Unit 1.2: Advanced interview

Question 1

Describe active listening

Answer 1

-This takes active practice
-Listen to the patient and summarize what you hear
-If you’re clever, you can incorporate this into a review of your HPI at the end of the interview

Question 2

Describe empathetic responses

Answer 2

-Demonstrate the capacity to identify with them
-This does not mean you should give a glib, mechanical response
-Ex. “Your call is very important to us”
-This involves first listening, then opening yourself up to what they are going through, finally, allowing your own emotion to show in response
-For a response to be empathic, it must convey that you feel what they feel

Question 3

Guided questioning tips

Answer 3

1) Maintain their flow of ideas, but guide it toward what you need to know
2) Always start with open ended questions  then focus them
3) Elicit a graded response
4) Be careful about asking too many questions at once
5) Try offering multiple choice
6) Clarify
7) Encourage
8) Echo

Question 4

What are 6 important elements of nonverbal communication?

Answer 4

1) Watch their eye contact
-Avoidant or consistent
2) Expression
-Pained, flat, neutral
3) Posture
-engaged, distracted
4) Head position
-Nodding, or avoidant
5) Arms
-Fidgeting, open/closed, gesticulating
6) Be aware that some of this is entirely cultural
-Eye contact
-Expression
-Extremities

Question 5

Describe validation

Answer 5

-Legitimize their experience
-This does not always mean you agree
-But think, their behavior makes sense to them – if it didn’t, they wouldn’t act that way

Question 6

Describe reassurance

Answer 6

-You got this
-But again, don’t be glib – everything may not always “be alright”
-This won’t surprise you, but listen first; if you don’t have their buy in that you heard them, they will not believe that you are equipped to deal with their problem
-“If we find something, we’ll deal with it”

Question 7

What is partnering?

Answer 7

Expressing your commitment to them; you’re working together now

Question 8

What is summarization?

Answer 8

Do a recap of your HPI!
This is for you and them

Question 9

Give examples of transitions

Answer 9

-I’m gonna ask you about your past medical history
-I’m going to ask you about some sensitive info, this is only for your record
-I’m going to ask you a TON of questions now about your symptoms
*Let them know what will happen next

Question 10

Why should you empower your patient?
Describe how you can empower your patient

Answer 10

-You will be used to being in the clinic, hospital, ER; they won’t
-You might be seeing them on their worst day, or at least not a day that ranks high on the list
-Give them back some comfort and dignity by encouraging questions, not being defensive, and allowing them to make informed choices in their care

Question 11

Give examples of giving patients back some comfort and dignity by encouraging questions, not being defensive, and allowing them to make informed choices in their care

Answer 11

1) Ask their perspective
2) Convey interest in the person not just the symptom (back to empathy again)
3) Share information
4) Let them know about your clinical reasoning as much as you can
5) Don’t pretend to know more than you do

Question 12

What are the 10 fundamentals of skilled interviewing?

Answer 12

1) Active listening
2) Empathetic responses
3) Guided questioning
4) Reading nonverbal communication
5) Validation
6) Reassurance
7) Partnering
8) Summarization
9) Transitions
10) Empower the patient

Question 13

How should you prepare before a pt interview?

Answer 13

-Review the clinical record first. This is helpful in every setting. Review your goals for the interview, adjust the environment if needed –Set the tone, if only in your mind. (Check your appearance)
-Look at the vitals if you have them

Question 14

What is the sequence of a patient interview? (7 steps)

Answer 14

1) Greeting and rapport
2) Agenda
3) Invite their story
4) Get a sense of the person
5) Revise and encourage their story, refine your understanding
6) Tests
7) Closing and reflection

Question 15

What does considering cultural context mean?

Answer 15

Demonstrate cultural humility, to be defined

Question 16

Why should you interview the patient’s chart before their interview?

Answer 16

-Before you step in the room, it will aid you immeasurably to already know their age, gender, problem list, meds, allergies; why would you want to start entirely from scratch???
-But when you speak, keep in mind it may not all be correct! You may find “chart lore”; things that have been carried through their medical chart but aren’t actually accurate

Question 17

What goals should you set during interview preparation?

Answer 17

-Are you doing a comprehensive interview?
-Are you focused? If so, on what?
-Are you going to need to rush? Or do you have time?
Just a quick reflection on this will make you more effective.

