Introduction to Clinical Interviewing Flashcards
______ is established during the clinical interview, as are mutual expectations.
_________ factors are often more important to patients than technical expertise
Doctors must learn to be _________ & take care not to use their patients, consciously or unconsciously, to gratify their own needs
rapport
interpersonal factors
self-observant
What is the Biopsychosocial Model?
- George Engel (1977)
- More integrated way of looking at patients, diseases, symptoms & behaviors
- Widely accepted but increasing distant from real world medicine
Definitions
- Biological System
- Psychological System
- Social System
- Biological system – patient’s anatomical & molecular substrates of disease
- Psychological system – patient’s psychodynamic factors, motivations & personality in relation to their illness
- Social system – includes environmental, cultural & familial influences on the patient’s experience & expression of illness
________ is increasingly becoming accepted as part of the BPS model.
Spirituality
What are the 4 models of Doctor-Patient Interaction?
Which one is the most ideal?
-
Paternalistic
- “Autocratic”, “doctor-knows-best”
- Can be desirable (ex: emergencies)
- Preferred by many doctors & some patients
-
Informative
- Doctor dispenses accurate information, but choices are left to patient
- Preferred by many patients, but often difficult for doctors
-
Interpretative
- Doctor knows patient & his/her situation & values well
- Seeks to share decision-making responsibilities
- Often ideal, but requires more time & intimate knowledge of the patient
-
Deliberative
- Doctor acts as an ally who actively advocates a particular course of action (ex: weight loss, smoking cessation)
What is Transference?
- Unconscious process
- Patient attributes to the doctor aspects of important past relationships
- Especially early/parental relationships
- Patients may unconsciously transfer residual feelings from early relationships (usually w/ parental/authority figures) to doctors
- Unexpected, exaggerated, often disruptive rxns
- Transference can be **positive, negative or both/unstable **
What is Countertransference?
Doctor attributes to the patient aspects of important past relationships
What are the 3 basic functions of effective interviewing?
- Determining the nature of the problem
- Developing & maintaining a therapeutic relationship
- Communicating information & implementing a treatment plan
What are the additional goals of psychiatric interviews?
- Recognizing the psychological determinants of the patient’s rxns & behaviors
- Symptom classification leading to diagnosis
What are the 6 strategies of establishing rapport?
- Putting patient & interviewer at ease
- Finding patient’s pain & expressing concern
- Evaluating patient’s insight & becoming an ally
- Showing expertise
- Establishing authority or a physician or therapist
- Balancing the roles of empathic listening, expert & authority
Some basic tips for beginning an interview
- Know the patient’s name
- Introduce yourself & your role
- Tell the patient what you will do & why
- Provide the opportunity to have others present or speak in private
- Use desk/table for notes
- Set up the interview accordingly if you feel at risk
- Don’t talk down to your patients
What is the difference between an interview content vs. process?
- Content – literally what is said
-
Process – what is happening non-verbally
- Unspoken or unconscious feelings & rxns
- Process is very important in interviews where emotional factors are prominent
- Psychiatric illnesses
- Serious, painful, stigmatizing or debilitating diseases
What are some effective interview techniques? (17)
- good rapport
- open-ended questions early on
- closed-ended questions later on
- facilitation
- reflection
- clarification
- silence
- interpretation
- confrontation
- summation
- explanation
- transition
- positive reinforcement
- self-revelation
- reassurance
- advice
- ending the interview
Open-ended vs. Closed-ended Questions
Definitions
When to use & why
“Open-ended” questions are often helpful in building rapport
- Use open-ended questions FIRST
- Use closed-ended questions later on to establish diagnosis
-
Open-ended questions
- Invite patients to talk about whatever they feel is important (elaborate)
- Less time-efficient & less precise
- More effective at getting to the “real” problem when the presenting complaint can’t be taken at face value
-
Closed-ended questions
- Encourage patients to respond to what is asked & no more
Refers to various means of verbal & non-verbal communication that encourage the patient to continue telling his/her story
Facilitation
The supportive re-stating of what the patient has just told the doctor, though often in different, more succinct language
Reflection
Questioning that clarifies or encapsulates what the patient has just said, or that seeks additional related information
Clarification
When is redirection used?
- Used w/ patients who…
- Have disorganized or tangential thinking
- Talk excessively in an unhelpful way
- Initial attempts should be polite, but clear
- With rambling, psychotic patients, redirection may have to be quite blunt & frequent
So long as a posture of focused interest is maintained by the doctor, a long, often uncomfortable ______ gives patients “permission” to continue talking about the painful subject that precipitated the ______.
silence
Involves extrapolating another meaning from what the patient has said
Interpretation
When is confrontation used?
- Used to help the patient face something important that he or she is missing, ignoring or denying
- Must be done w/ skill & subtlety so as not to make the patient angry & defensive
- Sometimes necessary w/ non-compliant or substance-abusing patients
The doctor’s summary of what he or she understands the patient to have said
Summation
Explanation
When should it be done?
How should it be done?
- Essential once the doctor has arrived at a decision about treatment
- 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, & risks/benefits of different treatment options vs. no treatment
- Use layman’s terms for everything
Technique of smoothly moving from one topic to another once adequate information has been obtained
Transition
Lets the patient know that he or she can tell the doctor anything, no matter how painful or embarrassing
**Positive Reinforcement **
What should a doctor do with regards to 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, & should be tactfully turned back to the patient using transitional language
- REMEMBER: the patient is your patient, not your friend or confidante
Can increase patient trust & compliance, but must be truthful
Reassurance
When should advice be given?
- Should be given when needed, but timing & manner are important
- Patients should be given a chance to fully express their symptoms & concerns before advice is given
How should a doctor end 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
- Patient should be invited to ask any unanswered questions
- Patient should be thanked for coming in & for helping the doctor to understand the problems he/she has been having
