Art Of Interview Flashcards
Comprehensive history
Covers everything from CSE- ROS, full physical exam. For new patients
Focused history
Adapts scope of history to:
Patient’s concern and problem, doctor’s goals for assessment, clinical setting, amount of time available. Utilizes parts of comprehensive history
Physical exam
Comprehensive exam relevant to chief complaint. Used for urgent care concerns or those returning for follow-up
Sign vs symptom
Sign- noticed by physician
Symptom- noticed by patient
Subjective
What patient tells you. History, chief complaint, ROS
Objective
What you detect in examination. All physical exam findings
Chief complaint
Use patient’s own words and time duration
Interviewing
Improve wellbeing of the patient by establishing a trusting and supportive relationship, gathering information, offering information.
Prepare by reviewing medical record. Age, gender, problem list, allergies, meds. Setting goals for the interview
Use formal title to address patient. Acknowledge and address visitors. Attune to the patient’s comfort. Arrange the room
Establish the agenda
Reason for visit. Chief complaint/presenting problem
Inviting the patient’s story
Tell me more about that. Avoid bias by injecting new information. Don’t say “ok” after every question. Don’t interrupt. Use active listening skills. Lean forward, head nodding, “go on” or “I see”
Expand and clarify patient’s story
Start with open ended then focused questions. Cone theory. Seven attributes of a symptom - OLD CARTS (onset, location/radiation, duration, character, aggravating factors, relieving factors, timing, severity)
Generation and testing diagnostic hypotheses
ROS- list of questions arranged by organ system to uncover dysfunction and disease. All questions are in subjective section
Create shared understanding of the problem
FIFE
Feelings, fears or concerns of the problem
Ideas: about the nature and cause of the problem
Function: effect of problem on patient’s life and function
Expectations: of disease, clinician, or health care
Technique of skilled interviewing
Active listening, guided questions, nonverbal communication, empathic response, validation, reassurance, partnering, summarization, empowering patient, transitions
Guided questioning
Moving from open-ended to focus question
Using question that elicit a graded response
Asking a series of questions, one at a time
Offering multiple choices for answers if patient can’t describe the pain
Clarifying what the patient means
Encouraging with continues
Echoing
Nonverbal communication
Pay attention to own nonverbal communications. Crossing arms or tapping fingers
Empathic responses
Strengthen patient rapport
Identify the patient’s feelings
Offer a tissue or gently place hand on patient’s arm if needed
Reassurance
Key is not to give false reassurance, especially early in the visit. You can reassure them early on by identifying and acknowledging the patient’s feelings. Reassure them you will send them to the best specialist you know or will research the latest on the given disease.
Empowering the patient
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 patient Make clinical reasoning transparent Reveal limits of your knowledge
Transitions
Help put the patient at ease and let them know what to expect between- HPI, ROS, PMHx, FH, SHx, PE
Guidelines for sensitive topics (general)
Be non-judgmental
Goal: learn about the pt; help them attain better health
Explain why you need to know certain information
Find opening questions for sensitive topics
Acknowledge your discomfort with the topic; denial may cause you to avoid the topic altogether
Guidelines for sensitive topics- sexual history
Determine risk for pregnancy and STD’s
Allow patients to feel comfortable to ask more questions
Can be asked at different points of the interview depending on the chief complaint
Guidelines for sensitive topics- Alcohol and Tobacco use
Current and past use and changes in pattern of use
Types of tobacco- offer to quit. Congrats if quit
If concerned the patient may misuse alcohol, CAGE questionnaire. If answer 2 or more affirmative answers, need to ask more specific question; consider a referral to a community resource.
CAGE: Cutting down, Annoyance if criticized, Guilty feelings, and Eye-openers
- Have you ever felt the need to cut down on drinking?
- Have you ever felt Annoyed by criticism of drinking?
- Have you ever felt Guilty about drinking?
