Introduction to the Clinical Interview

1. Introduction to the Clinical Interview Susan Bentley, D.O.

2. Introduction • Patient –centered communication • Participatory interview style • Results: • Improved patient outcomes • Increased satisfaction with care • Decrease in overall costs

3. Overview • Elements of the patient-centered interview Building Rapport Listening Actively Dealing with Emotions Facilitating Patient Agenda Managing Information Finding Common Ground

4. “A successful dialogue between patient and physician is at the heart of working scientifically with patients…” G. L. Engel, 1995

5. Building Rapport • Establish Tone of Interview • Set Direction • Transition from Social to Medical

6. Facilitating the Patient’s Agenda • Encourage patient to communicate their medical story in their own terms • More accurate diagnosis and more effective time management • Includes verbal and non-verbal skills

7. Case vignette… • 59 year old woman in your practice 5 years • Irregular visits for hypertension • CC  urinary tract infection • Physical findings • Mild obesity • BP  160 / 92 mm Hg • UA +glucose, -protein, ketones, leukocyte esterase • Blood glucose  204 mg/dL • Clinical interaction

8. Missed Opportunities • Building Rapport – “What has been going on in your life?” • Facilitating Agenda – “What are you concerned about?”

9. Managing Information • Questioning skills: • Open ended questions • Closed ended questions • Goal • Balance • Patient perspective • Specific information

10. Active Listening • Recognition of clues to patients thoughts, unstated concerns, expectations • Patient personality affects communications style • “Oh by the way…” • Reluctance to accept recommendations • Strategies • Reflective listening • Exploring clues for meaning • Question to elicit patient’s perspective

11. Case vignette… • 67 year old man, new to practice, transferred care – dissatisfied with former doctor • CC  physical exam • Clinical interaction • “Follows” his diet • “Could do better” taking meds (some anxiety) • Reinforce compliance, write Rx, schedule follow-up in 3 months • Patient never shows up again

12. Getting to the issues • Active listening  insight into why glucose is not controlled • Open-ended Questions  patient has no concept of medical nutrition therapy • Non-verbal cues  exploration of discomfort leads to understanding patient fears

13. Dealing with Emotions • Visits to doctors can be emotionally charged (white coat syndrome) • Patient focus is physical complaints versus emotional distress • Explore patient feelings & respond appropriately to emotions • Develop treatment for the whole person

14. Strategies for Exploration • Silence • Non-verbal encouragement • Neutral utterances, continuers • Reflection, echoing • Open-ended requests • Summary or paraphrase • Direct questions about feelings • Forming hypotheses together

15. Strategies for Effective Responses • Naming • Understanding • Respecting • Supporting • Normalizing • Non-verbal behaviors • Exploring meaning behind expressions

16. Finding Common Ground • Shared vision of health • Reconciling patient and physician expectations • Strategies • Restate patient perspective • Explain clinical diagnosis, treatment plan • Check with patient on feasibility • Respectfully note different perspectives • Identify patient’s readiness to change • Brainstorm potential solutions, compromise • Reframe situation

17. Case Vignette … • 52 year old woman in your practice 6 years, • Frustrating non-compliance • CC  Type 2 diabetes, hypertension, hyperlipidemia • Physical findings • Mild obesity • Poor glucose control with increasing insulin dosage (glycosylated hemoglobin 10%) • Clinical interaction • Physician frustrated, • Decides to change approach

18. Negotiating “Win-Win” solution • Explore emotional presentation of anger • Acknowledge her distress (Naming) • Normalize patient frustration • Explore patient goals for treatment plans • Establish common ground • Set reasonable treatment goals

19. Conclusions • Patient – centered communication has proven effective in • Improved patient outcomes • Increased satisfaction with care • Decrease in overall costs • Involves patients in decision-making process • Engaging patient in care improves compliance • Improved interview skills enhances experience for both physician and patient

20. Where to Get More Information • Remaining lectures • Small group sessions • Assigned reading • Experience practicing these principles (try it, you’ll like it!)

21. The Beginning …