Bates Chapter 3 - Interviewing & Health Hx Flashcards
Skilled Interviewing
Both patient-centered and clinician-centered
- clinician must focus on pt to elicit the full story and be able to interpret key info about pt to reach assessment and plan for symptoms
Interview Process
more than a series of questions, requires a highly refined sensitivity to the pt’s feelings and behavioral cues and helps understand the pt’s story from all sides and is fluid
should be open-ended to encourage pt’s to open up and explain things
Health Hx Format
structured framework for organizing pt information in written or verbal form
- format focuses your attention on specific kinds of info you need to obtain to facilitate clinical information and help form a dx and plan of action
Skilled Interviewing Techniques
- active listening
- empathic responses
- guided questions
- nonverbal communication
- validation
- reassurance
- partnering
- summarization
- transitions
- empowering the pt
Active Listening
lies at the heart of the pt interview
- don’t allow yourself to drift into other thoughts
- pay attention to every part of hx pt is telling you
- don’t get caught up in dx
- show you are paying attention and hearing their complaints of symptoms
Empathic Responses
allows you to build pt rapport and promote healing for pt
- empathy has been described as the capacity to identify with the pt and feel the pt’s pain as your own
- to express empathy, you must first recognize the pt’s feelings, then actively move toward and elicit emotional content
- for response to be empathic, must show that you feel pain pt is feeling
Guided Questioning
always start open-ended and move into more focused questions as pt explains symptoms and pain
- try to avoid yes/no questions so that pt can explain situation
- ask questions that invoke graded responses: ex: how many steps can you climb before you get short of breath? vs do you get SOB w/climbing stairs?
- make sure to clarify things you do not understand in pt’s hx w/clarifying questions, shows you are listening and want to understand everything
- echoing can be used to get pt’s to explain more about symptoms as well
Nonverbal Communication
make sure to be aware of how you come off with your facial expressions, posture, gestures, etc.
- mirroring pt’s language (tone, voice, etc) can help build rapport as well
Validation
take time to validate the pt’s experience and how it affected them emotionally and physically
Reassurance
never reassure pt w/things like “it’s going to be all right.” instead, notice the pt’s feelings and recognize that they are okay and provide reassurance that you will do your best to get to the bottom of it
- best reassurance is after pt fully understands the problem at hand
Partnering
make clear to pt you are hear to provide the utmost care and build a relationship w/them even if in hospital setting
Summarization
helps you show pt you are listening and also clarify anything you might be missing or might need to know in addition to fully treat pt
Transitions
use transitions to let pt know what you are going to do next, why, and help pt understand the direction in which things are going
- helps pt feels less anxious and more comfortable w/you as their provider
Empower Patients
when you empower pts to ask questions, express their concerns, and probe your recommendations, they are most likely to adopt your advice, make lifestyle changes, or take medications as prescribed.
good techniques:
- evoke the pt’s perspective
- convey interest in the pt not just their problem
- follow the pt’s leads
- elicit and validate emotional content
- share info w/pt especially at transition points during visit
- make clinical reasoning transparent w/pt
- reveal limits of your knowledge, make yourself more like them
Sequence and Context of Interview
- Preparation
- Sequence
- Cultural Context
Preparation for Interview
should include:
- reviewing clinical records
- setting goals for interview
- reviewing your clinical behavior and appearance
- adjusting environment
Sequence of Interview
should include:
- greeting pt and establishing rapport
- establishing agenda for interview
- inviting the pt’s story
- exploring pt’s perspective
- identify and responding to pt’s emotional cues
- expanding and clarifying pt’s story
- generating and testing diagnostic hypotheses
- sharing treatment plan
- closing interview and visit
- take time for self-reflection
Cultural Context of Interview
demonstrating cultural humility throughout
Disease/Illness Distinction Model
helps elucidate the different yet complementary perspectives of the clinician and the patient
- Disease: the explanation that the clinician uses to organize symptoms that leads to a clinical diagnosis
- Illness: a construct that explains how the patient experiences the dise
ase, including its effects on relationships, function, and sense of well-being
*clinical interview needs to incorporate both of these views of reality. melding of these perspectives forms the basis for planning evaluation and treatment
FIFE
acronym for exploring the patient’s perspective
F: The patient’s FEELINGS, including fears or concerns about the problem
I: the patient’s IDEAS about the nature and cause of the problem
F: the effect of the problem on the pt’s life and FUNCTION
E: the pt’s EXPECTATIONS of the disease, of the clinician, or of health care, often based on prior personal or family experiences
Clues to Pt’s Perspective on Illness
- direct statement by pt of explanations, emotions, expectations or effects of illness
- expression of feelings about the illness without naming it
- attempts to explain or understand symptoms
- speech clues
- sharing a personal story
- behavioral clues indicative of unidentified concerns, disaatisfaction, or unmet needs such as reluctance to accept recommendations, seeking a second opinion, etc.
