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Recent literature on the medical interview runs to more than 50,000 articles, chapters, and books. Although only a modest portion of these are derived from empirical bases, sufficient work has been done to describe the interview's conceptual framework as having "structure" and "functions." Behavioral observations and detailed, reproducible analyses of interviews have related specific behaviors and skills to both structural elements and functions; performance of these behaviors and skills improves clinical outcomes. The following description of essential structural elements and their associated behaviors or techniques, although comprehensive, is not so exhaustive as to be impractical. Key behaviors are summarized in Table 1-3. One comprehensive model of this approach is shown in Figure 1-1.
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Preparing the Physical Environment
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Architects and designers believe that form follows function. Similarly, how practitioners organize their physical environment reveals core characteristics of their practice: how they view the importance of the patient's comfort and ease; how they want to be regarded; and how they as practitioners control their own environment. Does the patient have a choice of seating? Do both patient and provider sit at comparable eye level? Is the room accessible, quiet, and private? Optimal environments reduce anxiety and instill calm and a sense of well-being.
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Humans can process about seven bits of information simultaneously. Given this limitation, it is advisable to consider how many of these bits are consumed by distractions or trivia in a clinical encounter. The hypnotic concept of focus or the recently accepted psychological concepts of centering or flow apply to the clinical encounter (see Chapter 5). Thoughts about the last or next patient, yesterday's mistake, last night's argument, passion, or movie can affect concentration; information and opportunity are lost. In contrast, a focused practitioner, without external or internal distractions, can expect the interview to be a challenging, fascinating, and unique experience.
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Achieving a focused state of mind is personal and related to each situation. Nevertheless, successful centering includes: eliminating outside intrusion by beepers and phone calls, tuning out extraneous sound, eliminating internal distraction and intrusive thoughts by resolving not to work on other matters, letting intrusive thoughts simply pass through your mind for the moment, and controlling distracting reactions within the interview by noting them, considering their origins, and putting them aside.
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Such skills do not just happen. We teach our residents self-hypnosis; practitioners are routinely and efficiently able to get to a place of heightened, alert, and energetic focus. Using this skill together with the suggestions in Table 1-4, practitioners can enhance the opportunity for something profound to happen in each patient encounter.
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Observing the Patient
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A great deal can be learned by thoughtfully observing the patient's behavior and body language both before and during the encounter. Although initial behavioral observations are purely heuristic—used to generate testable hypotheses about the patient—non-verbal behaviors can reveal as much about the patient's state of mind as their verbal behavior. Physicians who are unaware of being influenced by initial reactions and observations in the patient interview may note that when they themselves get on a bus or an airplane, they instantly recognize the person next to whom they would prefer—or not—to sit. Such responses integrate multiple non-verbal cues. Similar input from patients relates to their overall health, vital signs, cardiac and pulmonary compensation, liver function, and more. Observations about grooming, state-of-rest, alertness, and style of presentation reveal the patient's self-confidence, presence of psychosis, depression, or anxiety, as well as the patient's personality style, culture or sub-culture, and important changes from prior visits. The physician may also detect signs of possible alcohol or drug use. Escorting patients from the waiting area, letting them walk slightly ahead into the office, allows the physician to observe gait, how patients use their waiting time, companions, and clues to the relationship with companions. Often, especially with new patients, the very first words spoken by the patient may be epigraphic or may foreshadow the encounter.
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Maximizing clinical observation skills starts with the commitment to do so. Developing the habit of systematically retaining and integrating initial observations will provide the physician with important data typically overlooked. Asking pertinent questions about behavioral cues will increase observation speed and comprehensiveness. Practicing in crowds, at rounds or lectures, on the airplane, or at parties will help train oneself to become a more astute observer. It is the physician's equivalent of practicing scales on the piano or taking batting practice.
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The greeting serves to identify each party, to set the social tone, to indicate intentions concerning equality or dominance, and to prevent mistaken identity. It also allows the practitioner to establish an immediate connection with patients, presenting a confident, compassionate professional the patient can trust. It enables the physician to learn how patients assert their own identity and how to pronounce their names. Using a standard greeting—saying virtually the same thing each time—provides data based on the individuality in a patient's response.
