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Fortin: Smith's Patient-Centered Interviewing 4e: An Evidence-Based Approach
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Fortin: Smith's Patient-Centered Interviewing 4e: An Evidence-Based Approach
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Language: EN.
Segment:0 .
Segment:1 Introduction.
I'm Dr. Bob Smith. Welcome to this series of videotapes. They're designed for those wanting to learn how to conduct a patient-centered interview. There are sections addressing students' special needs, including doctor-centered interviewing. It's particularly designed for medical students, nursing students, nurse practitioner students, and physician assistant students. We're going to present a step-by-step interviewing method that describes exactly what you do throughout the interview.
It works very well in our and many others' experience. We've also studied the method in a randomized control trial and confirmed that it was very effective. It was published here in the Annals of Internal Medicine. The interviewing method is detailed in your textbook. Now, I'm not going to repeat much of the text material here, so reviewing the book will help you to benefit most from this video presentation. Our aim with these tapes is simple, demonstrate how you conduct the interview step by step by step.
We'll also highlight key areas from a so-called evaluation perspective, that is, areas where you'll need to be especially skilled to do well with exams, preceptors, and clerkships. The plan for this series of videotapes is shown here. Tape 1, The Patient-Centered Interview; Tape 2, The Doctor-Centered Interview. The tapes are not intended for one continuous viewing, but rather for viewing and reviewing short segments, mastering each before you proceed.
While you'll see us interrupt the interview many times to discuss details, we also have included the same patient-centered interview without interruption at the end of this tape so you can see what it looks like as a whole.
Segment:2 Overview of the Medical Interview.
Let's now begin with a background for interviewing patients, just briefly summarizing from Chapter 1 in your book. Interviewing produces the data that allow us to formulate a biopsychosocial description.
There are two types of interviewing, doctor-centered and patient-centered. Doctor-centered interviewing elicits largely disease information, which leads to the bio piece of our biopsychosocial description. Doctor-centered interviewing also avoids much of the psychological and social information we need for a biopsychosocial diagnosis. Rather, it is centered only on the doctor's need to make a disease diagnosis.
Now in contrast, patient-centered interviewing elicits the patient's interests, needs, concerns, and ideas, which lead to much psychological and social data, therefore providing the psychosocial piece of a biopsychosocial description for diagnosis. Obviously, both doctor-centered and patient-centered interviewing are needed to obtain a full biopsychosocial description of the patient.
Let's get an overview of the integrated interview, which we see on the graphic. This is the whole interview. And this is the physical exam. Here is the patient-centered process of the interview, followed immediately, as you can see, by the doctor-centered process. Note that the patient-centered process takes an average of 10% of the total time available, while the doctor-centered process takes 90% or so. Now, these are just averages.
And the patient-centered may take longer. Because this is a new patient interview, it includes all components of the history. The history of the present illness, HPI, is the main reason the patient came in, is the most important component of the entire history. HI, or health issues, deals with issues such as medications, exercise, habits, and alcohol use. The past medical history, PMH, simply indicates significant past events that are not now active, such as a previous appendectomy.
The family history, FH, records information such as the ages of parents, any diseases running in the family. SH, the social history, records such routine information as what job one has, when they were married, what their education is. The ROS is the review of systems. This is a final screen for any symptoms not already mentioned. Now, note that the history of the present illness begins with the patient-centered process and then ends in the doctor-centered process.
It also takes-- the history of the present illness-- nearly half of the entire interview. All the remaining components of the history are obtained during the doctor-centered process. But you'll not remain entirely doctor-centered during this time. See these little patient-centered pockets out here? This is where you return to patient-centered process. For example, while obtaining the family history, if you ask the father's age and the patient begins to cry and says their father just died last month, the next question is not, "How old is your mother?" But rather, one again becomes patient-centered-- these little pockets-- and supports the patient and tries to further understand their sadness before going on with additional doctor-centered questions, such as the age of their mother.
Now, if the initial patient-centered process has been effective, most of the highly charged issues like this will already have been addressed. And these patient-centered periods out here should not take long. Thus, one begins patient-centered and then goes back and forth between patient-centered and doctor-centered, spending most of the time doctor-centered. You will find that the patient-centered process generates psychosocial, , and to a lesser extent, physical symptom data, and that, quite in contrast, the doctor-centered process generates physical symptom and to a lesser extent psychosocial data.
You then synthesize these data into a biopsychosocial description or diagnosis, that is, the patient's story. There are five patient-centered steps and seven doctor-centered steps. You'll be learning Steps 1 to 5 for patient-centered interviewing and Steps 6 through 12 for doctor-centered interviewing.
Segment:3 Basic Facilitating Skills (and demonstration).
Patient-centered interviewing is unique.
We learn much about the patient's psychosocial being here. But we also learn-- and many people don't understand this-- physical symptom data that are highly relevant to diagnosing disease. Before we can conduct the patient-centered process itself, though, you need to master some basic interviewing skills, what we call the facilitating skills. What are these skills? We usually began with open-ended questions, then move to emotion-seeking questions, and then to emotion-handling statements.
Generally, we follow the arrows not only between categories but within each category. So let's look more closely now at how this works. We'll start at the beginning, with non-focusing open-ended skills. There's no focus here. And the conversation just goes any place. For example, you're using silence like I've just done. Or you could use nonverbal encouragement, using your hand or being more attentive, or neutral utterances, such as "uh-huh," "oh," "ah," and things like that.
Basically when using just these non-focusing skills, one is simply sitting and listening and not very active, which we don't want. These skills are not used alone and are simply interspersed with the others. You become active, which we want, by using the next group of skills. Now, the focusing, focusing open-ended skills focus the patient on what they've already said. And they encourage the patient to continue on that topic.
For example, in a patient who's had chest pain, by echoing, you simply repeat the statement, "chest pain." Or you might use an open-ended request, "Tell me more about the chest pain," or a summary, "So the chest pain started yesterday, got worse today, and now you're concerned about your job." What this does with these focusing skills is to focus the patient on exactly where you want them to go, so they don't go off somewhere else.
Now, notice that addressing these focusing open-ended skills to psychosocial data will encourage that direction, while addressing them to physical symptoms encourages that direction. In our little example of chest pain yesterday, worse today, and concern about job, if I say, "Tell me more about your job," it'll take us off in a psychosocial direction. If I say more about "Tell me about chest pain," it'll take us off a physical direction.
