Flashcards in Ch. 12 - Interviewing Deck (18):
The Health Care Interview
- arguably the most sensitive of interviews because it deals with the mental and physical well-being of the interviewee. interviewers have wide variety of medical training, practices, specialities, competences, experiences and their interactions with patients may range from routine checkups, inquiries about health care concerns, treatment for minor illnesses, and minor surgeries to critical, life-threatening situations that seriously impair the patient's ability to communicate effectively
- purposes of HCI are to asses a person's mental or physical health, provide this person with relevant and accurate info, and prescribe courses of action that will meet the person's health needs and concerns
- whether or not you are planning a career in health care, you have and will take part in HCI's with varying degrees of seriousness throughout your lifetime. the growing emphasis on preventative medicine will increase the frequency of such interviews and you are likely to establish long term relationships with a wide range of health care professionals
Ethics and the Health Care Interview
- ethical issues are invovled in most, if not all decisions that relate to the goals, design, implementation and evaluation of any health care intervention. these ethical issues are often implicit and embedded in subtle decision-making processes and their delineation requires as assessment of unintended impacts
- it's difficult to create and apply a single code of ethics to complex health care interventions and assessments that pertain to specific individuals with specific needs, problems and abilities in specific situations, and with specific health care providers who may range from license practical nurses and emergency medical technicians to highly trained specialists in practices such as neurology, oncology and psychiatry
- the effort to develop a suitable code of ethics is important bc interventions that are sensitive to ethical concerns are more likely to gain the trust and respect of intended populations and collaborators. codes developed by a variety of health care associations provides us with a core of ethical principles of standards appropriate for the health care interview.
- the centuries old adage of do good and do no harm is considered paramount or foremost ethical maxim for health care providers and includes physiological, psychological, social and cultural aspects of harm and good.
- the intention to do good can result in harm. recommended physical activities or medications may result in injuries or health complications. to do good while avoiding harm, then, includes such principles as being competent as a health care provider, remaining within your area of competence, communicating truthfully, assuming responsibility for individual and professional actions, and reporting health care professional who appear to be deficient in character or competence.
Ethics and the Health Care Interview
- truthful communication also requires that all relevant information should be provided as indicated by the ethical standard of completeness and accuracy
- health care providers must respect the rights and dignity of each patient. U.S. public policy and medical ethics recognizes that access to quality emergency care is an individual right that should be available to all who seek it. the vulnerability of patients is of particular concern.
- caring defines nursing, as curing often defines medicine. the nurse attend to the vulnerability of a patient, principally because the patient's needs have the potential to create dependency.
- HCP must safeguard the patient's right of confidences and privacy and should disclose confidential info only with the consent of the patient or when required by an overriding duty such as the duty to protect others or to obey by the law
- HCPs must respect diversity of patients an avoid any act that excludes, segregates, or demeans the dignity of the patient. the code for emergency medical technicians says its providers must encourage the quality and equal availability of emergency medical care
- they must provide services based on human need, with respect for human dignity, unrestricted by consideration of nationality, race, creed, color or status. other codes include characteristics such as ethnic origin, age, socioeconomic status, and sexual orientation
- there may be built in problems with meeting this standard. the obligations to promote ppl's health by encouraging them to adopt health promoting behaviors may conflict with the obligation to respect their autonomy
- ppl have intrinsic right to make decisions by themselves and health care providers may come from dif ethnic groups, whose values and life circumstances are different from those of their patients
- use a culturally centered approach that provides marginalized groups with chances to engage in critical dialogues and have their voices heard by their own community
- must maintain appropriate boundaries in the provider patient relationship. the psychiatrist shall be ever vigilant about the impact that his or her code of conduct has upon the boundaries of the doctor patient relationship. the inherent inequality in the doctor patient relationship may lead to exploitation of the patient. the relationship of the provider and patient is critical to the health care interview
Patient-Centered Care (PPC)
- perceptions and practices of health care are undergoing significant changes in the 21st century as health care practitioners and patients espouse a collaborative partnership, as mutual participation in health care
- PPC places an emphasis on patients and providers as co-agents in the problem-solving context. tis new trend, or what some sources argue dates back to ancient Greece, assures that patient needs preferences and beliefs are respected at all times.
