Interviewing & Health History (Bates ch. 3) Flashcards
The primary goals of the patient interview are to ____ and to _____ __ ______ of the patient through a trusting and supportive relationship
The primary goals of the patient interview are to listen and to improve the wellbeing of the patient through a trusting and supportive relationship
High-quality patient-clinician communication has been shown to _______, _______, _______, ________, and ______
Improve patient outcomes, decrease symptoms, improve functional status, reduce litigation, and decrease errors
What is the most commonly performed clinical interviention?
The interview, which will occur thousands of times in a clinicians career
What is the foundation of a therapeutic alliance between patients and clinicians?
Trust
Skilled interviewing is both ___-centered and ____-centered
patient-centered and clinician-centered
What does the patient-centered interview focus on?
recognizing the importance of the patients’ expressions of personal concerns, feelings, and emotions
What does the patient-centered interview evoke?
the personal context of the patient’s symptoms and disease
Define the patient-centered interview
following the patient’s lead to understand their thoughts, ideas, concerns and requests without adding additional info from the clinician’s perspective
What does the clinician-centered interview focus on?
taking charge of the interaction to meet their own needs to acquire symptoms, details, and other data that will help in identifying a disease
Which is preferred, the patient-centered interview, clinician-centered interview, or an integration of both?
Integration of both
What does an integration of the patient and clinician-centered interview style lead to?
A more complete picture of the patient’s illness and the conveyance of respect, empathy, humility, and sensitivity
What does the interview process require attention to?
The patient’s feelings and behavioral cues
The health history format provides an important framework for organizing the patient’s story into various categories pertinent to the patient’s _____, ______, and _______
present, past, and family health
The interview process is rigid - true or false
False, it is fluid
The interview should be open-ended - true or false
True
Techniques involved in the interview to cue patients to tell their stories include _____, ______, _______, ______, ______, ______, and _______
active listening, guided questioning, nonverbal affirmation, empathetic responses, validation, reassurance, and partnering
The health history format focuses your attention on ….
the kind of information that is needed.
The health history format facilitates…
clinical reasoning
The health history format provides…
a standardized communication between other healthcare providers involved in a patient’s care
Which history gives the clinician an opportunity to see the patient as a person and better understand their outlook and background?
The Personal and Social History
The Review of Systems should not include clinician-centered closed-ended questions
False, yes and no questions should be limited to the Review of Systems
This kind of history is used for new patients in most settings
A Comprehensive Health History
What kind of interview/history is best for a patient seeking care for a specific concern like a cough?
A focused or problem-oriented history, which is more limited and tailored to that specific problem
What should the interview focus on for a patient seeking care for an ongoing or chronic problem?
The patient’s self-management, response to treatment, functional capacity, and quality of life
List the 10 skilled interviewing techniques
(at every great newspaper, very respectful people see their enemy)
- active listening
- empathetic responses
- guided questioning
- nonverbal communication
- validation
- reassurance
- partnering
- summarization
- transitions
- empowering the patient
(at every great newspaper, very respectful people see their enemy)
Define active listening
closely attending to what the patient is communicating, connecting to the patient’s emotional state, using verbal and nonverbal skills to encourage expansion from the patient
Active listening does not involve nonverbal cues - true or false
False, active listening involves attending to the patient’s verbal and nonverbal cues.
_____ has been described as the capacity to identify with the patient and feel the patient’s pain as your own and respond in a supportive manner
Empathy
To express empathy you must first ________, then __________
recognize the patient’s feelings, then actively move toward and elicit emotional content
For a response to be empathetic it must convey…
that you feel what the patient is feeling
______ _______ shows your sustained interest in the patient’s feelings and disclosures
Guided Questioning
List the 7 techniques of Guided Questioning
(four grad students make cake every evening)
- Moving from open-ended to focused questions
- Using questioning that elicits a graded response
- asking a series of questions one at a time
- offering multiple choices for answers
- clarifying what the patient means
- encouraging with continuers
- using echo
(four grad students make cake every evening)
What type of questioning is this?
“Tell me about your chest pain. (pause) where do you feel it? (pause) has it traveled? (pause)”
Moving from open-ended to focused questions
What type of questioning is this?
“How many steps can you climb before you get short of breath”
Questioning that elicits a graded response
What type of questioning is this?
“Do you have a history of tuberculosis? (pause) asthma? (pause) pleurisy? (pause)”
Asking a series of questions one at a time
What type of questioning is this?
“Which of the following best describes your pain: aching, sharp, dull, stabbing, burning?”
Offering multiple choices for answers
What type of questioning is this?
“Tell me exactly what you mean by the flu”
or
“When you said you were behaving just like your mother, what did you mean?”
Clarifying what the patient means
What type of questioning is this?
using nonverbal clues such as leaning in, gesturing, nodding your head, or saying “go on”, “mhm”
Encouraging with continuers
What type of questioning is this?
Patient: the pain began to spread.
PA: it spread?
Patient: yes and I felt like I was going to die.
PA: wow going to die?
Echoing
Being sensitive to nonverbal cues allows you to …
read the patient more effectively and send messages of your own
What should you pay attention to for nonverbal clues?