Now, either direction's OK at different times, as you'll see shortly. The point right now is that these focusing open-ended skills are the tools we use to focus the conversation where we want it to go. You'll sometimes want to focus on physical data and at other times on psychosocial data, all during patient-centered interviewing. You use these focusing open-ended skills repeatedly, time and time and again, during each interview.
They are the patient-centered skills most relied upon during any interview. The use of these skills will typically have generated some sort of personal story. At that point, emotion-seeking skills now are used to elicit the emotion underlying the story. Emotion is the high point in the interview. And a prime objective of most interviews is to understand the patient's emotional state.
How do we do this? The direct emotion-seeking skills involve the classic interviewing question, "How do you feel about that" or 1,001 variations off that question. The indirect emotion-seeking skills are employed when the direct emotion-seeking skills produce no emotion. A patient may say, well, I don't know. I don't have any feeling. It's a way with the indirect skills to kind of prime the pump, as it were, to find some emotion.
These indirect skills are self-disclosure, inquiring what the impact of the problem is on the patient or on others in the family, or asking the patient about their explanatory model. For example, a patient who acknowledges no emotion on losing a job, you might use the indirect skills this way. "You know, I lost my job once. And I was pretty upset," or "Losing this job, how's this going to affect you?" or "How is this going to affect your family?" or "Why is it you lost this job?
What do you think happened?" All of these are designed to prime the pump and generate some emotion. Now, direct emotion-seeking usually suffices to produce emotion. What do we do when we get an emotion? That's where the next set of skills come in, emotion-handling skills. These are specific statements we use to address whatever emotion has been expressed. We name the emotion.
"You're sad." We understand it. "I can understand that." We respect it. "Gee, you've been through a lot." And we support it. "I'm here to help in any way that I can." The mnemonic, NURS-- for Naming, Understanding, Respecting, and Supporting-- helps to recall these emotion-handling skills.
These should be used three to four times in every interview, even if emotion is not prominent, as you'll see me doing soon. Let's now see a demonstration of the facilitating skills. So Deb, how are you doing? Well, my throat's been a little scratchy and sore. Mm-hmm. Yeah. Say more about the throat. It seems very dry.
And I'm hoarse. And it just hurts a lot when I swallow, especially. Dry and hoarse. Keep going with that. It's just scratchy. And I'm coughing a lot. Mm-hmm. So sore throat, voice, hurting to swallow. That went on for about three days?
Three days. Mm-hmm. And it's getting worse. Getting worse? Uh-huh. OK. OK. How so?
Well, when I wake up in the morning it seems to be the worst. And then as the day goes on, the more I talk, the more I'll lose my voice. As the day goes on? Mm-hmm. Say more about your day. Well, at work, especially. Work. And I just started my job. And so I can't miss any work.
And I really feel like I need to go home, but I really don't want to do that. What is the emotion that goes with that? Can you identify that? Well, it's scary, I mean-- Scary? Yeah. It sounds like it. It's scary. And I'm just very run-down by the end of the day.
Scary about what? Well, that I might lose my job. Lose your job. Mm-hmm. And I don't want to lose it. I just started the job. And I can't take any time off. Mm-hmm. So that's a scary situation for you, isn't it?
It is. I understand. Now, I'm getting the picture of that. Yeah. You've just gotten a new job. And now you've been sick. And you're not being able to perform well. Exactly. I appreciate your mentioning it.
It helps to understand things a little better. We'll have to see if we can't work on something on that to get you better with this. Good. OK. OK. So how do you feel about that? Well, I'm OK with it, I suppose. Mm-hmm.
It doesn't bother me. Doesn't bother you at all? No. You know, I was once in a difficult job situation like that. And I was-- I got to feeling kind of upset myself about it in a difficult job situation like that. Yeah. It is-- it is scary. So how do you feel about that?
I'm OK with it. Doesn't seem to bother me. Doesn't bother you? No. Not too much. How it's affecting your life? Well, my family depends on me to bring home the paycheck. So the family's depending on you, isn't it? Mm-hmm.
Yeah. Yeah. How's that feel for you? It's stressful. I have to-- since I can't take time off and I don't feel well. And it's-- so they're depending on me. They're depending on you. And that is pretty stressful then, it sounds like. Yeah.
And I come home, I'm tired. Yeah. I'm cranky. So you're feeling kind of cranky and stressed and so on. OK. So how are you doing with this emotionally? How does it make you feel? It's OK.
It's OK. Any particular reaction to it, or personal response to it, emotions? No. Not really. Yeah. Yeah. Not really. I'm OK with it. Why do you think this is all happening to you?
In other words, how have you pieced this together in your own mind? What's happening here? You know, maybe the start of a new job, and I'm a little stressed maybe because of that. So there is some stress with that. A little. Yeah, there's a little bit of stress. And it's a little scary. I see. So it is stressful and scary for you, isn't it?
Yeah. Yeah. OK. Well, you've now seen the core skills in the interview. When you're practicing these skills in role play, I suggest you keep the book open to help with recall initially, or even better, write them on the board where the interviewer can see them. They should quickly become second nature. And then you'll no longer need help.
When you've got these facilitating skills down, typically in one session or so, you'll also notice that you're adding no information to the conversation, but rather that you're simply drawing out and facilitating what the patient already has introduced. Indeed, that's the key definition of patient-centeredness in the interview itself. The patient introduces all new ideas. Let's look at some specific suggestions for this practice.
Use only facilitating skills for five minutes, therefore asking no closed-ended questions and inserting no new information into the conversation. You should be able to replicate what you saw me do on the tape by the end of the session. There are some issues we need to think about. Non-focusing skills are easy. Work especially on silence. And note in particular when it causes discomfort, which of course is to be avoided. Focusing questions also are easy.
The key is to use all three types repeatedly, so keep using them off and on to develop a story of any type, medical or personal. Emotion-seeking skills are less familiar to most of us. Also, such inquiry occurs only after you've heard enough about the story to sense that some emotion might be present. Be sure also to practice the indirect emotion-seeking skills, which is what you do when the patient says they have no emotion.
