Art Of Interview

Question 1

Comprehensive history

Answer 1

Covers everything from CSE- ROS, full physical exam. For new patients

Question 2

Focused history

Answer 2

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

Question 3

Physical exam

Answer 3

Comprehensive exam relevant to chief complaint. Used for urgent care concerns or those returning for follow-up

Question 4

Sign vs symptom

Answer 4

Sign- noticed by physician

Symptom- noticed by patient

Question 5

Subjective

Answer 5

What patient tells you. History, chief complaint, ROS

Question 6

Objective

Answer 6

What you detect in examination. All physical exam findings

Question 7

Chief complaint

Answer 7

Use patient’s own words and time duration

Question 8

Interviewing

Answer 8

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

Question 9

Establish the agenda

Answer 9

Reason for visit. Chief complaint/presenting problem

Question 10

Inviting the patient’s story

Answer 10

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”

Question 11

Expand and clarify patient’s story

Answer 11

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)

Question 12

Generation and testing diagnostic hypotheses

Answer 12

ROS- list of questions arranged by organ system to uncover dysfunction and disease. All questions are in subjective section

Question 13

Create shared understanding of the problem

Answer 13

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

Question 14

Technique of skilled interviewing

Answer 14

Active listening, guided questions, nonverbal communication, empathic response, validation, reassurance, partnering, summarization, empowering patient, transitions

Question 15

Guided questioning

Answer 15

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

Question 16

Nonverbal communication

Answer 16

Pay attention to own nonverbal communications. Crossing arms or tapping fingers

Question 17

Empathic responses

Answer 17

Strengthen patient rapport
Identify the patient’s feelings
Offer a tissue or gently place hand on patient’s arm if needed

Question 18

Reassurance

Answer 18

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.

Question 19

Empowering the patient

Answer 19

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

Question 20

Transitions

Answer 20

Help put the patient at ease and let them know what to expect between- HPI, ROS, PMHx, FH, SHx, PE

Question 21

Guidelines for sensitive topics (general)

Answer 21

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

Question 22

Guidelines for sensitive topics- sexual history

Answer 22

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

Question 23

Guidelines for sensitive topics- Alcohol and Tobacco use

Answer 23

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?

Question 24

Guidelines for sensitive topics: Illicit Drugs

Answer 24

Specifics: last use, how often, substances, used, amount
Modes of consumption: injected, smoked, pills
CAGE questions can be adapted to drug use

Question 25

Negotiating a plan

Answer 25

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

Question 26

Mental health history

Answer 26

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.

Question 27

Possible scenarios: silent patient

Answer 27

Are they emotional? Am I asking too many quick and short questions? Assess nonverbal cues. Depression? Dementia?

Question 28

Possible scenarios: Confusing patient

Answer 28

May answer yes to every question, vague complaints. Stay focused and do your best

Question 29

Possible Scenarios: Talkative patient

Answer 29

Never show impatience. May eventually need more close ended questions. Transition them by giving a summary of what they have told you

Question 30

Possible scenarios: crying patient

Answer 30

May be therapeutic, learn to wait, offer a tissue, allow them to compose themselves. I’m glad you were able to express your feelings

Question 31

Possible scenarios: angry patient

Answer 31

Allow them to express why they are angry. Stay composed, new diagnosis, family problems, waiting for the appointment

Question 32

Possible scenarios: language barrier

Answer 32

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

Question 33

Possible scenarios: Vision impaired

Answer 33

Shakes hand, introduce anyone else in the room, student or nurse. In detail describe whatever part of the exam is next

Question 34

Possible scenario: personal problems

Answer 34

Rather than solve, encourage patient to discuss their own solutions, community resources that can assist them

Question 35

Possible scenario: family violence

Answer 35

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

Question 36

Possible scenarios: physical abuse clues

Answer 36

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

Question 37

Cultural humility

Answer 37

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

Question 38

Ethics - sexual contact

Answer 38

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

Question 39

Ethics- NBAC

Answer 39

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

Question 40

Greet the patient

Answer 40

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

Question 41

List the steps in an interview sequence

Answer 41

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

Question 42

Emotional cues

Answer 42

NUR Naming the emotion Understanding or legitimization Respect (how patient is reacting)

Question 43

Open ended vs closed (direct) questions

Answer 43

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?)

Question 44

Non-verbal vs verbal communication

Answer 44

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

Question 45

State and demonstrate statements or questions an interviewer might use in closure of a patient interview

Answer 45

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?”

Question 46

Describe the guidelines for working with an interpreter

Answer 46

“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

Question 47

Discuss the use of educationally appropriate and culturally sensitive language

Answer 47

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

Question 48

7 attributes of a symptom

Answer 48

AA QQ SALT ``` Location Quality Quantity Alleviating or aggravating factors (remitting or exacerbating) Timing Setting Associated symptoms ```

Question 49

2 mental health screening questions

Answer 49

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