Interviewing & Health History (Bates ch. 3) Flashcards
(104 cards)
1
Q
The primary goals of the patient interview are to ____ and to _____ __ ______ of the patient through a trusting and supportive relationship
A
The primary goals of the patient interview are to listen and to improve the wellbeing of the patient through a trusting and supportive relationship
2
Q
High-quality patient-clinician communication has been shown to _______, _______, _______, ________, and ______
A
Improve patient outcomes, decrease symptoms, improve functional status, reduce litigation, and decrease errors
3
Q
What is the most commonly performed clinical interviention?
A
The interview, which will occur thousands of times in a clinicians career
4
Q
What is the foundation of a therapeutic alliance between patients and clinicians?
A
Trust
5
Q
Skilled interviewing is both ___-centered and ____-centered
A
patient-centered and clinician-centered
6
Q
What does the patient-centered interview focus on?
A
recognizing the importance of the patients’ expressions of personal concerns, feelings, and emotions
7
Q
What does the patient-centered interview evoke?
A
the personal context of the patient’s symptoms and disease
8
Q
Define the patient-centered interview
A
following the patient’s lead to understand their thoughts, ideas, concerns and requests without adding additional info from the clinician’s perspective
9
Q
What does the clinician-centered interview focus on?
A
taking charge of the interaction to meet their own needs to acquire symptoms, details, and other data that will help in identifying a disease
10
Q
Which is preferred, the patient-centered interview, clinician-centered interview, or an integration of both?
A
Integration of both
11
Q
What does an integration of the patient and clinician-centered interview style lead to?
A
A more complete picture of the patient’s illness and the conveyance of respect, empathy, humility, and sensitivity
12
Q
What does the interview process require attention to?
A
The patient’s feelings and behavioral cues
13
Q
The health history format provides an important framework for organizing the patient’s story into various categories pertinent to the patient’s _____, ______, and _______
A
present, past, and family health
14
Q
The interview process is rigid - true or false
A
False, it is fluid
15
Q
The interview should be open-ended - true or false
A
True
16
Q
Techniques involved in the interview to cue patients to tell their stories include _____, ______, _______, ______, ______, ______, and _______
A
active listening, guided questioning, nonverbal affirmation, empathetic responses, validation, reassurance, and partnering
17
Q
The health history format focuses your attention on ….
A
the kind of information that is needed.
18
Q
The health history format facilitates…
A
clinical reasoning
19
Q
The health history format provides…
A
a standardized communication between other healthcare providers involved in a patient’s care
20
Q
Which history gives the clinician an opportunity to see the patient as a person and better understand their outlook and background?
A
The Personal and Social History
21
Q
The Review of Systems should not include clinician-centered closed-ended questions
A
False, yes and no questions should be limited to the Review of Systems
22
Q
This kind of history is used for new patients in most settings
A
A Comprehensive Health History
23
Q
What kind of interview/history is best for a patient seeking care for a specific concern like a cough?
A
A focused or problem-oriented history, which is more limited and tailored to that specific problem
24
Q
What should the interview focus on for a patient seeking care for an ongoing or chronic problem?
A
The patient’s self-management, response to treatment, functional capacity, and quality of life
25
List the 10 skilled interviewing techniques
*(at every great newspaper, very respectful people see their enemy)*
- active listening
- empathetic responses
- guided questioning
- nonverbal communication
- validation
- reassurance
- partnering
- summarization
- transitions
- empowering the patient
*(at every great newspaper, very respectful people see their enemy)*
26
Define active listening
closely attending to what the patient is communicating, connecting to the patient's emotional state, using verbal and nonverbal skills to encourage expansion from the patient
27
Active listening does not involve nonverbal cues - true or false
False, active listening involves attending to the patient's verbal and nonverbal cues.
