The Medical Interview: Communication Skills I

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The Medical InterviewCommunication Skills I

• Ted J. Ruback, M.S., PA-C
• Associate Professor and Head
• Division of Physician Assistant Education
• Director, OHSU Physician Assistant Program

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Objectives

• Describe the characteristics of positive regard
  for patients and how this leads to willingness to
  join patients as partners
• Explain the purpose of each of the three basic
  functions of the interview.
• List the topics of an initial interview and
  written history.
• Describe how to greet and put a patient at ease.
  How to open, close, organize and guide the
  interview.

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Why a session on medical interviewing and patient
communication skills?

• Evidence supports the importance of learning good
  patient communication skills. Research shows
• 69 of interviews were interrupted by the
  physician within the first 18 seconds of the
  interview
• 77 of the time, patients reason for coming to
  the physician were not fully elicited
• When patients are asked to discuss their illness
  and treatment immediately after leaving their
  physicians office, they were able to correctly
  identify only about 50 of the critical
  information.

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Objectives of the Medical Interview

• Gather information
• Establish rapport
• Educate, support and motivate

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Setting the stage

• Create an environment designed to facilitate
  communication. What factors are important?
• Atmosphere
• Personal approach

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Beginning the patient encounter

• Review chart
• Review identifying information
• Note, record date/time
• Knock on the door
• Whats next?

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Introductions

• Introduce yourself and explain your role
• Address the patient appropriately
• Express interest
• Ask permission
• How do you introduce yourself?

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SOAP

• Subjective
• Objective
• Assessment
• Plan

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Subjective vs. Objective

• Subjective
• What a patient feels, describes indirectly with
  words
• SYMPTOMS
• Objective
• Physiologic quantities observed directly
• SIGNS

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Subjective vs. Objective

• True or False
• Objective data is more important than subjective,
  because subjective data is lacking in
  quantification?

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Subjective vs. Objective

• FALSE!
• Research suggests
• 80 of diagnoses are made based on history
  alone.
• Physical exam adds another 10

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• Subjective
• or
• Objective?

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The Complete Medical History

• Identifying information
• Chief complaint or concern (CC)
• History of present illness (HPI)
• Past medical history (PMH)
• Family history (FH)
• Social history (SH)
• Review of systems (ROS)

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The Complete Medical History

• Identifying information
• Often ignored
• Name, age, gender, occupation
• Source of referral
• Source of history, reliability
• PCP, nearest relative, contact information

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The Complete Medical History

• Chief Complaint or Concern (CC)
• One of more symptoms or concerns for which the
  patient is seeking care or advice
• Eliciting the chief complaint
• Patients direct statement in response to an
  open-ended question, recorded accurately

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The Complete Medical History

• Documenting the Chief Complaint
• The primary reason the patient is seeking medical
  attention, recorded using the patients own words,
  in quotes X duration
• One sentence, never more than two
• Do not editorialize or embellish
• The chief complaint is not your interpretation of
  why a patient is seeking help, but the patients
• The chief complaint is not a diagnosis

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The Complete Medical History

• History of Present Illness (HPI)
• Description of the patients chief complaint
  starting from the last time the patient felt well
• Attempt to understand the full story of the
  development and expression of the chief complaint
  in the context of the patients life
• Determine the actual reason for coming in at this
  particular time

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The Complete Medical History

• Eliciting the HPI
• The open-ended interview
• Begin with open-ended questions
• Move to more directed questions to clarify and
  embellish
• You need to know what information is needed and
  how to get it
• You need to be able to evaluate the relevance of
  the information obtained

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The History of Present Illness the seven
dimensions of a complaint

• Location
• Quality
• Severity
• Timing
• Context
• Modifying factors
• Associated signs and symptoms
• Risk factors

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The History of Present Illness the seven
dimensions of a complaint

• To help you remember - LOCATES
• L ocation
• O ther associated symptoms
• C haracter (or quality)
• A lleviating/aggravating
• T iming
• E nvironment/setting
• S everity

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The History of Present Illness the seven
dimensions of a complaint

• To help you remember PQRSSTA
• P rovocative/Palliative
• Q uality
• R egion
• S everity
• S etting
• T iming
• A ssociated symptoms
• Mosby has two other suggestions

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The Open-ended Interview

• Goal is to guide the interview, not dominate it
• Open ended questions to begin least control
• More specific closed-ended questions as late in
  the interview as possible

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The Open-ended Interview

• When needed
• Laundry list or multiple choice
• Closed-ended, more direct, yes/no questions
• Avoid at all times
• Leading questions
• Multiple questions
• Yes/no questions for sensitive topics

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Other suggestions for a successful interview

• Pertinent negatives and positive symptoms
• What does not occur in the course of an illness
  can be as important as what does 
• Reminder in investigating pertinent negatives,
  avoid leading questions which encourage certain
  responses

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Other suggestions for a successful interview

• How the present illness has affected the patients
  quality of life is an important aspect of the
  HPI. The impact of the illness on
• Interpersonal relationships
• Work/school
• Sexual relationships
• Emotional stability
• It is more productive to ask how rather than
  whether it has, in such instances

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Other suggestions for a successful interview

• Guiding the interview, encouraging communication
• Facilitation
• Reflection
• Clarification
• Empathetic response
• Confrontation
• Summary

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Transition to the PE

• Always give the patient the opportunity for the
  last word Is there anything else we havent
  covered that you would like to discuss before I
  examine you.
• PE is a continuation of the interview process
• Goals are same

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Closing the interview

• The closing interaction solidifies the
  relationship and sets the stage for managing the
  problem
• Is there anything further youd like to tell me
  or ask me? unfinished business
• Appropriate closure implies a contract

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Closing the interview

• Share findings physical findings, differential
  dx, your dx or hypothesis
• Problem list and priorities
• Negotiate a plan of action, clarify
  responsibilities
• Educate
• Summation
• Physical parting