Introduction to the Clinical Interview Susan Bentley, D.O. 5/9/2019

Introduction Patient –centered communication Participatory interview style Results: Improved patient outcomes Increased satisfaction with care Decrease in overall costs 5/9/2019

Facilitating Patient Agenda Overview Elements of the patient-centered interview Building Rapport Listening Actively Facilitating Patient Agenda Dealing with Emotions Managing Information Finding Common Ground 5/9/2019

“A successful dialogue between patient and physician is at the heart of working scientifically with patients…” G. L. Engel, 1995 5/9/2019

Building Rapport Establish Tone of Interview Set Direction Transition from Social to Medical 5/9/2019

Facilitating the Patient’s Agenda Encourage patient to communicate their medical story in their own terms More accurate diagnosis and more effective time management Includes verbal and non-verbal skills 5/9/2019

Case vignette… 59 year old woman in your practice 5 years Irregular visits for hypertension CC  urinary tract infection Physical findings Mild obesity BP  160 / 92 mm Hg UA +glucose, -protein, ketones, leukocyte esterase Blood glucose  204 mg/dL Clinical interaction 5/9/2019

Missed Opportunities Building Rapport – “What has been going on in your life?” Facilitating Agenda – “What are you concerned about?” 5/9/2019

Managing Information Questioning skills: Goal Open ended questions Closed ended questions Goal Balance Patient perspective Specific information 5/9/2019

Active Listening Recognition of clues to patients thoughts, unstated concerns, expectations Patient personality affects communications style “Oh by the way…” Reluctance to accept recommendations Strategies Reflective listening Exploring clues for meaning Question to elicit patient’s perspective 5/9/2019

Case vignette… 67 year old man, new to practice, transferred care – dissatisfied with former doctor CC  physical exam Clinical interaction “Follows” his diet “Could do better” taking meds (some anxiety) Reinforce compliance, write Rx, schedule follow-up in 3 months Patient never shows up again 5/9/2019

Getting to the issues Active listening  insight into why glucose is not controlled Open-ended Questions  patient has no concept of medical nutrition therapy Non-verbal cues  exploration of discomfort leads to understanding patient fears 5/9/2019

Dealing with Emotions Visits to doctors can be emotionally charged (white coat syndrome) Patient focus is physical complaints versus emotional distress Explore patient feelings & respond appropriately to emotions Develop treatment for the whole person 5/9/2019

Strategies for Exploration Silence Non-verbal encouragement Neutral utterances, continuers Reflection, echoing Open-ended requests Summary or paraphrase Direct questions about feelings Forming hypotheses together 5/9/2019

Strategies for Effective Responses Naming Understanding Respecting Supporting Normalizing Non-verbal behaviors Exploring meaning behind expressions 5/9/2019

Finding Common Ground Shared vision of health Reconciling patient and physician expectations Strategies Restate patient perspective Explain clinical diagnosis, treatment plan Check with patient on feasibility Respectfully note different perspectives Identify patient’s readiness to change Brainstorm potential solutions, compromise Reframe situation 5/9/2019

Case Vignette … 52 year old woman in your practice 6 years, Frustrating non-compliance CC  Type 2 diabetes, hypertension, hyperlipidemia Physical findings Mild obesity Poor glucose control with increasing insulin dosage (glycosylated hemoglobin 10%) Clinical interaction Physician frustrated, Decides to change approach 5/9/2019

Negotiating “Win-Win” solution Explore emotional presentation of anger Acknowledge her distress (Naming) Normalize patient frustration Explore patient goals for treatment plans Establish common ground Set reasonable treatment goals 5/9/2019

Conclusions Patient – centered communication has proven effective in Improved patient outcomes Increased satisfaction with care Decrease in overall costs Involves patients in decision-making process Engaging patient in care improves compliance Improved interview skills enhances experience for both physician and patient 5/9/2019

Where to Get More Information Remaining lectures Small group sessions Assigned reading Experience practicing these principles (try it, you’ll like it!) 5/9/2019

The Beginning … 5/9/2019