Subject: Physical Diagnosis Topic: Interview and Communication Skills I: Interview Techniques Lecturer: Dr.

Katigbak Date of Lecture: 06/14/2011 Transcriptionist: Naypi Pages: 5

Patient Centered Medical Interview y General objectives: o Accuracy: would like to get correct diagnosis and treatment plan o Efficiency: as doctors we have limited time and correct time management. o Supportiveness: Also have to communicate sense of supportive, caring doctor to the patients. Specific objectives: o Determine nature of disease and explore illness experience Understand the whole person o Find common ground regarding management o Incorporate prevention and health promotion o Develop and maintain therapeutic relationship o Be realistic

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Remove any physical barriers between you and the patient. Take note of lighting i.e. Don t let bright light shine on patient s face like in police interrogations. Give patient your undivided attention. Try not to look down to take notes or read the chart but look at the patient. Small talk can also put patient at ease at the start of the interview.

Starting the Medical Interview A. 6 Strategies to establish rapport 1. Put patient at ease and address discomfort If timid, shy, anxious, scared, y Observe: y no eye contact y stooped y sit far y quivering y crying y does not say much Do: y Allow companion y smile y calm voice y pat back y use patient s words y encourage y show understanding concern y give reassurance y acceptance

Phases of the Medical Interview 1. Starting the interview: y establishing rapport y identify reason for consult 2. Interview proper: y Assessment, gather information, ranking, transitions y Build relationship, explain, and plan 3. Conclusion of interview: thank the patient and allow the patient to ask questions. Preparing for the Interview y Arrange setting: quiet, private y Comfortable, lighted y Protect your time: no interruptions y Paper tools: outline, take notes. However, make sure to make eye contact with patient otherwise, they may not think you are paying attention to them. *** GENERAL GUIDE TO PUT PATIENT AT EASE: y Arrange the room in such a way that the distance between you and the patient is comfortable for both. y Choose distance that facilitates conversation and good eye contact. y Sit at eye level with the patient. y

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*** Give patient your undivided attention. Try not to look down to take notes or read the chart but look at the patient. Small talk can also put patient at ease at the start of the interview. If intrusive, a. Observe: y expose to breath y spit, y talkative y touch you and things

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y turns on radio y rearrange furniture y feet on desk y tense y erect y chin up b. Do: y move back y tell patient to stop y redirect firmly y set limits and boundaries y raise your voice y assert authority y remain professional y show expertise 2. Find the pain and show compassion y Facts: S/S of chief complaint express distress in words y Emotions: patient s feelings and reactions to signs and symptoms. o Doctor should show interest. o Respond with true empathy and concern 3. Gain trust and become an ally y Levels of insight y Split off sick vs. participative role in treatment y Set treatment goals discuss with patient, secret 6 levels of insight y Complete denial y Aware but deny y Aware blame external factor y Aware unknown y Aware own contribution (-)change y Aware own contribution (+)behavior change 4. Show expertise y Put illness in perspective Disease vs. illness y Show knowledge y Deal with distrust 5. Establish authority and Take Control y Take responsibility for patient s welfare 6. Balance all roles y Doctor: empathic listener, expert, authority y Patient: carrier of illness, sufferer, VIP **Role interaction: Doctor- Patient Relationship

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Identify reason for consult a. Greet patient y Introduce self y Define your role as a doctor b. Establish agenda y Get informed consent y Clarify expectations c. Invite patient s story y Explore chief complaint y Why is patient here now? ***The initial moments of your encounter with the patient lays the foundation for your on-going relationship. Greet the patient by name and introduce yourself by giving your name. ***If first contact, explain your role, including your status as a student and how you will be involved in patient s care. E.g. I m Kathy Munoz, 2nd yr medical student. I am here to interview you about your medical problem and also part of the medical team to take care of you. *** If there are other visitors/ relatives in the room, greet them as well. Ask patient s permission before conducting the interview *** Patient has specific questions and concerns that he wants answered by this consultation i.e. Probably re his symptoms and illness, while the Dr also has specific goals that he wants to accomplish by the end of the interview such as arriving at a dx and proper treatment plan addressing patient s illness/ problems. Thus the need to know what prompted patient to seek medical consult at this specific time. *** Begin with open ended questions that allow patient to respond more freely. E.g. What made you come to see the doctor today? or How can I help you? Listen to patient s answer without interrupting. After allowing patient to express self fully, inquire anything else?

