Chapter 1 Flashcards
general structure and sequence of the clinical enounter
-initiate the encounter- setting the stage/preparation, greeting the pt and establishing initial rapport
-gathering information- initiating information gathering, exploring pts perspective of illness, exploring biomedical perspective of disease including relevant background and context
-performing the PE
-explaining and planning- provide correct amount and type of information, negotiate plan of action, shared decision making
-closing the encounter
biopsychosocial model
-explicitly acknowledges the interdependence of pts biological (disease), psychological and social characteristics, making it consistent with general system theory
behavioral medicine
-clinical psychology subspecialty
-to provide evaluation and treatment of presenting problems which have medical, behavioral and psychological elements
nonverbal listening behavior
-let the pt complete the opening statement
-listen to pt, he is telling you the dx
-good physician treats the disease, the great physician treats the pt
questioning style
-direction/clarification
-facilitation
-checking/summarizing
-when in doubt -> check
skills to assess and understand the pts problem
-survey problems
-impact of illness
-negotiate agenda
-develop narrative of the problem
-avoid leading questions
-explore pt perspective
-ICE- ideas, concerns, expectations
goal of the core functions
-help students and practicing clinicians master a core set of basic and advanced skills to facilitate: empathic, effective, efficient communication with pts
-integrating pt and clinician centered interviewing allows more complete picture of pts illness and allows the clinician to show respect, empathy, humility, and sensitivity
skills for partnership: Pearls
-Partnership
-empathy- reflection and legitimation
-support
-respect (affirmation)
assess and understand the pts problems
-use inductive and deductive information gather techniques
-to dx, assess, and understand pt problems as well as the pt as a person who is experiencing those problems
-inductive reasoning- look at a trend and generalize
-deductive- using a formulae to figure out whats happening
empathy
-NURS(*E)
-Naming the feeling/emotion
-Understanding
-Respecting (praising or appreciating the pt and/or acknowledging his/her situation)
-Supporting
-Explore- how else were you feeling about it
hierarchy of natural systems
-social -> psyhco -> bio
-social- culture, community, 2-person, family, clinician
-psycho- person (experience and behavior)
-bio- nervous system, tissues, cells, organelles
open ended skills
-nonfocusing- silence, nonverbal encouragement, continuers
-focusing- echoing, requesting, summarizing
emotion seeking skills
-direct
-if necessary use indirect
-indirect- impact on life or others, beliefs about the problem, intuit how the pt might be feeling, triggers
empathy
-name ->
-understand ->
-respect ->
-support
behavioral menu
-1. ask pt if he or she is interested in hearing ideas (ask permission)
-2. present a range of potential action ideas
-3. suggest that hearing other ideas may in fact trigger new ideas from the pt
patient centered interviewing: step 1- stage for the interview
-welcome pt
-use pts name
-introduce self and identify specific role (student/nurse/student doctor/resident/fellow)
-ensure pt readiness and privacy
-remove barriers to communication
-ensure comfort and put pt at ease
patient centered interviewing: step 2: elicit chief concern and set agenda
-indicate time available
-forecast what you would like to have happen during the interview
-obtain list of all issues pt wants to discuss, specific symptoms, requests, expectations, understanding
-summarize and finalize the agenda, negotiate specifics if too many agenda items
patient centered interviewing: step 3: begin the interview with non focusing skills that help the patient to express her/himself
-start with open ended request/question
-use non focusing open ended skills
-obtain additional data from nonverbal sources, nonverbal cues, physical characteristics, accoutrements, environment, self
patient centered interviewing: step 4: use focusing skills to elicit 3 things: symptom story, personal context, and emotional context
-further elicit symptom story- description of symptoms, using focus open ended skills
-elicit personal context- broader personal/psychosocial context of symptoms, pt beliefs/attributions, against focusing on open ended skills
-elicit emotional context- use emotion seeking skills, direct, indirect, impact (belief, triggers, self disclosure, resonate with unexpressed feeling)
-respond to feelings/emotions- use empathy skills to address the feelings and emotions (naming, understanding, respecting, and supporting)
-expand the store- continue eliciting further personal and emotional context -> address feelings and emotions (NURS)
patient centered interviewing
: step 5: transition to middle of interview
-brief summary
-check accuracy
-indicate that both content and style of inquiry will change if the pt is ready
patient centered interviewing: step 6-11
-6. complete a chronological description of HPI/OAP
-7. past medical history
-8. social history
-9. family history
-10. review of systems - PE
-11. end of interview
patient centered approach
-pt often do not seek healthcare only bc of a symptom
-pt usually bring more than 1 concern to their clinician
-allowing the pt to tell their symptom story- diagnostically useful and therapeutic
-pts do not want us to try to fix everything they tell us about
-pts may not experience our caring and compassion unless we give voice to them
needs communicated by patients: very common
-needs to express symptoms, personal context of illness, feelings, and emotions, interests, desire for information and other ideas
-ex. worry about cancer, cant work with back pain, feeling down, wants to lose weight, fever
needs communicated by patient: common
-special communication needs
-ex. non english speaker, deaf, cognitively impaired
needs communicated by patient: uncommon
-urgent, sometimes life threatening needs requiring immediate attention
-biomedical- unconscious, hematemesis, symptoms of acute myocardial infarction, recent hx of syncope..