27
_____ has been described as the capacity to identify with the patient and feel the patient's pain as your own and respond in a supportive manner
Empathy
28
To express **empathy** you must first ________, then __________
recognize the patient's feelings, then actively move toward and elicit emotional content
29
For a response to be **empathetic** it must convey...
that you feel what the patient is feeling
30
______ _______ shows your sustained interest in the patient's feelings and disclosures
Guided Questioning
31
List the 7 techniques of Guided Questioning
*(four grad students make cake every evening)*
- Moving from open-ended to **f**ocused questions
- Using questioning that elicits a **g**raded response
- asking a **s**eries of questions one at a time
- offering **m**ultiple choices for answers
- **c**larifying what the patient means
- **e**ncouraging with continuers
- using **e**cho
*(four grad students make cake every evening)*
32
What type of questioning is this?
"Tell me about your chest pain. (pause) where do you feel it? (pause) has it traveled? (pause)"
Moving from open-ended to focused questions
33
What type of questioning is this?
"How many steps can you climb before you get short of breath"
Questioning that elicits a graded response
34
What type of questioning is this?
"Do you have a history of tuberculosis? (pause) asthma? (pause) pleurisy? (pause)"
Asking a series of questions one at a time
35
What type of questioning is this?
"Which of the following best describes your pain: aching, sharp, dull, stabbing, burning?"
Offering multiple choices for answers
36
What type of questioning is this?
"Tell me exactly what you mean by the flu"
or
"When you said you were behaving just like your mother, what did you mean?"
Clarifying what the patient means
37
What type of questioning is this?
using nonverbal clues such as leaning in, gesturing, nodding your head, or saying "go on", "mhm"
Encouraging with continuers
38
What type of questioning is this?
Patient: the pain began to spread.
PA: it spread?
Patient: yes and I felt like I was going to die.
PA: wow going to die?
Echoing
39
Being sensitive to nonverbal cues allows you to ...
read the patient more effectively and send messages of your own
40
What should you pay attention to for nonverbal clues?
- Eye contact
- facial expression
- posture
- head position and movement
- distance
- placement of arms or legs
41
True or false - all forms of nonverbal communication are universal
False, many can be culturally bound
42
A clinician can mirror posture and paralanguage (qualities of speech) to increase rapport - true or false
True
43
Another way to affirm the patient is to ____ the legitimacy of their emotional experience
validate
44
List a few problems with reassurance
- it may be premature and counterproductive
- it may be misleading
- it may block further disclosure
- it may make the patient feel that you are uncomfortable with their anxiety
- it may make the patient feel that you don't understand/believe them
45
Define partnering
expressing your commitment to an ongoing relationship when building rapport with them in order to provide their care
46
Summarization allows you to demonstrate that you have been listening and can help...
identify what you do and don't know, allowing the patient to add info or correct misunderstanding
47
What are these phrases an example of within guided questioning?
"now i'd like to ask you some questions about xyz"
"before we move on is there anything else about xyz"
"Now I'd like to examine you, I will step out for a few minutes while you put this gown on"
Transitioning
48
What happens when you empower patients to ask questions, express concerns, and probe your recommendations?
They are more likely to adopt your advice, make lifestyle changes, or take meds as prescribed
49
Techniques for sharing power
- evoke the patient's perspective
- coney interest in them as a person
- follow the patient's lead
- elicit and validate emotions
- share info especially at transition points
- make clinical reasoning apparent
- reveal limits of knowledge
50
What does the preparation phase of the interview entail?
- reviewing the records
- setting goals
- checking appearance and clinical behavior
- adjusting the environment
51
List the primary things to look for when reviewing the record in preparation for the interview
-identifying data (age, gender, address, insurance)
-problem list
-medication list
-allergies
52
Goal setting should balance both _______ and _______
**provider-centered goals** and **patient-centered goals**
53
Best practice clinical behavior includes ______ and _______
**professionalism** and **unconditional positive regard**
54
Adjusting the environment ensures that...
the patient is as comfortable as possible through privacy and basic comfort needs
55
# Sequence of the interview
What is the first step in the sequence of the interview?
Greeting the patient by name and establishing rapport
56
# Sequence of the Interview
What should be included in a greeting?
- your name
- possible handshake
- your role
- your status as a student
- how you will be involved in their care
57
# Sequence of the interview
What should you do if there are visitors in the room during the greeting?
