Communication Skills – A practical Approach

Dr Ajit Kulkarni M.D.(Hom.)
This innovative article highlights the basics of communication skill, positive and negative qualities of communication, qualities needed for an homeopathic interview, various effective communication techniques, hints for pediatric case taking, effective case taking etc.

 “In every art there are few principles and many techniques.”     – Dale Carnegie

1.Introduction
Today I am going to share some fundamentals on an important subject of communicating with our patients. Our syllabus at undergraduate (BHMS) level or at Post – graduate (M.D.) level doesn’t contain the subject of communication although we get very few points on case taking. Case – taking in homoeopathy is a multi-dimensional complex process, which demands the full exploration of a human being in its totality. It is not merely gathering of some symptoms here and there through a certain frame of questions. To be frank with you when I began my homoeopathic career, I was unaware of the depth of case – taking and communication skills. My entire interview was based on questions alone and I used to bombard my patients with innumerable, stereotyped, successive spells like Rawalpindi Express of Shoaib Akhtar(a fast baller in the game of cricket). I was not concentrating on length and accuracy but on speed. This resulted in many fours and sixes as there were many ‘Sachins’( a popular batsman in cricket) in my patients. I lost many matches and yet I was confused: why I lost? Why those dropouts occurred?

I started looking seriously and I found that communicating with the patient has a heavy bearing upon physician – patient interaction. Now I realize that communication is a critical component of all medical interactions, it is not “just talking” and that communication is the keystone of the doctor-patient relationship.

All human activities are based on environmental experiences which in turn is the result of communication. We are the result of our sanskaras (training) and environmental interactions. Communication is at the root of what we are.

The field of communication is fast moving and rapidly growing. The population explosion, information explosion and compelling competitiveness are important factors of today’s world and the need of appropriate communication has tremendously increased.

2. Communication: Meaning

The term communication is grossly overworked. Everything; from billboards, to encyclopedias, to television, to holding hands; is communication. However, exchange of words only doesn’t constitute ‘communication’. The word ‘communication’ originates from Latin term “communicare” or “communico” which means TO SHARE. When a patient communicates his grievances, his complaints, his painful experiences from his life, he is actually SHARING with the physician. SHARING involves a deeper process of human interaction and relation.

Webster dictionary defines communication as “the interchange of thoughts or opinions”. Interchange: to inform, tell, express, or show in order to get a reaction or a response. It also means to listen, understand, weigh or evaluate. Charles Estes defines communication “—— the reception, digestion, and transmission of meanings, attitudes and feelings through words, gestures and symbols.”

Communication has a basic attribute of enlargement of feelings, facts, attitudes and ideas. So when a physician starts interrogating, the patient is unearthed, unfolded and he appears as a living vibrating individual; his facts are known, his inner feelings are brought on the surface, his attitudes and inclinations are understood and his ideas are known.

The system of communication is commonly owned, accepted and recognized by the concerned. It enables them to acquire, exchange, store, retrieve and process the information. It is a network of interactions and both the physician and the patient keep on changing their roles.

Communication is not a momentary event; in fact it is a momentary intensification of a continuing, cumulative process that starts even before actual communication takes place and continues even after it has occurred. Communication is not merely transmission of meaning from one person to another through symbols. It involves the pathway Source à Sender à Sent à Received à Receiver à Result. It takes place not only through words, but also through attitudes, feelings and actions.

“The success of communication is measured not only in terms of the effective transmission of the message but also the achievement of intended result.” This sentence indeed is the crux. Only concentrating on sending the message, a physician shouldn’t feel relaxed; he must also concentrate on what is the net result of communication. This net result is the feedback which every patient gives to a physician.

The ways in which a physician communicates with a patient significantly affect.

 1. The adequacy of the clinical interview

 2. The accuracy of detection of ‘problem’

 3. The patient’s understanding and compliance to the physician’s advice

 4. Patient satisfaction

There are two critical skills – Active listening and Feedback.

2.a.Listening: Eloquent silence 

I give pivotal importance to listening. It is the most important ingredient of communication. I have found that most of the homoeopaths are relatively poor listeners. There is a wrong belief that communication means verbal exchange. Hence there has always been emphasis on verbalization. A homoeopathic physician who sits on a chair with holistic philosophy in his mind, who has to deal with the patient from totalistic viewpoint, who has to keep his awareness fully to focus on emotions, on every body movement, gestures, postures, speech modulations etc., has to be a good listener. It is said that a knowledge-seeker has to be a good listener. The process of case taking is a knowledge-seeking process. Ultimately it is the patient who gives knowledge to a homoeopathic physician.