-psychosocial- suicidal, homicidal, disruptive, overtly psychotic, severe brain syndrome, anxious
biopsychosocial story
-synthesis of patient centered (psychosocial and symptom date) + clinician centered (symptom and psychosocial data)
obtaining and describing data without interpreting it
-expand the description of symptoms already introduced by the pt
-describe symptoms not yet introduced in the already identified body system (and general health symptoms)
interpreting data while obtaining it
-testing hypotheses about the possible diseases causing symptoms
-describe relevant symptoms outside the body system involved in the HPI
-inquire about the presence or absence of relevant non symptom data (secondary data) not yet introduced by the pt
understand the patients perspective
-impact (meaning) of illness on self/others
-health beliefs
-triggers for seeking care
components of history
-chief complain
-history of present illness- OLD CARTS
-other active problems
-past medical history
-social history
-family history
-review of systems
medications
-dose
-interval
-route
-home remedies
-OTC
-herbal/nontraditional
-generic
past medical history
-if pertinent to HPI can put the specific section below or pertinent info in the HPI
-childhood and adult
-obgyn
-past surgical history
-past psychiatric history
collaboratively manage the problems
-education
-pt activation
-shared decision making
-self management support
-motivational skills to facilitate collaboration for management of pt problems
skills
-elicit
-tell pt first chunk of info
-ask about understanding and concerns
-care
-counsel
-tell back/tech back
skills: Support self-management brief action planning
-is there anything youd like to do about your health in the next week or two
-SMART behavioral planning- specific, measurable, achievable, relevant, time specific (what, where, when, how often)
-commitment statement
-about how confident do you feel you can carry out your plan from 1-10 (greater than 7)
-when would you like to come back and review how youre doing with plan
-plan is patient centered -> what the pt wants to do
problem solving
-if confidence is less than 7 -> low confidence
-work with pt to overcome barriers to implementing the plan
-achieve a 7
-patient should be on board
follow up
-nonjudgemental inquiry
-reassurance if the plan was not completed successfully
-checking into the pts ideas and desires about most appropriate next steps
end of interivew
-share information- orient pt to end of interview, ask permission to begin discussion, frame discussion, iteratively provide info, use plain language
-assess understand- teach back, provide written plans
-invite pt to participate in shared decision making
-close the visit
-next steps
-encourage questions
-acknowledge and support
skilled interview techniques
-active listening
-empathic responses (reflection, legitimization)
-guided questioning (open ended questions, echoing)
-nonverbal communication
-validation
-reassurance
-partnering
-summarization
-transitions
-empowering pts
7 rules
-If you feel uncomfortable touching a patient, do not touch the patient (other than what is absolutely necessary for the physical examination).
-Any sexual relationship between a medical practitioner and a patient is always an abuse of power and should never occur.
-Do not answer medical questions during your time as a student. Refer questions politely back to the primary medical team. (I will share the information you have given me, and I will return with my preceptor to discuss the findings further)
-Respond to an emotion as soon as it appears.
-When in doubt about how to respond to an emotion, use reflection and legitimation.
-Never promise a patient absolute confidentiality.
-Communicate all clinically relevant information a patient may have told you back to the treatment team. Do it yourself
10 concerns
-Why should the patient want to talk to or Be examined by a student?
-Is a student interview or examination a humiliation or indignity for the patient?
-How should I dress? Should I wear a white coat?
-Should I introduce myself as “doctor”? If I do that, am I not deceiving the patient?
-If the patient is in pain or emotional distress, should I continue with the interview?
-Should I shake the patient’s hand? Under what circumstances is it acceptable to touch a patient?
-If the patient asks me questions, should I answer the questions if I know the answers? -What should I do if I do not know the answers?
-What do I do if the patient starts crying or if the patient gets angry with me?
-What should I do if the patient promises to tell me some important secrets if I agree to maintain his or her confidence?
-What should I do if the patient tells me something his or her doctor does not know? -For example, what if the patient tells me that he or she is depressed or suicidal?
Sympathy vs Empathy
Sympathy- I feel sorry for you
Empathy- putting yourself in shoes and showing that you understand
clinician centered approach
-clinician is asking all the questions
-in an emergency situation you do not start with a patient centered approach
paper notes
-date
-military time
-patients name (initials)- HIPAA
-age
-gender
-race (physical features)/ethnicity (cultural background)
-reliability of info
-source
-location- hospital, clinic
hyposmia & anosmia
-hx- systemic illnesses, medication, injuries etc.
-PEx- nose and nervous system focus
-testing:
-University of Pennsylvania Smell Identification Test (UPSIT)- self administered scratch and sniff test useful for hyposmia, anosmia, and malingering
-treatment- secondary causes -> endoscopic sinus surgery
-education- seasoning, safety issues
nose and sinus disorders
-epistaxis
-nasal polyps
-foreign bodies
epistaxis
-90% pts with this can be treated in ED
-classification dependent on primary bleeding site
-anterior- most common
-posterior
VINDICATE
-used to build up differentials for any case
-VASCULAR
-INFLAMMATORY
-NEOPLASTIC
-DEGENERATIVE/DEFICIENCY
-IDIOPATHIC/IATROGENIC, INTOXICATION
-CONGENITAL
-AUTOIMMUNE/ALLERGIC/ANATOMIC DEFECTS
-TRAUMA
-ENDOCRINE/EXPOSURES (ENVIRONMENTAL, OCCUPATIONAL) OSLER-WEBER-RENDU SYNDROME (HHT)