Interview Proper y Assessment by: o Gathering Information o Exploring Problems o Understanding Patient s Perspective o Providing Structure to Consultation Explain and plan by: o Give correct amount and type of information

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Aid accurate recall and understanding Achieve shared understanding Incorporate patient s perspective Share decision planning

Build relationship by: o Developing rapport o Involving the patient Content o What is said between doctor and patient o Explore chief complaint o What is troubling patient o Gathering info diagnostic & treatment plan Process o Non verbal/ verbal Communication o What Occurs non verbally between the doctor and the patient o Doctor- Patient Relationship:  Feelings and reactions to each other Facilitating patient s story: interview techniques

2. Adaptive questioning  Open ended question before detailed close ended question: What brings you here today? Ano ho ba ang nararamdaman nyo at nagpatingin kayo ngayon? Non-verbal communication  Read patient s feelings, reactions, message  Pay attention to: degree of eye contact, facial expression, head position, body movement, placement of arms and legs  Mirroring *** Be sensitive to patient s non verbal cues and decoding them to better understand patient s emotions and feelings. Patient s distress may not be verbalized but may be noted in their body language. o ***Watch out for signs of distress such as: avoiding eye contact, fidgeting, shifting around in seat, holding body tensely. *** Stay attuned to both verbal and non verbal cues, watching discrepancies with what is being said vs. how it is said and being sensitive to what is not being said. ***Respond immediately to verbal and non verbal cues that indicate distress. Best to seize the moment rather than letting these go unaddressed. Given the signal to proceed from the MD, patients will generally express their feelings at this point. ***Don t assume that you ve interpreted patient s body language correctly. Check if you are right by asking patient- it seems you are worried about *** Take note of cultural differences in body language as well. o Empathic responses: verbal  Identify patient s feelings  Respond with understanding and acceptance (validation)

1. Active listening: Facilitate- Encourage patient to talk o Non-verbal attending behaviors  Eye contact  Body posture lean forward  Gestures nodding  Facial expression Verbal following:  Pausing before asking following up questions  Use patient s own words  Tapos , ah . , uhuh Listen to body language  Be prepared to listen- Listen more, talk less. Because physicians are trained to be efficient about their time and to actively solicit information from patients, it is difficult for them to listen.  Sense patient s emotions

***ACTIVE LISTENING IS THE SINCERE ATTEMPT TO UNDERSTAND WHAT IS BEING COMMUNICATED AND INVOLVES BEING PREPARED TO LISTEN VS. RUSHING THE PATIENT BECAUSE OF OTHER COMMITMMENTS OR YOU HAVE TO GO HOME. ***Active listening techniques often encourage patients to express their emotions e.g. Nod head, face patient directly, maintain eye contact, sit close to patient and say mm- hmm, I see, go on..

***Identify patient s feelings- Mukang nag aalala na kayo tungkol sa sakit ng tiyan nyo. Respond with understanding- Oo nga pa, talaga naman nakakapag alala yon ganon sakit. ***Validate patient s feelings- Patients need to be reassured that their feelings are acceptable and normal. Reassure them that these feelings are expected given the circumstances and that there is nothing 3

inappropriate in feeling or expressing them. ***Give and ask feedback from patient: it sounds like you re feeling.. Is that right? It seems like you re saying.. Does that sound about right? o Empathic responses: non-verbal  Show kindness and concern  Offer tissue if crying  Patting hand or shoulder gently Echoing  Simple repetition of patient s words Reflection  Paraphrasing to check if the doctor understood patient  Reassure patient that the doctor was listening to patient Interrelation  Handing patient s emotions: validate, accept  Focus on Doctor-patient relationship/partnership you are on patient s side

