Patient Centered Interviewing Flashcards
Apart from being knowledgeable, what else makes a good clinician?
- Good communicators
- Empathetic and makes patient feel cared for
- Great bedside manner
- Collaborative
What are the 3 core skills for medical encounters?
- Build and maintain an effective patient-clinician relationship
- Assess and understand the patient’s problem
- Collaborative management
Why is professionalism important?
• You have 7 seconds to make a good impression
* Dress code matters * Patients prefer clinicians who are dressed in formal attire and white coats→ associated with trustworthiness, being knowledgeable, caring and approachable * Impressions depended on type of physician:
* Surgery and emergency rooms→scrubs with white coats
* Primary care and hospital physician→formal attire with white coat
What are the types of communication skills used by Clinicians?
Open-Ended Skills
- Non-focusing
a. Silence
b. Nonverbal communication
c. Neutral utterances and continuers - Focusing
a. Reflection (Echoing)
b. Open-ended questions
c. Summarizing
—>
Emotion Seeking
- Direct
- Indirect
a. Impact on life, others
b. Belief about problem
—>
Empathy
a. Naming
b. Understanding
c. Respecting
d. Supporting
Describe the Open-Ended skills
- Non-focusing
a. Silence
b. Nonverbal communication
c. Neutral utterances and continuers - Focusing
a. Reflection (Echoing)
b. Open-ended questions
c. Summarizing
What are the Non-focusing Open-Ended Skills?
- Silence: The physician says nothing which prompts the Pt to fill the gap with information that might be on their mind
- Nonverbal communication: use of body language and facial expressions to encourage the Pt to speak freely and to show that the physician is listening
• Examples: eye contact, leaning forward, nodding
Use behaviors to show you are listening and interested
- Neutral utterances & continuers: there are non-committal statements that encourage the Pt to continue speaking without the physician directing the conversation
• Examples: “uh huh”, “go on”, “uhmmm”
What examples of listening behaviors should be maintained?
DO:
• Maintain eye contact
• Use body postures that show interest→lean forward, open body position, etc.
- DO NOT:
- Slouch, cross your legs/hands, tap your legs (or any other nervous signs)
- Hide behind a desk
- Drink coffee while talking
- Read or write in the chart while trying to listen
What are the focusing open-ending skills?
- Reflection (Echoing): When the physician repeats a word or phrase that was said by the Pt, it lets the Pt know that they are being heard. It encourages them to continue speaking.
- Open-ended questions/statements: this focuses the Pt on already mentioned information that the physician wants expanded. This allows for a more detailed discussion on a topic.
- Summarizing or Paraphrasing – the physician recaps information collected from the Pt especially after a long discussion. This ensures that the information collected is accurate and allows for clarification.
What are the Close-Ended skills?
• These skills limit the response from the Patient
• They are used to confirm or refute specific information or redirect a Patient who is
longwinded
• These types of questions should be used sparingly
What are the types of emotion seeking skills?
Direct:
• Most times this is a follow-up from a non-verbal cue from the Pt.
• The physician asks the Pt a suitable variation of the open-ended question,
“how did that make you feel?”
• Avoid any form of judgement→“You must be so excited about being pregnant!”
Indirect:
• Sometimes a Pt might not respond to a direct inquiry about their emotion.
• Find indirect ways to explore emotions and feelings without directly
acknowledging it
a) What does the Pt think is the cause of the problem
b) How has it impacted their life, family, friends
c) Why did they come to the physician now
d) What are their expectations
What are the empathy skills?
- Many persons believe that empathy is an inborn trait that cannot be taught.
- However, research shows that medical students who are not taught empathic communication will become clinicians who show little empathic abilities and decreased levels of empathy for their patients over time.
- After the patient has expressed an emotion (verbal or non-verbal), the clinician should express empathy to show that the patient is understood and cared for.
- Empathy = feeling with or alongside someone vs Sympathy = feeling sorry for someone
How can empathy be used as a tool to promote partnership between clinician and patient?
Patient: • Increases patient satisfaction • Builds trust • Improves treatment compliance and coping skills • Decreases anxiety
Medical student:
• Reduces burnout (higher levels of empathy correlated with lower levels of burnout)
Clinician:
• Enriches the clinician-patient relationship
• Reduces malpractice complaints
What is the significance of NURS in empathy skills?
Naming – repeat the expressed emotion to show that you have heard the Pt
Understanding – deepen your understanding of the emotion by asking exploring questions. Acknowledge that the Pt’s emotion is understood
Respecting/Praising/Acknowledging – show appreciation, acknowledge how difficult things have been for the Pt. Praise their efforts.
Supporting – indicate to the Pt that you are prepared to work together as a team to find a solution to their problem.
What is the format of a clinical encounter ?
