Introduction to the Clinical Interview

(Adapted from Jeffrey L. Clothier, M.D)

  1. Objectives
    • To describe the basic types of Doctor-Patient interactions
    • To describe the difference between directed and open ended questioning and identify when each might be preferred method of inquiry.
    • To describe common adverse reactions between doctors and patients and identify ways to diffuse them.

  2. Introduction
    • This is not meant to substitute for your introduction to clinical medicine or physical diagnosis course
    • Meant to review some aspects of the doctor patient relationship in the context of behavioral sciences

  3. Initial encounter
    • Only one first impression
    • Actually begins before you see the patient
      • office
      • staff, etc
      • Importance of clinical leadership
    • Rule 1: Set an example of caring and compassion of those around you.

  4. Data collection
    • A history has form and content
    • collect as much of both as possible
    • premature diagnosis is common
    • Avoid premature closure of the interview
    • need rigid format
    • To get the facts don't judge the patient
    • Rule 2: It is the patient's history, allow them to tell it.

  5. Things to remember
    • The patient probably has a hypothesis of why they are having their symptoms
      • helps make sense of the sickness
      • may not be biomedical
      • explains aspects of the medical model they find important
      • Filters the symptoms to fit their hypothesis

  6. Data collection
    • Two basic forms of inquiry
      • Open ended
      • specific and direct
    • Specific and direct may lead to premature closure of the interview
    • Open ended requires discipline on the interviewer

  7. Open ended questions
    • Assumes the patient is verbal
    • Should always be the initial phase of the interview.
      • Ex: "What brought you here today"
    • The patient formulates content and form of response which can be helpful for the clinician

  8. Open ended questions
    • More power - sharing with the patient.
    • Sometimes awkward
      • Patients may answer with short replies.
        • May mean the patient is shy
        • May mean they have some expectations/preconceptions
        • May mean the patient is uncomfortable
      • Patients with nonspecific verbous replies
        • dramatic patients
        • hidden agendas

  9. Response to brief answers to open ended question
    • 3 options
      • facilitate- "Tell me more"
      • silence
      • move to direct questioning
    • First two are better in the early stages of the interview

  10. Role of silence
    • Silence makes most people anxious
    • Silence can be hard for the interviewer to tolerate.
    • It is usually rewarded by the patient presenting a richer fuller history

  11. Example interview
    • Doctor: "How can I help you?"
    • PT: "My head hurts"
    • Doctor: "Can you tell me more about it"
    • PT: (after silence) "It started yesterday after I got into an argument with my wife. I was real upset and started to have a throbbing headache"
    • Doctor: "What else did you notice?"
    • PT: "I noticed flashing lights and numbness in my right arm. That lasted only about two hours but the headache has continued."
    • Same information might have been obtained with a directed approach but would have taken longer.

  12. When should you use directed questions
    • Demented or delirious patients
    • floridly psychotic patients
    • small children ?
    • Patients in severe discomfort

  13. Special considerations for medical students
    • Specific knowledge does not predict interview skill
    • patients are sick-they were angry before you got there
    • your role in the team is important even though you may have limited authority

  14. Values in the best clinicians
    • Respect:
      • Habits of annoying patients
      • Incongruent medical models
      • hostile patients
      • help rejecting patients
      • demonstrated by : knocking on the door, sitting at eye level, giving clear introduction to your name, occasional touch, warning patient about what you will be doing
    • genuineness
      • Be yourself---student doctor
      • express appropriate feelings- "I'm sorry to hear that" etc
      • rarely helpful to display anger or disgust
      • can inquire about inconsistencies
      • personal anecdotes should be confined to professional aspects of the relationships
      • not moral or political
    • empathy
      • Emotional understanding
      • not an emotional state
      • levels of responding
        • PT- it was the worst pain I've ever had"
        • Ignoring- "just the facts"
        • minimizing-"I'm sure that it wasn't that bad"
        • interchangeable-" sounds pretty horrible"
        • You: additive- "Were you afraid you might die?"
    • Rule 3: these values are more important in many patients than what you prescribe

  15. Nonverbal aspects of communications
    • Paralinguistics-prosody and body language
      • Interpret with care
      • raised index finger/finger to ear-urge to interrupt
      • finger to lips- urge to suppress comment
      • crossed arms- defensive, insecurity
      • "white knuckle"-anxiety/tension
      • shifting forward- interest in the topic
    • personal space
    • Are they congruent with expressed affect?