Question 18

Describe how you should review your behavior and appearance before a pt interview

Answer 18

-Reviewing behavior and appearance
-Be intentional about your demeanor
-Calm, sitting, focused, empathetic
This is about you as well. . .
-What will you think when you enter the room
-What now?! Or a meditation on your oath

Question 19

How should you adjust the environment before a pt interview?

Answer 19

1) Keep it confidential (as much as possible)
2) Put them at ease
3) If you can’t do anything to make it better, at least address it

Question 20

Describe how you should greet a patient at the beginning of a patient interview

Answer 20

-Identify yourself and your medical role
-Introduce yourself to any family or accompanying people first since you’re going to be spending all your attention on the pt from here out
-If there are visitors, address confidentiality
“I’m ok if they stay; are you comfortable with others being present during your interview?”
-“Is it all right if I fill them in on what’s going on?”
-Use the patient’s name if you know it. People love the sound of their own name; this practice quickly builds rapport.
It also ensures that you are with the right patient!

Question 21

What does establishing an agenda in a patient interview mean?

Answer 21

Get the CC, or if you already know it, address it

Question 22

What does establishing a story in a patient interview mean?

Answer 22

-Start with open ended questions
-NO YES OR NO’S AT FIRST
-“Tell me the whole story”

Question 23

What does expanding the story in a patient interview mean?

Answer 23

-Begin to narrow it down
-But try to follow patient’s leads
-Use finesse, being more demanding or gentle based on the patient’s demeanor

Question 24

How should you explore a patient’s perspective? What is the mnemonic to remember this?

Answer 24

The illness as portrayed by “FIFE”
1) Feelings
How they feel about it
2) Ideas
What they think caused it
3) Function
The effect on their life
4) Expectations
What they think will happen next

Question 25

Name 2 emotional clues to the patient’s perspective on illness?

Answer 25

1) Direct statements
-If they openly report to you their feelings, do not blow past it and grind through your HPI! Acknowledge it!
-We are always worried about time. You will be surprised as how quickly you can do this!
2) Expressions of feelings, which may not be directly correlated to the illness
-So instead of saying, “I’m worried this might be cancer.” “I’m worried.”

Question 26

List 3 more emotional clues to the patient’s perspective on illness?

Answer 26

1) Attempt to explain or understand symptoms
-Resist the temptation to shut down superfluous information. It might not be clinically relevant to you but it matters to them. If it didn’t, they wouldn’t be telling you.
2) Speech clues
-The long pause. . .
-Repetition (this can be hard on providers)
-Emotional vocal changes
3) Sharing personal story
-Some patients will wrap their illness in a bunch of narrative. See if you can teach yourself to work with this.

Question 27

1) What clues should you look for?
2) What might make it harder to earn a patient’s trust?
3) How can you resonate with the type of person the pt is?

Answer 27

1) Behavioral clues indicative of unidentified concerns, dissatisfaction, unmet needs such as reluctance to accept recommendations, seeking a second opinion, early return appointment
2) Some patients will have a high level of anxiety at baseline, and you will have to work harder to earn their trust.
3) It may require a little bit of acting, but think about it, you wouldn’t communicate with a middle-aged farmer, a college sophomore, and a homeless schizophrenic the same way

Question 28

What should your response be to the patient’s emotional cues?

Answer 28

-Will we practice “patient centered care” or “provider centered care”?
-As so much of this lecture indicates, the soul of medical practice emerges when you shift your focus from your self to the other

Question 29

What is the mnemonic to remember how to respond to emotional cues from a patient? What does each part stand for?

Answer 29

“NURSE”
1) Name the experience
2) Understand of legitimize
3) Respect the response
4) Support, by stating your commitment to help
5) Explore, see if they have other thoughts about it

Question 30

Describe how to Expand and clarify the patient’s story

Answer 30

Ask for onset, location, duration, character, aggravating/alleviating factors, radiation, timing

Question 31

Describe how shared decision making should be done

Answer 31

-When and when not to
-Introduce choices and options
-Explore patient preferences
-Move to decision

Question 32

1) Define motivational interviewing
2) What does it do?
3) Give an example

Answer 32

-The path toward behavioral change
-Defines “why and how they might change”
-This type of interviewing gets the patient to discuss their motivation for change through questioning; it’s the opposite of a lecture
-Ex: On a scale of 1-5 how interested are you in quitting smoking?
-If 3, ask “Kind of middle of the road. I’m curious, why not lower?”
-Pt will then wind up expanding on the part of them that does want to quit

Question 33

How should you close a pt interview?