Major difference between ‘hearing’ and ‘listening’ must be understood. Hearing alone is not listening. Hearing is merely picking up sound vibrations while listening is making sense out of what we hear. Hearing is related with ‘ear’ functioning while listening is related with ‘ears, brain and mind’.

The greatest stumbling block to real communication is the one-sided nature of talking. Truly effective communication can’t be a monologue in which only the speaker is at work. It must be a dialogue. Listening is an active pursuit. It’s demanding, hard work. Establishment of Rapport and building of relationship are the outcome of a good listening.

2.b..Listening: mirror and sounding board
A homoeopathic physician as a good listener should play the role of both mirror and sounding board that throws back a reflection of the patient, giving him a chance to see and listen himself in a way that might not otherwise be possible. A mirror doesn’t add anything of its own. It only reflects as it is! Hahnemann’s requisite of ‘unprejudiced observer’ is akin to the concept of a physician acting as a mirror.

“Active listening is an important way to bring about changes in people. Despite the popular notion that listening is a passive approach, clinical evidence and research clearly shows that sensitive listening is the most effective agent for the change of individual personality and group development ”( Rogers and Farson).

To be an active listener, developing following skills will help a homoeopathic physician.

• Making an eye contact.
• Exhibiting affirmative head nods & appropriate facial expressions.
• Avoiding distracting actions or gestures.
• Asking questions.
• Paraphrasing.
• Avoiding interrupting the patient.
• Avoiding over talking.
• Making smooth transitions.

2.c.Feedback
The Second critical skill is Feedback. The process of interview evokes innumerable responses from a patient. Some responses may not be acceptable but a physician has to keep his mind balanced. A physician must remember, “Positive feedback is more readily and accurately perceived than negative feedback.”

2.d.Skills for feedbackFocusing on specific behavior

• Keeping feedback impersonal
• Keeping feedback goal-oriented
• Making feedback well-timed
• Ensuring feedback positive
• Directing forward behavior
• Using humor in interaction

1.  Focus on specific behavior
   There are 3 questions, why, how and when of Feedback. Let us take an example.

A flatterer is sitting before you as a patient. He is pleasing you, “How wonderful! Doctor, you are great, what a nice interview”. What a physician should do about such statements? Instead of engaging himself in appeasement of his own ego from the emotional overtone, the physician should focus on the specific behaviour that is flattery. In other words, explore the rubric and the personality of the patient.

2. Keep feedback impersonal
A physician is one who has to keep balance between his subjectivity, his emotionality and his professionalism. He must be able to look at the patient as he is. It is here that Hahnemann expects from him the state of being unprejudiced. In the above example of flattery, a physician should not feel himself great and excited. He must look at it impersonally. He should not get carried away. Keeping the feedback impersonal is reflective of maturity on the part of a physician. Finally his goal in practice is to treat the patient and this goal must not be forgotten.

Let us take another example: Interview begins and patient starts abusing the medical profession, “You all are blood suckers”. The physician should not take this statement in the personal context. He should understand that a patient has strong antipathic notions against the medical profession. The hostile attitude of a patient should make a physician to find out disposition. He should find out why a patient has developed hatred or resentment. For the selection of similimum what is necessary is to find the inner personality characters.

3. Keep feedback goal oriented
The goal of the interview is to seek A² : that is Accurate and Adequate data. The goal is to understand the patient as he is e.g.: In the flattery example the goal is to know the dimensions of flattery i.e. why he developed this disposition? What are the consequences of this as far as his family and social interactions are concerned? There should be pertinacity in achieving the goals. For a physician who has trained himself in making the vision of totality clear, this becomes easier as goals are known.

4. Make Feedback well-timed
Let us take an example here- A patient takes an appointment and is very punctual, but anyhow he has to sit for a long time. He expresses his resentment to the physician.  The physician must take this feedback into consideration and should honor the punctuality of a patient in the subsequent follow-ups.

It is the presence of mind of the physician that makes the feedback well-timed. 