- partnership building communication assists patients in assuming a more active role in the medical dialogue, either through active enlistment of patient input (asking for patient's opinion and expectations, use of interest cues, paraphrasing and interpreting the patient's statements to check for physician's understanding and explicitly asking for patient understanding) or passivity by assuming a less dominating stance within the relationship (being less verbally dominant)
- advocates of co-agency contend that when patients are more actively invovled as partners, rather than passive bystanders, they are more satisfied with their care, receive more patient-centered care such as info and support, are more committed to treatments and managing health issues, have a stronger sense of control over their health and experience better health
- patient-centered health care can advance in the US if both parties hare control and actively seek to reduce relational distance.
- although both parties are unique in some way, they share many perceptions, needs, values, beliefs, attitudes and experiences. both should strive to maintain dignity, privacy, self-respect and comfort.
- goal of HCI is the develop a reciprocal relationship, where the exchange of information, identification of problems, and development of solutions is an interactive process
- relationship btwn patient and provider is the most critical component of the health care delivery process. establishing a collaborative relationship tends to ensure that HCPs respect patients wants, needs and preferences and that patients have the info and support to make effective decisions to take part in their health care.
Patient-Centered Care (PPC)
- how patients perceive their relationships with their providers influences how they take part in the interview
- reducing relational distance is central but neither party should rush this relationship too quickly. each party must try to know and understand one another bc mutual understanding reduce relational distance. may enhance relationship by trying to be relaxed and confident, showing interest in one another as unique ppl, maintaining objectivity, being sincere and honest, using respect, paying attention to verbal and NV cues, remaining flexible and maintaining appropriate degrees of control
- a reciprocal relationship is key, both parties must strive to reduce relational distance
- respect rights and dignity of every patient.
- although it takes two parties to form a productive relationship, providers and patients continue to believe the provider has the burden to make the relationship work.
- the health care providers ability to be flexible and adaptable is extremely important in medical encounters.
- the patient-physician relationship is of greatest benefit to patients when they bring medical issues to the attention of their physicians in a timely fashion, provide info about their medical problem to the best of their ability and work with their physician in a mutually respectful way and alliance. this would be collaboration at its best.
Patient-Centered Care (PPC):
- sharing control is first step to building a collaborative relationship
- traditionally, power and authority have been lopsided in the HCI
- the provider is highly trained, sees the situation as routine, speaks in scientific terms and jargon few understand, appears to be in control of self and situation, is emotionally uninvolved, and is fully clothed in a suit or uniform. control gravitates to the provider bc this party chooses and controls the setting, timing and structure of the interview.
- closed questions, limited reactions, changing of topics and interruptions signal who is in charge. when patients challenge this situation, providers may quickly reassert their authorial presence or ignore the challenge.
- physicians may dismiss internet research patients found as face threatening and assert their authority. male patients in particular perceived that physicians felt a loss of control when they mentioned internet research, perhaps bc they feared they would be proved wrong or didn't know enough
- patient is often uninformed, sees the situation as a crisis, is emotional, has little medical knowledge, and may be partially nude, highly medicated, or in pain. patients are party to blame for the parent child relationship that may exist in the interview b dutifully taking on a subordinate role and remaining compliant.
- while majority of patients, particularly younger ones, want to be invovled some prefer a paternalistic model of health care in which the provider maintains control. they may fail to ask qs at critical times during interviews
- a patient may seem to be compliant while employing subtle control strategies such as changing topics, asking questions, giving short unrevealing answers to open questions, withholding info, or talking incessantly
- patient may demonstrate relational power through silence rather than conversational dominance or agree with a provider during an interview and then ignore prescriptions, regimens and advice afterwards.
- while there is considerable agreement on what constitutes competent physician communication, there is little evidence of what constitutes competent patient communication.