Use all four emotion-handling skills-- name, understand, respect, support-- together in one statement at least three times during the same interview. This is good practice in learning them. Now, during later actual interviews, you usually just use one or two of these at any one time. Among the NURS statements, respect is the most difficult. Practice it and master it. These skills should quickly become second nature where you don't have to think about them.
Keep using them with colleagues, friends, and family. You might even want to try to use them with your professors. Now, see what responses you get. Take your time now and turn the tape back on when you're ready to continue.
Segment:4 Step 1 (Setting the Stage).
Well, now that you can use the facilitating skills, we're ready to begin the actual interview step by step. Step 1 sets the stage for being patient-centered and involves many courtesies and actions to enhance rapport.
Follow your checklist that's in the table. And see how I do. You'll note that I miss some substeps and that others are not in the same order. But don't worry about this. We're pretty flexible and things seem to work out OK. Miss Line? Yes. I'm Dr. Smith.
Hi. Good morning. Hello. Welcome to the clinic. Thank you. Have a seat there, would you? OK. So-- that comfortable for you? Mm-hmm.
That chair is a little awkward sometimes. No, that's fine. Thanks. OK. Good. Good. Did you have any problems getting up here today? Oh, the construction created a few problems for me. But I weaved in and out.
And I'm here. You have to be pretty agile down there with some of that, don't you? Yeah. I was. OK. Good. Well, I apologize for it. It's going to make things better in the long run. But it's hard right now.
How did I do with these six substeps? I accomplished the first three substeps in just a few words at the outset. "Miss Line? I'm Dr. Smith. Welcome to the clinic." Note that I used both of our last names. Get to know the patient before you work on a first-name basis, unless the patient specifies otherwise. Don't hesitate to indicate that you're a medical, or nursing, or physician assistant, or nurse practitioner student.
Be confident that you have something significant to contribute. This is part of your own professional identity. You also should always try to shake hands with the patient. If that's not possible, somebody that's acutely ill, for example, make some sort of body contact, a pat on the knee or the shoulder. Now, except to observe that there was no problem, I really didn't do anything about substeps 4 and 5.
If Miss Line had been distracted, to assist readiness, I'd have attended to what was causing that. Maybe she'd lost her car keys in the waiting room. To ensure privacy, if there had been a lab technician or someone in the room, I'd respectfully have excused them. Now, to get rid of any barriers to communication, I'd have closed the door or turned off a noisy TV set if these were a problem. If there's any question about a patient's ability to hear or see, you should address these problems to maximize communication.
For example, a person with impaired hearing may need to see your lips to best understand what you're saying. Many of these issues are more pressing with inpatients that we're talking about in this first step. For example, someone on a commode or somebody in severe pain, they may not be ready to interview when you arrive. I spent much of the time here in substep 6, ensuring Miss Line's comfort and putting her at ease.
Generally, inquire about comfort, such as the chair. Then engage in some small talk to put the patient at ease. Now this should concern something relevant to them and their care, such as, in this example, convenience getting to the clinic. With inpatients, it could concern something like hospital food or care. These are always good subjects to talk about. This light talk lets the patient know you're a real person. It gives them a chance to warm up a bit.
Segment:5 Step 2 (Chief Concern and Agenda).
Now let's move to Step 2 of the same interview, running continuously.
In Step 2, the interviewer continues to prepare the patient for the heart of this patient-centered process you'll see shortly in Steps 3 to 5. The main goal here in Step 2 is to obtain a list, a list of things the patient wants to cover. Keep critiquing me now by following your checklist. I apologize for it. It's going to make things better in the long run. But it's hard right now. Yeah.
We've got about 40 minutes today. And I need to examine you and ask you a lot of questions. But the main thing I want to know is what you wanted to cover today. That's more important. Well, I'm here because I've got this stomach pain. It's just a lot of pain right here. And I wanted to get this appointment made with you to talk about it. And so that's why I'm here today. OK.
Is there anything else? We'll get back to that. Yeah. Because that's really, really important. Well, I have allergies. And this is the time of the year-- I used to have a prescription. And I think I'll need some refills for that. OK. So the stomach, the allergies.
Anything else? Well, I think I probably need a mammogram since I'm in my 40s now. OK. Good for you. I've been reading I should probably have that. OK. Well, we'll talk some more about that. All these are very important. I still want to be sure if there's anything else you'd like to look at.
I think that's it. I mean, this is why I'm here mostly is the stomach. The stomach is the main thing, it sounds like. Yeah. Yeah. OK. Well, how'd I do with these four substeps? Again, in a few words at the outset, I achieved substeps 1 and 2. I gave the time with "We've got about 40 minutes" and my agenda with "I need to ask a lot of questions and examine you." In the same statement, I then began substep 3, "The most important thing, though, is what did you want to cover today?" Substep 3 can be difficult. It wasn't with Mrs. Line, but it can be.
Here, you simply want to get a list of things that the patient wants covered. It's essential at times-- it wasn't here-- to respectfully interrupt patients who want to tell their whole story right away. That's understandable. Interrupting someone who has begun giving the details of abdominal pain, for example, you might say something like "Now that's important. And we'll get back to that in just a minute. But first I want to make sure we cover everything you want to get at today. Is there anything else?" One then summarizes the agenda, and should be clear on what the major problem-- and that's sometimes called the chief complaint, but be clear on what the major problem is.
If too many problems have arisen, you negotiate which ones to address at this time and set up another appointment to address the others later. Now, some people don't like obtaining the agenda up front like this. They prefer to do it later. That's OK. The problem is this. Most people forget to do it. And then you never learn all the things the patient wanted to address. And this is a common patient complaint.
I didn't get to tell the doctor everything I wanted to. This is a good point now to stop and practice these new skills in Steps 1 and 2. Here's a suggestion on the graphic to guide you. Conduct both Step 1 and Step 2 together, including all substeps. There are six in Step 1 and four in Step 2. Work on developing simple opening statements for each step, much as I demonstrated on the tape. Include several substeps in one sentence or four.
It doesn't take more than that. Another learner can critique which substeps you missed, how effectively you were with each substep, and make recommendations for the next exercise. You should practice these until you can do them without looking at the book. It's OK to look at the start. It won't take you long. Let's pause here now and practice.
Segment:6 Step 3 (Opening the History of Present Illness [HPI]).