- Greeting and Introduction
- Setting the agenda
- History taking
- Physical examination
- Assessment
- Plan
How should physicians conduct greetings and introduction?
a) Knock before entering:
• This is the first trust building step, and it shows respect
• Knock x3, wait 3 seconds then enter the room→enter after 3 seconds even if no response
b) Introduction:
• This sets the tone for the interview
• Use your “title + first + last name + role” OR “title + last name + role”
• Always maintain eye contact
• If you wish, offer a handshake→relaxes patient
• May not always be appropriate
C) Confirm the Pt’s name and how they would like to be addressed
D) remove barriers to communication
• Sit to the right of the Pt at a 45-degree angle approximately 2-3 feet away
• Eye contact
• Ensure Pt readiness, comfort and privacy
• Give Pt an idea of what to expect for the session
How is the agenda set?
Let the Pt know what to expect for the session:
• Example: “Today I would like to ask you a few question and then do a physical examination.”
Obtain consent before proceeding:
• Example: “Will that be okay with you?”
How should history taking be done?
Chief complaint:
Part 3: History Taking
a)
• Use an open-ended question such as: “How can I help you today?”
• Allow the Pt to make a list of their complaint/s→symptoms (manifestations
of illness as reported by the patient)
- Use continuers such as: “Is there anything else?”
- Keep asking until there are no more concerns
- Then summarize what will be discussed:
- Example: “So, today we will discuss X, Y and Z.”
History of presenting:
b)
• This is where the physician gets the narrative about the chief complaints.
• It is patient centred:
• Use focused open-ended questions and non-focusing skills
• Allow the Pt to speak freely
• Respond to emotions from the Pt
• It is physician centred:
• If the Pt has missed any information or the physician wants to clarify any
information→use close-ended questions
• Summarize
C) Other personal Pt details:
• Past medical history→previous illnesses, hospitalization, medications, allergies, immunization
• Family history→any illnesses in the family (age of diagnosis)
• Sexual history→if relevant to the chief complaint
• Obstetric/Gynaecological history→if relevant to the chief complaint
• Social history→substance use (alcohol, tobacco, illicit drugs), exercise, diet, occupation, stress level, home life
D) Review of systems:
• A head-to-toe list of close-ended questions from every body system to ensure that the Pt has not missed any symptom.
How do we transition from history to physical examination?
- Example of a transition statement: “Thank you for answering all of these questions. I would like to now do a full examination of you.”
- Explain the purpose of the examination and technique using non-medical terminology.
- Obtain consent before proceeding.
- Remember to sanitize your hands again
What should be kept in mind in physical examination?
- Signs→manifestation of illness as observed by the physician
- Begin with an examination of the Pt’s general appearance
- Vital signs: heart rate, respiratory rate, blood pressure, temperature • Head, eyes, ears, nose and throat (HEENT)
- Chest: heart and lung sounds
- Abdominalexamination
- Neurologicalexamination
- Upper and lower extremities
How do we transition FA history & physical examination to closure of the encounter?
Transition from the History & Physical Examination to the Closure of the Encounter
• Summarize pertinent findings from history and physical examination
• Determine how much the Pt knows and how much they would like to know about the possible diagnosis
If the patient comes with chest pain, what should the clinician be thinking about?
- Acute coronary syndrome
- Acute panic attack
- GERD
Describe the SOAP notes format of taking notes
a) Chief complaint (CC)
b) History • History of presenting illness (HPI) • Past medical history (PMH) • Medications • Allergies • Family history (FH) • Social history (SH) • Review of system (ROS) Subjective Objective Assessment Plan
Objective:
a) Physical examination
• Vital signs: blood pressure (BP), heart rate (P), respiratory rate (R), temperature (T)
• General examination (GA)
• Focused physical examination→the specific system relevant to the
complaint
b) Previous investigations
Assessment:
a) A list of three possible differential diagnoses beginning with the most likely to the least likely
b) Give findings from the history & physical examination that supports each differential diagnosis
- Plan:
a) New and pertinent investigations→be specifi
What language should be used when writing notes?
Rememberwhilewritingyournotesandspeakingwithyourpatient,to always use people-first language.
• People-first language: emphasizes the person, not the disorder
What are the stages of the Change Model?
Aspartofyourplan,theremightbelifestylemodificationsrequiredby the patient.
• Before a person decides to change a behavior, there are several stages that they typically go through:
❑ Stage 1 Pre-contemplative ❑ Stage 2 Contemplative
❑ Stage 3 Preparation
❑ Stage 4 Action
❑ Stage 5 Maintenance
Describe the Pre complative stage
- The person is NOT considering change at this point
- Does not see any problem with behavior
- Tried and failed repeatedly and has given up
Your role as a health care provider:
- Listen with empathy and curiosity
• Educate by increasing awareness of health risks and benefits of quitting
• Raise doubt
What are the complative stage features?
• The person is considering change but is ambivalent (weighing the pros and the cons)
• Your role as a health care provider:
• Emphasize the health risks and benefits of change in relation to the person’s
medical, psychological and social status
• Help strengthen the person’s sense of self-efficacy i.e. the belief that they can do it
• Focus on past “successes” even if short • Indecisiveness is norma