NURSE (acronym)
mnemonic for understanding emotional cues
N: name–“that sounds like a scary experience”
U: understand–“its understandable you feel that way”
R: respect–“you’ve done better than most people would do with this”
S: support–“I will continue to work on you with this”
E: explore–“how else are you feeling bout it
OLD CARTS
mnemonic for 7 attributes of a symptom
O: Onset
L: Location
D: Duration
C: Character
A: Aggravating/Alleviating Factors
R: Radiation
T: Timing
Seven Attributes of a Symptom
- Location: Where is it? Does it radiate?
- Quality: What is it like?
- Quantity/Severity: How bad is it?
- Timing: When did (does) it start? How long does it last? How often does it happen?
- Onset (setting in which symptom occurs): Include environmental factors, personal activities, emotional reactions, etc.
- Remitting or Exacerbating Factors: Is there anything that makes it better? Worse?
- Associated Manifestations: Have you noticed anything else that accompanies it?
Premature Closure
shutting down the pt’s story too quickly which can lead to errors in diagnosis, always get full story from pt!
Shared Decision Making
working with the pt to create a treatment plan
- pinnacle of patient-centered care
- Three-Step Process:
1. Introducing choices and describing options using pt’s decision support tools when available
2. Exploring pt’s preferences
3. Moving to a decision, checking that the pt is ready to make a decision and offering more time if needed
The Guiding Style of Motivational Interviewing
- “Ask” open-ended questions: invite the pt to consider how and why they might change
- “Listen” to understand your patient’s experience: capture their account w.brief summaries or reflective listening and recognize the difficulties w/changing their way of life
- “Inform”: by asking permission to provide info, and then asking what the implications might be for the pt
Teach back
technique to assess pt’s understanding; whereby you invite the pt to tell you in their own words the plan of care
Cultural Competence
“a set of attitudes, skills, behaviors and policies that enable organizations and staff to work effectively in cross-cultural situations. It reflects the ability to acquire and use knowledge of the health-related beliefs, attitudes, practices, and communication patterns of clients and their families to improve services, strengthen programs, increase community participation and close the gaps in health status among diverse population groups.”
Cultural Humility
“a process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners.”
Three Dimensions of Cultural Humility
- Self-Awareness: learn about your own biases; we all have them.
- Respectful Communication: work to eliminate assumptions about what is “normal,” learn directly from your patients (they are experts on their culture and illness)
- Collaborative Partnerships: build your patient relationships on respect and mutually acceptable plans
Elements of Decision-Making Capacity
Patients must have the ability to:
1. Understand the relevant info about proposed diagnostic testing or treatment
2. Appreciate their situation (including their underlying values and current clinical situation)
3. Use reason to make a decision
4. Communicate their choice
INTERPRET
mnemonic for guidelines for working with an interpreter
I: Introductions: introduce all individuals in the room
N: Note Goals: note the goals of the interview (find dx, treatment, f/u, etc.)
T: Transparency: let pt know that everything said will be interpreted
E: Ethics: use qualified interpreters (not fam members) when conducting an interview
R: Respect Beliefs: likely will have different beliefs than yourself and can work w/interpreter to understand those differences
P: Patient Focus: pt is focus of the encounter and should always make eye contact w/them not interpreter
R: Retain Control: make sure you maintain control of convo and don’t let pt or interpreter take over
E: Explain: use simple language and short sentences to avoid miscommunication
T: thank the interpreter and pt for their time and mark interpreter info in chart notes
Guidelines for Broaching Sensitive Topics
- Nonjudgmental: your role is to learn from the pt and help the pt achieve better health. Acceptance is the best way to reach this goal
- Explain why you need certain info: makes pt less apprehensive and more willing to share
- Find opening questions for sensitive topics and learn the specific kinds of info needed for your shared assessment and plan
- Consciously acknowledge whatever discomfort you are feeling. Denying discomfort may lead you to avoid the topic altogether
Tolerance
A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drugs effects over time
Physical Dependence
a state of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of antagonist
Addiction
A primary, chronic, neurobiological disease, with genetic, psychosocial and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.
Clues to Physical and Sexual Abuse
- unexplainable injuries that seem inconsistent w/pt story
- delay in getting treatment for trauma
- history of repeated accidents/injuries
- presence of alcohol or drugs abuse in patient or partner
- partner tries to dominate during visit
- pregnancy at young age
- repeated vaginal infections, STIs
- difficulty walking or sitting
- vaginal lacerations/bruises
- fear of pelvic exam/physical contact
- fear of leaving exam room
Building Blocks of Professional Ethics in patient Care
- Nonmaleficence or primum non nocere: do no harm. Always provide correct information for pt and their problem. Avoid irrelevant topics that create barriers to pt understanding
- Beneficence: the dictum that the clinical acts in the best interest of the pt
- Autonomy: informed pts have the right to Mae their own medical decisions. important to respect pt’s decision even if they refuse treatment
- Confidentiality: all pts have right to privacy and their information should not be shared and spread w/others not a part of the direct care team of the pt
Tavistock Principles
- Rights: people have a right to health and healthcare.
- Balance: care of the individual pt is central, but the health of populations is also of 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 that 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 healthcare
