The Medical Interview: Communication Skills I


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The Medical Interview: Communication Skills I

  1. 1. The Medical Interview: Communication Skills I Ted J. Ruback, M.S., PA-C Associate Professor and Head Division of Physician Assistant Education Director, OHSU Physician Assistant Program
  2. 2. Objectives <ul><li>Describe the characteristics of positive regard for patients and how this leads to willingness to join patients as partners </li></ul><ul><li>Explain the purpose of each of the three basic functions of the interview. </li></ul><ul><li>List the topics of an initial interview and written history. </li></ul><ul><li>Describe how to greet and put a patient at ease. How to open, close, organize and guide the interview. </li></ul>
  3. 3. Why a session on medical interviewing and patient communication skills? <ul><li>Evidence supports the importance of learning good patient communication skills. Research shows: </li></ul><ul><ul><li>69% of interviews were interrupted by the physician within the first 18 seconds of the interview </li></ul></ul><ul><ul><li>77% of the time, patients’ reason for coming to the physician were not fully elicited </li></ul></ul><ul><ul><li>When patients are asked to discuss their illness and treatment immediately after leaving their physician’s office, they were able to correctly identify only about 50% of the critical information. </li></ul></ul>
  4. 4. Objectives of the Medical Interview <ul><li>Gather information </li></ul><ul><li>Establish rapport </li></ul><ul><li>Educate, support and motivate </li></ul>
  5. 5. Setting the stage <ul><li>Create an environment designed to facilitate communication. What factors are important? </li></ul><ul><ul><li>Atmosphere </li></ul></ul><ul><ul><li>Personal approach </li></ul></ul>
  6. 6. Beginning the patient encounter <ul><li>Review chart </li></ul><ul><li>Review identifying information </li></ul><ul><li>Note, record date/time </li></ul><ul><li>Knock on the door </li></ul><ul><li>What’s next? </li></ul>
  7. 7. Introductions <ul><li>Introduce yourself and explain your role </li></ul><ul><li>Address the patient appropriately </li></ul><ul><li>Express interest </li></ul><ul><li>Ask permission </li></ul><ul><li>How do you introduce yourself? </li></ul>
  8. 8. SOAP <ul><li>Subjective </li></ul><ul><li>Objective </li></ul><ul><li>Assessment </li></ul><ul><li>Plan </li></ul>
  9. 9. Subjective vs. Objective <ul><li>Subjective </li></ul><ul><ul><li>What a patient feels, describes indirectly with words </li></ul></ul><ul><ul><li>SYMPTOMS </li></ul></ul><ul><li>Objective </li></ul><ul><ul><li>Physiologic quantities observed directly </li></ul></ul><ul><ul><li>SIGNS </li></ul></ul>
  10. 10. Subjective vs. Objective: <ul><li>True or False: </li></ul><ul><li>Objective data is more important than subjective, because subjective data is lacking in quantification? </li></ul>
  11. 11. Subjective vs. Objective: <ul><li>FALSE! </li></ul><ul><li>Research suggests: </li></ul><ul><ul><li>~80% of diagnoses are made based on history alone. </li></ul></ul><ul><ul><li>Physical exam adds another 10% </li></ul></ul>
  12. 12. <ul><li>Subjective </li></ul><ul><li>or </li></ul><ul><li>Objective? </li></ul>
  13. 13. The Complete Medical History <ul><li>Identifying information </li></ul><ul><li>Chief complaint or concern (CC) </li></ul><ul><li>History of present illness (HPI) </li></ul><ul><li>Past medical history (PMH) </li></ul><ul><li>Family history (FH) </li></ul><ul><li>Social history (SH) </li></ul><ul><li>Review of systems (ROS) </li></ul>
  14. 14. The Complete Medical History <ul><li>Identifying information </li></ul><ul><ul><li>Often ignored </li></ul></ul><ul><ul><li>Name, age, gender, occupation </li></ul></ul><ul><ul><li>Source of referral </li></ul></ul><ul><ul><li>Source of history, reliability </li></ul></ul><ul><ul><li>PCP, nearest relative, contact information </li></ul></ul>
  15. 15. The Complete Medical History <ul><li>Chief Complaint or Concern (CC) </li></ul><ul><ul><li>One of more symptoms or concerns for which the patient is seeking care or advice </li></ul></ul><ul><ul><li>Eliciting the chief complaint </li></ul></ul><ul><ul><li>Patient’s direct statement in response to an open-ended question, recorded accurately </li></ul></ul>
  16. 16. The Complete Medical History <ul><li>Documenting the Chief Complaint </li></ul><ul><ul><li>The primary reason the patient is seeking medical attention, recorded using the patients own words, in quotes X duration </li></ul></ul><ul><ul><li>One sentence, never more than two </li></ul></ul><ul><ul><li>Do not editorialize or embellish </li></ul></ul><ul><ul><li>The chief complaint is not your interpretation of why a patient is seeking help, but the patient’s </li></ul></ul><ul><ul><li>The chief complaint is not a diagnosis </li></ul></ul>
