The Medical Interview: Communication Skills I

The Medical Interview:Communication Skills I

Ted J. Ruback, M.S., PA-CAssociate Professor and HeadDivision of Physician Assistant EducationDirector, OHSU Physician Assistant Program

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.

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 physician’s office, they were able to correctly identify only about 50% of the critical information.

Objectives of the Medical Interview

Gather information

Establish rapport

Educate, support and motivate

Setting the stage

Create an environment designed to facilitate communication. What factors are important?

Atmosphere

Personal approach

Beginning the patient encounter

Review chart Review identifying information Note, record date/time Knock on the door What’s next?

Introductions

Introduce yourself and explain your role Address the patient appropriately Express interest Ask permission

How do you introduce yourself?

SOAP

Subjective

Objective

Assessment

Plan

Subjective vs. Objective

SubjectiveWhat a patient feels, describes indirectly with

wordsSYMPTOMS

ObjectivePhysiologic quantities observed directlySIGNS

Subjective vs. Objective:

True or False:Objective data is more important

than subjective, because subjective data is lacking in quantification?

Subjective vs. Objective:

FALSE!Research suggests:

~80% of diagnoses are made based on history alone.

Physical exam adds another 10%

Subjective

or

Objective?

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)


Identifying informationOften ignoredName, age, gender, occupationSource of referral Source of history, reliabilityPCP, nearest relative, contact information


Chief Complaint or Concern (CC)One of more symptoms or concerns for which

the patient is seeking care or advice

Eliciting the chief complaint

Patient’s direct statement in response to an open-ended question, recorded accurately


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 patient’s The chief complaint is not a diagnosis


History of Present Illness (HPI)Description of the patient’s chief complaint

starting from the last time the patient felt wellAttempt to understand the full story of the

development and expression of the chief complaint in the context of the patient’s life

Determine the actual reason for coming in at this particular time


Eliciting the HPIThe “open-ended” interview

Begin with open-ended questions Move to more directed questions to clarify and

embellishYou need to know what information is needed

and how to get itYou need to be able to evaluate the relevance

of the information obtained

The History of Present Illness:the seven dimensions of a complaint

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


To help you remember - LOCATESL ocationO ther associated symptomsC haracter (or quality)A lleviating/aggravatingT imingE nvironment/settingS everity


To help you remember – PQRSSTAP rovocative/PalliativeQ ualityR egionS everityS ettingT imingA ssociated symptoms

Mosby has two other suggestions

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

The “Open-ended Interview”

When neededLaundry list or multiple choiceClosed-ended, more direct, yes/no questions

Avoid at all timesLeading questionsMultiple questionsYes/no questions for sensitive topics

Other suggestions for a successful interview Pertinent negatives and positive

symptomsWhat 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

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

Other suggestions for a successful interview Guiding the interview, encouraging

communicationFacilitationReflectionClarificationEmpathetic responseConfrontationSummary

Transition to the PE

Always give the patient the opportunity for the last word “Is there anything else we haven’t covered that you would like to discuss before I examine you.”

PE is a continuation of the interview process

Goals are same

Closing the interview

The closing interaction solidifies the relationship and sets the stage for managing the problem

“Is there anything further you’d like to tell me or ask me?” – unfinished business

Appropriate closure implies a contract

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

The Medical Interview: Communication Skills I

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