5. Ensure Feedback Positive
Once the goal is fixed and it is understood that the feedback should not be perceived personally, it is possible to ensure a feedback positive. In positive feedback the physician acts more as a learner, as a care-taker and as a trustworthy human being.

For Example: Mother-in-law and Daughter-in-law are at cross with each other. New daughter-in-law behaves arrogantly and in the interview Mother-in-law expresses the agony and goes to the extreme to knock out DIL out of the house. The physician advises her not to take an extreme stand. MIL sarcastically expresses, “It is better for you to give an advice by just sitting on a chair”. The physician should take this statement lightly. He should try to understand the dynamic relations, try to explore the personality profile and in the subsequent follow-ups should make a statement in a laughing tone, “I am just giving you an advice by sitting on a chair.” 

6. Direct forward behaviour
The physician must be greedy in eliciting the data. A patient often becomes disorganized, wanders here and there, doesn’t stick to any specific issue and doesn’t narrate the totality. It is here that direct forward behavior has to be followed.

The reflective technique of communication as well as resonant body language is very useful in forwarding the interview in right direction.

Guidelines for receiving feedback 

• Taking criticism as advice
• Summarizing the criticism accurately and succinctly
• Leaning forward in conversation
• Smiling at appropriate time
• Asking for specific suggestions of ways to improve
• Thanking the person if you feel the criticism or advice useful
• Always being a learner

Communication skills are not innate or fixed. They can be learned or improved and consequently the physician can improve the health outcomes.

4. Adherence
Every physician has insecurity in his mind. Whether my patient will stick with me or will he leave? Insecurity hovers. State of anxiety develops. And the reaction develops, characteristics” is a myth. In fact no consistent relationship is seen between adherence and the following factors:

• Age
• Gender
• Social / Economic status
• Marital status
• Personality traits (introverted, gregarious etc.)

Then what affects adherence? 

Patient’s adherence would depend on the following factors: 

• The patient’s perception of seriousness of the disease.
• The patient’s perception of efficacy of the treatment.
• The duration of treatment and illness.
• The complexity of the regimen.
• The relationship with a physician.

Skills for improving Adherence

• Demonstrate compassion
• Communicate:
•   Personal concern for the patient
•   Personal interest with patient’s well being
•   Activate patient’s motivation
•   Share responsibility with the patient
•   Discuss the patient’s beliefs

8. Barriers to communication
When I started practice I was unaware of ‘barriers’ to communication. I found that there are some patients with whom I was unable to communicate. In some patients I was right at the selection of a remedy or repetition, but not knowing how to handle the patients through positive communication. Subsequently I understood that good communication skills are required not only in the first interview but also in subsequent follow-ups. The dropouts in my practice taught me to see the barriers, which are collectively termed as Noise.

8. Noise
Now let’s focus on the factors, which produce the “Noise” and see that the communication is smooth and free of any barriers.

• Absence of a common frame of reference.
• Badly encoded messages.
• Disturbance in transmission channel.
• Poor retention (esp. in face to face communication).
• Inattention by a patient or a physician.
• Premature evaluation of the message.
• Unclarified assumptions.
• Mistrust between a patient or physician.

• Different perceptions of reality
• Semantic difficulties.
• Vagueness about the objectives to be achieved.
• Misinterpretation of the message.
• Clash of attitudinal nuances of the patient and physician.
• Psycho – physical factors.
• Selection of wrong variety of language.

Absence of Common frame of reference
The frame of reference relates to the environmental setting in which the interview take place. The concept is that the environment must be congenial for the free ventilation of patient’s narration. The patient should feel that the environment in the clinic is favorable and there is no obstacle. The common frame of reference implies the context in which communication takes place. Both the patient and physician must be able to focus their mind meaningfully on the message if the context is well-defined.

Example: The sitting posture between patient and physician must be face to face. If physician is looking at north-west and patient at south-west, it is not favorable frame of reference. The room should have a refreshing odor. Strong smell can be an irritating experience for both the patient and physician. The word common represents at least the prescribed notions of the expected environmental settings.

Badly encoded messages:-
It is the fundamental right of a patient to get all the message of a physician in clear terms. Many physicians have the habit of talking in a rapid way or they talk as if muttering with the self. The coding of message must be in the format which is digestible by a patient.