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Beginning the Interview
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The introductory phase of a medical encounter provides an opportunity for both parties to express their understanding of the purpose and condition of the encounter, to check each other's expectations, and to negotiate differences. For example, the patient may expect to be seen by the head of the clinic, but the physician is only a year out of residency. The patient wants relief from back pain and the practitioner is worried about the high blood pressure of the patient that day. The cardiologist expects the consultation to lead to cardiac catheterization, whereas the patient thinks the cardiologist's opinions will be sent to his primary care physician for a decision. Perhaps, the physician planned a 15-minute visit, but the patient feels an hour is needed.
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One of the best predictors of the outcome of a dyadic relationship is concordance of expectations; therefore, clarifying and reconciling these is extremely valuable before proceeding to the main part of the interview.
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The beginning of the interview, especially with a new patient, sets the interactional tone (although one can always change tone by changing one's behavior). Although many attempt idle social chat, bland social questions may confuse the professional focus or make the patient feel compelled to present a positive tone. It is useful to consider using a fairly stereotyped beginning, such as "what brings you in to see me today?" (As opposed to "… how may I help you" which prejudges the purpose of the interview).
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Detecting & Overcoming Barriers to Communication
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Many factors that interfere with communication place even more barriers between the doctor and the patient. Sometimes these are tangible barriers: delirium, dementia, deafness, aphasia, intoxication (patient or physician), or ambient noise. Psychological barriers include depression, anxiety, psychosis, paranoia, and distrust. Social barriers often involve language, cultural differences, and fears about immigration status, stigma, cost of the visit, or legal issues. It is essential to detect barriers early in an encounter. Failure to do so not only wastes time but can seriously and, sometimes, dangerously mislead the physician. For example, residents and students often spend an hour or more trying to extract history from a delirious patient, resulting in an hour lost and highly unreliable historical data. In addition, detecting barriers is the first step toward correction, whether by waiting until delirium or intoxication has cleared, finding a professional interpreter or signer, moving to a quiet place, or deferring difficult issues until trust is established.
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Patients come to medical encounters with multiple problems and, for various reasons, may not lead with the most pressing issue. Physicians typically interrupt very quickly (18–23 seconds on average). It is of vital importance not to jump in at the first important-sounding problem, but instead to elicit all problems. For example, the physician might ask, "What problems are you having?" or "What issues would you like to work on first?" After getting the initial answer or series of answers, the physician can then ask "… what else?" until the list of problems is completed and mutual priorities are established.
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Negotiating Priorities
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Once the physician and the patient clearly understand the full set of problems, the physician should then ask, "Which of these would you like to work on first?" If the physician believes that something else is more important, there should be a negotiation about this difference: "Our time is limited today, and I think your shortness of breath is potentially more dangerous than your back pain. Suppose we deal with that first and, if we have time, go on to your back pain. If not, we'll take that up on your next visit."
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Appropriate and understandable resentment results when the physician does not ascertain and acknowledge the patient's priorities. This can lead to treatment adherence problems or failure to return to the office.
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Developing a Narrative Thread
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Once the physician and the patient have decided which problem has priority, exploration of that problem begins. Note the term "exploration." All too often the approaches are either to jump into a review of systems ("do you have rectal bleeding … are your gums bleeding … ?") or to elicit the seven cardinal features of the sign or symptom ("where is it, does it radiate, what makes it better or worse … ?" and so on). The most efficient method is to explore the problem by asking the patient to tell the story of the problem, as in "Tell me about your rectal bleeding." Although many will begin at an appropriate point and move toward the present, some patients may need guidance to begin when the patient last felt healthy, when the current episode began, or when the patient thinks the problem started. The patient may not appreciate the necessary level of detail and may be too inclusive or superficial. It may be necessary to interrupt to indicate a desire to hear more or less about the problem. Clarifying questions shows the patient what is needed and most patients respond with the appropriate level of detail.