Now that you've worked effectively with Step 1 and Step 2, we can begin using the facilitating skills you've already learned.
Step 3 is very brief. It relies on the simple, non-focusing facilitating skills-- silence, neutral utterances, and nonverbal responses. The patient can go wherever they wish during this very brief step as we just sit and listen. Keep critiquing. That's it. I mean, this is why I'm here mostly, is the stomach. The stomach is the main thing it sounds like. Yeah.
Yeah. OK. So how are you doing with that? Well, it hurts right here. And it's been hurting for a while. But it's worse than it used to be. I mean, I've had this for a long time. But it's worse than usual. It hurts.
I just-- I have to have somebody check me out, because it's really bothering me. Yeah. It sounds like it. So how did I do this time with these three substeps? My open-ended beginning question was "Tell me more about that," the stomach pain. This question always refers to the major problem, chief complaint, just elicited in Step 2. Sometimes when there's just one or a few related agenda items, the patient begins talking freely, in which case a beginning question is not even necessary.
Practice open-ended beginning questions. And be sure they focus on the chief complaint and then let the patient go anywhere they want with that. In essence, after opening, after this open-ended beginning, I just sat back and listened attentively. I used a lot of silence. I was attentive nonverbally. And I made some neutral utterances, you know, "uh-huh," "oh," and stuff like that. It's impossible to focus the patient this way, however.
Therefore, it goes anywhere. This thus is a very short step. And you must take care not to continue in this passive way for more than 20 or 30 seconds. Because you've practiced the facilitating skills already, we're not going to repeat practice sessions now for Step 3, 4, and 5 individually. We'll review the remainder of the patient-centered interview--
Segment:7 Step 4 (Completing the HPI – most important step).
steps, 3, 4, and 5-- and then practice the whole interview together. Now to Step 4.
This is a much longer step. It's the key step in the entire interview, doctor-centered or patient-centered. This is where you're going to spend most of your time practicing. Now, let me urge you to review this material in your text, especially the transcript. This will help you learn this most difficult step of the whole interview. Here the interviewer becomes much more active and repeatedly focuses on parts of the conversation already introduced by the patient.
Thus, while not introducing new material, the interviewer focuses on certain utterances of the patient to draw out the story in a focused or selective way. To summarize, you have already set the stage and the agenda in Steps 1 and 2, and listened attentively in Step 3, this whole thing probably taking you no more than a minute or two to get to this point. You now use the skills on the graphic in the order given.
Selectively focus on physical symptom utterances using focusing open-ended skills, taking maybe one to two minutes. Shift the focus to psychosocial utterances, again with focusing open-ended skills, in a matter of maybe two to four minutes. Then the third shift is to shift to emotion-seeking skills to elicit the patient's emotion. Once you've got the emotion, address it using your emotion-handling skills.
Now this is just a simple recap of what you've heard already. And indeed you've practiced it already when you learned the facilitating skills. There's absolutely nothing new here except that we now specify where to place the focus with these skills and in what sequence, again physical to psychosocial to emotional. Step 4 is more complex. And because of this, we're going to stop for discussion after each substep.
We'll do all we can to keep this clear. In our experience, you'll be able to conduct the patient-centered interview being demonstrated after you've practiced it with two to three patients. Proceeding continuously from Step 3, you now become much more active in Step 4. Patients usually present with physical symptoms. They're in a medical setting. This is the usual affair. Focus on these initially using the focusing open-ended skills.
Remember echoing, requests, summaries. check me out, because it's really bothering me. Yeah. It sounds like it. Say more about the pain. Well, it kind of burns in here. And it hurts a lot of the time. It's not just every now and then. Lately it's been hurting much more.
Mm-hmm. And it just goes on and on and on. And so I decided just to make an appointment. You say lately. Oh, probably the past couple weeks, it just seems worse than usual. Like I said, it's been on again, off again for years. But-- So it has been going on for years. That's what I was-- Oh, yeah.
This has been going on for years, since-- It's going on for years, worse in the past couple weeks. Yes. And you're wanting to get this looked into. Yes. Aren't you? Yeah. Yeah. It just bugs me.
Let's review now some of the critical points we've seen. For my choice, I said, "Say more about the pain," an open-ended request that focused her on the physical symptom. If she'd also said the pain was affecting her job at that point, that's not a physical symptom, but a psychosocial utterance. And to focus on the job would move her away from the physical symptom we need first to hear about. So for right now, always get the physical symptom data first.
Later you may want to vary this some time. Note how I use these skills repeatedly, echoing "lately," and then "going on for years," and then summarising to focus on physical symptoms rather than psychosocial utterances. I resisted the urge to insert new information and ask about certain details I know we'll need to diagnose disease. For example, where'd this pain radiate? What relieved it?
Were there any black stools? I know we need all this information for disease diagnosis. But I also know we'll get to these in the doctor-centered interview in 5 or 10 minutes. It's during this substep that highly diagnostic disease information often develops. This is in addition to psychosocial information. In fact, this is what Osler was telling us when he said listen to the patient. She or he is telling you the diagnosis.
You probably will want to stay focused on the physical symptoms for another minute or so longer than I did here. I cut it too short, I think. While I could've kept her there, I decided to select a non-physical focus, that the problem bugs me. This leads us to the next step, where we get to the psychosocial context of her abdominal pain. You'll see now how this story shifts from physical to psychosocial.
Now the interviewer will focus on the previously avoided psychosocial utterances to now get the personal context of the physical symptom, again using the same skills-- focusing open-ended skills, echoes, requests, summaries. This will produce an essential transition from physical to psychosocial, the start of the mind-body connection, or if you prefer, the connection of bio and psychosocial.
It just bugs me. It hurts and irritates me. It bugs you, yeah. How-- bugs, irritates. Say more about that. It just-- I don't have time for this pain. I do not have time for the stomach bothering me. I'm a busy person. And it's just aggravating me.
Yeah. Tell me more about busy. Well, I'm a lawyer. And I work all day. I have-- I'm married. My husband travels a lot. And we have two kids, two twins. OK. And so it's a lot of stuff.
Wow. Wow. Twins. Twins. Yeah. They're busy little beavers. I'll bet they are. How old? They're only four years old.
Wow. Yeah. So they're active little guys, you know. Both of them are running around. So you're a lawyer. You've got twins. Your husband's traveling a lot. Yes. And you've got stomach trouble.
