Being attentive and receptive
Comprehend and store the information (cognitive level)
Evaluate and digest (emotional level)
Making decisions and adapting behavior (behavioral level)
The CELI model, which is derived from the Yale persuasion model [3], differentiates the communicative tasks a health professional must perform to ensure that the psychological processes listed above run smoothly. These tasks or sub-competences—control, explaining, listening, and influencing—are shown in the outer oval of Fig. 26.1 [2]. The following sections provide further clarification of these sub-competences. In the section titled Tips and Tricks in this chapter, an overview is given of the patient education skills that go with these sub-competences. The limited scope of this chapter does not allow us to discuss all patient education skills in detail; we will examine only those aspects of patient education that are of particular importance to health professionals who work according to the BPS model.
Case History: Ms. Mustard Revisited
Even though it takes great effort, Dr. White asks Ms. Mustard to sit down again. “Sorry, I forgot something,” he says.
Ms. Mustard sits down again, a bit surprised, but because of this Garry knows he has her full attention. “Last time we talked about things like smoking and drinking. I had the impression that that didn’t really help you and I’d like to do something about that. I want you to know that in the first place my job is to care for you, regardless of what you do or don’t do. At all times—even when you do things I’m personally not happy about. OK?”
Ms. Mustard looks at him with relief. “I’m glad to hear that, doctor, because the last time I felt just like a little girl being put in the naughty corner. And of course I know I should really stop smoking and drinking, but I just don’t see how I can do it.”
In the first instance, Garry feels inclined to talk to her about the importance of a healthy lifestyle for her unborn child. Fortunately he realizes just in time that this would be more of the same and would therefore be counterproductive. “People always act as though it’s easy, but I think that right now it might be harder than ever to break certain habits that actually give you a kind of support.”
Ms. Mustard nods and immediately agrees with him. “Exactly doctor, you do it almost without thinking about it. But if I don’t light up a cigarette, it’s as though the whole world is coming at me.”
Garry now agrees with what she has said. “OK, so on the one hand it’s extremely difficult to break habits like these, and on the other hand, we agree that you really should stop or at least smoke and drink as little as possible.”
Ms. Mustard nods and shows that she has more self-knowledge than he had thought. “Perhaps I should talk to someone about the panic I suddenly feel sometimes, it’s really not normal….”
26.2.1 Control and Rapport
Case History: Ms. Peach
“But doctor, it must be something. That pain comes back all the time!”
“Well, Ms. Peach, I don’t think there’s anything wrong. I couldn’t feel anything abnormal during the internal examination, your blood test was OK, there were no abnormalities in your urine or feces, and there was nothing unusual in the ultrasound scan either. Everything looks fine. I think you should just wait and see if your symptoms get any worse. Perhaps your pains have something to do with stress factors at home, and they’ll go away if you get some rest.” Garry should not have added those last few words.
Ms. Peach looks at him indignantly and protests fiercely. “Come on, doctor, do you think I’m pretending? Do you think I’m mad? I’ve had this awful abdominal pain for ages and all you can say is it’s probably all in my mind. Great doctor you are! I’ll find another one.” With her face flushed with anger, Ms. Peach picks up her coat and leaves the surgery, leaving Garry White behind, dumbfounded.
Information can only sink in if the patient is ready and able to listen to the information and be open to it. The most important prerequisites for this are:
The patient is aware of and agrees with the goals of the consultation.
The patient’s attention is not distracted during the consultation by external stimuli.
The patient’s emotions will not prevent them from taking in and processing the information.
The patient feels at ease—as much as possible—during the consultation and has confidence in you.
To a large extent, these prerequisites will be met if you stay in control of the conversational flow and also make sure you have good rapport with the patient. Appropriate use of the other sub-competences will also have a positive effect on your control of the conversation and your rapport with the patient. It is important to be a good host in the contact with your patient; a medical consultation is not an ordinary conversation; it is a meeting with preset goals, and the health professional is primarily responsible for the attainment of these goals. The health professional must therefore control the conversational flow. However, control does not mean that the patient is a passive contributor to the consultation. On the contrary, good control entails the health professional inviting the patient to actively participate in the conversation [4]. The control task relates to three aspects of the consultation: (1) control over the situation to ensure the conversation is undisturbed and private; in Fig. 26.1, this control task is positioned outside the consultation oval since this task must be performed before the consultation starts; (2) guiding the conversation in order to reach the preset goals [5, 6]; and (3) fostering the relationship [4, 7]. Control includes activities such as initiating and ending the session, structuring the conversation, building and monitoring rapport, encouraging patient participation and collaboration, and using the available time efficiently. For instance, at the beginning of the consultation, you should give a brief summary of what has happened before the consultation and what the reason for and the goal and agenda of the consultation will be. When doing this, you must be sensitive to the patient’s questions and wishes and make it clear what the patient can expect. Having this agenda will also help you to keep track of the topics that need to be covered. It means you can redirect the conversation if it starts to stray from the intended topics. In addition, during the conversation, you can refer the patient to the agreed agenda if they dwell too long on one point or raise issues that are not really relevant.