- Eye contact
- facial expression
- posture
- head position and movement
- distance
- placement of arms or legs
True or false - all forms of nonverbal communication are universal
False, many can be culturally bound
A clinician can mirror posture and paralanguage (qualities of speech) to increase rapport - true or false
True
Another way to affirm the patient is to ____ the legitimacy of their emotional experience
validate
List a few problems with reassurance
- it may be premature and counterproductive
- it may be misleading
- it may block further disclosure
- it may make the patient feel that you are uncomfortable with their anxiety
- it may make the patient feel that you don’t understand/believe them
Define partnering
expressing your commitment to an ongoing relationship when building rapport with them in order to provide their care
Summarization allows you to demonstrate that you have been listening and can help…
identify what you do and don’t know, allowing the patient to add info or correct misunderstanding
What are these phrases an example of within guided questioning?
“now i’d like to ask you some questions about xyz”
“before we move on is there anything else about xyz”
“Now I’d like to examine you, I will step out for a few minutes while you put this gown on”
Transitioning
What happens when you empower patients to ask questions, express concerns, and probe your recommendations?
They are more likely to adopt your advice, make lifestyle changes, or take meds as prescribed
Techniques for sharing power
- evoke the patient’s perspective
- coney interest in them as a person
- follow the patient’s lead
- elicit and validate emotions
- share info especially at transition points
- make clinical reasoning apparent
- reveal limits of knowledge
What does the preparation phase of the interview entail?
- reviewing the records
- setting goals
- checking appearance and clinical behavior
- adjusting the environment
List the primary things to look for when reviewing the record in preparation for the interview
-identifying data (age, gender, address, insurance)
-problem list
-medication list
-allergies
Goal setting should balance both _______ and _______
provider-centered goals and patient-centered goals
Best practice clinical behavior includes ______ and _______
professionalism and unconditional positive regard
Adjusting the environment ensures that…
the patient is as comfortable as possible through privacy and basic comfort needs
Sequence of the interview
What is the first step in the sequence of the interview?
Greeting the patient by name and establishing rapport
Sequence of the Interview
What should be included in a greeting?
- your name
- possible handshake
- your role
- your status as a student
- how you will be involved in their care
Sequence of the interview
What should you do if there are visitors in the room during the greeting?
-acknowledge and greet the visitors
- let the patient decide if they should stay in the room or not
- ask the patient’s permisison before conducting the interview in front of visitors
Sequence of the interview
How should you establish the agenda?
(Discuss chief complaint or presenting problems)
-begin with open ended questions
-prompt if there was anything missed or unsaid
sequence of the interview
How to invite the patient’s story
-ask open ended questions
-follow the patient’s lead and don’t interrupt
-use continuers
sequence of the interview
Disease is the…
explanation that the clinician uses to organize symptoms that leads to a clinical diagnosis
Sequence of the interview
Illness is a…
construct that explains how the patient experiences the disease, including its effects on relationships, function, and sense of wellbeing
sequence of the interview
4 domains of exploring the patient’s perspective (FIFE)
F.I.F.E.
-Feelings about the problem
-Ideas about the nature and cause of the problem
-Function and the problem’s effect on patient’s life
-Expectations of the disease, clinician, healthcare
Sequence of the interview
These are examples of what?
“how did you feel about that?”
“Many people would also be frustrated by this, you are not alone”
identifying and responding to the patient’s emotional cues
Sequence of the interivew - mnemonic for emotional cues
NURSE
- NAME - that sounds like a scare experience
- UNDERSTAND - it’s understandable that you’d feel this way
- RESPECT - you’ve done better than most would with this
- SUPPORT - I will continue to work with you on this
- EXPLORE - how else were you feeling about this?
sequence of the interview - expanding/clarifying the story
OLD CARTS
- Onset
- Location
- Duration
- Character
- Aggravating/Alleviating Factors
- Radiation
- Timing
Sequence of the interview
7 attributes of a symptom
- location: where is it and does it radiate?
- quality: what is it like?
- severity: how bad is it?
- timing: when did it start and how long does it last or how often does it come?
- onset: setting and circumstances that may have contributed to the issue when it arose
- remitting/exacerbating factors: is there anything that makes it worse or better?
- associated manifestations: is there anything that happens with it?
sequence of the interview
generating and testing diagnostic hypotheses allows you to consider…
which disease or patterns might be present and lead to differential diagnosis
sequence of the interview
3 steps of shared decision making
- introduce and describe choices/options
- exploring patient preferences
- make a decision, checking that the patient is ready to make that decision
sequence of the interview
what is motivational interviewing?