Big stomach stuff going on. And I feel like I don't have time to keep up with everything, because I've got a lot of demands going on. Mm-hmm. So that's why I came here today, to see what medicine or whatever I can do to take care of this. Oh, I think it's a good thing to come in. It sounds like it needs to be looked at. I echo Miss Line's "bugs me." This is not a physical symptom, but a psychosocial utterance.
Notice the difference. I find having done that that she's busy, another psychosocial utterance, to which I make an open-ended request. "Tell me more about busy." She then indicates having twins. I echo this. And after a long silence, she indicates they're busy little beavers. In a matter of just a few seconds, by selectively focusing on psychosocial utterances, we've learned that she is bugged, busy, and why.
Much of the remainder of the interview simply amplifies this theme. Recall that Miss Line also mentioned her husband. But I didn't focus on that. I could have just as well. The basic story doesn't change. And the material about the twins, had I focused on the husband, would simply have arisen a little later. Just as you'll see shortly, that material about her husband emerges. Don't worry about which clue to focus on.
Just pick whatever seems to be a good one and stay with that narrative thread. The specific open-ended skill used doesn't make any difference. For example, one might use open-ended request, "Tell me more about that," where I've used echoing and vice versa. It's an important point that patients don't give the whole story all at once. They don't just dish it out to you, as you saw with Miss Line. The story rather must be drawn out a step at a step at a step at a time, using the facilitating skills every point along the way.
You just keep drawing the story out. Notice that Miss Line returned to physical complaints. We were in psychosocial. But she went back to physical just before we stopped this segment. We don't usually want to return to a physical focus once we've moved beyond it, because this will prevent further development of psychosocial and emotional material. These things don't get as well developed if you go back to physical. Besides, we're going to be addressing physical symptom details in just a few minutes in the doctor-centered inquiry.
Refocusing the patient often involves interrupting. Always done respectfully, such interruptions allow us to focus on crucial information in an efficient but caring way. This in fact would've been a very good time to refocus on her husband. I didn't do that. But it would've been a good idea.
I, after a brief supportive remark, chose to refocus her on a special type of psychosocial data, her emotions and our next topic. We began Step 4 with a focus on physical symptoms, and then extended our focus to the psychosocial context of the symptoms, as you just saw. We now expand further to learn the emotional context, thus fully establishing the critical mind-body link.
Although continuing to use focusing open-ended skills, we will also begin to use the emotion-seeking skills. These identify the emotional responses of the patient. And inquiring once is often not sufficient, as you'll see. If the patient does not respond with an emotion to my direct inquiry, the interviewer tries again a couple more times.
And if that doesn't work, then you go to using the indirect emotion-seeking skills. So let's see how this looks. It sounds like it needs to be looked at. I want to backtrack just a little bit. How are you feeling about this, you know, emotionally with all this going on? What's-- Well, it just-- this is really hurting me. It just, it hurts and just doesn't feel good. Painful.
Yeah. It's pain. Yeah. But what's the emotion that goes with that? Can you identify that inside of you? Well, I'm ticked off. I guess that's-- I thought you said that earlier. That's what I was wondering.
Yeah. I mean, I get a little angry if I have pain, and it's bothering me, and I'm trying to get things done. So I don't know why that's important. But I mean it-- yeah. And my husband is gone much of the time. He travels a great deal. So he's gone. He's gone much of the time.
And so I do a lot of this by myself. How do you feel about that? Well, I get a little angry, I guess. That might be the appropriate word. Frustrated. Frustrated, angry. At-- At the amount of time that I'm always busy. I guess I'm just frustrated that I don't have time to do everything.
There are several important points here. It turns out that many are not familiar with exactly what an emotion is. Now in general, emotions can be classified in three categories, mad, glad, sad. But you want to be able to be more refined than this in identifying your patient's emotions, so take some time to review the various and many different emotions.
Emotions are the earliest-- they're preverbal, before we ever learn to talk-- and they are the most important form of communication about the person. Accordingly, they are a central focus in patient-centered interviewing. Eliciting and responding to emotion is the key-- underline, the key-- to establishing the relationship and maximizing communication.
Now, of course if the patient is already expressing emotions as a result of previous open-ended inquiry, the emotion-seeking skills are not needed and one proceeds to handle the emotion, as we'll show you in the next substep. In the usual case, though, where patients are not spontaneously expressing emotion, the direct inquiry suffices, using something like, "So how does that make you feel?" "How do you feel about that?" "What's the feeling that goes with that," and so on.
There are 1,001 variations of that. Now with some patients, you need to specify that you're not talking about a physical feeling. When you say, "How do you feel about that," they might say, "Well, it hurts." So in this circumstance, it helps to emphasize, "How do you feel, you know, personally or emotionally?" Now there's an important caveat. As we saw indeed with Miss Line, people often seem to respond when asked about an emotion.
But they give instead a thought. In this case, you've got to recognize this disparity and redirect them to the emotion. For example, "I understand you're thinking about that. Now what I'm asking you is, what's the emotion, you know, personally in here? What's your emotional reaction, your feelings?" From a skills perspective, note also that we keep using and interspersing open-ended skills to better develop the emotion.
For example, once having identified frustration, "Say more about being frustrated." That's an open-ended request. So that once you hear an emotion, develop it with your focused open-ended skill. To this point, however, we've done nothing about the emotions. We've just developed them. When we've heard enough about the emotion to ourselves understand the situation, we then proceed to address the emotion.
Once emotions have been identified, either by the emotion-seeking inquiry we just outlined or sometimes spontaneously expressed emotion, once identified, they are addressed using yet another set of the facilitating skills that you've already heard about, the emotion-handling skills-- naming, understanding, respecting, and supporting, N-U-R-S. Because emotions are the most basic means of human expression and communication, deep contact with the patient is possible only when emotion-seeking and emotion-handling skills are used.
Let's see how. I don't have time to do everything. And then I get this pain. It's-- I got it. It's frustrating. Yeah. Yeah. Well, I understand.
You've done so much stuff. You're working all the time. Then you come home and work. That's a busy, tough life. It is busy. Isn't it? It's busy. Mm-hmm. I appreciate your sharing it here.
