Dr.Paul’s Clinic Approach to Medical Interview: The medical interview is the medium through which the patient’s needs and requests are made known, the human connections are established, and almost all the work of doctoring is conducted. Many diagnoses can be made based on the patient’s history alone.
Three functions of the medical interview have been identified :
The three functions of the interview are interwoven throughout the dialogue of the clinician and patient.
Data-gathering — Data-gathering enables the clinician to establish a diagnosis or recommend further diagnostic procedures, suggest courses of treatment, and predict the nature of the illness. The tasks of this function are to:
●Acquire the appropriate knowledge base of diseases and disorders
●Acquire the knowledge base of psychosocial issues that contribute to the patient’s illness behavior
●Bring the data that have been elicited into focus
●Generate and test multiple hypotheses during the course of the interview
The verbal skills that facilitate accomplishing these tasks include asking open-ended questions (and waiting for the answers); active listening; making facilitative utterances (“uh-huh, tell me more… yes… go on…”); making orienting remarks (“I will ask you about x, and then we will do y…”); asking focusing questions when needed (“Where was the pain? What made it worse?”); eliciting and prioritizing the patient’s agenda for the visit (“What should we be certain to get done today?”); checking for understanding; and summarizing what the clinician has heard (“Let me be sure I have this right. You felt fine until you started shoveling snow, then you felt dizzy and thought you might faint,” etc) .
The nonverbal skills that facilitate good data collection start with “clearing the clinician’s mental and physical slate” before entering the room with the patient. Important and often neglected nonverbal skills also include being aware of and consciously shaping how the clinician’s appearance, body language, voice qualities (eg, tone, volume, pace), and the spatial arrangements of furniture and people in the room affect the interactions. As health care providers increasingly use electronic medical records (EMRs), they must master the skills needed to use the computer to assist effective data-gathering and -sharing and the skills needed to avoid allowing the computer to become a barrier between the patient and the provider .
Relationship-building — Relationship-building seeks to ensure the patient’s willingness to provide diagnostic and other important information, to relieve the patient’s physical and psychosocial distress, to ensure the patient’s willingness to accept the treatment plan or a process of negotiation, and to ensure both the patient’s and clinician’s satisfaction with work well-done. The tasks of this function are to:
●Define the nature of the relationship
●Communicate professional expertise
●Communicate interest, respect, support, and empathy
●Recognize and resolve various relational barriers to patient/clinician communication
●Elicit the patient’s perspective
The skills of effective relationship building are both verbal and nonverbal. The power and importance of nonverbal communication cannot be overstated. Consider, for example, the effect of nonverbal empathy when the clinician gently touches the shoulder of the newly widowed woman. All behavior is communication. Patients are reading nonverbal messages from clinicians consciously or unconsciously throughout each visit . Does the clinician lean towards or away from the patient? Is there appropriate eye contact and head nodding to indicate listening? The clinician and patient assess whether the unspoken messages match the words. When they match, the veracity of the words is likely. A mismatch suggests need for some explicit checking (eg, patient says “OK, I’ll fill the prescription” but looks absently out the window). The skillful clinician is consciously monitoring and controlling his/her own nonverbal messages to the patient while reading the nonverbal communication from the patient.
The skillful clinician is also evaluating his/her own thoughts and emotions and how these affect verbal and nonverbal responses to the patient and even influence clinical judgment. Is a growing sense of irritation in the clinician during an interview related to actions of the patient, or unrelated issues (eg, that second cup of coffee, air conditioning problems, or a disagreement at home the previous night?). Awareness of the effects of our own mental processes on our relationships with patients is often referred to as “mindful practice” and has been described as “cultivation of the observing self in the midst of the complexity and chaos of everyday work” . Through mindful practice, clinicians improve their attention and ability to sense subtleties, reduce bias and premature categorization, and enhance openness to new ideas and actions.
The appropriate use of language is also a crucial aspect of relationship building. Both what is said and how it is said are important. Verbal relationship building skills include statements of partnership, empathy, apology, respect, legitimation, and support (PEARLS) . Empathy is most easily conveyed by the use of reflection. Communication of understanding of emotion through reflective statements such as “that was tough for you” or even “gosh!” can deepen the therapeutic relationship and improve patient satisfaction. Legitimation refers to voicing acceptance or validation of the emotions or reactions of the patient. A simple “I’d be upset by that too” can be reassuring to an anxious or angry patient and turn a difficult encounter into a productive one.
Patient education — Patient education seeks to ensure the patient’s understanding of the illness, to suggest diagnostic procedures and treatment possibilities, to foster consensus between clinician and patient, and to create a firm foundation for informed consent, improved coping mechanisms, and the promotion of healthy lifestyle change. Providing appropriate patient education to foster consensus and allow full informed consent is one way that clinicians show respect for their patients.
The tasks of this function are to:
●Determine the areas of differences (potential conflict) between the clinician and patient, and promote negotiation to resolve the differences
●Communicate about the diagnostic significance of the problem(s)
●Recommend the appropriate diagnostic procedures and treatment, including appropriate preventive measures and lifestyle changes
●Enhance coping ability by understanding and working with the social and psychosocial consequences of the disease and treatment
The skills of patient education involve asking questions to discover what the patient knows about the illness, how s/he feels about it, what s/he believes about it, what meanings s/heattaches to it, and what s/he expects to happen because of the illness and/or its treatment. The two keys to successful patient education are the use of comprehensible language and avoidance of “too much, too soon, too fast.”
The skillful clinician’s questions probe the patient’s “need to know” in each of these areas. S/he then calibrates responses in both content and tone to exactly what the patient wants to know. If the clinician senses resistance to learning about something that is important from her/his perspective, this resistance must be explored. Invariably, such an exploration will uncover important patient concerns, fears, prior adverse experience, or serious misunderstanding of what the clinician is saying. In summary, the content of effective patient education rests upon the clinician’s knowledge, but that is not enough. Its implementation requires an open, trusting clinician-patient relationship. Patient education is best accomplished in a true conversation between clinician and patient, not through a clinician monologue.
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