Answer 33

-Let them know it’s coming, esp. if there are time constraints
-Even if all goes well, they may still have many questions
“Teach back”
-If there are directions or counseling points they need to know, have them teach these to you. Or give them a quiz!

Question 34

Describe reflection post-pt interview

Answer 34

Take a minute to digest everything; can happen during charting

Question 35

1) Define cultural competence
2) What does it involve?
3) What is the critique of this?

Answer 35

1) The ability to work with others across cultural differences
2) Involves developing a baseline of understanding of separate cultures, employing this acumen into the delivery of effective healthcare
3) Critique of this lies in the perceived danger for stagnation of beliefs, rifts between cultures, and unintentional solidification of stereotypes

Question 36

1) What does cultural humility mean?
2) What could help you in these?
3) What happens during this process?

Answer 36

1) Means that you are able to “see things their way”; does not mean you have studied every culture
2) Knowing a few specifics in your patient population won’t hurt; compare these points to your own culture and look for resonance and dissonance
3) Practitioners question their own beliefs and open themselves to others in the process

Question 37

What are the 3 dimensions of cultural humility?

Answer 37

1) Self-awareness > consider your own biases
Center of the universe
2) Respectful communication > work to eliminate assumptions about normalcy, and be open to learning about your patient’s perspective
Let your patient be the expert on their worldview
It may be different
-Ex: Is there such a thing as psychiatric illness in the culture your patient is from?
3) Collaborative partnerships > build your patient relationships upon mutual respect and develop a plan from there
We practice evidence-based medicine
But this does no good if the patient does not care one whit about your treatment plan

Question 38

What should you do if you have a silent patient?

Answer 38

-Don’t fill every void, watch and listen
-One interview tactic is to allow pauses to happen.
-Sometimes the patient will fill the space and give key information
-Watch for body cues here is there an emotional undercurrent to why they are quiet that you need to explore?
-Sometimes it’s simply the way questions are put. Change things up.

Question 39

Why might a patient be confusing during an interview?

Answer 39

-Sometimes they just have a lot going on and you have to deal
-Sometimes they are anxious and endorse every symptom you inquire about
-Narrow it down
-Sometimes there is a psych component you need to explore
-Sometimes there is an organic process that is impairing their functioning – get on it

Question 40

How should you interview a pt if they’re altered (i.e. impaired)

Answer 40

-If they can’t respond at all, you need to look for another source
-Pick the person who seems best informed by demeanor or connection
-Establish whether the patient has “capacity” (a medical term) to make decisions for themselves
-If not, look for POA
-If none, then look to souse or close family member
-If none, then provider may need to intervene

Question 41

What capacity must a patient have in order to make decisions for themselves?

Answer 41

1) Must understand relevant information about tests and procedures
2) Must appreciate their situation
3) Must use reason to make decisions
4) Must communicate their choice

Question 42

What should you do if a patient is too talkative during an interview?

Answer 42

-Focus on what’s most important to the patient, gently frame the conversation in this way
-“With all this going on, how is your heart, sleep, liver, big toe. . .”
-Don’t show impatience

Question 43

What should you do if a patient is crying during an interview?

Answer 43

-Can be therapeutic
-Try not to get them to cease, though this may be your impulse

Question 44

What should you do if a patient is angry during an interview?

Answer 44

1) If it’s something you did, acknowledge it, apologize if you need to, and move on
2) AVOID substantiating criticism of other clinicians
3) Show understanding of their problem, mirror concern, deescalate
4) Stay safe!

Question 45

What should you do if a patient has a language barrier?

Answer 45

1) ALLOW FOR MORE TIME!
2) Get an interpreter, obviously; then ALLOW FOR EVEN MORE TIME!
3) Not all interpreters are created equally. Make your questions succinct.
4) Be on the lookout for cultural barriers
-Do they communicate in a fundamentally different way?
-Do they give “clues” rather than direct answers?
-Ex. “I ate something light.” “Something sweet”

Question 46

What should you do during an interview if a patient has low literacy/ vocabulary?

Answer 46

1) You can ask about their education, but be careful not to display judgment
2) You will need to “translate” into layman’s terms

Question 47

What should you do during the interview if a patient has hearing loss?

Answer 47

1) You may have interpreter
2) You may need to write things down
3) You may need to speak loudly and truncate your discourse
4) Be careful when you’re shouting, it can make you (sound) angry

Question 48

What should you do during the interview if a patient is talking about personal problems?