-acknowledge and greet the visitors
- let the patient decide if they should stay in the room or not
- ask the patient's permisison before conducting the interview in front of visitors
58
# Sequence of the interview
How should you **establish the agenda**?
| (Discuss chief complaint or presenting problems)
-begin with open ended questions
-prompt if there was anything missed or unsaid
59
# sequence of the interview
How to **invite the patient's story**
-ask open ended questions
-follow the patient's lead and don't interrupt
-use continuers
60
# sequence of the interview
Disease is the...
explanation that the clinician uses to organize symptoms that leads to a clinical diagnosis
61
# Sequence of the interview
Illness is a...
construct that explains how the patient experiences the disease, including its effects on relationships, function, and sense of wellbeing
62
# sequence of the interview
4 domains of exploring the patient's perspective (FIFE)
F.I.F.E.
-Feelings about the problem
-Ideas about the nature and cause of the problem
-Function and the problem's effect on patient's life
-Expectations of the disease, clinician, healthcare
63
# Sequence of the interview
These are examples of what?
"how did you feel about that?"
"Many people would also be frustrated by this, you are not alone"
identifying and responding to the patient's emotional cues
64
# Sequence of the interivew - mnemonic for emotional cues
NURSE
- NAME - that sounds like a scare experience
- UNDERSTAND - it's understandable that you'd feel this way
- RESPECT - you've done better than most would with this
- SUPPORT - I will continue to work with you on this
- EXPLORE - how else were you feeling about this?
65
# sequence of the interview - expanding/clarifying the story
OLD CARTS
- Onset
- Location
- Duration
- Character
- Aggravating/Alleviating Factors
- Radiation
- Timing
66
# Sequence of the interview
7 attributes of a symptom
- location: where is it and does it radiate?
- quality: what is it like?
- severity: how bad is it?
- timing: when did it start and how long does it last or how often does it come?
- onset: setting and circumstances that may have contributed to the issue when it arose
- remitting/exacerbating factors: is there anything that makes it worse or better?
- associated manifestations: is there anything that happens with it?
67
# sequence of the interview
generating and testing diagnostic hypotheses allows you to consider...
which disease or patterns might be present and lead to differential diagnosis
68
# sequence of the interview
3 steps of shared decision making
- introduce and describe choices/options
- exploring patient preferences
- make a decision, checking that the patient is ready to make that decision
69
# sequence of the interview
what is motivational interviewing?
a set of techniques that improve health outcomes and helps patients say why and how they might change, based on guided interviewing
70
# motivational interviewing
3 points of the guiding style of motivational interview
- ask: open ended questions
- listen: to understand the patient's experience
- inform: ask permission to provide info and ask about what the implications may be
71
# sequence of the interview
how to close the interview/visit
let the patient know the visit is ending and allow time for any questions and understanding of a mutual plan
72
# sequence of the interview
this is the last step of the interview
self reflection and mindfulness
73
Define cultural competence
a set of attitudes, skills, behaviors, and policies that enable organizations and staff to work effectively in cross-cultural situations
74
cultural humility
a process that requires humility as individuals continually engage in self-reflection and self- critique as lifelong learners and reflective practitioners
75
Define culture
a system of shared ideas, rules, and meanings that influence how we view the world, experience it emotionally, and behave in relation to other people
76
3 dimensions of cultural humility
- self awareness
- respectful communication
- collaborative partnerships
77
# How to address
the silent patient
- allow silence as time for them to think
- reword or try more guided questioning
- ask if the patient has been made upset
- begin exploratory mental status exam if depression or dementia may be present
78
# how to address
the confusing patient
- watch for an underlying issue related to the tangentiality
- guide the interview into a psychosocial assessment
- conduct mental status exam if you suspect mental illness or neurologic disorder
79
# How to address
the patient with altered cognition
- seek the best information source
- obtain historical information from records, family, or caregivers
- do not break hipaa if seeking collateral from others
- determine decision making capacity
80
____ is a clinical designation and can be assessed by a clinician, whereas ____ is a legal designation and can only be decided by a court
capacity; competence
81
# Elements of decision making capacity
the patient must have the ability to...
