Clinical Interviewing Flashcards
Physicians and patient care
67% docs thought patients knew their names
18% of pts that correctly identified physicians name
77% of physicians believe pts know dx vs 57% pts that know dx
98% docs state they discussed pts fears/anxieties vs 54% pts say docs never do this
Chasm for excellence
Physician communication when prescribing medicaitons: 26% failed to mention name of new med 13% failed to mention purpose of meds 65% failed to review adverse effects 66% failed to tell pt the duration of tx
Key on what pts value
People place more importance on doctors interpersonal skills then their medical judgement or expierence
Benefits of good interviewing
resolving symptoms, improves compliance with meds and appts, helps devo trust adn can lead you to find info that’s essential in making correct dx, decreased risk of being sued
Malpractice litigation
Patient compliants predict malpractice
8% physicians account for 85% of claim payouts, most important predictor in being sued = Quality of Relationship between pt and doctor
cited reasons for litigation
didn’t listen, didn’t return calls, showed little interest, rude, not enough time, didn’t answer questions adequately
What pts want
- Treats you with dignity and respect
- Listens carefully to your health concerns
- Easy to talk to
- Takes concerns seriously
- Willing to spend enough time with you
- Truly cares about you and your health
How to be valued by your pt
Get to know your patients
Become an expert interviewer
Let your patients tell their stories- be a good listener.
What you say and how you say it does make a difference.
Communication and Interpersonal Skills are now a Core Competency for all of Medicine.
is the essential core of all medical practice
Good ______ (French for “relationship” or “connection”) is essential for a good DPR
Rapport is established during the ______, as are mutual expectations
The doctor-patient relationship (DPR)
“rapport”
clinical interview
_______ are often more important to patients than technical expertise
A good doctor is _____but still maintains an appropriate DPR with clear role definitions and boundaries
Doctors must learn to be______and take care not to use their patients, consciously or unconsciously, to gratify their own needs
All of the above are especially important in psychiatry, where effective communication, often involving sensitive topics, is paramount
Interpersonal factors
empathic (attentive, supportive, caring)
self-observant,
Proposed by George Engel in 1977 as a more integrated way of looking at patients, their diseases, symptoms, and behaviors
The model is now widely accepted, but increasingly distant from the way medicine is actually practiced in the real world of 15-minute office visits
Biopsychosocial Model
The ______ refers to the patient’s anatomical and molecular substrates of disease
The ______ refers to the patient’s psychodynamic factors, motivations, and personality in relation to their illness
The______ includes environmental, cultural, and familial influences on the patient’s experience and expression of illness
biological system
psychological system
social system
a.k.a. “autocratic”, “doctor-knows-best”. Can be desirable, e.g., in emergencies. Preferred by many doctors and some patients
Paternalistic
doctor dispenses accurate information, but choices are left to the patient. Preferred by many patients, but often difficult for doctors
Informative
doctor knows patient and his or her situation and values well, and seeks to share decision-making responsibilities. Often ideal, but requires more time and intimate knowledge of the patient
Interpretative
doctor acts as an ally who actively advocates a particular course of action (e.g., weight loss or smoking cessation)
Deliberative
are hypothetical constructs originating in psychoanalytic theory. They are very useful in understanding disturbed DPRs that can lead to poor care
Transference and countertransference
refers to the unconscious process in which the patient attributes to the doctor aspects of important past relationships, especially early/parental relationships
Transference
*Patients may unconsciously transfer residual feelings from early relationships (usually with parental/authority figures) to doctors, leading to unexpected, exaggerated, often disruptive reactions
What is countertransference?
unconscious process in which the DOCTOR attributes to the PATIENT aspects of important past relationships, especially early/parental relationships
According to Lipkin, ALL interviews serve three basic functions
- Determining the nature of the problem
- Developing and maintaining a therapeutic relationship
- Communicating information and implementing a treatment plan
What two additional functions do pysch interviews do?
- Recognizing the psychological determinants of the
patient’s reactions and behaviors - Symptom classification leading to diagnosis
6 strategies for developing Rapport
- Putting patient and interviewer at ease
- Finding patient’s pain and expressing compassion
- Evaluating patient’s insight and becoming an ally
- Showing expertise
- Establishing authority as a physician or therapist
- Balancing the roles of empathic listener, expert, and authority
Benefits of open ended questions
Use open-ended questions at first (e.g., “So, where shall we begin?”)