Case History: Ms. Peach Revisited
“We saw each other a fortnight ago about your recurring abdominal pain. I examined you and I understood that you were worried about this pain. Last week you had some tests and I will discuss the results with you. I hope I can relieve your anxiety to some extent. After that I want to talk to you about what we can do about the pain. This will require some effort on your part, which is why I want to talk to you about it in more detail. But first I want to hear how the abdominal pain is now.”
Ms. Peach reacts with relief, feeling that she is being taken seriously, and starts to talk.
Garry briefly summarizes what she has told him, stressing the partnership between them. “I think we have discussed the main issues. Your stomach pain is not a cause for concern, but if you want less trouble with it, you will need to be more careful about what you eat and drink. I’ve given you some recommendations and I hope you’ll manage to follow them. And if you still have stomach pain, you can take antacids. We’ll see each other again in 2 months to see if the recommendations have helped. Well, as far as I’m concerned, we are finished now, unless you have any questions.”
Once all the topics on the agenda have been covered and the necessary arrangements have been made, you can end the consultation. It is helpful for the patient if you clearly mark this ending with a summary of the most important conclusions and arrangements and then give the patient an opportunity to respond to this. Obviously, you will respond to any questions the patient has. Then you should check that:
You have given the patient any educational information you have promised.
You have completed any documentation or forms for further appointments such as follow-up tests.
The patient knows what to do directly after the consultation, for instance, making a new appointment at the reception desk.
Maintaining a good relationship entails:
A friendly greeting at the beginning of the consultation and a friendly goodbye at the end
Maintaining contact with the patient when you are doing other things such as typing in data, writing, or performing medical procedures
Showing you are committed, painstaking, and knowledgeable
26.2.2 Explaining
Case History: Continued
“It doesn’t get any easier,” sighs Garry White, while having a coffee with a colleague.
“What do you mean, Garry?” asks his colleague.
“I mean explaining to a patient who’s not that bright what the options are for artificial insemination. Just talking about IVF, ICSI, and IUI, all the acronyms were driving that woman mad.”
His colleague thinks calmly about Garry’s remark for a while. Then apparently he has had a eureka moment, because suddenly he starts talking enthusiastically. “You know, Garry, do you remember that British professor at the conference we went to in Berlin last year? I can’t remember his name, but I can still remember him vividly. He gave a fantastic talk about preeclampsia. Not an easy topic, but his talk was absolutely clear. I finally understood how all those interactions work.”
“Well, yes,” sighs Garry, “it was a fantastic talk, but he was speaking to fellow doctors. I have to explain things to an ordinary woman who just really wants to get pregnant.”
Garry’s colleague is undaunted. “I don’t know, Garry. I think you can still use a lot of the techniques he used when you’re giving information to your patients. It’s about structuring and presenting your material in such a way that your patients can follow it and understand it. And if you want to do that, I don’t think it’s such a good idea to bombard them with difficult terms like IVF, ICSI, and IUI.”
The patient must be able to cognitively understand and remember the information you give. By paying attention to the structure, wording, and presentation of your explanation, you can make sure your patients can comprehend your explanation and also remember it.
In the first place, a comprehensible explanation must have a clear structure, with an introduction, body, and conclusion. The aim of the introduction is to connect the explanation to the patient’s frame of reference. You should check what the patient already knows about the topic and what questions they have. In response to this, you can then provide an overview of what you are going to explain to the patient. The body of your explanation should obviously be well structured for your own sake but also for the patient’s sake; the patient needs to be able to keep track. By dividing your explanation into core components (subtopics), you can present it to the patient in “bite-sized chunks.” In the conclusion of your explanation, you should again stress the main points and check whether your patient has fully understood your explanation and whether the patient has any more questions. Finally, you can put your patient on a firm footing by being clear about what will happen next and giving them a brochure or showing them a website so that they can read your explanation again later and also show it to other people.
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