  17. 17. The Complete Medical History <ul><li>History of Present Illness (HPI) </li></ul><ul><ul><li>Description of the patient’s chief complaint starting from the last time the patient felt well </li></ul></ul><ul><ul><li>Attempt to understand the full story of the development and expression of the chief complaint in the context of the patient’s life </li></ul></ul><ul><ul><li>Determine the actual reason for coming in at this particular time </li></ul></ul>
  18. 18. The Complete Medical History <ul><li>Eliciting the HPI </li></ul><ul><ul><li>The “open-ended” interview </li></ul></ul><ul><ul><ul><li>Begin with open-ended questions </li></ul></ul></ul><ul><ul><ul><li>Move to more directed questions to clarify and embellish </li></ul></ul></ul><ul><ul><li>You need to know what information is needed and how to get it </li></ul></ul><ul><ul><li>You need to be able to evaluate the relevance of the information obtained </li></ul></ul>
  19. 19. The History of Present Illness: the seven dimensions of a complaint <ul><li>Location </li></ul><ul><li>Quality </li></ul><ul><li>Severity </li></ul><ul><li>Timing </li></ul><ul><li>Context </li></ul><ul><li>Modifying factors </li></ul><ul><li>Associated signs and symptoms </li></ul><ul><li>+ Risk factors </li></ul>
  20. 20. The History of Present Illness: the seven dimensions of a complaint <ul><li>To help you remember - LOCATES </li></ul><ul><ul><li>L ocation </li></ul></ul><ul><ul><li>O ther associated symptoms </li></ul></ul><ul><ul><li>C haracter (or quality) </li></ul></ul><ul><ul><li>A lleviating/aggravating </li></ul></ul><ul><ul><li>T iming </li></ul></ul><ul><ul><li>E nvironment/setting </li></ul></ul><ul><ul><li>S everity </li></ul></ul>
  21. 21. The History of Present Illness: the seven dimensions of a complaint <ul><li>To help you remember – PQRSSTA </li></ul><ul><ul><li>P rovocative/Palliative </li></ul></ul><ul><ul><li>Q uality </li></ul></ul><ul><ul><li>R egion </li></ul></ul><ul><ul><li>S everity </li></ul></ul><ul><ul><li>S etting </li></ul></ul><ul><ul><li>T iming </li></ul></ul><ul><ul><li>A ssociated symptoms </li></ul></ul><ul><li>Mosby has two other suggestions </li></ul>
  22. 22. The “Open-ended Interview” <ul><li>Goal is to guide the interview, not dominate it </li></ul><ul><li>Open ended questions to begin – least control </li></ul><ul><li>More specific “closed-ended” questions as late in the interview as possible </li></ul>
  23. 23. The “Open-ended Interview” <ul><li>When needed </li></ul><ul><ul><li>Laundry list or multiple choice </li></ul></ul><ul><ul><li>Closed-ended, more direct, yes/no questions </li></ul></ul><ul><li>Avoid at all times </li></ul><ul><ul><li>Leading questions </li></ul></ul><ul><ul><li>Multiple questions </li></ul></ul><ul><ul><li>Yes/no questions for sensitive topics </li></ul></ul>
  24. 24. Other suggestions for a successful interview <ul><li>Pertinent negatives and positive symptoms </li></ul><ul><ul><li>What does not occur in the course of an illness can be as important as what does   </li></ul></ul><ul><ul><li>Reminder: in investigating pertinent negatives, avoid leading questions which encourage certain responses </li></ul></ul>
  25. 25. Other suggestions for a successful interview <ul><li>How the present illness has affected the patients quality of life is an important aspect of the HPI. The impact of the illness on </li></ul><ul><ul><li>Interpersonal relationships </li></ul></ul><ul><ul><li>Work/school </li></ul></ul><ul><ul><li>Sexual relationships </li></ul></ul><ul><ul><li>Emotional stability </li></ul></ul><ul><li>It is more productive to ask how rather than whether it has, in such instances </li></ul>
  26. 26. Other suggestions for a successful interview <ul><li>Guiding the interview, encouraging communication </li></ul><ul><ul><li>Facilitation </li></ul></ul><ul><ul><li>Reflection </li></ul></ul><ul><ul><li>Clarification </li></ul></ul><ul><ul><li>Empathetic response </li></ul></ul><ul><ul><li>Confrontation </li></ul></ul><ul><ul><li>Summary </li></ul></ul>
  27. 27. Transition to the PE <ul><li>Always give the patient the opportunity for the last word “Is there anything else we haven’t covered that you would like to discuss before I examine you.” </li></ul><ul><li>PE is a continuation of the interview process </li></ul><ul><li>Goals are same </li></ul>
  28. 28. Closing the interview <ul><li>The closing interaction solidifies the relationship and sets the stage for managing the problem </li></ul><ul><li>“Is there anything further you’d like to tell me or ask me?” – unfinished business </li></ul><ul><li>Appropriate closure implies a contract </li></ul>
  29. 29. Closing the interview <ul><li>Share findings: physical findings, differential dx, your dx or hypothesis </li></ul><ul><li>Problem list and priorities </li></ul><ul><li>Negotiate a plan of action, clarify responsibilities </li></ul><ul><li>Educate </li></ul><ul><li>Summation </li></ul><ul><li>Physical parting </li></ul>