Interviewing Techniques as Tools for Diagnosis and Treatment, part 3 The Helpful Interview The Practice of Medicine -1 Christine M. Peterson, M.D.

Techniques as Tools u Week 2: Introduction to observing, using non- verbal and verbal active listening skills, and giving feedback. [SG - Mentor Hospital Interviews]  Week 3: Practice observing, using active listening skills, and giving and receiving feedback. [SG - SP or Hospital Interviews]  Week 4: Become more “patient-centered” in the interview. [SG – Hospital or SP Interviews]

Functions of the Medical Interview u Gather data and understand it u Develop rapport and respond to emotions u Educate and motivate è Begin both diagnostic and healing processes

Techniques Are Not Results u The true endpoint of your use of techniques is the patient’s performance in the interview. l Complete (facts, concerns & requests, context) l Truthful (facts and emotions)

The Patient-Centered Interview u Focuses on the patient’s needs u Activates the patient to play a larger role u Is characterized by “active listening” u Has a positive impact on patient outcome

Review of techniques u Behavior that BEFITS a physician u FOCUS on active listening u PREP to obtain patient-centered information u REALLY PREPARE to show empathy

Issues from 3 x 5 cards u *Motivating behavior change u *Cultural (and other) differences u *Sensitive topics u *Challenging interviews / relationships u *Talking with children & parents

Issues from 3 x 5 cards u Organizing the interview (order of inquiry, keeping on track) u Time management / efficiency u Interpreting verbal and non-verbal communication l metacommunication u Dealing with emotions u Note-taking / documentation u Closing the interview u Being a beginner

u Four “pearls”

Active listening u “Not really” actually means “I’m not going to tell you until I really know you’ll try to understand what I’m saying.”

Levinson w et al. JAMA 1997;277(7):553-9 Communication Behaviors of “No Claim” Primary Care Physicians u Longer visits u More orienting statements u More humor, more laughter u More facilitating comments

Mc Whinney’s Taxonomy of Medical Help-Seeking Behavior u Limits of tolerance for symptom u Limits of tolerance for anxiety about symptom u Problems of living presenting as symptoms u Preventive/routine care u Administrative reasons

History of Present Illness: “O-P-Q-R-S-T” questions u Onset and circumstances of Occurrence u Provocative and Palliative factors u Quality and/or Quantity of symptom u Region of body and Radiation to other areas u Severity of symptom (0 to 10 scale, if applicable) and associated Symptoms u Time (duration) and Temporal associations

u Video # 8 [doc.com] “Gather Information” Characterize the symptoms

Conclusive information for determining the diagnosis Provided by:Per cent History73% Physical examination62% Imaging studies35% Standard lab tests22%

Diagnostic information sources ConclusiveErroneous History73%1-2% Physical examination62%1-2% Imaging studies35%7% Standard lab tests22% “Inaccurate, incomplete, or misinterpreted patient histories are among the leading causes for diagnostic errors.” Feddock C. Am J Med 2007;120(4):374-8.

u A woman presents to her doctor and requests a mammogram to find out whether she has breast cancer. u Is that a good idea?

u Why aren’t mammograms recommended for all women? l Expense l Reliability

How reliable is a mammogram? u If she has breast cancer, the probability that the mammogram will be abnormal is 80%. u “Sensitivity” = 80% [i.e., 80% of women with breast cancer have an abnormal mammogram, and 20% of women with breast cancer have a normal mammogram (“false negative” result) due to biology and/or interpretation.]

How reliable is a mammogram? u If she does not have breast cancer, the probability that the mammogram will be normal is 90%. u “Specificity” = 90% [i.e., 90% of normal women have a normal mammogram and 10% of healthy women have an abnormal mammogram (“false positive” result) due to biology and/or interpretation.]