- one study showed that from the physicians perspective, the communicatively competent patient is well prepared, gives prior thought to medical concerns, educates himself about the illness, comes with an agenda, provides detailed info, and seeks info by asking questions
- the patient's perspective mirrored the physicians
- this study discovered that there was not a significant correlation between perceptions of competence and patients actual discourse, that perceptions of communication in a medical interview do not necessarily match what is actually said. what physician and patients think they see and hear often does not match reality
Patient-Centered Care (PPC):
- both parties must negotiate and share control as partners striving for a common goals. as a provider. develop positive relational climates by showing interest in the patients lifestyle, non-medical concerns, and over all well being. supportive talk that includes statements of reassurance, support and empathy demonstrates interpersonal sensitivity and sincere interest in the patient as a person
- empathy is an essential element of the relationship and showing empathy increases patient satisfaction and reduces time and expense.
- empathy is not just something that is given from physician to patient. instead, a transactional communication perspective informs us that the phys and pat. mutually influence each other during the interaction
- while some patients give repeated chances for empathetic responses, others provide little or none.
- when pats. did so, phys had a clear tendency of acknowledging, pursuing and confirming patients empathic opportunities. this is a positive trend in a physician-patient relationship.
- as a provider, encourage patients to express ideas, expectations, fears, and feelings about a medical problem and value their expertise. goal is to treat others as equals
- as a patient, come to each interview well informed about the problem, give details and be honest and accurate as possible, give concerns, respond to questions effectively and state opinions, suggestions and preferences.
- takes two to tango/form a relationship
Patient-Centered Care (PPC):
- diversity among pats and providers is a reality both parties must acknowledge and address. we understand intuitively that patients, particularly ones that are from other cultures, experience and react different to heath care interviews but few of us are aware that providers also experience stress and anxiety when dealing with different types of patients and those from other cultures.
- there may be a significant association between physician's ethnicity and their perceptions of patients.
- women are more concerned about health than men and more verbal during interactions
- this may be a learned difference bc more health care info in the media is aimed at women than men. women spend more com. time with prov. and are more active coms during these visits, but their providers take their concerns less seriously.
- on the other hand, male patients tend to be more domineering than females regardless of the gender of their provider. a by-produce of more females entering the fields of obstetrics and gynecology is the significant percentage of women patients choosing female physicians.
- this has led male physicians to work on improving their interpersonal com skills
- age and sex influence communication and treatment.
- age is a growing factor as life expectancy increases and the baby boomer gen. reaches retirement age.
- older patients are more reluctant to challenge the doctors authority than younger patients, often with good reason. providers who are mostly under 55 are significantly less egalitarian, less patient and less respectful with older patients, perhaps reflecting society's changing attitudes toward aging and the wisdom of our elders.
- providers less likely to raise psychological issues with older patients. younger patients are more comfortable with bothering health care ppl and less awed by authority and creds.
- if a patient is incapacitated, often bc of age, it may be wise to involve a surrogate or heath care proxy who may have important info to share with the doctor and be able to collaborate about the patients care.
- 47 million ppl in the US who speak a different language than english in home and this does not include the millions of international travelers who come to US each year.
- globalization and cultural differences affect com. in many ways. black and hispanic patients said their race, ethnicity and lower economic status influence negatively their info seeking and health care.
- patients of lower social class may be openly reluctant to challenge physicians so they attempt to control the relationship.
- Arab cultures practice close proximity and kissing among men, both actions seen as offensive in american or european HCI
- native americans and asians prize nonverbal communication while american and german prize verbal com. Latinas are a good fit with patient centered health care bc they value interactions with physicians more than Europeans and blacks
- medical differences and philosophies in dif. countries might pose challenges for nonnative health care providers and patients.
- French phys tend to discount stats and emphasize logic
- German phys tend to be authoritarian romantics
- English phys tend to be paternalistic
- American phys tend to be aggressive and want to do something
- these dif. affect communicative roles and control sharing in medical interviews
- providers must be culturally sensitive to dif. in reporting pain, understanding informed consent, using appropriate language and disclosing info that may rely on cultural knowledge, modesty and comfort.
- affect ways providers see and treat patients. perception of patient as childlike is revealed in condescending attitudes and baby talk with adults.
- study showed baby talk used in nursing homes - 20% of staff used baby talk
- health care providers use elder-speak when addressing older adults such as hi sweeties, its time for our exercise, good girl you at all of your dinner, good morning big guy are we ready for our bath. the results of such inappropriate intimate and childish baby talk and elder-speak are decreased self esteem, depression, withdrawal and assumption of dependent behaviors congruent with stereotypes of frail elders.