It helps. It helps me to get a little better sense of what needs to be done, maybe how we can help you better with that. But that's been a tough time. I didn't use all four skills at once. I named anger and frustration several times earlier, and then used the last three, the U-R-S, understanding, respecting, and supporting. Respecting was "You've been through a lot." And I also praised her for coming in.
And the support was "It better helps me to help you." Now, once you've learned these skills, they're then used just one or two at a time. And you might think of it as sprinkled throughout the interview like this, as you'll see me do through the patient-centered and the doctor-centered interview. You're always sprinkling a little dose of the emotion-handling skills all through the interview. Respect is shown in two ways. "You've been through a lot" acknowledges the patient's plight.
"Your did right in coming in" praises the patient. So acknowledge plight, praise the patient in some way. That's a respect statement. Support is shown by direct statements. "We're here to help you." But it works even better if you use an inclusive type of language. "We," "you and I," "us," "working together." Note that Miss Line added the following information we'd not yet heard after I used the NURS, that she was always taught to hang in there.
Thus, NURS not only addressed emotion, but it also generated and led to deepening the story, initiating a new chapter, which you then pursue open-endedly, as we'll see next. Because as you saw, addressing emotion usually produces additional non-emotional information, the interviewer can start a new cycle of skills. You simply return to the focusing open-ended skills to develop the newly arising story, the new chapter, and then in turn seek additional emotion, and then handle the newly developed emotion using NURS.
This amounts to the second chapter in the story. The third and subsequent chapters are similarly developed using the same cycle of core dynamic skills. Let's look for new chapters now in Miss Line's story. hang in there and do all this. Hang in there. What-- where does that come from? What do you mean? Oh, I guess it probably comes from my parents.
We just always had to hold on, you know, hang on and get things done and-- Mm-hmm. We-- that's just the way I was raised. Yeah. So you were raised to kind of be a pull them up by the bootstraps person. Absolutely. Yes. And work ethic, strong work ethic. Work ethic.
Yeah. It sounds like it. So I don't complain often, which is-- you know, it's unusual for me to even be here. But I finally thought enough is enough. What's that like being here and talking about that? It feels good to say to you that I get angry and frustrated. It's just that I'm not used to saying that. And it's part I don't really talk about much. Yeah Yeah.
I don't talk a whole lot about the feelings usually. But that's-- feels OK. Yeah. Good. Good. What are the important points to be made here? How many additional chapters of the story did we hear? With my repeat of a respect statement-- "It's been tough," I said-- she initiated the next chapter when she went on to say she didn't think of it as tough, that she'd always been taught to just hang in there, she said.
I echoed this. "Hang in there." And she then went on to mention her parents and how she'd been taught this attitude. I summarized with a pull yourself up by the bootstraps comment. And she further deepened the story by noting her work ethic. She then volunteered that she didn't complain and that in fact it was unusual even being here, referring to our interaction.
Now, instead of focusing on the obvious comment about never complaining and it's attended emotion-- which I probably should have, it would have been very appropriate to do-- I moved her to yet the next chapter by asking what it was like being here seeing me. So in a very short time, we've heard two more chapters of her story. In general, it doesn't make much difference which of several clues you follow, because as they say, all roads lead to Rome.
That is, whatever clue you pick is heading the same basic place. If one focuses on utterances from the here and now and those referring to emotion, the story moves along more quickly. The only difference from usual hypothesis testing during patient-centered interviewing is that you can't directly ask the question if it adds new information. Rather, you focus the patient in the area where their continued narration produces the answer to your hypothesis.
For example, if you hypothesized, and you well might have, that Miss Line wanted to divorce her husband, you can't just ask that. It wouldn't be patient-centered, because she hasn't mentioned divorce. Rather, she has mentioned her husband. So you focus the conversation on her husband, and she'll inform the question herself. That's how you test a hypothesis. Even if the patient doesn't raise the issue, it's appropriate towards the end of the patient-centered process, when you realize you're getting to the end, to inquire about how your interaction with them has gone.
This is invaluable feedback. You are directly monitoring your doctor-patient relationship. I mean, in fact, we monitor blood pressure and pulse all the time. We also monitor our doctor-patient relationship. And by doing this, it allows us to calibrate our subsequent responses according to the feedback we get. Now, not unlike Miss Line, patients typically are quite positive with patient-centered inquiry. And they say, for example, things like how unique it was to be listened to, how they felt understood, how the doctor seemed to really care about them, and how different it was from their usual interactions.
I knew we were running close to 10 minutes, and that we'd heard several chapters of her story and that Miss Line was not acutely disturbed. You can see that yourself. That meant it was OK to move out of the patient-centered process, as we'll see next. On the other hand, it would have been appropriate to continue patient-centered exploration of Miss Line's story if I'd wanted to or had enough time. Even though patients typically have significant problems, it's truly rare that issues requiring immediate attention and therefore more time are present.
Thus, in the vast majority of circumstances, 5 to 10 minutes will suffice, making this method very efficient. Your guideline is, has the patient been able to say enough to feel understood and unique? You don't have to understand the multiple chapters in her entire story, just the first few. When first learning this material, though, I urge you to spend at least 15 or 20 minutes in this patient-centered process, just to experience the depth of people's stories, the human existence.
Segment:8 Patient-Centered Interviewing – Step 5 (Transition to Doctor-Centered Interview).
So we're now ready to make a transition to the doctor-centered process. This step is designed to provide a smooth transition from patient-centered inquiry, where the patient leads, to the doctor-centered inquiry, where the doctor leads and asks many questions of quite a different type. Much of the new information will be added by the doctor during this doctor-centered process.
If this transitional step is not performed, the patient can become confused by the change in interviewing style. One often summarizes the story, uses the emotion-handling skills one final time, and then announces that a change in style is about to occur. I don't talk a whole lot about the feelings usually. But that's-- feels OK. Yeah. Good. Good.
Well, my sense is you've had the stomach trouble off and on for quite some time. Mm-hmm. And there's lots of extra work and things involved in your life. And you're kind of angry, upset about some of these things. I'd like to ask a few more questions about the stomach, some specifics if it feels like it's an OK time to move to that. Oh, yeah. That's what I'm here for. So what are the critical points here?
