Calgary-Cambridge Guide to Communication in the Physical Examination

Original Editor - Mariam Hashem

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

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Introduction

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 challenging 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.

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.

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.