The interview vignette with Ms. Jones that we have presented thus far in this textbook is just one example of how the patient-centered interaction between a clinician and a patient can unfold. If you have viewed the AccessMedicine companion videos or the DocCom modules, you know that the patient-centered interview can be adapted to different clinical settings and all patient encounters. In this chapter, we will provide you with more instruction and details on working with patients and situations that differ from the routine medical visit and present challenges. We will discuss how you can adjust the interview to different clinical situations. Perhaps you worry about interviewing a patient who cannot seem to stop talking, or one who it feels hard to pull information from. The skills required in these situations are used primarily in the beginning of the interview (Steps 1–5). This chapter focuses only on how you can tailor the process of the interview in various medical encounters with a variety of patients and does not consider the content that needs to be addressed in specific clinical situations. Clinical textbooks will help you obtain the details that must be incorporated into many of the encounters discussed here.1
To aid you, we have developed several companion videos available at AccessMedicine (www.accessmedicine.com/SmithsPCI). Rather than have experts demonstrate the clinician's role, we have used resident trainees to make the videos more realistic and applicable for readers who are themselves new to interviewing. The demonstrations show what is possible after training.
BALANCING PATIENT-CENTERED AND CLINICIAN-CENTERED INTERVIEWING SKILLS
There is no fixed rule on how to distribute the time you have for an interview between the beginning of the interview, the middle, and the end. Based on the patient's needs, you will determine the initial balance during Steps 1 to 5. You might average 10% of your time in the beginning of the interview for most patients, but this allocation of time can vary from 2% for, say, a patient who needs a medication refill and has no personal issues to more than 50% with, for example, a patient with severe marital problems. The balance will depend on the severity and urgency of the patient's personal issues. It may also be necessary to return repeatedly to using patient-centered interviewing skills even late in the interview.
In the beginning of the interview, the main block of controllable time lies in Step 4, continuing the HPI. Steps 1 to 3 and Step 5 usually take little time and are similar from patient to patient. Consider the following examples where we first describe patient-centered medical encounters in a variety of clinical situations and then with patients who possess various styles and characteristics.
ADDRESSING VARIOUS MEDICAL ENCOUNTERS AND CHALLENGES
New Inpatient or Outpatient without Urgent or Complex Personal Problems