Disturbances in transmission channel:-
This relates to the interferences that are from various sources. Frequent ringing tones, vehicles on the road or T.V. or radio in the clinic making big sounds, receptionist interrupting, the students asking questions in between etc. 

Semantic Difficulties:-
The language is the prized possession of a human being, but it is the complex way of communication. Each word has many meanings and both patient and physician must have at least working knowledge of the meaning of words. The semantic difficulties relate to the use of ambiguous expressions or highly specialist vocabulary which is inappropriate to the situation. Language is the most widely used instrument of communication. It is one of the most prized possessions of Man. It acts as a repository of wisdom, a propeller for the advancement of knowledge and a telescope to view the vision of the future. Selection of a wrong variety of language results in poor rapport. It is always better to speak in the language of a patient as it gives a feeling of closeness.

Example: A patient from Tamilnadu speaking in Tamil language with a Maharashtrian physician. This will be the semantic difficulty experienced by a physician.

The differences in the attitudes
The differences of the physician and the patient may result in attitudinal clashes and consequently the communication suffers. The generation gap between a patient and a physician, the urban and village culture and samskaras are responsible for differences in attitudes.

The psycho-physical factors
These relate to mental or physical states like fatigue, previous unpleasant experiences, inability of the patient to tune himself with the physician etc.

Self concept
The major barrier to communication is the self-concept. We know that an individual clings to concept he possesses about himself, overlooking the data that is not congruent with it.

Roles, status, credibility
Another major barrier to clear, undistorted communication unfolds from the role relationships, or status differences, of individuals involved in inter-personal communication. Credibility of the source also affects communication. Generally speaking, individuals of high status are accorded greater credibility. Usually, we believe people who we define as “experts”.

Emotions
No communication is free from emotions, either on the part of a patient or a physician. Emotions form a part of the “modifiers system” that screens transmissions and inputs. A physician has to balance between his emotive field of operation and professionalism.

9. Basic Qualities of communication 

1.  Positive and attractive qualities

            Warmth                                   Honesty

            Friendliness                             Exciting

            Interest                                    Knowledgeable

            Organized                               Creativity

            Confident                                Inspiration

            Openness                                 Authenticity    

Warmth, friendliness, honesty, openness put us at ease. These qualities actively invite us to get closer, creating an environment in which we can relax our guard and relate more directly and openly.

Exciting, creative and interest promise pleasure and tranquilizes us in a feeling of anticipation and a curiosity about what comes next.

Knowledgeable and / or confident are very reassuring. One listens with trust. Organized satisfies the brain’s need for order and logic delivered in the format.

Authenticity gives us confidence that what we see is indeed what we get, that we’re down to bedrock; this is a truthful person speaking, without subterfuge i.e. excuse.

Inspiration appeals to our deeply rooted willingness to follow a person or rise above our own thoughts and to absorb other’s enthusiasm.

2.  Negative and turn-off qualities 

            Pompous                                               Vague

            Unenergized                                        Complexity

            Patronizing                                          Unsure

            Formal                                                 Irrelevance

            Stuffy                                                  Monotonous

            Hyper-Intense                               Nervousness

            Closed                                                 Synthetic 

Formal and stuffy styles show us someone operating from a rigid set of rules unrelated to the situation at hand.

Closed and synthetic are bothersome. Who is the person? How can I predict anything about what he / she really means, feels, believes in?

Pompous behavior tries to set the speaker apart and steps above the listener. This creates two problems; Firstly, the listener questions who put him/her up there and on what evidence? Secondly, who automatically wants to look up to someone before you yourself have designated him / her worthy?

Monotonous speakers turn our passive state into torpor. This results in looking for the nearest hatch. Unenergized state makes us mad.

Vague or complex speaker creates anxiety in the listener. We hate to know we don’t understand. It gives the feeling of betrayal.

Irrelevant messages betray the first rule of getting people to listen – one’s own self-interest.

Patronizing is insulting. A speaker should be in a position to share his knowledge and riches freely which we are unaware of and he should not look down upon of not possessing the same. Unsure or nervous behavior makes us really uncomfortable- ‘I am flying blind.’

Hyper-intensity starts us out at too high a level. Such person is already at a gallop at the stage when we have just begun to walk. It presumes the same level of passion and information on the part of a listener that the speaker has, without working on the gradual development that might get us there. The negative qualities have one thing in common: They make us UNCOMFORTABLE.

