Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

The Medical Interview: Communication Skills I

2,173 views

Published on

  • Be the first to comment

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>

×