1. Linda Gask University of Manchester

2. Problem-Based interviewing a model Development by Art Lesser in Canada in 1980s. One of several models!

3. Key features Simple- minimal theory! Active- videofeedback Based on real material ‘Problems’ not symptoms. Process not outcome. Extensively evaluated.

4. Three key sources of information What the patient says: the ‘History’- but also verbal cues What the doctor ‘sees’ and ‘hears’: nonverbal and vocal cues. What the doctor feels.

5. Problem detection skills Beginning the interview Picking up/responding to verbal cues Picking up/responding to non-verbal cues Demonstrating empathy Asking about health beliefs/concerns Controlling the interview

6. Picking up/responding to verbal cues Open question Clarification Example

7. Problem Management skills Ventilating feelings Information/education Making links Negotiation Motivating change/promoting self-management Conjoint interviewing

8. Skills needed in training Putting trainee at ease Selection of material Setting the agenda Stopping tape to teach: ‘decision points’

9. Skills needed in training Focus on skills Constructive criticism Hierarchy of prompts

11. Impossible patients? Much of the published literature is about problem patients. Is the problem really one of problematic interactions rather than problem patients?

12. Complex interactions Demanding problems? Multiple problems Social difficulties ‘not medical’ ‘Medically unexplained symptoms’ Unmet emotional needs

13. Complex interactions Complex communication Physical barriers (eg. deafness) Communication style Linguistic barriers Cultural barriers Emotional tone Atypical balance of power ‘Expert’ patients Consulting with fellow professionals

14. Complex interactions Potential for disagreement Physical or psychological? Having treatment or not? Changing behaviour or not? Complex dynamics Couples Families Parents and children

15. I came to medical school with the idea that really got reinforced in my training, that if you really learn everything and you really do care about your patients, if you really are a great doctor then you can take care of it all….. (From Gerber 1983)

16. Factors that predict our resistance to stress Character Challenge Commitment Control What do you get out of your work? What does your work get out of you?

17. Recognising and tackling problems Reflection- awareness of our thoughts, feelings, reactions Acknowledgement Ownership Motivation to change Action

18. Breaking the problem down Helps with clearer definition Enables sense of control and achievement earlier Fact or assumption? What, when, where, who and how?

19. Establish achievable goals What are the key sources of support that I have? Can I make use of them? If not, why not? What sources of relevant training do I have access to? Can I make use of them? If not, why not?

20. Establish achievable goals Are the expectations that I have of myself realistic or unrealistic in this case? Am I guilty of undervaluing what I have achieved so far?

21. Generating solutions to problems ‘Brainstorming’ The more the merrier Mix and combine Avoid judgement

22. KEY SLIDE22 Challenging the way we think about complex interactions with our patients Share your difficulties Challenge your attitudes but Also be prepared to Be clear about your boundaries Confront hopelessness in yourself but also be prepared to Accept your own powerlessness when necessary (Getting the balance right between the two)