Clinical Interviewing

Question 1

Physicians and patient care

Answer 1

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

Question 2

Chasm for excellence

Answer 2

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

Question 3

Key on what pts value

Answer 3

People place more importance on doctors interpersonal skills then their medical judgement or expierence

Question 4

Benefits of good interviewing

Answer 4

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

Question 5

Malpractice litigation

Answer 5

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

Question 6

cited reasons for litigation

Answer 6

didn’t listen, didn’t return calls, showed little interest, rude, not enough time, didn’t answer questions adequately

Question 7

What pts want

Answer 7

1. Treats you with dignity and respect
2. Listens carefully to your health concerns
3. Easy to talk to
4. Takes concerns seriously
5. Willing to spend enough time with you
6. Truly cares about you and your health

Question 8

How to be valued by your pt

Answer 8

 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.

Question 9

 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

Answer 9

The doctor-patient relationship (DPR)
“rapport”
clinical interview

Question 10

_______ 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

Answer 10

Interpersonal factors
empathic (attentive, supportive, caring)
self-observant,

Question 11

 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

Answer 11

Biopsychosocial Model

Question 12

 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

Answer 12

biological system

psychological system

social system

Question 13

a.k.a. “autocratic”, “doctor-knows-best”. Can be desirable, e.g., in emergencies. Preferred by many doctors and some patients

Answer 13

Paternalistic

Question 14

doctor dispenses accurate information, but choices are left to the patient. Preferred by many patients, but often difficult for doctors

Answer 14

Informative

Question 15

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

Answer 15

Interpretative

Question 16

doctor acts as an ally who actively advocates a particular course of action (e.g., weight loss or smoking cessation)

Answer 16

Deliberative

Question 17

are hypothetical constructs originating in psychoanalytic theory. They are very useful in understanding disturbed DPRs that can lead to poor care

Answer 17

Transference and countertransference

Question 18

refers to the unconscious process in which the patient attributes to the doctor aspects of important past relationships, especially early/parental relationships

Answer 18

Transference
*Patients may unconsciously transfer residual feelings from early relationships (usually with parental/authority figures) to doctors, leading to unexpected, exaggerated, often disruptive reactions

Question 19

What is countertransference?

Answer 19

unconscious process in which the DOCTOR attributes to the PATIENT aspects of important past relationships, especially early/parental relationships

Question 20

According to Lipkin, ALL interviews serve three basic functions

Answer 20

1. Determining the nature of the problem
2. Developing and maintaining a therapeutic relationship
3. Communicating information and implementing a treatment plan

Question 21

What two additional functions do pysch interviews do?

Answer 21

1. Recognizing the psychological determinants of the
   patient’s reactions and behaviors
2. Symptom classification leading to diagnosis

Question 22

6 strategies for developing Rapport

Answer 22

1. Putting patient and interviewer at ease
2. Finding patient’s pain and expressing compassion
3. Evaluating patient’s insight and becoming an ally
4. Showing expertise
5. Establishing authority as a physician or therapist
6. Balancing the roles of empathic listener, expert, and authority

Question 23

Benefits of open ended questions

Answer 23

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

Question 24

When to use Close-ended questions

Answer 24

Use closed-ended questions later on to establish diagnosis

closed-ended questions encourage them to respond to what is asked, and no more

Question 25

refers to various means of verbal and non-verbal communication that encourage the patient to continue telling his or her story

Answer 25

Facilitation

1. Nodding one’s head in acknowledgement
2. Leaning forward and increasing eye contact
3. Using phrases like, “Yes, and then…?” or “I see, go on…”

Question 26

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

Answer 26

Reflection

Question 27

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

Answer 27

Clarification

Question 28

is used with patients who have disorganized or tangential thinking, or who talk excessively in an unhelpful way

Answer 28

Redirection
* Initial attempts at redirection should be polite, but clear.
With rambling, psychotic patients, redirection may have to be quite blunt and frequent.

Question 29

 is one of the most important (and hardest to use) interviewing techniques

Answer 29

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

Question 30

 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

Answer 30

Interpretation

Question 31

“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?”

Answer 31

Interpretation

Question 32

 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

Answer 32

Confrontation

Question 33

“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”

Answer 33

Confrontation

Question 34

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

Answer 34

Summation

Question 35

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

Answer 35

Explanation

Question 36

is the technique of smoothly moving from one topic to another once adequate information has been obtained

Answer 36

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

Question 37

“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”

Answer 37

Transition technique

Question 38

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)

Answer 38

Self-revelation

Question 39

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

Answer 39

tactfully turned back to the patient using transitional language

Question 40

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

Answer 40

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

Question 41

can increase patient trust and compliance, but must be truthful

Answer 41

Reassurance

* False reassurance is essentially lying, and should be avoided

Question 42

_____ should be given when needed, but timing and manner are important

Answer 42

Advice

* Patients should be given a chance to fully express their symptoms and concerns before advice is given

Question 43

Key for ending an interview

Answer 43

 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

Question 44

Be fucking polite when ending an interview

Answer 44

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