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Lecture 2

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9-4-09, first hour

9-4-09, first hour

Published in: Health & Medicine, Spiritual

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  • 1. V550 The Health Interview: Facilitating Questions Richard E. Meetz, OD, MS 2008
  • 2. Facilitating Questions
    • Questions Facilitation: Promoting communication through verbal or non-verbal means
    • The patient is encouraged to speak, but no direction is provided.
  • 3. Facilitating Questions
    • The interviewer makes use of gestures, facial expressions, an attentive manner and a few words to urge the patient to continue discussion.
  • 4. Facilitation: Facial Expressions
    • Nod of the head:
      • Means “Go on, I’m listening”; “I heard you”
      • Beware of the “Nervous Nod”
        • “ Constant Nod” or “Bobble Head Nod” -Misleading and looks silly
  • 5. Facilitation: Facial Expressions
    • Perplexed Facial Expressions
      • Raised eye brow, pursed lips etc...
      • Means “I don’t understand you”, “I can’t follow you”, “Does not make sense”
      • Beware these can be interpreted as disapproval
  • 6. Facilitation: Facial Expressions
    • Head shake:
      • Can mean disapproval or unbelievable
      • “ Does not sound correct”, “Not possible”
      • “ Not good”
    • Frown: above
    • Raised eye brows:
      • Can mean “surprised” or “disbelief”
  • 7. Types of Facilitation: Verbal Help
    • Continue : encourage patient along same lines
      • “ Yes?”
      • “ Uh-huh”
      • “ I see”
      • “ Go on…”
  • 8. Types of Facilitation: Verbal Help
    • Repeating/Reflection : use when more information is needed after patient has stopped.
      • Repeating patient’s last few words in the form or intonation of a question
      • Repeating a phrase used earlier to change a topic which was brushed over
        • Patient: “…and then I had this eye pain.”
        • Response: “You had this eye pain?”
  • 9. Types of Facilitation: Verbal Help
    • Clarification : use when a word is ambiguous or confusing
      • “ Tell me what you mean by _____ “
      • Example: Dizziness
        • “ Tell me what you mean by dizziness.”
        • If the patient is having difficulty, give some examples: “Does the room spin around or do you get light headed?”
  • 10. Types of Facilitation: Verbal Help
    • Empathy : Recognizing and acknowledging a person’s feelings.
      • Used to show you recognize feelings and are “OK” with them.
      • “ This must be very difficult for you.”
  • 11. Types of Facilitation: Verbal Help
    • Confrontation : Observation or statement to show discrepancies, especially in affect.
      • “ You smile when you tell me that your mother passed away.”
      • “ You say all is resolved, yet you sound angry.”
  • 12. Types of Facilitation: Verbal Help
    • Interpretation : based not upon observation but rather upon inference, linking statements to imply cause.
      • “ It seems that every time you wear your contact lenses, your eyes are crusted the next morning.”
  • 13. Types of Facilitation: Verbal Help
    • Explanation : of why a question is going to be asked or has been asked.
      • “ When the eyes are this red for this length of time, we need to ask other questions about your activities and about symptoms in other areas of the body.”
      • IMPORTANT: There is a reason for every question that we as Optometrists will ask. Know the reasons for them!!
  • 14. Types of Facilitation: Verbal Help
    • Summary:
      • Condenses facts and conveys how you understand the patient’s Health/Vision problems and/or needs.
  • 15. Types of Questions and Statements
    • Open-ended : unstructured, undirected
      • Allows the patient to choose own focus, typical opening question of a case history.
      • Starts with: “What, how, when, where…”
      • Example: “What brings you in for an eye exam today?”
  • 16. Types of Questions and Statements
    • Closed : structured, directed “Yes-No”
      • Seeks specific details
      • Starts with “Do you…, Does anyone…, Are you…?”
      • Example: “Are you taking any medications?”
  • 17. Types of Questions and Statements
    • Direct Question : focuses on specific information
      • Short answer, can be yes-no.
      • Ex: Direct Open – “What type of activities do you do at work?”
      • Ex: Direct Closed – “Are you currently working?”
  • 18. Types of Questions and Statements
    • Indirect Question : Open-ended questions that do not sound like a question
      • Ex: “Your glasses are very heavy. That must cause you difficulty in school.”
  • 19. Types of Questions and Statements
    • Compound Question : “Double Barreled”
      • Two questions at once. Confusing to the patient, “which do I respond to?”
      • Ex: “Do you ever get headaches or see double?”
      • AVOID !!
  • 20. Types of Questions and Statements
    • Multiple Choice : “Laundry List”
      • Provides patient with a list of responses. Used to narrow down the “Time of Onset” or frequency of a Sx.
      • Good for patients who are unsure how to respond or to control the talkative or rambling patient.
  • 21. Types of Questions and Statements
    • Multiple Choice cont’d:
    • Often used when a patient doesn’t know an answer to onset or frequency
      • Ex: “How often are your headaches? Every day? Once a week? Twice a week or a few times a week?”
      • Limits responses and tends to put the examiner’s word into the patient’s symptoms.
  • 22. Types of Questions and Statements
    • Leading (Suggestive) Questions :
      • Suggests the “correct answer”
      • Ex: “You don’t smoke, do you?”
      • Judgmental! Don’t use!
  • 23. Types of Questions and Statements
    • Informing Questions :
      • Asked in a way that information is given as to why a question was asked.
      • Ex: “This medication is usually taken for… ____ is that why you are taking it?”
      • Ex: “Side effects with that medication are common for…1,2,3 have you notice any of those?”
  • 24. Types of Questions and Statements
    • Facilitative Questions
      • Shows attention or interest. Encourages the patient.
      • Ex: “Tell me more about that.”
  • 25. Types of Questions and Statements
    • Clarifying Questions and Statements :
    • 4 Types
      • Used to confirm what was heard and to jog patient’s memory for more information.