I will briefly outline some more qualities needed for a physician in a homeopathic interview.

10. Homoeopathic interview: qualities needed

• Not to get over involved. To have a well-defined ego.
• Healthy attitude towards patient.
• Empathy, sensitivity and sensibility.
• Adequate intelligence to understand and co-ordinate in a coherent way.
• Interview skills for warm and effective verbal and non-verbal communication.
• Maintaining professionalism in an open and trusting way.

• Ability to create supportive climate in the interview to make patients express their true feelings and honest opinions without fear of rejection or denial.
• Knowledge of related subjects: clinical, para-clinical, social, psychology etc.
• Calm, quiet, balanced but an alert mind.
• Jovial, charming, cheerful communication.
• Awareness and observational eye.
• Conversational control
• Precision of mind.
• Asking the right question(s) at right time.
• Appropriate use of memory.

Now  if  you  think of knowing  the  basics  of  communication,  you  know  key communication skills and you are in a position to take an interview, you may face a lot of difficulties; for, you must know communication techniques.

11. Communication techniques

1. Facilitation – Verbal or non-verbal communication that encourages the patient to elaborate his view, idea, feeling, concept etc. It can be followed by several methods viz. repeating patient’s last word or sentence or asking questions like “ can you say more about that?” or through words like O.K., yes, vow, silence, “Hmm” or “Go on” or “I am  listening” or  “oh” or “Achcha”. etc. or through body gestures like nodding of head, questioning and eagerly looking at patient, leaning forward, hand movements etc. These gestures reduce unnecessary questions during interview.

2. Open-ended Questions – Requests stated in general terms for non-specific information. Open ended question gives a wide platform to talk with free association.

Example: A patient is telling about pain in abdomen and open ended question is “Tell me more about your pain.”

A patient is narrating grief incidence but in a brief way then O-E-Q is- “Tell me more about your grief”.

Questioning is one of the modes of eliciting the data but although it may result in factual data, it fails to develop satisfactory relationship. The benefit of OEQ is that there is no bombardment of questions and a physician does not restrict the patient in the golden cage of questions. The ventilation of patient’s thoughts and emotions occur spontaneously, freely and adequately. You must also know the disadvantage of OEQ. It should be cautiously followed in over-talking patients and this technique may take valuable time of a physician.

3.Direct Questions – Are those that ask the patient for specific information. “What then?” “What happened next?” Direct Questions should not be leading. Questions like “Did your stools look like tar?” are leading questions; they should give a graded response than yes or no. In a leading question there is no choice for the patient but to say “yes” or “no”. Direct questions have their own place in interview techniques. Direct Questions are helpful in reserved and introvert patients.

If a patient is unable to answer without help, it is better to offer multiple choices. In asking a direct question, ask only one question at a time. Asking double or multiple questions at a time could lead to a negative answer out of confusion. Example:  “Does night – watching cause nausea, vomiting, acidity, diarrhoea, or constipation?”

4. Support – Indicates physician’s interest, concern and his willingness to help the patient. Support should not be offered before the patient has expressed his feelings.

5. Empathy – Is communication that expresses understanding and sympathy for the patient’s feelings. It is basically dependent on sensitivity with which a physician receives the patient. Empathy can make a physician too emotive and it could result in emotional involvement and this could become a force of hindrance. An empathetic physician is likely to show it even though it is not needed.

Examples: “I understand.” “You must have been very upset.” “That must have been very depressing for you.” Empathy could be non-verbal.

6. Silence – It gives the patient a chance to explore and express deeper thoughts and emotions. A physician must know when to keep silence and when not to keep silence. Many physicians think that communication means talking and if we are not talking, it is not communication. Silence has great power to make others talk and its value should not be underestimated. 

Silence expresses a range of responses from total disinterest to active concern.  The demerit of silence is that some wayward patients may take disadvantage of silence on the part of physician and can go bizarre in wandering.

7. Reflection – A response from the physician that repeats mirrors or echoes a portion of what the patient has just said. Closely akin to facilitation. Useful in eliciting both facts and feelings. There is no risk of biasing the story or interrupting the patient’s train of thought.

