Using time

In general, psychiatrists working in primary care settings have more patients than time to take care of them. Effective triage of new patients, including the ability to accommodate urgent consultations, is necessary to provide good care (Table. ...2.). Also helpful are timely and complete transfer of patient data, referral letters, and results of psychological tests that are done prior to the initial consultation. The psychiatrist must develop an interview style that can adapt to the primary care setting.

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Table 2 Communicating by telephone

Primary care is characterized by brief but frequent patient interviews. Patient histories and family information are readily available in the primary care setting, as the physician has usually cared for several family members over time. Although it is essential to create and sustain an emotional connection with the patient during the interview, a good interview is not necessarily individual, non-directive, interpretive, or characterized by deep silences and revelations. The other interview extreme—using standardized questionnaires—allows physicians to obtain answers, but, as Balint said, only answers; (1,8> the most meaningful patient information may not be revealed. The 'high control' style characterized by simple yes/no responses may lead the clinician to a correct, but narrow diagnosis that does not result in understanding the patient.(21) Given the lack of time, the challenge for physicians is to find some balance between being directive versus non-directive, and listing emotions versus exploring them. Following are some guidelines to help achieve that balance. (22>

• Attend to all aspects of a patient's behaviour, appearance, speech, emotional state, thoughts, and judgement when making overall assessments of the patient's health.(23> Non-verbal cues provide valuable information from the outset of the interview. Physicians who maintain better eye contact detect more emotional distress.(24)

• Use 'windows of opportunity'.(25) Patients often do not disclose the issues that are most frightening to them in the first encounter with a clinician, and often not at the beginning of the visit. Thus, probing should occur when a patient gives a clue, often indicated by a casual remark, a repeated comment, or a loaded question ('Could this be something serious?'). Often, the clinician cannot predict which topics the patient will find most difficult to discuss. A patient who speaks freely about a past history of sexual abuse, for example, may have tremendous difficulty talking about an extramarital affair (or vice versa).

• Use the words that the patient uses to describe his or her experience. Patients will often not have had experience with psychiatrists, and will not readily distinguish between problems that physicians consider somatic (e.g. fatigue) and psychiatric (e.g. depression). When describing mood, check the patient's understanding of words such as 'weak' or 'paranoid'.

• Address confidentiality. Elicit concerns from the patient, and discuss how to handle communication with other members of the team caring for the patient, as well as with the patient's family members.

• Find ways to respect the patient. This can be especially difficult when a patient discloses information that violates the physician's own personal values (such as a patient who admits to child molestation). In this instance, the physician can acknowledge the patient's courage to make such a disclosure. Let the patient know that he or she is a person with intrinsic worth and positive qualities. Actions will speak louder than words in this regard.

• Use the primary physician's long-term relationship with the patient and the family to gather historical information, especially prior adaptation to illness, and baseline level of functioning. This will provide clues to chronicity of symptoms, expectations for treatment, and underlying personality disorders. Prior psychiatric treatment, hospitalizations, and medications will give clues to previous diagnostic thinking, even if the patient is unaware of or unwilling to disclose prior psychiatric diagnoses.

Some other basic skills are summarized in Table 3.

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Table 3 Basic communication skills in primary care

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