Purpose of medical interviewing:
-To gather information
-To establish a safe atmosphere and trusting relationship with the patient
-To provide patient education (inform and motivate the patient)
Biomedical approach:
-Focuses on biological factors
-Defines health as the ‘absence of disease’
Biopsychosocial approach:
-Connects biological factors with psychological and social
-Allows for increased understanding of illness and health
Determinants of health:
Rationale for improving medical interviewing:
-Patients often seek care due to their experience, not their symptom(s)
-Patients often ahve more than one concern
-Being able to tell one’s symptom story is diagnostically useful + therapeutic
Medical interviewing skills:
Clinician-centered interviewing:
-Clinician in charge of interaction
-clinician-driven priorities and beliefs (bias)
-Interview to elicit symptoms of disease
-typically, more close-ended questioning
-differentiates potential conditions the patient may be suffering from
Patient-centered interviewing:
-patient leads interaction
-allows patient to express importance/expectations
-interview to elicit experience of disease (symptoms + personal concerns, feelings and emotions)
-typically uses open-ended questioning
-builds and maintains clinician-patient relationship
Open-ended data-gathering skills:
a. non-focusing:
-silence
-nonverbal encouragement (eye contact, hand gestures, leaning forward)
-continuers (ex. “uh-huh”, “hmmm”)
b. Focusing:
-echoing (repeating a word of phrase the patient has said)
-requesting (“go on,” “tell me about your pain”)
-Summarizing (paraphrasing your understanding of what the patient has said)
Close-ended data-gathering skills:
-Questions that produce a yes/no answer
-questions that produce brief replies
-multiple-choice questions
Emotion-seeking skills:
a. Direct inquiry: ex. “how did that make you feel?”
b. Indirect inquiry:
-Inquiring about impact: (“how has that effected your day-to-day life?”)
-Eliciting beliefs or attributions (“what do you think may be causing your pain?”)
-Intuiting how the patient might be feeling (sharing how your or others might respond)
-Asking about triggers (what made you come to see me about this now?)
Conveying empathy skills:
a. Naming the feeling/emotion
-repeating the feeling expressed by the patient (“you felt sad”)
-state the feeling you observed (“you look a little teary-eyed. or “you sound frustrated”)
b. Understand statement (“given what has happened, it makes sense to me.”)
c. Respect (praise, appreciate and/or acknowledge the patients situation)
d. Support (“I am here to help in any way that I can.”)
“NURS”
Examples of interviewing questions:
Integrated medical interviewing:
(Step 1) Setting the stage:
- Prepare for patient consult by reading intake form/chart to familiarize yourself with patients problem list, medications, allergies and relevant past medical history
- Welcome/greeting the patient
- Use patients name
- Introduce yourself and identify specific role
- Ensure patient readiness and privacy
- Address barriers to communication (sit down)
6) Ensure comfort and put patient at ease
(Step 2) Elicit chief concern + set the agenda:
1) Indicate time available
2) Forecast what you would like to happen during the interview
3) Obtain a list of all issues the patient wants to discuss (ex. specific symptoms, requests, expectations, understanding)
- Summarize and finalize the agenda (negotiate specifics if too many agenda items)
(Step 3) Opening the history of present illness (HPI):
- Start with open-ended questions/statements
- Use non-focusing open-ended skills (attentive listening)
- Obtain additional data from non-verbal sources: physical characteristics, autonomic changes, accoutrements, environment and self
Non-verbal information:
-physical characteristics: general health, skin and hair color, odor, deformities, habitus (emaciated, disheveled, “uremic” breathing, jaundice, amputated lef, kyphoscoliosis)
-Autonomic changes: heart rate, skin color, pupil size, skin moisture, skin temperature
-Accoutrements or accessories: clothing, jewelry, eyeglasses, tattoos, make-up (ex. expensive jewelry, thick eyeglasses, tattoos and body piercings, no make-up or poorly applied make up)
-Environment: hospital (greeting cards, flowers, photographs)
-Self: aware of your own emotions and reactions to patients
(Step 3) Learn patient experience of illness:
- Obtain further description of the symptom(s) =symptom story
- Elicit or develop understanding of personal context (psychological and social)
- Elicit or develop understanding of emotional impact
- Respond to feelings and emotions with empathy skills (re. NURS)
- Expand the story to new chapters
(Step 5) Transition to middle of interview:
- Brief summary
- Check accuracy
- Indicate that both content and style of inquiry will change if the patient is ready
(Step 6) History of presenting illness (HPI):
Complete a chronological description of the patient’s chief concern and other active problems.
- obtaining & describing data w/o interpreting it:
a. expand the description of symptoms already introduced by the patient
b. Describe symptoms not yet introduced in the already identified body system (and general health symptoms)
recall: OLD CARTS (Onset, Location/radiation, Duration, Character, aggravating factors, Relieving factors, Timing, Severity)
-utilizes primarily clinician-centered interviewing skills
- Interpreting data while obtaining it: testing hypotheses about the possible disease-causing symptoms.
a. Describe relevant symptoms outside the body system involved in the HPI
b. Inquire about the presence or absence of relevant non-symptom data (secondary data) not yet introduced by patient - Understand the patients perspective: impact (meaning) of illness on self/others, health benefits, triggers for seeking care
(Step 7) Past Medical History (MH):
-Screen for major diseases/diagnoses
-Previous injuries or medical interventions
-hospitalizations
-Immunizations
-Preventative/public health screening (ex. mammography in women >50 years)
-Medications and other treatments
-Allergies and drug reactions
(Step 8) Social or Psychosocial History (SH):
-Occupation
-Health promotion (diet, physical activity)
-Safety (ex. seat belt use, smoke detectors in home)
-Health screening (ex. cervical cancer, colon cancer hypertension)
-Exposures (pets, travel, illness at home/work)
-Substance use (caffeine, tobacco, alcohol, drugs)
-Personal (living arrangement, relationships/support systems, sexual orientation/practices, stress, mood, spirituality)
-Health literacy
-Hobbies/recreation
-Important life experiences (ex. military service, family relationships)
-Legal issues (incl. Emergency contact)
(Step 9) Family History (FH):
-Information on contagious, toxic, familial and heritable diseases
Examples:
-Anyone else in your home with similar symptoms?
-What age was your mother and grandmother diagnosed with breast cancer?
(Step 10) Review Of Systems (ROS):
-Ask about relevant symptoms or any secondary data not yet addressed
-ROS is used as a final screening tool to understand the degree of impact the illness has placed on the patient’s life
-Complete physical exam and discuss results of available laboratory findings
