GP 01 & 02 - Medical Interviewing 1 & 2

Question 1

What is an integrated medical encounter?

Answer 1

The best type of medical ecounter, where both physician centered and patient centered encounter techniques are used to elicit the maximum amount of useable data from the patient.

Question 2

What are the three most important communication skills to having an integrated medical encounter?

Answer 2

1. Data Gathering Skills.
2. Emotion Seeking Skills.
3. Empathy Skills

Question 3

List and briefly describe the sub-skills that make up data gathering communication skills.

Answer 3

• Open Ended Skills.
  
  • Focused Open Ended Skills - allow the patient to develop their narrative but help keep them focused on the important aspects of their narrative.
  • Non-focused open ended skills - allow the patient to speak freely with minimal disturbance.
• Closed Ended Skills - present the patient questions the limit their responses (e.g. - yes/no questions). Used mainly to confirm or refute specific ideas. Too much of this will diminish the quality of the encounter.

Question 4

What communication techniques are key to developing Focused Open Ended Skills?

Answer 4

• Open ended questions.
• Use of continuers like “mm-hmm” and “go on”.
• Reflection (echoing) - repeating key words or phrases to signal that you are listening.
• Summarization

Question 5

What communication techniques are key to developing Non-focused Open Ended Skills?

Answer 5

• Non-Verbal Communication that prompts the patient to talk freely and demonstrates listening.
• Silence (avoid awkwardness though)
• Neutral Utterances and continuers

Question 6

Describe the primary techniaues used to develop Emotion Seeking Skills.

Answer 6

• Direct Inquiry - specifically ask the patient’s feelings regarding an issue/topic. This is best done by using open ended questions, non-verbal cues, and avoiding judgement.
• Indirect Inquiry - used if direct inquiry does not elicit a response. Ask about:
  
  • impact on patient’s life/family/friends
  • the patient’s beliefs about the issue
  • impact on the patient directly
  • the trigger for the visit (why now).

Question 7

Differentiate sympathy from empathy

Answer 7

Sympathy is feeling compassion, sorrow, or pity for the hardships that another person encounters, while empathy is putting yourself in the shoes of another.

Question 8

Give the mnemonic used to help remember that best ways to show empathy.

Answer 8

NURS.

• Name - repeating the expressed emotion to show you have heard the patient.
• Understand - verbally indicating comprehension of the expressed emotion.
• Respect - praising or acknowledging the patient’s plight.
• Support - offering partnership of concrete solution to the problems

Question 9

What is the general sequence of an integrated medical interview? Which steps are patient centered or doctor centered?

Answer 9

Steps 1-5 are patient centered, the rest are clinician centered

1. Set the stage for the interview.
2. Elicit C.C. (chief complaint) and set agenda.
3. Opening the HPI (history of present illness).
4. Use focusing skills to learn the symptom story and personal/emotional context.
5. Transition to the middle of the interview.
6. Obtain a chronological description of the HPI.
7. PMHx (past medical history).
8. SHx (social history).
9. FHx(family history).
10. ROS (review of systems).
11. Physical Examination.
12. End of encounter

Question 10

What are the important parts to Step 1 of the integrated medical interview - Setting the Stage of the Interview?

Answer 10

• Welcome the patient.
• Introduce yourself and identify your specific role.
• Inquire the patient’s name and how they would like to be addressed.
• Ensure patient readiness and privacy.
• Remove barriers to communication (sit down).
• Ensure comfort and put the patient at ease.

Question 11

What are the important parts to Step 2 of the integrated medical interview - Elicit C.C. and set agenda?

Answer 11

• Obtain a list of the issues the patient wishes to discuss using open ended skills.
• Negotiate and finalize the agenda

Question 12

What are the important parts to Step 3 of the integrated medical interview - Opening the HPI?

Answer 12

• Start with focused open ended questions
• Use non focusing skills (e.g. - silence, neutral utterances)
• Obtain additional information from other nonverbal sources (e.g. - the patient’s physical appearance)

Question 13

What are the important parts to Step 4 of the integrated medical interview - Symptom story and Personal/Emotional Context?

Answer 13

• Use focused open ended questions to clarify topics not discussed and elicit personal context
• Use emotion seeking skills to determine the patient’s thougths, emotions, and feelings towards the symptoms (emotional context)
• Respond to that emotion

Question 14

What are the important parts to Step 5 of the integrated medical interview - Transition to Middle of the Interview (clinician-centered process)?

Answer 14

• Summarize data obtained from Steps 1-4
• Verify any mistakes or misunderstandings
• Transition
  
  • indicate to the patient that you are switching gears

Question 15

What are the important parts to Step 6 of the integrated medical interview - Obtain a chronological description of the HPI?

Answer 15

• Use closed ended questions
  
  • to elicit cardinal features of the symptom not yet introducted by the patient
  • to inquire about other relevant symptoms outside of the C.C.
  • to inquire about non-symptom data used to test hypotheses

Question 16

What are the important parts to Steps 7-10 of the integrated medical interview - Obtain details from the PMHx, SHx, FHx, and ROS?

Answer 16

Use the clinician centered approach to elicit these details. In particular, use yes/no closed ended questions.