Interpretation  State feelings, thoughts, or behavior that patient unaware of

Sa tingin ko baka natatakot kayo mag pa opera kaya hindi na kayo bumalik para mag pa check up ano? o Self-revelation  If limited and discreet put patient at ease and help in treatment

Ako rin po takot sa operasyon pero iniisip ko na lang kailangan ko para gumaling ng tuloy tuloy. Silence  Allow patient time to contemplate, cry  Provide accepting environment ***Allows patient time / space to think; also encourages patient to say more; longer periods may be appropriate if patient having difficulty in expressing self/ becoming emotional. Doctor should be aware of the fine line between comfortable/ uncomfortable silence, between encouraging communication and interfering with it by creating uncertainty and anxiety. o o Explanation  Dx and tx in simple non-technical terms Clarification  Getting more details  Clarifying what patient means Checking symptoms  Use checklist Probing  Explore further Generalization  Getting general sense of current health status Summarization  Can be done at any point during interview  Help Doctor reorganize data and thoughts  Review what was discussed  Focus on pertinent dx, tx

***Handling patient: Kahit sino po nasa lugar nyo, ganun din ang maging reaksyon nila. ***It is imperative that patient should feel satisfied with the doctor s efforts since many who file cases of malpractice against their doctor is when they feel that the doctor has not been caring enough. Studies have also shown that there is a significant association between the degree of empathy expressed by the physician and patient s adherence to treatment advice. There has been convincing evidence that building positive therapeutic relationships makes a difference in the process and outcome of care. Thus doctors should be more attuned to the feelings of their patients so as to manifest their humanity & empathy. ***Show that you are receptive to patient s emotions i.e. That it is ok for them to bring up and discuss difficult emotional issues; one way to accomplish this is by asking about patient s feelings e.g. How are you feeling about that? What is your biggest worry in all this? Are things at home or at work bothering you? ***Focus on Doctor-patient relationship: Nandito lang po ako kung meron po kayong mga tanong. ***Show partnership & support to reinforce that you are on the patient s side and will help him work thru/ resolve medical problems: We ll work together to decide what the best course of treatment is I m available anytime if you have any questions or other concerns...

***Summarizing is useful for checking if you have an accurate understanding of patient s perspective. It involves encapsulating what patient has said, then inviting him to correct your interpretation and to provide further, clarifying information. ***Interval summarizing focuses on specific part of interview and may be used periodically throughout

the session to ensure that info has been interpreted accurately. ***End summarizing pulls together the entire interview. Without summarizing to check for completeness and accuracy, doctors may end up guessing and assuming inaccurately/ incorrectly thus susceptible to distortion and misinterpretation of data given by patient. o Continuation  Allow patient to take lead  Encourage patient to talk  Keep on right track Curbing  Refocus on topic Specification  Close ended question  Ask series of question, one by one  Offering multiple choice question Leading questions  Avoid presumptions Nakakalimutan ba ninyong inumin ang gamot nyo?  Help patient confess to other s/s, non-compliance Papano kadalas nyo nakakalimutan inumin ang gamot nyo sa isang linggo?

Confrontation  Point out inconsistency between words and actions  Challenge denial  Respectfully help patient face reality Effective reassurance  At the end of interview after complete history, PE, lab  Not premature, no false promises  Be Truthful

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So do not fear, for I am with you; do not be dismayed, for I am your God. I will strengthen you and help you; I will uphold you with my righteous right hand. -Isaiah 41:10

Transitions  Give patient some sense of control  Orient by brief transitional statement that prepares for next part of interview Types of transitions  Smooth: cause and effect, temporal  Accentuated: Doctor summarizes before next topic  Abrupt:  Doctor introduce new topic without warning or introductory statement  Topic unrelated to previous topic  Jump from one topic to next and back and forth Timing:  Announce how much time for interview  Don t rush, interrupt patient  Establish priority issues for session  Give reason to cut short  Continue on next scheduled appointment