I made a summary. I also checked to see if she had any more to add. And I then indicated that specific questions about her pain-- I was warning her we were about to change to lots of questions-- that these were about to follow. Notice as with Steps 1, 2, and 3, this step, Step 5, takes very little time. I took no more than 15 or 20 seconds here, I don't think. Miss Line now should be prepared for the different type of closed-ended doctor-centered questioning that's about to come in the doctor-centered process on the next tape.
Now that you've seen the entire patient-centered interview, let's revisit the question we considered in your first exercise on this tape. What is the value of taking a small amount of time to perform the patient-centered interview? It took about six minutes with Miss Line. That is, what argues for including this quickly-obtained, patient-centered material rather than going straight to doctor-centered interviewing to make a disease diagnosis?
Let's review the very distinct advantages from integrating patient-centered interviewing with doctor-centered, as shown by many rigorous studies cited in your text. For example, patient satisfaction, and in turn patient compliance, are significantly related to patient-centered practices. Shopping for another doctor is decreased among patient-centered caretakers. Malpractice suits are decreased if we simply integrate a patient-centered approach.
Most important of all, though, health outcomes are improved if we incorporate a patient-centered approach, as shown in many randomized control trials. To cite just a few examples, it's been well shown that there is better blood pressure control in hypertensives if we're patient-centered. It's been shown that there is more rapid healing of ulcers in duodenal ulcer patients if we're patient-centered. It's also been shown that there is better glycohemoglobin and blood sugar control in diabetics if we're patient-centered.
We've seen also that there are improved perinatal outcomes when mothers received patient-centered care. And there are shorter and less complicated post-operative stays in surgical patients treated in a patient-centered way. Now, there are much more data than this. But we already can see the tremendous benefit that accrues from spending just a small amount of time being patient-centered. This is especially important in this era where evidence-based medicine is rightly valued.
These data I've cited show that patient-centered medicine meets the criteria of evidence-based medicine. That is, there are rigorous data supporting a general patient-centered approach. I'm now going to suggest some practice guidelines for learning the entire patient-centered interview, the five steps and the 25 substeps. Initially it works best to practice the interview in role play, typically during small group sessions. At first, use the book or write the steps and substeps on the board so the interviewer can see them.
Soon you'll have mastered these. And you won't need this help. Colleagues can critique how well you did in getting all the substeps in each step during your role play. On the graphic, I've listed some suggestions to guide your early role play interviews. First, perform a patient-centered interview in 15 minutes. This is your charge. Spend about one minute each in Steps 1, 2, and 3, and Step 5. And then spend the remainder of the time, 10, 12 minutes, in Step 4.
Your initial goal is to be able to get through all 5 steps and 25 substeps. Now, this seems like a lot. But these are very easy. And they come quickly. Indeed, they become reflexive with just a little bit of practice. When you're critiquing a colleague's interview, you can help considerably. Be sure to note which substeps were incomplete or missed. This is essential feedback in learning the patient-centered interview.
When you can recall and use all the steps and substeps in role play, usually in one or two sessions, you're ready to start working with patients, real patients or simulated patients. It helps for subsequent critiquing if these patients' interactions are videotaped or audiotaped. After initial mastery of the substeps, the problems on the following graphic often merit special attention to guide further progress. Avoid hurrying too much to get into the interview.
At the outset, attend to the patient's comfort, including some small talk related to their care, convenience of the clinic, what's the hospital food like, or whatever's appropriate to the situation. Be careful about inefficient agenda setting. Recall that all you want in Step 2 is a list of the patient's concerns. And remember also that you may need to respectfully interrupt to be efficient. Don't prolong Step 3. Step 3 should last no more than 20 or 30 seconds as you simply listen attentively.
A major problem we've observed is not touching the three key bases in Step 4. Recall that you begin with an open-ended focus on physical symptom utterances, then shift the open-ended focus to psychosocial utterances, and then elicit and address the emotional findings. The single greatest problem we've seen is incomplete use of emotion-seeking and emotion-handling skills.
Be sensitive to comments that suggest some underlying emotion, even positive emotions. And then, actively seek these emotions out with your emotion-seeking skills. "How'd that make you feel?" When you have elicited and understood the emotion, then NURS it. Name it, understand it, respect it, support it. As a general guideline, you should inquire about emotion at least three different times in an interview. In turn, you should use the NURS at least three times in each interview.
Now, even if you get little emotion using NURS, use it anyway in any difficult situation. You're always sprinkling one or two NURS statements throughout the interview. Ineffectively signaling the patient about the transition to doctor-centered interviewing can also be a problem. This takes just a couple comments to prevent this, and keeps the patient from being surprised and confused. Now, you'll overcome these common problems easily with a little work and good feedback from your colleagues.
As your progress continues, you'll notice that the items in the next graphic start falling into place. You'll develop a nice narrative flow, producing a sensible story. This is the patient's story. The story often is not complex or emotion-laden. But it is this particular patient's story. And its understanding is essential to developing a relationship. You'll find also that you understand how symptoms link to personal and emotional items.
That is, you have elicited and understood the mind-body connection, or the biopsychosocial totality of the patient. You'll find also that you can use these focusing skills to guide the interview wherever you want it to go. This lets you test hypotheses and be efficient, as well as to initially focus on physical symptoms and later change the focus to personal and emotional issues. You'll find also that you can skillfully and respectfully interrupt.
The old idea that interrupting is bad applies only if you change the subject to something the patient has not yet talked about. It's perfectly OK to change the conversation back to something the patient already has mentioned. This indeed is how you refocus the patient to address key areas that may have slipped by ever so quickly, especially critical personal and emotional utterances.
Now, you'll find also that you are indeed in control of the interview. While you're yielding control to hear the patient's needs and concerns, you are in charge of this process. And you control its direction and how long it lasts. You'll find also that you can effectively critique a colleague's interview. Now this is essential for their learning and for your continued success, as we'll develop shortly. You'll find also that you are efficient. Most interviews, by the time you've learned this, should require no more than 5 to 10 minutes in this patient-centered process.
Indeed, when you become facile, it usually can be accomplished in three to five minutes. Again though, I urge you while learning to spend much more time exploring the depths of patient stories. This is how you learn about the human condition. When you've completed this instruction, you will have mastered the most complex skill required of the caretaker, the patient-centered interview. You will now be able to establish an effective relationship with your patients and communicate effectively with them and achieve the improved outcomes we just reviewed, especially health outcomes.