- Eye-opener: Have you ever take a drink first thing in the morning to steady your nerves or get rid of a hangover?
Guidelines for sensitive topics: Illicit Drugs
Specifics: last use, how often, substances, used, amount
Modes of consumption: injected, smoked, pills
CAGE questions can be adapted to drug use
Negotiating a plan
Further evaluation, treatment, patient education, self-management support, and prevention
Give patient brief summary of their history, after HPI
Let the patient know you will discuss with attending and be back.
Ask for further questions, assess plan, promise to address new issues in the future.
Ask closed ended questions to end conversation
Mental health history
Harder for most patients to talk about depression, schizophrenia than diabetes and HTN. Start with broad based questions, then move to specific questions. Depression is common and underdiagnosed. Be sensitive to mood changes, fatigue, tearfulness, weight change, insomnia, vague complaints. If concerned about depression, ask about suicide.
Possible scenarios: silent patient
Are they emotional? Am I asking too many quick and short questions? Assess nonverbal cues. Depression? Dementia?
Possible scenarios: Confusing patient
May answer yes to every question, vague complaints. Stay focused and do your best
Possible Scenarios: Talkative patient
Never show impatience. May eventually need more close ended questions. Transition them by giving a summary of what they have told you
Possible scenarios: crying patient
May be therapeutic, learn to wait, offer a tissue, allow them to compose themselves. I’m glad you were able to express your feelings
Possible scenarios: angry patient
Allow them to express why they are angry. Stay composed, new diagnosis, family problems, waiting for the appointment
Possible scenarios: language barrier
Trained interpreter is better than family member. Talk to the patient with interpreter close by. Short simple sentences. Be patient it may take more time and provide less information. INTERPRET
Possible scenarios: Vision impaired
Shakes hand, introduce anyone else in the room, student or nurse. In detail describe whatever part of the exam is next
Possible scenario: personal problems
Rather than solve, encourage patient to discuss their own solutions, community resources that can assist them
Possible scenario: family violence
Children, women, elderly are at risk. Start with general “normalizing” questions. If suspect abuse, try to spend part of the encounter alone with the patient. Don’t force the issue
Possible scenarios: physical abuse clues
If injuries are unexplained, seem inconsistent with patient’s story, concealed by patient, cause embarrassment. Delayed getting treatment for trauma. Past history of repeated injuries or accidents. Patient or someone else has alcohol or drug abuse. Partner tries to dominate the interview, will not leave, the room or seems anxious
Cultural humility
Self-awareness. Respectful communication. Do your own research on different cultures; learn directly from your patients as they are experts on their culture and illness. Collaborative partnerships based on trust, respect, and willingness to reexamine concerns of the patient. Based on continual work on self-awareness and seeing through the lens of others
Ethics - sexual contact
Any sexual contact or romantic relationship with patient is unethical. If patient makes sexual advances, calmly but firmly make it clear that relationship is professional. If it continues, leave the room and find chaperone to continue the interview
Ethics- NBAC
Nonmaleficience- “first, do no harm” never want to give a patient information that you don’t know is true
Beneficence- actions need to be motivated by what is in the patient’s best interest
Autonomy- patients have the right to determine what is in their best interest; collaborative relationship
Confidentiality- anyone involved in patient care is obligated not to repeat what you learn from or know about a patient
Greet the patient
Greet the patient by name and introduce yourself, giving your own name, shake hands if possible, explain your role (student doctors). If this is your first meeting use formal title of patient
List the steps in an interview sequence
1) greet and establish rapport- lay the foundation for your ongoing relationship. Introduce self and introduce to any other people present with patient. Before starting ask patient about privacy ie whether they want person present or not during interview. Address patient with formal title. Be attuned to patient comfort. Give patient undivided attention.
