These slide are extracted from Bates Guide to physical examination Unit #01, Chapter#03 for interviewing techniques.

1. INTRODUCTION TO HEALTH ASSESSMENT
UNIT#01
Foundations of Health Assessment
C H A P T E R#03
Interviewing and the Health History
Prepared By:
Afza Malik (BScN ,CCRN)
Coordinator,
CON National Hospital & Medical Centre,
Lahore.

2. Interviewing and the Health History
• The health history interview is a conversation with a purpose.
• Relating effectively with patients is among the most valued skills of
clinical care.
• Interviewing is both a skill and an art. Skilled interviewing is both
patient-centered and clinician-centered.
• The interviewing process is quite different from the format of the
health history.
• The health history format is a structured framework for organizing
patient information in written or verbal form.

3. Sir William Osler
•“The good physician treats the disease;
the great physician treats the patient
who has the disease.”

4. Different Kinds of Health Histories
For new patients, in most settings, you will do a comprehensive health history.
For patients seeking care for specific concerns, for example, cough or painful
urination, a more limited interview tailored to that specific problem may be
indicated; this is sometimes known as a focused or problem-oriented history.
For patients seeking care for ongoing or chronic problems, focusing on the patient’s
self-management, response to treatment, functional capacity, and quality of life is
most appropriate.
Patients frequently schedule health maintenance visits with the more focused goals
of keeping up screening examinations or discussing concerns about smoking, weight
loss, or sexual behavior.
A specialist may need a more comprehensive history to evaluate a problem with
numerous possible causes.

5. The Fundamentals of Skilled Interviewing
Skilled Interviewing Techniques
• Active listening
• Empathic responses
• Guided questioning
• Nonverbal
communication
• Validation Reassurance
• Partnering
• Summarization
• Transitions
• Empowering the patient

6. Conti……
Active Listening.
Active listening lies at the heart of the patient interview.
Active listening means closely attending to what the
patient is communicating, connecting to the patient’s
emotional state, and using verbal and nonverbal skills to
encourage the patient to expand on his or her feelings
and concerns. Active listening allows you to relate to
those concerns at multiple levels of the patient’s
experience.

7. Conti….
Empathic Responses
To express empathy, you must first recognize the patient’s
feelings, then actively move toward and elicit emotional
content.

8. Techniques of Guided Questioning
• Moving from open-ended to focused questions
• Using questioning that elicits a graded response
• Asking a series of questions, one at a time
• Offering multiple choices for answers
• Clarifying what the patient means
• Encouraging with continuers
• Using echoing

9. Conti….
Nonverbal Communication.
Both clinicians and patients continuously display nonverbal
communication that provides important clues to our underlying
feelings. Being sensitive to nonverbal cues allows you to “read
the patient” more effectively and send messages of your own.

10. Conti…
Validation
Another way to affirm the patient is to validate the legitimacy
of his or her emotional experience. A patient caught in a car
accident, even if uninjured, may still feel very distressed.

11. Conti….
Reassurance
When patients are anxious or upset, it is tempting to provide
reassurance like “Don’t worry. Everything is going to be all
right.”

12. Conti….
Partnering
When building rapport with patients, express your commitment
to an ongoing relationship. Make patients feel that no matter
what happens, you will continue to provide their care.

13. Conti….
Summarization
Giving a capsule summary of the patient’s story during the
course of the interview serves several purposes. It
communicates that you have been listening carefully. It
identifies what you know and what you don’t know. “Now, let
me make sure that I have the full story.

14. Conti….
Transitions
Patients may be apprehensive during a health care visit. To put
them more at ease, tell them when you are changing directions
during the interview. Just like signs along the highway,
“signposting” transitions help prepare patients for what comes
next.

15. Conti….
Empowering the Patient
The clinician–patient relationship is inherently unequal. Your
feelings of inexperience as a student predictably change over
time as you grow in clinical experience. Patients, however,
have many reasons to feel vulnerable. They may be in pain or
worried about a symptom. They may feel overwhelmed by
even scheduling a visit, a task you might take for granted.

16. Empowering the Patient:
Techniques for Sharing Power
• Evoke the patient’s perspective.
• Convey interest in the person, not just the problem.
• Follow the patient’s leads.
• Elicit and validate emotional content.
• Share information with the patient, especially at transition points
during the visit.
• Make your clinical reasoning transparent to the patient.
• Reveal the limits of your knowledge.

17. The Sequence and Context of the Interview
Preparation, Sequence, and Cultural Context
• Preparation: Reviewing the clinical record. Setting goals for the interview.
Reviewing your clinical behavior and appearance. Adjusting the environment.
• The Sequence of the Interview: Greeting the patient and establishing rapport.
Establishing the agenda for the interview. Inviting the patient’s story. Exploring
the patient’s perspective. Identifying and responding to emotional cues. Expanding
and clarifying the patient’s story. Generating and testing diagnostic hypotheses.
Sharing the treatment plan. Closing the interview and the visit. Taking time for
self-reflection.
• The Cultural Context of the Interview: Demonstrating cultural humility—a
changing paradigm.