- stereotypical good patient is cooperative, quiet, obedient, grateful, unaggressive, considerate, dispassionate. good patients tend to get better treatment than bad patients. patients sen as lower class get more pessimistic diagnoses and prognoses.
- overweight patients are deemed less likable, seductive, well education, in need of help or likely to benefit from help and more emotional, defensive warm and likely to have continuing issues.
Patient-Centered Care (PPC):
Creating and Maintaining Trust
- trust is essential bc HCI deal with intimate and sensitive personal info and must maximize self disclosure. trust comes when both parties see one another as legitimate agents of knowledge and perception. beaches of confidentiality may lead to discrimination, economic devastation, or social stigma. trust is destroyed and with it any hope of building and maintaining a productive relationship. breaches of confidentiality may be intentional or unintentional and occur in many places such as elevator, hallway, cafe, office, rooms, parties, phone, etc.
- confidentiality and trust go hand in hand
- talk and answer qs in soft tones, only exchange info with providers who have need to know, and conduct interactions in private secure locations
- trust is established in early mins. of interview, when each party is determining if the other can be trusted.
- it is further negotiated as both parties enact behaviors that construct shared expectations of a trusting relationship.
- humor can facilitate positive patient-provider interactions and create a patient-centered environment that affects their positive attitude and happiness. results in positive perceptions of care givers that enhance trustworthiness and lead to better health outcomes increase compliance with providers advice and fewer malpractice suits. spontaneous humor is most effective
- also enhance through supportive talk that increases patient participation in interviews and by eliciting full disclosure of info, clarifying info, and assessing social and psychological factors invovled in illness.
- communication is clearly central to patient-centered care and to establishing a productive relationship. observable communication skills may not be sufficient to achieve either.
- the differences in interviewing skills may not be associated with patient responses. phys may learn to go through the motions of a patient-centered interviewing without understanding what it means to be truly attentive and a responsive listener.
- the education about communication should go beyond skills training to a deeper understanding of what it means to be a responsive partner for the patient and to create a meaningful and insightful common ground between parties
- four specific aspects of ongoing relationships that were significantly associated with satisfaction, namely, the relationship between the parent and the physician, the relationship between child and phys, the parent's comfort asking the phys questions and the parents trust in the phys
Opening the Interview
Enhancing the Climate:
- opening the HCI, when and where it takes place and who initiates it have significant impact on the remainder of the interview
- provider should create an atmosphere where the patient feels free to express opinions feelings and attitudes. both parties rely heavily on interviews to get and give info, but the process if often take for granted.
- parties fail to realize that cooperation is essential for sharing info and attitudes toward courses of action.
- select comfortable, attractive, quiet, nonthreatening and private locations free of interruptions in which interactions will remain confidential.
- ex. pediatrics areas are designed with pictures, games, toys, plants, books for young kids and parents to minimize fear and anxiety and maximize cooperation and communication
- waiting rooms for adults tend to be stark with a tv and a few magazines. the adult patients is then called to the treatment room, given a few tests asked to put on gown and then left along for several minutes, this setting is not likely to decrease anxiety or tension
- location and setting promote collaborative interactions
Opening the Interview
- individualize your opening, open physician-patient communicative style is not the universal solution to patient needs. there is a need for tailoring the health care providers communicative styles depending on the needs of the patient.
- begin with a pleasant greeting and introduction of yourself and position if you're unacquainted with this person or family. if you address the patient by first name while you address yourself by title, you may create a superior-to-subordinate relationship from the start. if you are acquainted with this person, open with a personal greeting that takes note of your relationship. the patient must return the greeting and take an active part in the opening.
- employ small talk, humor and self disclosure to relax the patient increase trust and enrich the relationship
- this patient-centered approach enhances patient satisfaction
- reduce apprehension by carefully explaining procedures, being attentive and relaxed, treating patients as equals, and talking to them in their street clothes rather than hospital gowns.
- rapport building and orientation are strengthened if the phys reviews patient file before entering the exam room so the interview can begin on a personal and knowledgable level
- neither rush nor prolong the opening unless trust is low bc both parties prefer to get to the point after establishing a personal connection.