Open-ended questions are less time-efficient and less precise, but more effective at getting to the “real” problem when the presenting complaint can’t be taken at face value.
Five-minutes of open-ended conversation at the beginning of the interview can save much time in the endB
When to use Close-ended questions
Use closed-ended questions later on to establish diagnosis
closed-ended questions encourage them to respond to what is asked, and no more
refers to various means of verbal and non-verbal communication that encourage the patient to continue telling his or her story
Facilitation
- Nodding one’s head in acknowledgement
- Leaning forward and increasing eye contact
- Using phrases like, “Yes, and then…?” or “I see, go on…”
is the supportive re-stating of what the patient has just told the doctor, though often in different, more succinct language (think reflection = mirror)
confirms that the doctor is listening to, thinking about, understanding, and empathizing with what the patient is trying to communicate
Reflection
is questioning that clarifies or encapsulates what the patient has just said, or that seeks additional related information
demonstrates the doctor’s attentiveness and desire to clearly understand the patient
is especially helpful in confirming what patients with disorganized thinking are trying to communicate
Clarification
is used with patients who have disorganized or tangential thinking, or who talk excessively in an unhelpful way
Redirection
* Initial attempts at redirection should be polite, but clear.
With rambling, psychotic patients, redirection may have to be quite blunt and frequent.
is one of the most important (and hardest to use) interviewing techniques
Silence
So long as a posture of focused interest is maintained by the doctor, a long, often uncomfortable silence gives patients “permission” to continue talking about the painful subject that precipitated the silence
involves extrapolating another meaning from what the patient has said
should only be used when good rapport has been established, as it can sound (and be) presumptuous and make the patient defensive
Interpretation
“When you talk about how angry you are that your family has not been supportive, I think you’re also telling me that you’re afraid that I won’t be supportive, either. What do you think?”
Interpretation
is used to help the patient face something important that he or she is missing, ignoring, or denying
must be done with skill and subtlety so as not to make the patient angry and defensive
is sometimes necessary with non-compliant or substance-abusing patients
Confrontation
“You said that you are no longer drinking, but your liver tests tell us otherwise. We really need to know the true amount of your recent alcohol use in order to provide you with the best possible treatment”
Confrontation
is the doctor’s summary of what he or she understands the patient to have said
is vital to ensuring accuracy of understanding, and should be used repeatedly in most interviews
Summation
is essential once the doctor has arrived at a decision about treatment. It is essential for compliance
Be concise but sufficiently thorough in explaining to the patient what the problem or diagnosis is, what treatment you are recommending, why you are recommending it, and risks/benefits of different treatment options vs. no treatment
Explanation
is the technique of smoothly moving from one topic to another once adequate information has been obtained
Transition
*Expert interviewers use the patient’s own statements as transition points, so that the interview feels like a seamless conversation rather than a “question and answer” session
“I drink a fifth of vodka per day, unless my wife finds it and pours it down the sink.” Doctor replies, “It sounds like the drinking may be causing you problems in your marriage”
Transition technique
Can be used by the doctor at first put patients at ease, if the revelations are not too personal (e.g. telling the patient where you are from or where you went to school, if asked)
Self-revelation
Excessively personal self-revelation by the doctor, even when asked, is abusing the DPR in order to meet an unfulfilled need in the doctor’s own life
Uncomfortably personal questions by patients often convey unspoken feelings for or concerns about the doctor, and should be
tactfully turned back to the patient using transitional language
Remember: your patient is your patient – not your friend or confidante
______ should be avoided to the extent possible without making the
patient feel embarrassed for having asked a personal question
Self revelation
** Students often reveal because they do not feel they have much to offer- but this is not the case. Being a good listener is invaluable to the patient
can increase patient trust and compliance, but must be truthful
Reassurance
* False reassurance is essentially lying, and should be avoided
_____ should be given when needed, but timing and manner are important
Advice
* Patients should be given a chance to fully express their symptoms and concerns before advice is given
Key for ending an interview
The doctor should end the interview on a positive note whenever possible
Giving the patient a chance to bring up anything that wasn’t addressed is important, e.g., “Well, you’ve given me a lot of very helpful information. Before we stop, is there anything else you’d like to discuss?”
Explanation should be given, as previously mentioned
Be fucking polite when ending an interview
Patient should be thanked for coming in and for helping the doctor to understand the problems he or she has been having. This reinforces to the patient the importance of honest communication, helps cement the DPR, and enhances compliance