Question 17

What are the important parts to Step 11 of the integrated medical interview - Physical Examination?

Answer 17

• Use transitional skills to prepare the patient for the physical examination
  
  • Explain techniques, purpose, and expectations of the exam
  • Ask permission to conduct the examination

Question 18

What are the important parts to Step 12 of the integrated medical interview - Closure of the Encounter?

Answer 18

• Summarize relevant details
• Orient the patient to the end of the encounter
• Explain the possible diagnosis using minimal jargon
• Explain testing and/or treatment options
• Incorporate patient’s informational needs (provide education)
• Invite patient to participate in shared decision making
• Allow the patient to summarize
• Invite the patient to ask questions and express concerns
• Agree on the next time of communication
• Acknowledge and say goodbye

Question 19

Describe the general outline of how you should “set the agenda” for the medical interview.

Answer 19

1. Is there anything else you’d like to talk about today (assuming they’ve already told you the C.C.)? Keep asking this question until there’s nothing else.
2. Assure the patient that you’ll address those concerns today.
3. OK, so we’ll be talking about X, Y, and Z today. Let’s start with X.

Question 20

What are the important topics to ask about when collecting a HPI from the patient?

Answer 20

The seven cardinal features of symptoms.

1. Onset and Chronology.
2. Position and Radiation.
3. Quality - what does the pain feel like.
4. Quantification - quantify the severity (1-10 scale).
5. Related Symptoms.
6. Setting - is it better or worse when you’re in different positions.
7. Transforming factors - are there other factors that make the symptom better or worse

Question 21

Describe what the data gathering “funnel technique” is.

Answer 21

• Start with broad open-ended questions to obtain maximum information.
• Move on to clarifying questions to fill in gaps of missing information.
• End with closed-ended questions to elicit specific points.

Question 22

When conducting a medical interview, how should you be interpreting the data to ensure you obtain a sufficient amount of data?

Answer 22

1. Gather data using the funnel technique
2. Assess each piece of information for its reliability, completeness, and relevance to the problem.
3. Process and evaluate this information to find the link amon presented symptoms.
4. Focus on the presence or absence of certain symptoms that could be related to your differential diagnosis.

Question 23

List the basic steps to hypothesis testing in the medical field.

Answer 23

1. Acquire Data.
2. Interpret & Organize data.
3. Make DDxs (differential diagnoses) based upon pattern recognition, must not miss Dxs, most probable, anatomical, organ systems approach, mnemonics.
4. Test DDxs.
5. If enough data rules out a DDx, trash it. If enough data rules in a DDx, treat it. If there is not enough data to either rule a DDx in or out, collect more data.

Question 24

What are the important topics to ask about when collecting a PMHx?

Answer 24

1. Major illnesses
2. Hospitalizations
3. Surgeries
4. Serious Injuries
5. Allergies
6. Medications (ask about reason, dosage, frequency, and compliance)
7. Complementary Medicine (alternative medicine)
8. Supplements (e.g. - vitamins)

For any positive findings, always ask about date, duration, and location

Question 25

When collecting a FHx, which family members are you most concerned with and which illnesses are you most concerned with?

Answer 25

Family Members - mother, father, grandparents, siblings, children

Illnesses - cancer, high BP, heart disease, diabetes, alcoholism, depression

Question 26

When does the CDC suggest a sexual history be taken

Answer 26

1. Patient’s initial visit
2. During routine preventive exams
3. Symptoms and Signs of STDs

Question 27

Describe how a sexual history should be taken.

Answer 27

Start by asking if they’re currently sexually active or if they have ever been sexually active. If yes, aske the 5 Ps

• Partners - how many have you had and were they male, female, or both
• Practices - what kind of sexual practices do you engage in
• Protection - do you use it and what kind
• Past History of STDs
• Prevention of Pregnancy - are you seeking to become pregnant? Do you use contraceptives?

Question 28

What are the topics that should be covered when taking a SHx?

Answer 28

• Lifestyle Habits - caffeine, tobacco, alcohol, drug use
• Health Promotion Habits - diet, exercise, safety, screening
• Personal Life - occupation, hobbies, home life, sexuality, stress, spirtuality/religion, exposures, important life experiences, legal issues

Question 29

How is patient smoking quantified?

Answer 29

In pack years (not packs per year)

(packs smoked/day)*(number of years smoked)

Question 30

What does the CDC consider binge drinking and heavy drinking?

Answer 30

Binge Drinking

• Women - greater than 3 drinks per occasion
• Men - greater than 4 drinks per occasion

Heavy Drinking

• Women - greater than 7 drinks per week
• Men - greater than 14 drinks per week

Question 31

What are the CAGE questions and what do they assess?

Answer 31

Questions designed to screen for problem drinking or possible alcohol problems. Two yes responses indicate that the possibility of alcoholism should be investigated further

• Have you ever felt the need to Cut down on your drinking
• Have people Annoyed you by criticizing your drinking
• Have you ever felt Guilty about drinking
• Have you ever felt you needed a drink first thing in the morning (Eye-Opener) to steady your nerves or get rid of a hangover