You'll perform some 200,000 interviews during your career, so it is essential to continue practicing these skills and to continue monitoring your own patient-centeredness. This can be done easily by self-critique of audiotaped recordings that you make of your own patient interactions during all levels of training and subsequent work. Keep reviewing how patient-centered you are. You've now completed by far the most difficult part of the interview.
With practice, the five-step method will become second nature and automatic. You are well on your way to becoming a humanistic and scientific physician. Good luck and godspeed.
Segment:9 Steps 1-5 Uninterrupted by Commentary.
Miss Line? Yes. I'm Dr. Smith. Hi. Good morning.
Hello. Welcome to the clinic. Thank you. Have a seat there, would you? OK. So is that comfortable for you? Mm-hmm. Yeah. That chair's a little awkward sometimes.
No, that's fine. Thanks. OK. Good. Good. Did you have any problems getting up here today? Oh, the construction created a few problems for me. But I weaved in and out and I'm here. You have to be pretty agile down there with some of that, don't you?
Yeah. And I was. OK. Good. Well, I apologize for it. It's going to make things better in the long run. But it's hard right now. Yeah. We've got about 40 minutes today.
And I need to examine you and ask you a lot of questions. But the main thing I want to know is what you wanted to cover today. That's more important. Well, I'm here because I've got this stomach pain. It's just a lot of pain right here. Yeah. And I wanted to get this appointment made with you to talk about it. And so that's why I'm here today. OK.
Is there anything else? We'll get back to that. Oh, yeah, because that's really, really important. Well, I have allergies. And this is the time of the year. I used to have a prescription. And I think I'll need some refills for that. So the stomach, the allergies. Anything else?
Well, I think I probably need a mammogram. OK. Good for you. Since I'm in my 40s now, I've been reading I should probably have that. OK. We'll talk some more about that. All these are very important. I still want to be sure if there's anything else you'd like to look at. I think that's it.
I mean, this is why I'm here mostly, is the stomach. The stomach is the main thing it sounds like. Yeah. Yeah. OK. So how are you doing with that? Well, it hurts right here. And it's been hurting for a while. But it's worse than it used to be.
I mean, I've had this for a long time. But it's worse than usual. It hurts. I just-- I have to have somebody check me out, because it's really bothering me. Yeah. It sounds like it. Say more about the pain. Well, it kind of burns in here. And it hurts a lot of the time.
It's not just every now and then. Lately it's been hurting much more. And it just goes on and on and on. And so I decided just to make an appointment. OK. You said lately. Oh, probably the past couple weeks, it just seems worse than usual. Like I said, it's been on again, off again for years, but-- So it has been going on for years.
Oh, yeah. That's what I was-- OK. Oh yeah. This has been going on for years, since-- It's going on for years, worse in the past couple weeks. Yes. And you're wanting to get this looked into. Yes. Aren't you?
Yes. It just bugs me. It hurts and irritates me. It bugs you, yeah. How-- bugs, irritates. Say more about that. It just-- I don't have time for this pain. I do not have time for the stomach bothering me. I'm a busy person.
And it's just aggravating me. Yeah. Tell me more about busy. Well, I'm a lawyer. And I work all day. I have-- I'm married. My husband travels a lot. And we have two kids, two twins. OK.
And so it's a lot of stuff. Wow. Wow. Twins. Twins. Yeah. They're busy little beavers. I'll bet they are. How old?
They're only four years old. Wow. Yeah. So they're active little guys. You know, both of them are running around. So you're a lawyer. You've got twins. Your husband's traveling a lot. Yes.
And you've got stomach trouble. Big stomach stuff going on. And I just-- I feel like I don't have time to keep up with everything, because I've got a lot of demands going on. Mm-hmm. So that's why I came here today, to see what medicine or whatever I can do to take care of this. Oh, I think it's a good thing to come in. And it sounds like it needs to be looked at.
I want to backtrack just a little bit. How are you feeling about this, you know, emotionally with all this going on? What's-- Well, it just-- this is really hurting me. It just, it hurts. It just doesn't feel good. Painful. Yeah. It's pain.
What's the emotion that goes with that? Can you identify that inside of you ? Well, I'm ticked off. I guess that's-- Well, I thought you said that earlier. That's what I was wondering. Yeah. I mean, I get a little angry if I have pain, and it's bothering me, and I'm trying to get things done.
So I don't know why that's important. But it-- I mean, it-- Yeah. And my husband is gone much of the time. He travels a great deal. So he's gone. He's gone much of the time. And so I do a lot of this by myself. How do you feel about that? Well, I get a little angry, I guess.
That might be the appropriate word. Frustrated. Frustrated, angry. At-- At the amount of time that I'm always busy. I guess I'm just frustrated that I don't have time to do everything. And then I get this pain. It's-- I got it.
It's frustrating. Yeah. Yeah. Well, I understand. You've done so much stuff. You're working all the time. You come home and work. That's a busy, tough life. It is busy.
Isn't it? Mm-hmm. I appreciate your sharing it here. It helps. It helps me to get a little better sense of what needs to be done, maybe how we can help you better with that. But that's been a tough time for you. Well, I guess that I hang in there and do all this. Hang in there.
What-- where does that come from? What do you mean? Oh, I guess it probably comes from my parents. We just always had to hold on, you know, hang on and get things done. And-- Mm-hmm. That's just the way I was raised. Yeah. Yeah.
So you were raised to kind of be a pull them up by the bootstraps person. Absolutely. Yeah. Work ethic, strong work ethic. Work ethic. Yeah. It sounds like it. So I don't complain often, which is-- you know, it's unusual for me to even be here. But I finally though enough is enough.
What's that like being here and talking about that? It feels good to say to you that I get angry and frustrated. It's just that I'm not used to saying that. Uh-huh. And it's part I don't really talk about much. Yeah. Yeah. I don't talk a whole lot about the feelings usually. But that's-- feels OK.
Yeah. Good. Good. My sense is you've had the stomach trouble off and on for quite some time. Mm-hmm. And there's lots of extra work and things involved in your life. And you're kind of angry, upset about some of these things. I'd like to ask a few more questions about the stomach, some specifics if it feels like it's an OK time to-- Oh, yeah.
That's what I'm here for.
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