a set of techniques that improve health outcomes and helps patients say why and how they might change, based on guided interviewing
motivational interviewing
3 points of the guiding style of motivational interview
- ask: open ended questions
- listen: to understand the patient’s experience
- inform: ask permission to provide info and ask about what the implications may be
sequence of the interview
how to close the interview/visit
let the patient know the visit is ending and allow time for any questions and understanding of a mutual plan
sequence of the interview
this is the last step of the interview
self reflection and mindfulness
Define cultural competence
a set of attitudes, skills, behaviors, and policies that enable organizations and staff to work effectively in cross-cultural situations
cultural humility
a process that requires humility as individuals continually engage in self-reflection and self- critique as lifelong learners and reflective practitioners
Define culture
a system of shared ideas, rules, and meanings that influence how we view the world, experience it emotionally, and behave in relation to other people
3 dimensions of cultural humility
- self awareness
- respectful communication
- collaborative partnerships
How to address
the silent patient
- allow silence as time for them to think
- reword or try more guided questioning
- ask if the patient has been made upset
- begin exploratory mental status exam if depression or dementia may be present
how to address
the confusing patient
- watch for an underlying issue related to the tangentiality
- guide the interview into a psychosocial assessment
- conduct mental status exam if you suspect mental illness or neurologic disorder
How to address
the patient with altered cognition
- seek the best information source
- obtain historical information from records, family, or caregivers
- do not break hipaa if seeking collateral from others
- determine decision making capacity
____ is a clinical designation and can be assessed by a clinician, whereas ____ is a legal designation and can only be decided by a court
capacity; competence
Elements of decision making capacity
the patient must have the ability to…
- understand relevant info about proposed tests or treament
- appreciate their situation
- use reason to make a decision
- communicate their choice
how to address
the talkative patient
- give free reign for the first 5-10 min
- focus on what seems important to the patient
- interrupt curteously for clarification and guidance of the interview
- prompt for another longer visit if needed
how to address
the crying patient
- offer a tissue
- make supportive remarks
how to address
the angry or disruptive patient
- acknowledge the situation
- accept angry feelings mindfully
- validate
- alert security staff and ensure a safe environment if needed
how to address
the patient with a language barrier
- work with an interpreter
- use bilingual written materials/questionnaires
guidelines for working with an interpreter
INTERPRET
- introductions: everyone is introduced and their roles
- note goals: what are the goals, the diagnosis, the treatment, the follow up
- transparency: let the patient know everything will be interpreted throughout the session
- ethics: only use qualified interpreters, not family
- respect beliefs: cultural beliefs must be taken into account and interpreter may be able to help with this as a cultural broker
- patient focus: patient should remain the focus and be spoken to directly
- retain control: remain in control of the interactions and conversation
- explain: use simple language and short sentences so info can be conveyed as best as possible
- thanks: thank the interpreter and patient and note need for interpreter in chart
how to address
the patient with low literacy or low health literacy
- ask about school or comfortability filling out a form
- do not confuse with lack of intelligence
how to address
the patient with hearing loss
- find preferred method of communication
- use ASL interpreter
- speak at normal volume and rate
- emphasize key points first
- write out instructions in closing
how to address
the patient with impaired vision
- shake hands as part of greeting
- orient patient to room as needed
- adjust light if needed
- spend more time on verbal explanations as gestures may be unseen
how to address
the patient with limited intelligence
- pay attention to school record and ability to function independently
- find out about sexual history
- transition to mental status exam as needed
- turn to family or caregivers as needed in respectful manner
how to address
the patient with personal problems
- ask about pros and cons rather than giving advice
- let patient talk through the problem
how to address
the seductive patient
- be aware of feelings and situation
- calmly and firmly set clear limits if needed
- leave room if needed
- find chaperone if needed
- examine your own behavior
Sensitive topics
When to ask about sexual history
- during the OBGYN section of past medical history
- in conversation about health maintenance
- in personal and social history when exploring lifestyle and relationships
- during the review of systems if it is a comprehensive history
- as part of expanding and clarifying the story if the chief complaint involves genitourinary symptoms
sensitive topics
What language to use when talking about sexual history
specific and clear language, like penis or vagina
sensitive topics
How to ask about mental health history
- take into account culture
- ask about issues with emotions or mental illnesses
- ask about past treatment
sensitive topics
How to address substance use
- general questions asking about use of alcohol
- historical or current use of illegal drugs or prescription meds
- CAGE questionnaire
cutting down, annoyance when criticized, guilty feelings, eye openers
sensitive topics
Intimate partner violence and domestic violence
- can begin by normalizing statements like “because this is common in many peoples lives”
- use probing questions then direct questions like “are you in a situation where you have been hit or threatened?”
- continue asking and be empathic when validating after disclosure in a nonjudgemental way
sensitive topics
death and dying patients
- allow space to talk about feelings
- clarify patient’s wishes about treatment and end of life
- encourage establishing a health proxy
- explore religious or spiritual beliefs and needs
ethics
nonmaleficence in the interview
giving only relevant and correct information and ensuring open barriers to communication
ethics
beneficence in the interview
the clinician acts in the best interest of the patient
ethics
autonomy in the interview
informed patients have the right to make their own clinical decisions
ethics
confidentiality in the interview
privacy is fundamental
ethics
The Tavistock Principles
(really big cool cats in some oasis)
- rights - right to health and healthcare
- balance - patient centered with concern for population
- comprehensiveness - treating illness as well as suffering and quality of life
- cooperation - cooperation with those we serve and others in each sector
- improvement - serious and continuing responsibility to improve health care
- safety - do no harm
- openness - being open honest and trustworthy
(really big cool cats in some oasis)