18. Exploring the Patient’s Perspective (F-I-F-E)
• The patient’s Feelings, including fears or concerns, about the problem
• The patient’s Ideas about the nature and the cause of the problem
• The effect of the problem on the patient’s life and Function
• The patient’s Expectations of the disease, of the clinician, or of health
care, often based on prior personal or family experiences

19. Clues to the Patient’s Perspective on Illness
• Direct statement(s) by the patient of explanations, emotions, expectations, and
effects of the illness
• Expression of feelings about the illness without naming the illness
• Attempts to explain or understand symptoms
• Speech clues (e.g., repetition, prolonged reflective pauses)
• Sharing a personal story
• Behavioral clues indicative of unidentified concerns, dissatisfaction, or unmet
needs such as reluctance to accept recommendations, seeking a second opinion, or
early return appointment

20. Generating and Testing Diagnostic Hypotheses.

21. The Guiding Style of Motivational Interviewing
1. “Ask” open-ended questions—invite the patient to consider how and
why they might change.
2. “Listen” to understand your patient’s experience—“capture” their
account with brief summaries or reflective listening statements such as
“quitting smoking feels beyond you at the moment”; these express
empathy, encourage the patient to elaborate, and are often the best way
to respond to resistance.
3. “Inform”—by asking permission to provide information, and then
asking what the implications might be for the patient.

22. Closing the Interview and the Visit
A useful technique to assess the patient’s understanding is to
“teach back,” whereby you invite the patient to tell you, in his
or her own words, the plan of care.

23. Taking Time for Self-Reflection
The role of self-reflection, or mindfulness, in developing
clinical empathy cannot be overemphasized. Mindfulness
refers to the state of being “purposefully and nonjudgmentally
attentive to [one’s] own experience, thoughts, and feelings.”

24. The Cultural Context of the Interview
Demonstrating Cultural Humility—A Changing Paradigm.
• To moderate these disparities, clinicians are increasingly
urged to engage in self-reflection, critical thinking, and
cultural humility as they experience diversity in their clinical
practices.

25. The Three Dimensions of Cultural Humility
1. Self-awareness. Learn about your own biases; we all have
them.
2. Respectful communication. Work to eliminate assumptions
about what is “normal.” Learn directly from your patients; they
are the experts on their culture and illness.
3. Collaborative partnerships. Build your patient
relationships on respect and mutually acceptable plans.

26. Advanced Interviewing
Interviewing the Challenging Patient
• The Silent Patient.
• The Confusing Patient.
• The Patient with Altered Cognition.
• The Talkative Patient.
• The Crying Patient.
• The Angry or Disruptive Patient.
• The Patient with a Language Barrier.
• The Patient with Low Literacy or Low Health
Literacy.
• The Patient with Hearing Loss.
• The Patient with Impaired Vision.
• The Patient with Limited Intelligence.
• The Patient with Personal Problems.
• The Seductive Patient. The Sexual History. The Mental
Health History.
• Intimate Partner Violence and Domestic Violence.
• Death and the Dying Patient.

27. Guidelines for Working with an
Interpreter: “INTERPRET”
• I Introductions
• N Note Goals
• T Transparency
• E Ethics
• R Respect Beliefs
• P Patient Focus
• R Retain Control
• E Explain
• T Thanks

28. Building Blocks of Professional
Ethics in Patient Care
• Nonmaleficence or primum non nocere is commonly stated as, “First,
do no harm.” In the context of the interview, giving information that is
incorrect or not really related to the patient’s problem can do harm.
Avoiding relevant topics or creating barriers to open communication
can also do harm.
• Beneficence is the dictum that the clinician acts in the best interest of
the patient.
• Autonomy reminds us that informed patients have the right to make
their own clinical decisions. This principle has become increasingly
important over time and is consistent with collaborative rather than
paternalistic clinician– patient relationships.

29. Conti….
• Confidentiality can be one of the most challenging principles.
As a clinician, you are obligated not to repeat what you learn
from or know about a patient. This privacy is fundamental to
our professional relationships with patients. In the flurry of
daily patient care, it is all too easy to let something slip. You
must be on your guard. Note that some frameworks posit
Justice as the fourth critical principle, namely that all patients
be treated fairly with equitable distribution of health care
resources.

30. The Tavistock Principles
• Rights: People have a right to health and health care.
• Balance: Care of the individual patient is central, but the health of populations is
also our concern.
• Comprehensiveness: In addition to treating illness, we have an obligation to ease
suffering, minimize disability, prevent disease, and promote health.
• Cooperation: Health care succeeds only if we cooperate with those we serve, each
other, and those in other sectors.
• Improvement: Improving health care is a serious and continuing responsibility.
• Safety: Do no harm.
• Openness: Being open, honest, and trustworthy is vital in health care.

31. Any Question ?

32. Thank You….!