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  

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Why Communication is important?

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 differ 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.It is an essential practice that has shown to improve the patient's willingness to engage in the treatment. 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 management plan.

Communication is defined as a set of procedures for improving outcomes of care. Good communication is a learned skill rather than a personality trait.

Learning to communicate effectively is similar to becoming a professional tennis player. Mastering the sport requires being specific and focusing on skills and strategies. Like any other skill, good patient-centred communication will atrophy if you stop practicing it. Experience, although a habit reinforcer, it tends not to discern very carefully between good habits and bad.

Patient-Centred Communication

Best practices for Pharmacist Provided Patient-Centered Communication ^a.

Goal	Pharmacist Responsibility	Communication Skills
Foster the Relationship	Build rapport Appear open Demonstrate respect Demonstrate caring and commitment Acknowledge feelings and emotions	Greet patient warmly and appropriately Maintain eye contact Show interest Listen actively Express empathy
Gather Information	Determine purpose of encounter Discover biomedical perspective (disease) Understand patient perspective (illness)	Ask open-ended questions Allow patient to complete responses Clarify and summarize information Explore impact of illness on patient
Provide Information	Identify patient informational needs Share information Overcome health literacy barriers	Speak plainly and avoid jargon Use “Patient-Oriented Evidence that Matters” (POEMs) Encourage questions Check for understanding
Share Decision-Making	Identify patient goals Outline collaborative treatment plan	Explore patient preferences Identify barriers to treatment choices Negotiate agreement
Enable Treatment Success	Assess the patient’s capacity for self-management Arrange for needed support Advocate for and assist patient with health system	Summarize treatment plan Elicit patient understanding Discuss follow-up

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^a Adapted from King A, Hoppe RB. Best practice for patient-centered communication: A narrative review. JGME. 2013;5(3):385–393.

How to become a good communicator?

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.

Communication Models

Calgary–Cambridge model 

Calgary–Cambridge model Silverman, Kurtz and Draper developed the Calgary– Cambridge model in 1998. It has many similarities to Pendleton’s earlier model. This is another five-stage model, which is very patient-centred. It incorporates the physical, psychological and social aspects of the consultation (the RCGP ‘triaxial model’) and is also very practical (Silverman et al., 2008). In addition to its five stages, there are two ‘threads’ that run throughout the consultation. These are called ‘Building the relationship’ and ‘Providing structure’. Figure 2 demonstrates the

Calgary–Cambridge model diagrammatically, and shows the ‘threads’ that run throughout it. ‘Building the relationship’ consists of rapport building, which involves using the computer/patient notes in a way that does not interfere with the consultation, and demonstrating empathy and sensitivity. Doctors are also encouraged to share their thoughts by thinking out-loud and ‘accepting the legitimacy of the patient’s view and feelings’. ‘Providing structure’ is about ensuring the consultation flows well, and that the doctor and patient are clear about what will happen during it. For example, you may say to the patient that you need to ask them a few more questions before you examine them, and after you have done that you will talk more about how you can help them. The first stage, called ‘Initiating the Session’, consists in establishing rapport with the patient and ascertaining why the patient has attended. At this stage, an agenda that incorporates the needs of both the patient and doctor should also be generated. In the second stage, called ‘Gathering Information’, the doctor explores the problem using open and closed questions; picking-up on cues; establishing the patient’s ideas, concerns and expectations, and developing the structure of the consultation. Attention to structure is a thread that runs throughout the consultation. It ensures that the doctor is conscious of the ‘flow’ of the consultation and that the organisation of the consultation is clear, both to the doctor and the patient. The third stage consists of the ‘Physical Examination’. ‘Explanation and Planning’ is the fourth stage. Important aspects of this step are: providing information in ‘chunks’ rather than in great detail at the end of the consultation, and checking the patient’s understanding throughout. The doctor is also encouraged, where appropriate, to use written or diagrammatic information to help clarify their explanations. Finally, we are helped to ‘Close the Session’, by summarising and ensuring that the agreed plan is clear. It is crucial that the plan is clear to both parties (Silverman et al., 2008).

The Calgary–Cambridge model is practical, giving us tasks to complete. It is also ‘triaxial’, incorporating physical, psychological and social factors. The model may help trainees with assessments as it shares many features with the Consultation Observation Tool (COT) marking scheme, as shown in Box 1. There are also common areas with the CSA which assesses the doctor’s ability to ‘[communicate] with [the] patient and ... use ... recognised consultation techniques to promote a shared approach to managing problems’ (RCGP, 2011b). As we will discuss in more detail later, this model will not suit every consultation, although today it is widely promoted and widely taught. Some trainees will find it hard to use, and some patients may not like it, preferring a more paternalistic approach whereby decisions are made for them by the doctor.

Reference: Denness C. What are consultation models for?. InnovAit. 2013 Sep;6(9):592-9.

Neighbour Model

Neighbour In 1987, Roger Neighbour published The Inner Consultation which is one of the most salient and wellknown consultations models. In it, he describes a fivestage model which he firmly believes will ‘enable [us] to consult more skilfully, more intuitively and more efficiently’ (Neighbour, 1987). In the first stage, he talks about ‘Connecting’. This is the stage where the doctor establishes rapport with the patient and endeavours to see things from the patient’s point of view. The second stage focuses on ‘Summarising’. This was the first consultation model to include this concept. Summarising is the opportunity for the doctor to ask ‘have I sufficiently understood why this patient has come to see me?’ If your summary is inaccurate, patients have the opportunity to make amendments. If they are satisfied with your summary, then you can start to move on to the next stage (Moulton , 2007; Neighbour, 1987). The third stage is known as ‘Handover’. This describes the point where the doctor and patient formulate a management plan together. This will involve giving patients options, checking their understanding and may involve some negotiation skills. It also involves transferring responsibility for some aspects of the management plan back to the patient. The fourth stage concentrates on ‘Safety-netting’. At this point in the consultation, a contingency plan is formed. This covers the patient and the doctor if the doctor has go the diagnosis wrong, or if something unprecedented happens. The fifth and final stage introduces the idea of ‘Housekeeping’. This was another step that was introduced for the first time by Neighbour. It prompts us to acknowledge and deal with any emotions arising from the consultation before we see the next patient, to prevent this having any adverse effect on our next consultation. Figure 1 is an aide-memoire for Neighbour’s model that can be used in practice. Neighbour provides us with a model that is structured and easy to recall. Its five steps feel more achievable than Pendleton’s seven steps. It is patient-centred, but also attends to the doctor’s feelings, and tries to tackle the tricky areas that Byrne and Long identified as leading to dysfunctional consultations. It also builds on the idea introduced by Pendleton about handing over responsibility, and discusses in more detail about how this may be achieved. However, many GPs and trainees struggle with the limited time available, both in real-life and in the Clinical Skills Assessment (CSA), and therefore value advice on how to end a consultation. Neighbour does not really help us with that problem. Others would also argue that the ‘connecting’ part of the model should not just be at the start of the consultation, i.e. rapport should be built throughout

A guide to communication in the Physical Examination

Unlike 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.