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Establishing the Life Context of the Patient
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Once the narrative thread is established, the physician can take the opportunity to inquire about specific points. It is important to respond at the patient's first mention of psychosocial matters in order to signal to the patient that such matters are as important as biotechnical ones. Such inquiries help the physician learn in detail about the context in the patient's life—spouse, family, neighborhood, job, and culture. When enough information has been supplied, simply saying, "You were saying …" or "What happened next?" returns the patient to the narrative. This approach works because almost everyone knows how to tell a story and remembers key points intrinsically organized by what actually happened.
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Creating a Safety Net
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Once the problems the patient wishes to discuss have been explored, areas or questions may remain. For these, the physician may choose to ask a series of specific review of systems-type questions. Questions may take the form of the seven dimensions of a complaint, delineated as the location, duration, intensity (use a ten-point scale with zero "no pain at all" and ten "the worst possible pain"), quality, association, radiation, exacerbants, and ameliorants, or a subset of these dimensions. Such final closed-ended questions tie up loose ends and provide the safety of completeness.
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Talking During the Physical Examination & Procedures
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During the physical examination, there is a tension between the quiet focusing of the senses needed to observe and hear and feel findings and mutually necessary conversation. Practitioners need their senses of smell, sight, touch, and hearing to examine the patient. They need heightened sensory awareness for the encounter. Patients need an explanation of what is being done and what to expect ("this may hurt"), instruction about what to do ("please sit here" … "bring up your knees" … "hold your breath"), and a check on how they are doing and responding ("does this hurt?"). The examination often stimulates the memory of relevant experiences and problems the patient may have forgotten to mention. Some physicians like to explain what is happening in detail ("I am looking in the back of your eye because it is the one place in the body where blood vessels can be seen"). Others do their review of systems during the physical examination. In general, it is wise to minimize distractions during the physical examination or a procedure by confining talk to the task and the needs of the patient. Explanation of findings can be reserved for the end of the examination.
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Presenting Findings & Options
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After the history-taking and physical examination have been completed, it is time for the physician and patient to discuss what the problems or probabilities appear to be, related findings, the physician's hypotheses or conclusions, and possible approaches to further diagnostic evaluation and treatment. This should be done in language free of jargon and at a level of abstraction the patient can understand.
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Bad news includes any information that will change the patient from their idealized self-image to a lesser one. While telling someone she has diabetes may seem routine to a jaded practitioner, to a patient who has heard tough stories about diabetes, or has a relative who died of it, or is simply a fearful person, it is certainly life-altering and might seem disastrous. It is valuable to foreshadow any bad or potentially upsetting news (see Chapter 3). This prepares the patient to hear and retain the information. It may be useful to suggest the patient bring along a trusted companion (although this flags the likely news as bad). When bad news is a certainty, it is useful to record the explanation and discussion for the patient. These days, a digital recorder in the room allows the doctor to provide a copy of the encounter when it ends. The patient can review it after shock has cleared and share it with family or friends. It has been documented that listening to such recordings produces better patient understanding and improves outcomes like quality of life. It is essential not to underestimate the potential impact of both positive and negative findings on the patient. After presenting each item, the physician should explore the patient's understanding and reactions. The presentation itself should be problem-oriented and systematic—and as simple and succinct as possible. Although the dictum is "be brief," necessary content and empathy should not be sacrificed for brevity.
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Once patients have been factually informed of the diagnosis and prognosis, it is crucial to involve them actively in making choices and in developing diagnostic and therapeutic plans. Such "activation" of patients has been shown to increase their adherence to plans and improve their medical outcome and quality of life.
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When the physician and the patient disagree in emphasis or choice, negotiation is necessary. The principles of negotiation can be summarized: find and emphasize areas of mutual agreement (e.g., live as long as possible, retain dignity, and avoid suffering), and avoid the adoption of inflexible positions that lead only to conflict, wherein one side or the other loses. If physicians take time to understand patients' positions and respect concerns, the issues can usually be worked out. For example, it can be agreed upon to do a procedure after a grandchild's graduation or to do non-invasive tests first with hope they will suffice.
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Closing the Interview
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The closing should include: actively reviewing principal findings, plans, and agreements using a talk back or teach back in which the patient is asked to recall what decisions and recommendations have been made, making arrangements for the next visit and giving patient instructions, making sure outstanding issues have been covered, and saying good-bye. In the future, both the physician and patient may review the physician's notes together.