Reflection is one of the most important techniques of homoeopathic interview. In this technique the patient directs a physician through words, sentences and body language. A physician has to scrutinize and use them intelligently with perseverance. Here the patient plays an active role and guides a physician to the similimum. This technique should not be employed in all cases. It is more useful in intelligent, expressive and freely communicating patients who are able to unfold the depths of their feelings and sensations.     

     Patient: The pain got worse and began to spread (pause).

     Response:  It spread?

     Patient: Yes, it went to my shoulder and down my left arm to the fingers. It was so bad  that I thought I was going to die (pause).

     Response:  You thought you were going to die.

     Patient: Yes. It was just like the pain my father had when he had heart attack, and I  was afraid the same thing may happen with me.

     See that a physician is adding nothing of his own and allowing the patient to elaborate.

8. Clarification – A response that asks the patient for further information and explanation for the sake of clarity. If the patient is giving information in an ambiguous way, this technique is useful. In factors of noise (cited above), clarification must be used. Ultimately a homoeopathic physician needs hard facts. Example: “Your symptoms occur when you are asleep; how are you aware of this?”

9. Confrontation – A technique that brings the patient face to face with the physician. It is useful when patient is giving inconsistent story. It is a sharp weapon. A physician can bring the feelings out by pointing out to patient about his own words or observed behavioral clues to anger, anxiety or depression. Should be used with caution as it may result in drop-out.

Examples: “You plan to continue smoking in spite of worsening of your emphysema?” “Your hands are trembling whenever you talk about that.” “You say you don’t care but there are tears in your eyes.”

10.  Summation – Reviews the information that has been given by the patient. This is a review given by a patient. It’s like summing up in a concise way and again asking the patient to comment. Summation is useful for facilitation and clarification.

11.  Interpretation – Formulation by the physician of data, events or thoughts into terms that make the patient aware of their inter-relationship. It makes an inference, rather than the observation made with confrontation.

12. Hypothetical: In order to explore the true portrait of the patient’s mental state, an imaginary situation is produced by a physician and the patient is asked to elaborate on it. e.g.:- In order to understand what exactly happens when a patient develops anticipatory anxiety, physician puts up the scenario before the patient, like a patient undergoing the air-travel for the first time or a patient is caught in an accident etc.

A physician can get a deeper level of sensations, feelings and delusions.

13.  Assurance – In some cases, assurance reduces drop-outs. However, assurance doesn’t mean giving guarantee of cure. It is wrong to give guarantee in incurable cases.

14.  Non-acceptance – In order that a patient should talk more about his sufferings, this technique is sometimes followed. However, it should not be stretched to the extent that patient should feel betrayed. In the psychotherapeutic setting, it helps the patient to review his perception.

15.  Body language – “Your words tell me the story but your body tells me the whole story.” A gesture, facial expression or a posture can open up a window in interview itself.

I have applied all these techniques in my interview chamber and I have found them extremely beneficial. I request the readers, to apply these techniques and send me the feedback.

Now you know about communication techniques and you must be thinking that it is easy to take an interview as you are equipped with weapons. But still something more is required. 

12. Interview hints: General

1. As far as possible it is extremely important to begin an interview with an open mind. A physician must exhibit Decency Skills.

There are three decency skills-
Greeting, Politeness and Kindness. “Decency skills facilitate and pave the way to the depth of interpersonal relationship.”

2. It is the physician’s responsibility to infuse energy in the interview.

3. Ask the patient to talk about himself first, before proceeding to specific questions.

4. Negative traits are more important than the positive ones.

5. Denial of negative trait’ as the spontaneous expression, actually may be an issue for  that patient e.g. “I am not a jealous person”.

6. Ask whether the patient possessed negative traits in the past; these traits can be used in homoeopathic assessment. Never consider the patient’s words at its face value.

7. Very often, the way in which patient narrates his complaints is more important than the complaints itself.

8. Very often the impression given by the patient is more useful than the content of his speech.

9. Information that is volunteered by the patient is far more reliable than what is given as a response to a specific question.

10. What would you like to change about your personality?

11. If a patient says, “I don’t get angry very often.” It is worth asking,” But do you feel angry inside?” – The degree of anger felt is a better guide to the remedy.

12. The personalities of parents / relatives (close) may be utilized to find out the  constitutional remedy.

13. A patient can give many sensations and feelings and a physician should try to go  deeper in the nucleus through the principle of generalization.