Answer 48

1) If asked about something outside of your scope, refrain
2) Ask them how they are thinking through it, let them think

Question 49

What should you do during the interview if a patient is seductive?

Answer 49

1) If patient makes sexual advance toward you, you may be tempted to ignore it, but you need to calmly and firmly set limits
2) If attracted to a patient, acknowledge it privately, but move on

Question 50

What are some topics that are sensitive for patients?

Answer 50

Alcohol, sex, death and dying, money, racial bias, domestic violence, psychiatric illness, physical deformity, bowel function, sexual preference, gender identity.

Question 51

What are 6 things you should do when talking about sensitive topics with patients?

Answer 51

1) Be Nonjudgmental
2) Meet patients where they are at!
3) Explain why you need to discuss the information
Preferably, you will be able to gear this toward patient care in a tangible way
4) Avoid the wrong assumptions
-Elderly, trans men, adolescents, and married couples
5) Find an opening that you like to use, that you can be genuine while saying
6) Acknowledge our discomfort, privately.
-Denying it can make it worse.

Question 52

What are the two types of sexual history interviews? Describe what each does

Answer 52

1) Comprehensive interview:
-Can alert you to risky behavior for STI, abuse, unwanted pregnancy
-Do not omit sexual history from older patients, patients with disability, or pts with chronic illness.
2) Acute history:
-May directly pertain to making the diagnosis
-If it’s a part of their CC, you may be able to guide patient interview to this initially

Question 53

Give some examples of sexual history questions

Answer 53

“Are you sexually active?”

“When was the last time you had intercourse? “

“How many partners in the past 3 months? 5 years? Lifetime?”

“Do you prefer men, women, or both?”

“Do you use condoms? Every time? “

“Do you have concern about HIV or AIDS?”

Question 54

What are two things you shouldn’t do during a sexual health interview?

Answer 54

-Do not use euphemisms.
-Refer to genitalia by its name. Ex: Don’t say “private parts”
-Do not make assumptions

Question 55

What are some examples of mental health history questions?

Answer 55

-“Do you have problems with emotional or mental illnesses?”
-“Have you ever been treated by a counselor or therapist?”
-“Have you taken medicine for this? DO you take medicine for this?”
-“Have you ever been hospitalized for an emotional or mental health problem?”

Question 56

What should mental health interviews touch on? Give examples of questions that should be asked

Answer 56

1) Depression is so prevalent; it is worth having some decent screening questions
-Validated questions
“Over the past two weeks, have you felt down, depressed, or hopeless?”
“Over the past two weeks, have you felt little interest or pleasure in doing things?”

Question 57

What should you ask about alcohol, drugs, and tobacco

Answer 57

1) “I’m a social drinker” should be followed by some type of attempt to quantify consumption. . .
Find out how many drinks per week.
-One drink = 12 oz beer, 5 oz wine, 1.5 oz liquor
2) Ask about illicit drug use
3) Inquire about DOC, and don’t assume that’s all – if you display nonjudgmental disposition, patients will often be forthcoming with this information
4) Ask about abuse of prescription drugs
-Risks of prescription drug use:
-Taking them more often than prescribed
-Taking them in higher quantities than prescribed
-Taking them for the desired side-effect

Question 58

What should you ask about partner violence?

Answer 58

1) Ask “Do you feel safe in your home?”
-Partner violence is very common. . .
2) It would be calloused, then, to ignore this part of your history
-You might even begin with a normalizing statement
-“Because abuse is so common, I’ve started asking about it routinely”
-“Have you been attacked or threatened?”

Question 59

What are some clues to physical and sexual abuse (11)?

Answer 59

1) Unexplained injuries or inconsistent story
2) Delay in getting treatment
3) History of repeated injuries or “accidents”
4) Presence of ETOH or drug abuse in pt. or partner
5) Partner tries to dominate the visit
6) Pregnancy at young age; multiple partners
7) Repeated vaginal infections and STIs
8) Difficulty walking/sitting due to genital/anal pain
9) Vaginal lacerations or bruises
10) Fear of pelvic examination or physical contact
11) Fear of leaving exam room

Question 60

What is important to consider when talking to patients about death? What will you need to do and guide them through if they’re dying?

Answer 60

-You need to find ways to talk to patients and families about death.
-You will need to guide them to making decisions about treatment in a way that is tactful
-“Some families say we want everything done’ some say we don’t want him/her to go through all that”
-“None of these questions are easy, but none of the answers are wrong”