2) establish agenda for appointment- chief complaint, begin with open ended questions, identify all concerns at the beginning
3) invite patient story- don’t inject info or interrupt, active listening, guided questions for missed concerns
4) identify and respond to emotional cues- ask about impact of illness (NUR)
5) expand and clarify patient story- HPI, use patient’s words, open questions then focused (cone)
6) create and test Dx Hypothesis- open to get idea, focuses questions to narrow down Dx
7) create shared understanding of problem- disease is clinician explanation and illness is how the patient experiences the symptoms and pt perspective of the illness (FIFE) need both
8) negotiate a plan
9) plan follow-up and close interview - ask patient if they have questions, make sure they understand the plan, make follow-up appointment
Emotional cues
NUR
Naming the emotion
Understanding or legitimization
Respect (how patient is reacting)
Open ended vs closed (direct) questions
Open ended- question that lets the patient generate Andy answer. (Was there a specific health concerns that brought you in today?
Direct: yes/no or multiple choice (do you have blood in your stool? Have you been vomiting?)
Non-verbal vs verbal communication
Nonverbal: posture, facial expression, eye contact, head position, movement, distance, arm and leg placement, mirroring, touch if appropriate or close contact
Verbal: empathetic response, validation, reassurance, partnering (with patient through anything), summarization, transition, empower patient. Must first ID patient feeling and acknowledge
State and demonstrate statements or questions an interviewer might use in closure of a patient interview
Asking for further questions- “We need to stop now. Do you have any questions about what we’ve covered?”
Assessing plans- “So, you will take the medicine as we discussed, get the blood test before you leave today, and a make a follow-up appointment for 4 weeks. Do you have any questions about this?”
Promising to address new issues in the future- “That knee pain sounds concerning. Why don’t you make an appointment for next week so we can discuss it?”
Describe the guidelines for working with an interpreter
“INTERPRET”
I- INTRODUCTION: make sure to introduce all the individuals in the room. During the introduction, include information as to the roles individuals will play
N- NOTE GOALS: note the goals of the interview. What is the diagnosis? What will the treatment entail? Will there be any follow-up?
T- TRANSPARENCY: let the patient know that everything said will be interpreted throughout the session
E- ETHICS: use qualified interpreters (not family members or children) when conducting an interview. Qualified interpreters allow the patient to maintain autonomy and make informed decisions about his or her care
R- RESPECT BELIEFS: limited English proficient (LEP) patients may have cultural beliefs that need to be taken into account as well. The interpreter may be able to serve as a cultural broker and help explain any cultural beliefs that may exist.
P- PATIENT FOCUS: the patient should remain the focus of the encounter. Providers should interact with the patient and not the interpreter. Make sure to ask and address any questions the patient may have prior to ending the encounter. If you don’t have trained interpreters on staff, the patient may not be able to call in with questions.
R- RETAIN CONTROL: it is important as the provider that you remain in control of the interaction and not let the patient or the interpreter take over the conversation
E- EXPLAIN: use simple language and short sentences when working with an interpreter. This will ensure that comparable words can be found in the second language and that all the information can be conveyed clearly
T- THANKS: thank the interpreter and the pt for their time. On the chart, note that the patient needs an interpreter and who served as an interpreter this time
Discuss the use of educationally appropriate and culturally sensitive language
Self awareness
Respectful communication
Work to eliminate assumptions on what is “normal”
Do your own research on different cultures
Learn directly from your patients- they are the experts on their culture and illness (acknowledge ignorance)
Collaborative partnership
Based on trust, respect, and willingness to re-examine concerns of the patients
Based on continual work on self-awareness and seeing through the “lens” of others
Be flexible and creative in making plans
7 attributes of a symptom
AA QQ SALT
Location Quality Quantity Alleviating or aggravating factors (remitting or exacerbating) Timing Setting Associated symptoms
2 mental health screening questions
1) Over the past 2 weeks, have you felt down, depressed or hopeless?
2) over the past 2 weeks, have you felt little interest in doing things?
If concerned about depression, also ask about suicide