        • Reflection – Repeat last statement as a question
        • Paraphrasing – shortening phrase in your terms for record
        • Checking – repeat last statement
        • Summarizing – brief review
  • 26. Types of Questions and Statements
    • Validation Questions :
      • To confirm meaning & accuracy. Involves both observation & interpretation of cues.
      • Ex: “You seem worried about those findings…”
  • 27. Types of Questions and Statements
    • Acknowledging Questions :
      • Acknowledges your observation and asks “What would the patient like?”
      • Ex: “You are nervous about this test. Is there anything I can do to make you more comfortable?”
  • 28. Types of Questions and Statements
    • Confronting Questions :
    • “ State the obvious”
      • Acknowledge emotions, conflicts in information, avoiding.
      • Ex: “You say you’re not upset but you sound very angry. We need to clarify this before we go on.”
  • 29. Types of Questions and Statements
    • “ Why” Questions :
      • Requires the patient to account for behavior.
      • Ex: “Why didn’t you take your medication?”
    • BEWARE:
        • Shows Dr’s feelings of helplessness or frustration
        • Overtones of accusations
        • Can antagonize the patient
        • Patient can feel like Dr is finding fault
  • 30. Types of Questions and Statements
    • “ Why” Questions cont’d:
      • Typical response: “because” or alibi, excuses and rationalization
      • Avoid!
        • Shuts down communication
      • Suggestive alternative: “I’m not clear on why…”
  • 31. Types of Questions and Statements
    • Patient’s Questions :
      • Clarification (terms, treatment)
        • Know lay explanation for any jargon you use.
        • May need to write out patient instructions.
  • 32. Types of Questions and Statements
    • Patient’s Questions cont’d:
      • Information (Dx, treatment progression, risks)
        • Dr must know the reason for all questions asked.
        • Dr must be familiar with many different diseases/treatments of both ocular disorders and systemic disorders.
  • 33. Types of Questions and Statements
    • Patient Questions cont’d:
      • Personal questions
        • May just wish to know your background as a person
          • Best to keep answers to “Yes/No”
        • Manipulations
          • Patient seeking special care, “your friend”
          • If get more questions after your 1 st “Yes/No,” don’t ask, “Why?” Say: “I believe we are here to discuss your eyes and vision….”
  • 34. Communication Patterns and Approaches to Interviewing
    • We will use these different question styles to open up a patient to give us the information we need.
    • By changing or combining these question types we will be able to focus a general complain down to the essential information needed to make a diagnosis.
  • 35. Communication Patterns and Approaches to Interviewing
    • Funnel Approach
    • Inverted Funnel Approach
    • Tunnel Approach
    • Repeated Funnel Approach
    • Hourglass Approach
    • Diamond Approach
  • 36. Communication Patterns and Approaches to Interviewing
    • Funnel Approach
    • This is the standard approach to most patients
      • We start off with a very broad “open” question
      • Then we slowly change to more closed questions as we focus down to the details of the problem
  • 37. Communication Patterns and Approaches to Interviewing
    • Inverted Funnel Approach
      • Is used for patients who are closed or not sure what or if they have a problem
      • We start out closed “yes-no” questions then to open as the patient opens up
  • 38. Communication Patterns and Approaches to Interviewing
    • Tunnel Approach
      • Is used for those closed patients who never open up and for those overly talkative patients
      • We use a series of repeated closed, “yes-no” and list questions
  • 39. Communication Patterns and Approaches to Interviewing
    • Repeated Funnel Approach
      • Is used for patients whom have multiple problems
      • We often have to start over with the open to close questioning for each symptom
  • 40. Communication Patterns and Approaches to Interviewing
    • Hourglass Approach
      • This is more typical of the approach we will take with most of our patients
      • We start open then focus them down. Then we open them back up to complete the rest of their medical history ending with the summery and asking is there anything else to add.
  • 41. Communication Patterns and Approaches to Interviewing
    • Diamond Approach
      • Is with the Inverted Funnel Approach on patients who where initially closed who then opened up we then refocused them down to find our WDx.
  • 42. Traps
  • 43. Ten Traps of Interviewing
    • Nonproductive, defeating verbal messages that restrict the patient’s response:
    • 1) Providing Assurance or Reassurance
      • “ Don’t worry, I’m sure it will be all right.”
        • Trivializes anxiety and problems.
  • 44. Ten Traps of Interviewing
    • 2) Giving Advice
      • “ If I were you, I’d do……”
      • Shifts accountability for decisions to you. Increases YOUR liability.
    • 3) Using Authority
      • “ Your doctor knows best”
      • Promotes feelings of inferiority
  • 45. Ten Traps of Interviewing
    • 4) Using Euphemisms or Language of Avoidance
      • “… passed on…”
      • Avoids reality
    • 5) Engaging in Distancing
      • use of impersonal language/speech “We find…” to erect barriers between you and your patient
  • 46. Ten Traps of Interviewing
    • 6) Use of Professional Jargon
      • sounds condescending, excludes patient, makes them feel like you are talking over their head.
    • 7) Leading or Biased Questions
      • “ You don’t smoke, do you?”
      • Judgmental
      • Implies that one answer is “better”
  • 47. Ten Traps of Interviewing
    • 8) Talking Too Much/Teaching During History
      • Patient loses train of thought
      • Wastes time
        • most will forget information
      • If exam takes long even due to their questions the patient still sees you as inefficient…Competent?
  • 48. Ten Traps of Interviewing
    • 9) Interrupting
      • The most common trap doctors fall into
      • Cuts patient off, seen as rude?
      • Discourages elaboration
    • 10) Using “Why” Questions
      • Implies blame, condemnation
  • 49. *