Breast cancer risk varies by age Risk of breast cancer in women at current age is: l age 20: 1 in 1,837 (0.054%) l age 30: 1 in 234 (0.42%) l age 40: 1 in 70 (1.4%) l age 50: 1 in 40 (2.5%) l age 60: 1 in 28 (3.6%) l age 70: 1 in 26 (3.8%) Current entire ♀ population (20 to 80): 1 in 100 (1%) Source: American Cancer Society Breast Cancer Facts and Figures Over a lifetime: 1 in 8 (12.5%)

Prevalence of breast cancer u In the population as a whole what per cent of women 20 and older have breast cancer today? u 1 %

Random mammogram Breast cancer Yes No Total Abnormal Mammogram result Normal Total

Random mammogram Breast cancer Yes No Total Abnormal Mammogram result Normal ? Total

Random mammogram Breast cancer Yes No Total Abnormal Mammogram result Normal 10 x 80% 8 Total

Random mammogram Breast cancer Yes No Total Abnormal Mammogram result Normal 10 x 80% 8 2 Total

Random mammogram Breast cancer Yes No Total Abnormal Mammogram result Normal 10 x 80% 8 2? Total

Random mammogram Breast cancer Yes No Total Abnormal Mammogram result Normal 10 x 80% x 90% 891 Total

Random mammogram Breast cancer Yes No Total Abnormal Mammogram result Normal 10 x 80% x 90% 891 Total

Random mammogram Breast cancer Yes No Total Abnormal Mammogram result Normal 10 x 80% x 90% Total

Random mammogram Breast cancer Yes No Total Abnormal Mammogram result Normal 10 x 80% 8 True pos 99 False pos False neg 990 x 90% 891 True neg 893 Total

Random mammogram Breast cancer Yes No Total Abnormal Mammogram result Normal 10 x 80% 8 True pos 99 False pos False neg 990 x 90% 891 True neg 893 Total Positive predictive value of random mammogram = 8 / 107 = 7.5%

Interpreting mammogram results Cancer; 80% pos mammo Healthy; positive mammo Healthy; negative mammo Mammogram sensitivity = 80%; specificity = 90. Breast cancer overall prevalence = 1% (varies with risk!) Each box = 10 women.

u For which women are mammograms recommended? l Risk factors: u Previous breast cancer u Genetic mutations (BrCA-1, BrCA-2) u Breast mass u Age u Etc.

Breast cancer risk varies by age Risk of breast cancer in women at current age is: l age 20: 1 in 1,837 (0.054%) l age 30: 1 in 234 (0.42%) l age 40: 1 in 70 (1.4%) l age 50: 1 in 40 (2.5%) l age 60: 1 in 28 (3.6%) l age 70: 1 in 26 (3.8%) Source: American Cancer Society Breast Cancer Facts and Figures

Mammogram at age 50 (prevalence = 2.5%) Breast cancer Yes No Total Abnormal Mammogram result Normal 25 x 80% 20 True pos 97.5 False pos False neg 975 x 90% True neg Total Positive predictive value of mammogram at age 50 = 20 / = 17%

Mammogram at age 50 with mass (prevalence ~ 50%) Breast cancer Yes No Total Abnormal Mammogram result Normal 500 x 80% 400 True pos 50 False pos False neg 500 x 90% 450 True neg 550 Total Positive predictive value of mammogram at age 50 with mass = 400 / 450 = 89%

u A thorough history and physical exam = more accurate assessment of “prior probability” that the patient has a particular disease. u This helps guide appropriate choice and interpretation of lab and imaging tests. u And leads to better diagnosis and more effective treatment.

u An accurate history and physical exam are essential for arriving at the correct diagnosis.

u Video # 8 Mr. Dade

Patient-Centered Interview u Allows patients to express their concerns u Seeks patients’ specific requests u Elicits patients’ explanations of their illnesses u Facilitates patients’ expression of feeling u Gives patients information u Involves patients in developing a plan for evaluation and treatment u IMPROVES OUTCOME AND SATISFACTION.

u A good physician can talk to anyone…

u But a great physician can listen to anyone.

u Doc.com #13: Responding to Strong Emotions