- understand relevant info about proposed tests or treament
- appreciate their situation
- use reason to make a decision
- communicate their choice
82
# how to address
the talkative patient
- give free reign for the first 5-10 min
- focus on what seems important to the patient
- interrupt curteously for clarification and guidance of the interview
- prompt for another longer visit if needed
83
# how to address
the crying patient
- offer a tissue
- make supportive remarks
84
# how to address
the angry or disruptive patient
- acknowledge the situation
- accept angry feelings mindfully
- validate
- alert security staff and ensure a safe environment if needed
85
# how to address
the patient with a language barrier
- work with an interpreter
- use bilingual written materials/questionnaires
86
# guidelines for working with an interpreter
INTERPRET
- introductions: everyone is introduced and their roles
- note goals: what are the goals, the diagnosis, the treatment, the follow up
- transparency: let the patient know everything will be interpreted throughout the session
- ethics: only use qualified interpreters, not family
- respect beliefs: cultural beliefs must be taken into account and interpreter may be able to help with this as a cultural broker
- patient focus: patient should remain the focus and be spoken to directly
- retain control: remain in control of the interactions and conversation
- explain: use simple language and short sentences so info can be conveyed as best as possible
- thanks: thank the interpreter and patient and note need for interpreter in chart
87
# how to address
the patient with low literacy or low health literacy
- ask about school or comfortability filling out a form
- do not confuse with lack of intelligence
88
# how to address
the patient with hearing loss
- find preferred method of communication
- use ASL interpreter
- speak at normal volume and rate
- emphasize key points first
- write out instructions in closing
89
# how to address
the patient with impaired vision
- shake hands as part of greeting
- orient patient to room as needed
- adjust light if needed
- spend more time on verbal explanations as gestures may be unseen
90
# how to address
the patient with limited intelligence
- pay attention to school record and ability to function independently
- find out about sexual history
- transition to mental status exam as needed
- turn to family or caregivers as needed in respectful manner
91
# how to address
the patient with personal problems
- ask about pros and cons rather than giving advice
- let patient talk through the problem
92
# how to address
the seductive patient
- be aware of feelings and situation
- calmly and firmly set clear limits if needed
- leave room if needed
- find chaperone if needed
- examine your own behavior
93
# Sensitive topics
When to ask about sexual history
- during the OBGYN section of **past medical history**
- in conversation about **health maintenance**
- in **personal and social history** when exploring lifestyle and relationships
- during the **review of systems** if it is a comprehensive history
- as part of *expanding and clarifying* the story if the chief complaint involves genitourinary symptoms
94
# sensitive topics
What language to use when talking about sexual history
specific and clear language, like penis or vagina
95
# sensitive topics
How to ask about mental health history
- take into account culture
- ask about issues with emotions or mental illnesses
- ask about past treatment
96
# sensitive topics
How to address substance use
- general questions asking about use of alcohol
- historical or current use of illegal drugs or prescription meds
- CAGE questionnaire
| cutting down, annoyance when criticized, guilty feelings, eye openers
97
# sensitive topics
Intimate partner violence and domestic violence
- can begin by normalizing statements like "because this is common in many peoples lives"
- use probing questions then direct questions like "are you in a situation where you have been hit or threatened?"
- continue asking and be empathic when validating after disclosure in a nonjudgemental way
98
# sensitive topics
death and dying patients
- allow space to talk about feelings
- clarify patient's wishes about treatment and end of life
- encourage establishing a health proxy
- explore religious or spiritual beliefs and needs
99
# ethics
**nonmaleficence** in the interview
giving only relevant and correct information and ensuring open barriers to communication
100
# ethics
**beneficence** in the interview
the clinician acts in the best interest of the patient
101
# ethics
**autonomy** in the interview
informed patients have the right to make their own clinical decisions
102
# ethics
**confidentiality** in the interview
privacy is fundamental
103
# ethics
The Tavistock Principles
| *(really big cool cats in some oasis)*
- **rights** - right to health and healthcare
- **balance** - patient centered with concern for population
- **comprehensiveness** - treating illness as well as suffering and quality of life
- **cooperation** - cooperation with those we serve and others in each sector
- **improvement** - serious and continuing responsibility to improve health care
- **safety** - do no harm
- **openness** - being open honest and trustworthy
| *(really big cool cats in some oasis)*
