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Interviewing Techniques as Tools for Diagnosis and Treatment, part 3 The Helpful Interview

Interviewing Techniques as Tools for Diagnosis and Treatment, part 3 The Helpful Interview. The Practice of Medicine -1 Christine M. Peterson, M.D. Techniques as Tools.

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Interviewing Techniques as Tools for Diagnosis and Treatment, part 3 The Helpful Interview

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  1. Interviewing Techniques as Tools for Diagnosis and Treatment, part 3The Helpful Interview The Practice of Medicine -1 Christine M. Peterson, M.D.

  2. Techniques as Tools • Week 2: Introduction to observing, using non-verbal and verbal active listening skills, and giving feedback. [SG - Mentor Hospital Interviews] • Week 3: Practice observing, using active listening skills, and giving and receiving feedback.[SG - SP or Hospital Interviews] • Week 4: Become more “patient-centered” in the interview. [SG – Hospital or SP Interviews]

  3. Functions of the Medical Interview • Gather data and understand it • Develop rapport and respond to emotions • Educate and motivate • Begin both diagnostic and healing processes

  4. Techniques Are Not Results • The true endpoint of your use of techniques is the patient’s performance in the interview. • Complete (facts, concerns & requests, context) • Truthful (facts and emotions)

  5. The Patient-Centered Interview • Focuses on the patient’s needs • Activates the patient to play a larger role • Is characterized by “active listening” • Has a positive impact on patient outcome

  6. Review of techniques • Behavior that BEFITS a physician • FOCUS on active listening • PREP to obtain patient-centered information • REALLY PREPARE to show empathy

  7. Issues from 3 x 5 cards • *Motivating behavior change • *Cultural (and other) differences • *Sensitive topics • *Challenging interviews / relationships • *Talking with children & parents

  8. Issues from 3 x 5 cards • Organizing the interview (order of inquiry, keeping on track) • Time management / efficiency • Interpreting verbal and non-verbal communication • metacommunication • Dealing with emotions • Note-taking / documentation • Closing the interview • Being a beginner

  9. Four “pearls”

  10. Active listening • “Not really” actually means “I’m not going to tell you until I really know you’ll try to understand what I’m saying.”

  11. Communication Behaviors of “No Claim” Primary Care Physicians • Longer visits • More orienting statements • More humor, more laughter • More facilitating comments Levinson w et al. JAMA 1997;277(7):553-9

  12. Mc Whinney’s Taxonomy of Medical Help-Seeking Behavior • Limits of tolerance for symptom • Limits of tolerance for anxiety about symptom • Problems of living presenting as symptoms • Preventive/routine care • Administrative reasons

  13. History of Present Illness: “O-P-Q-R-S-T” questions • Onset and circumstances of Occurrence • Provocative and Palliative factors • Quality and/or Quantity of symptom • Region of body and Radiation to other areas • Severity of symptom (0 to 10 scale, if applicable) and associated Symptoms • Time(duration) and Temporal associations

  14. Video # 8 [doc.com]“Gather Information” Characterize the symptoms

  15. Conclusive information for determining the diagnosis

  16. Diagnostic information sources “Inaccurate, incomplete, or misinterpreted patient histories are among the leading causes for diagnostic errors.” Feddock C. Am J Med 2007;120(4):374-8.

  17. A woman presents to her doctor and requests a mammogram to find out whether she has breast cancer. • Is that a good idea?

  18. Why aren’t mammograms recommended for all women? • Expense • Reliability

  19. How reliable is a mammogram? • If she has breast cancer, the probability that the mammogram will be abnormal is 80%. • “Sensitivity” = 80% [i.e., 80% of women with breast cancer have an abnormal mammogram, and 20% of women with breast cancer have a normal mammogram (“false negative” result) due to biology and/or interpretation.]

  20. How reliable is a mammogram? • If she does not have breast cancer, the probability that the mammogram will be normal is 90%. • “Specificity” = 90% [i.e., 90% of normal women have a normal mammogram and 10% of healthy women have anabnormal mammogram (“false positive” result) due to biology and/or interpretation.]

  21. Breast cancer risk varies by age Risk of breast cancer in women at current age is: • age 20: 1 in 1,837 (0.054%) • age 30: 1 in 234 (0.42%) • age 40: 1 in 70 (1.4%) • age 50: 1 in 40 (2.5%) • age 60: 1 in 28 (3.6%) • age 70: 1 in 26 (3.8%) Current entire ♀ population (20 to 80): 1 in 100 (1%) Over a lifetime: 1 in 8 (12.5%) Source: American Cancer Society Breast Cancer Facts and Figures 2007-2008

  22. Prevalence of breast cancer • In the population as a whole what per cent of women 20 and older have breast cancer today? • 1 %

  23. Random mammogram

  24. Random mammogram

  25. Random mammogram

  26. Random mammogram

  27. Random mammogram

  28. Random mammogram

  29. Random mammogram

  30. Random mammogram

  31. Random mammogram

  32. Random mammogram Positive predictive value of random mammogram = 8 / 107 = 7.5%

  33. Interpreting mammogram results Cancer; 80% pos mammo Healthy; positive mammo Healthy; negative mammo Each box = 10 women. Mammogram sensitivity = 80%; specificity = 90. Breast cancer overall prevalence = 1% (varies with risk!)

  34. For which women are mammograms recommended? • Risk factors: • Previous breast cancer • Genetic mutations (BrCA-1, BrCA-2) • Breast mass • Age • Etc.

  35. Breast cancer risk varies by age Risk of breast cancer in women at current age is: • age 20: 1 in 1,837 (0.054%) • age 30: 1 in 234 (0.42%) • age 40: 1 in 70 (1.4%) • age 50: 1 in 40 (2.5%) • age 60: 1 in 28 (3.6%) • age 70: 1 in 26 (3.8%) Source: American Cancer Society Breast Cancer Facts and Figures 2007-2008

  36. Mammogram at age 50(prevalence = 2.5%) Positive predictive value of mammogram at age 50 = 20 / 117.5 = 17%

  37. Mammogram at age 50 with mass(prevalence ~ 50%) Positive predictive value of mammogram at age 50 with mass = 400 / 450 = 89%

  38. A thorough history and physical exam = more accurate assessment of “prior probability” that the patient has a particular disease. • This helps guide appropriate choice and interpretation of lab and imaging tests. • And leads to better diagnosis and more effective treatment.

  39. An accurate history and physical exam are essential for arriving at the correct diagnosis.

  40. Video # 8 Mr. Dade

  41. Patient-Centered Interview • Allows patients to express their concerns • Seeks patients’ specific requests • Elicits patients’ explanations of their illnesses • Facilitates patients’ expression of feeling • Gives patients information • Involves patients in developing a plan for evaluation and treatment • IMPROVES OUTCOME AND SATISFACTION.

  42. A good physician can talk to anyone…

  43. But a great physician can listen to anyone.

  44. Doc.com #13: Responding to Strong Emotions

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