  16. Doctor-patient relationships
    • Three basic models
      • Activity-passivity model
      • Guidance-cooperation model
      • Mutual participation model (highest cooperation with patient)

  17. Adapting the interview
    • Pediatric patients- Course of interview is influenced strongly by the developmental stage of the child.
      • School aged child
      • More interactive in the interview
      • Psychosocial factors become important to consider
    • infant/toddler - observer-participant. Presence of the child during the interview aids in recall of important symptoms and historic details.
      • Stranger anxiety
      • prenatal history, family history, developmental milestones, immunization status etc.
      • importance of toys
      • model is guidance and cooperation- anticipate the common issues. Feeding, sleeping etc.
      • "parental guilt"
    • Adolescent
      • Interview the child alone!
      • establish confidentiality
      • Be tactful
    • The elderly patient
      • Similar to pediatric interview at times
      • Specific to developmental challenges
      • role of life review
      • Respect for patient's autonomy
      • What do you do when the patient is demented or otherwise unable to give reliable history?
      • Find another reliable source
      • do a mental status exam

  18. Difficult interviews
    • Reticent patient -Lack of detail in history.
      • tend to go into a yes/no interview
      • remedy-open-ended questions
        • Dr: Tell me what the problem is?
        • Pt: That's why I came to you.
        • Dr: What have your symptoms been?
        • Pt: Tired, awfully tired.
        • Dr: Can you tell me more about it?
    • Take time. Be quite for an extended period to see if that loosens up the patient.
      • Rambling historian -embellish their history with seemingly unrelated detail
      • Remedy-Redirect the patient back to the question without being rude
        • Dr: It sounds as though you had a hard time with that...Since our time is limited, perhaps you can tell me more about why you came today
    • The Vague patient - Ambiguous history
      • Remedy-Provide a choice of descriptors
        • Dr: Was the pain dull or sharp?
      • Remedy: Encourage specific details
        • Dr: Tell me more about what you mean by.....
    • The Dependent, Demanding patient
      • Remedy: Don't make promises that can't be kept
      • Remedy: Give patient responsibility
        • "Perhaps you can talk to the nurses about that"
        • Don't take credit for patient's remissions of symptoms
        • Suspect when patient makes you think you are the only one who understands them
    • Orderly and Controlling patients
      • Cope with stress by trying to gain control of situation
      • Explain the process thoroughly
      • Give patient responsibilities
    • Dramatizing, Manipulative Patient
      • Interesting and charming
      • seductive
      • Give feedback frequently, redirect gently
      • stay detatched and calm
    • Long-suffering, masochist
      • Help rejector, doctor defeater
      • Tend to be sick regardless of what is done
      • Can list long reasons why specific treatments are useless. (drug allergies, adverse effects)
      • Respond to paradox at times
    • The superior patient
      • Entitled demander
      • Threatening litigation
      • Hard on students and trainees
      • Take time, stay calm, respect patient wishes
      • May have to reiterate your role and explicitly state the need for a relationship

  19. Specific emotional responses
    • Anger (ie, at a student for repeating history)
      • Empathize "I know many doctors have already come by and bothered you.....
      • Elicit permission to continue "Is it all right if I ask you some questions to help understand what you are experiencing?"
        • If no, ask for reasons in a noncombative way
      • Inform the patient gently of your obligation to do the interview without exerting control?
        • Would it be ok if I return in about an hour?
      • recognize and acknowledge the anger
        • "I can see you are angry and frustrated"
      • Accept the anger by listening to the patient
      • Explore the contributing factors
        • ex: having to leave examination before completed
        • accept the patient's reason even if you don't agree
      • Acknowledge your mistakes.
    • Anxiety-
      • Be unhurried and calm
      • Sympathize but don't get drippy
      • Be specific- Don't speculate about etiologies
      • Normalize the anxiety about procedures
      • When a patient ask you what you think is wrong.-Redirect to the attending or resident and inquire what the patient thinks is wrong.
    • Sadness
      • Most will encounter patients who remind them of an important person in your life
        • learn to recognize your emotional responses
        • seek advice or counseling if it interferes with your enjoyment of the clinics.