13. Hints for Pediatric case-taking
Take care to avoid “talking down” to children, as they are sensitive to affectations of speech and condescending behaviors.

The history you obtain in the child’s presence may be less accurate and couched in more limited terms than when you interview the parent(s) alone.

Address the infant or child by name rather than by “him,” “her,” or “the baby.”

‘Observational eye’ of a physician plays an important role in pediatric case-taking. 

Observe the child for  

• Hyper-activity: Mind, Body
• Discontent, Anger, Tantrums
• Constitution: obese, frail, puny, skin and nails.
• Character of: discharge, stool, urine etc.
• Quietness, Passivity, Sluggishness
• Nutritional status
• Developmental landmarks
• Activity Index of the child: Senses / Reflexes / Energy
• School performance
• Mixing 

Suggestions
Presence of both parents is recommended during interview. Request one of them to talk, preferably mother. But remember that in some cases father can also contribute a good amount of history.

• Usually in describing their child’s symptoms, parents narrate according to their underlying assumptions and perceptions of the child. These are subject to parental biases and needs.
• Parents need practitioners who are supportive rather than adjudging or critical. Hence it is better to avoid criticizing the parents.
• In interviewing parents, open-ended questions are usually more productive than direct questions (except in the realm of psycho-social problems).
• The chief complaint may not relate at all to the apparent reason for which the parents have brought the child to a physician. The complaint may serve as a “ticket of admission” to care.
• Try to put the parents / grandparents at ease by making them sit down first in cases of acutely sick / emergency case.

14. Adolescents
Adolescents often do not answer questions in an “adult” manner. They respond positively to anyone who demonstrates a genuine interest in them, not as “cases” but as people.

Adolescents tend to “open up” when the focus of the interview is on themselves and not on their problems.

A good way to begin the interview with adolescents is to chat in an informal manner about their friends, school, hobbies, games, sports and family.

It is better to speak to the adolescent alone after obtaining past medical and social information from the parent(s). A confidential relationship should not be based on “keeping secrets” but on mutual respect.

Reflection, silence, confrontation techniques should be avoided in adolescents. It requires thinking skills not yet acquired for Reflection. They have no sufficient self-assurance to respond to silence. If a physician uses confrontation, “bringing feelings out in the open” may cause an adolescent to retreat into silence. “Play it straight”, act your age & don’t stretch.

16.  Interview of the elderly 

• Respect the aged person not in terms of consolation, but in terms of his personality.
• Pay extra-attention to them.
• Ageing patients have longer histories and may tell them slowly. Don’t be impatient.
• Do not try to accomplish everything in one visit.
• Try to determine the patient’s priorities and goals.
• Learn how they have handled crises in the past. This will help you in planning the old patients and also in selection of a constitutional remedy.
• Don’t be idle in physical examination. Also do investigations frequently / as and when necessary. 

17.  Communicating with loquacious patients
Garrulous, rambling patients often pose a problem before a physician. The physician has limited time and there is need to “get totality” and such patients do not give the type of data which a physician needs. Then a physician becomes impatient and exasperated. To handle such cases remember that there are no perfect solutions, but techniques.

• Give the patient free rein for the first 5 to 10 minutes of the interview.
• Observe the patient’s pattern of speech: Does the patient seem obsessively detailed or unduly anxious? Is there a flight of ideas? Is there a disorganization of thought process?
• Try to focus on important issues. Show interest and ask questions in those areas.
• Facilitate sparingly. Use summation.
• Interrupt if need arises, but courteously.
• Do not display your impatience.
• If you have used up the allotted time or, more likely, gone over it, explain that to the patient.

18.  Conclusion
My friends, I have tried to give you the basics of communication with some important hints. But remember that to explore the human being is not an easy task. One has to change the personality, look within us, banish our prejudices, wrong notions and beliefs and go ahead with vigor. Homoeopathic interview is a multi-dimensional, complex process and it is the foundation of everything – rapport, personality, clinical diagnosis, materia medica, repertory, analysis, evaluation, synthesis, research etc. etc.

It is said that a wise man has long ears, big eyes and a short tongue. A homoeopathic physician should imbibe these qualities of Lord Ganesha to become a skilled interviewer and a true healer!

Author Email : dr_ajitkulkarni@rediffmail.com