I'm going to guide you into doing a couple of movements and whenever you feel your familiar pain, I would like you to tell me and then move out of the uncomfortable position.

This gives a framework for the patient, informing them of what information we gained from the interview, what should they expect next and what feedback is expected from them.

Touch: Touch is a practice of professional feel and an exercise of care and sympathy. Palpation has always been considered a powerful diagnostic tool. In the scope of physiotherapy, touch provides safe space and empowers exercises and symptom modification. However, this practice comes with complications if perceived as improper and unprofessional, imposing challenges onto a core clinical skill Palpation of sensitive areas, such as genitals, or when the examined area is not directly correlating with the main complaint can make patients feel uncomfortable and protective of their personal space. Caution should be observed to respect cultural sensitivities and approaching certain population such as paediatrics and patients from the opposite sex, especially in the case of a male clinician with a female patient.

Touching gives professionals a means of communication “beyond words”. It helps distressing patients, particularly if verbal communication is limited and for some patients, it has emotional and spiritual meanings. Touch is a physical and metaphorically bi-directional phenomenon.

Clinicians should be mindful about the personal space of their patients, show respect and remain cautious of the patient's preference in terms of personal preference or culture, gender, age .etc. Thy mus decide if, when, and how to touch as they negotiate personal and professional boundaries specific to each case.

Undressing: While the majority of patients might be comfortable and understanding of undressing for the examination, some might be reserved.

Informing the patient ahead of the interview that they might need to undress is advisable to help ease the process. You might also like to inform the patients verbally and get them to agree before starting the examination.

Prior to asking the patient to undress, determine th need for undressing and how much should be exposed. If you sense their discomfort, you can offer a towel or a gown to minimise exposed areas. Patients have the right to refuse to undress. In this case, it is unethical to put pressure or insist that patients undress but explain to them, with respect, that insufficient exposure of the body can lead to clinical error and undressing or not allowing touch that they carry the responsibility of the risk of a faulty diagnosis or substandard management.

Physical examination is still a dynamic interaction between the clinician and the patient.

Briefly summarising the preliminary clinical hypothesis using easily understood terminology baring in mind that the summary is inconclusive. Following the interview, discuss your hypothesis with your patient to inform them what you need to test and do you need to rule out using short uncomplicated sentences.

Patients have the right to discontinue the process at any time and it's a good practice to inform them that they have the right to do so. They can take a more active role by asking you questions or add more information during the examination.

Refrain from using jargon. the specific movement command should be clear and easy to understand using verbal instruction, physical demonstration, or manual facilitation, or a combination of them all. The tone we use to communicate is highly important, refrain from the parental authoritative tone. Give your patient the space to ask for clarifications if they don't understand the command, this is particularly relevant in remote consultations done over the phone.

Only 12% of adults have proficient health literacy according to the National Assessment of Adult Literacy. In other words, 9 out of 10 adults may lack the skills needed to manage their health and prevent disease. It is helpful to consider all patients as having low heath literacy and use appropriate communication techniques that ensure understanding. At a minimum, slow down and speak in plain, non-medical language! Allow time for patients and families to ask questions by asking “What questions do you have?” instead of “Do you have any questions?” Check the understanding of a patient by asking them to restate it in their own words, not just repeat it, to ensure the message is understood.

Asking for permission to touch (Patient's consent) even if the patient expects you to touch them. It is an ethical practice and good manner to show respect for the patient's personal space.

Avoid negating mode when correcting a patient's pattern of movement for example saying: no, not like that.

For example, a patient performing lumbar side flexion but instead they do a combination of forward flexion and side flexion. Your response might be something like, "Good job, I want you to repeat the movement, this time focusing on going more sideways. Yes, that looks better."

Using positive affirmation while giving feedback without highlighting the error enhances the patient's confidence in the performance of the movementYou might need to rephrase your command or describe in simpler terms to facilitate the patient's understanding of the performance of the correct movement. For example: instead of telling the patient to move purely sideways, you might ask the patient to repeat the movement, sliding the hand down the side of the leg, as far as you can. This technique is particularly helpful with patients who are showing some anxiety of low levels of cognition.

Treating minors: parent's consent is a legal requirement for the treatment of children. Parents are very valuable, they serve as resources to help with advice on how to approach and manage their children. Parents can also serve as a facilitator between the clinician and the child. You can ask the parent to assist the child and get a good idea of the information that you would like to gain in your clinical examination.

Feedback: continues feedback throughout the assessment is important. Some patients might feel embarrassed and exposed, especially when they don't understand the relevance of the movements they perform during the examination. Providing inconclusive feedback and explaining the findings ease the patient's discomfort. Explain positive findings emphasise positive attributes without having all the focus on the problems. This lowers the anxiety factor and gives the patient some positive affirmation on themselves, improving their ideas of their movement and their body, and breaks down this whole idea of frailty.