- apologize if patient has been waiting for a while and explain reason for it. simple politeness and courtesy can defuse an angry or impatient interviewee and show you value their time and are sensitive to their perceptions and needs.
- relevance of politeness theory and how it can improve communication in HCIs
- politeness is used primarily to ease social interaction by providing a ritualistic form of verbal interaction that cushions the stark nature of many interactions such as requests, commands or questioning. politeness provides a means for covering embarrassment, anger, or fear in situations in which it would not be to one's advantage to show these emotions either as a reflection of one's self or because of the reaction of the other. politeness breeds politeness.
- politeness may help health care receivers safe face in a threatening situation over which they have little control.
- perception of time pressures and medical terminology influence patient participation and the development of rapport in medical encounters. when medical prof. spent more time in consultations and used little terminology, patients reported being more willing to ask for additional info as they felt a good relationship had been established.
- opening questions asked and how quickly they ask them after an interview begins are important to establishing a relationship, maintaining rapport, and getting adequate and insightful info
- some health care providers use electronic interviews with patients prior to in person visits.
- if patient has mentioned reason when making appointment or told the assistance or nurse ab the problem, the doctors opening question is likely to be a confirmatory q confirming the issue bringing the patient in
- another confirmatory q focuses on specific symptoms
- general inquiry qs elicit longer problem presentations including more current symptoms. more restrictive close qs constitutes a method for initiating problem presentation and distinctively communicates physicians readiness to initiate, enforce the initiation of the net phase which is info gathering. physician takes control and dictates where the interview is heading
- if provider initiates interview, the opening q may be open ended like how has your health been in the past year, etc.
- what takes place after the opening q depends on the purpose for the visit. if its a checkup the provider may orient the patient as to what will take place and then launch into the body of the interview, if it is a follow up session the doctor may move on with a series of qs directive toward a specific problem or results from previous treatments.
- HCIs devote significant portions of the interview to seeking information.
- info exchange is a major component of competence in provider-patient interactions
- not an easy task, and there are many barriers.
Barriers to Getting Information
- physical and emotional factors can make it hard for patients to recall and or articulate info accurately and completely.
- their concern is why they are ill rather than what they can do about it.
- scared and anxious patients leave out big parts of their medical histories and may camouflage the real problem by making allegorical statements such as you know how teens are.
- pats. say they don't want to be judged about smoking, weight, drugs, so they tell harmless white lies and aren't particularly concerned about the potential consequences.
- some overestimate the risk of a problem. many women overestimate their percentage of risk of breast cancer, even after they are received careful estimates
- they resist the info they received.
- one way to reduce this issue appears to be a social comparison strategy in which patients are asked to compare their risk to others. however, even after using this strategy, women continued to see their risk as 50% when the actual risk was closer to 14%. mothers recall only about half of their children's major illnesses.
- SD is critical to the info gathering process. imperative that interactions reach level 3 rather than an incomplete and superficial level 1 and 2.
- all too common for pats to withhold info or to give less than honest info to avoid embarrassment, feeling uncomfortable, getting bad news and receiving a lecture
- five physician characteristics significantly improved SD and honesty: gender, lack of hurriedness, use of first name introduction, use of open ended questions, and friendliness.
- open ended qs might demonstrate to the patient that they are com. partners who prioritize their relationship and this co-ownership. they facilitate trust and comfort with patients bc they encourage patient qs and demonstrate phys listening skills
- pats have a hard time giving others depressing news such as when a disease is progressing and believe that sharing such news may have more negative impact on their received support
- uncertainty plays a big role in ppl's disclosure decisions
- they asses what reaction they are likely to receive prior to sharing the info and if unsure about potential responses or outcomes, weight this factor into decision
- one solution is for the pat to share a small piece of info to assess the receivers responses, sort of testing the waters before willing to share fully
- history taking portion of interviews is often longer than discussions of diagnostic and prognostic issues. the manner tends to be impersonal, with many questions having little or nothing to do with patients current problems or concerns.
- he spent so long on things not wrong with me and it made me feel the interviewer had nothing to do with my illness. patients may become angry or numbed by endless, closed qs "negative weakening"