1. The Challenging Interview Practice of Medicine-1

2. Learning Objectives Describe four steps used in identifying and addressing barriers to a successful interview. Describe four steps used in identifying and addressing barriers to a successful interview. Describe and identify common barriers encountered in a clinical interview. Describe and identify common barriers encountered in a clinical interview. Demonstrate how to address these barriers in interviews Demonstrate how to address these barriers in interviews

3. Challenging Interview “This is not going well” “This is not going well” “I am stuck” “I am stuck” “This really sucks” “This really sucks”

4. Introduction Basic Approach to addressing common problems during a patient interview. Basic Approach to addressing common problems during a patient interview. Demonstrate interviews with standardized patients. Demonstrate interviews with standardized patients.

5. Basic Approach GET REAL!

6. “GET REAL” 4 steps to identification and resolution of problems Recognize that a problem exists. Recognize that a problem exists. Explore/Identify the problem. Explore/Identify the problem. Acknowledge the problem Acknowledge the problem Legitimize patient’s emotional response. (Be empathic) Legitimize patient’s emotional response. (Be empathic)

7. Recognizing the problem The problem can block effective communication and interfere with: The problem can block effective communication and interfere with: Acquisition of data.Acquisition of data. Development of a therapeutic relationship.Development of a therapeutic relationship. Management of the patient’s problems.Management of the patient’s problems. May be explicit or implicit May be explicit or implicit The root cause and resolution may be unclear initially The root cause and resolution may be unclear initially

8. Possible Signs Verbal-nonverbal mismatch Verbal-nonverbal mismatch Cognitive dissonance Cognitive dissonance Unexpected resistance Unexpected resistance Physician discomfort Physician discomfort Noncompliance Noncompliance Treatment not workingTreatment not working Exacerbation of chronic diseaseExacerbation of chronic disease

9. Explore/Identify the problem Analyze the data Analyze the data If the problem is not obvious: If the problem is not obvious: Generate hypothesis: Generate hypothesis: Test hypotheses during the patient interviewTest hypotheses during the patient interview Open exploration of a problem, if unable to identify a hypothesis. Open exploration of a problem, if unable to identify a hypothesis. Enlist patient’s help in identifying problem.Enlist patient’s help in identifying problem. Brainstorm with patientBrainstorm with patient What if the problem belongs to you? What if the problem belongs to you? Must be careful at explicitly sharing this information with the patient.Must be careful at explicitly sharing this information with the patient. Would it help strengthen the doctor-patient relationship? If not, should not be sharedWould it help strengthen the doctor-patient relationship? If not, should not be shared

10. Acknowledge the problem open acknowledgement by the interviewer. open acknowledgement by the interviewer. Don’t forget basic interview techniques! Don’t forget basic interview techniques! accept and respect patient’s feelings and coping style. accept and respect patient’s feelings and coping style.

11. Legitimize patient’s emotional response Validation of the patient’s emotional response or reaction as a reasonable one given the patient’s circumstances. Validation of the patient’s emotional response or reaction as a reasonable one given the patient’s circumstances. Be empathic. Be empathic. Very useful strategy to help build rapport Very useful strategy to help build rapport In very complex/difficult situations In very complex/difficult situations Explore the patient’s willingness to work through problems/barriersExplore the patient’s willingness to work through problems/barriers Physician must also be ready and capable of working through a barrier.Physician must also be ready and capable of working through a barrier.

12. Demonstrations

13. The Rambling Patient Potential Causes: Histrionic personality style Histrionic personality style Thought disorder Thought disorder Anxiety, loneliness Anxiety, lonelinessSolutions: Direct patient to the task at hand - be polite, yet firm. Direct patient to the task at hand - be polite, yet firm. Make patient aware of time limits. Make patient aware of time limits. Help patient to prioritize problems/complaints. Help patient to prioritize problems/complaints. Acknowledge your confusion. Acknowledge your confusion. Use summary statements. Use summary statements.

14. ‘I Don’t Want to Talk to a Medical Student’ Potential Causes: Uncertainty about medical student’s role Uncertainty about medical student’s role previous experience previous experience desire to speak with his/her doctor desire to speak with his/her doctor fatigue; pain; emotional distress; need for control. fatigue; pain; emotional distress; need for control.Solutions: Recognize and acknowledge patient’s feelings. Recognize and acknowledge patient’s feelings. Explore reasons for patient’s response. Explore reasons for patient’s response. Empathize and legitimize patient’s response. Empathize and legitimize patient’s response. Clarify your role, and address patient’s concerns. Clarify your role, and address patient’s concerns. Negotiate a solution. Negotiate a solution.

15. The Angry Patient Potential Causes Potential Causes Patient’s situation, treatment by other health care providers (or you), poor communication, reaction to illness, depression. Patient’s situation, treatment by other health care providers (or you), poor communication, reaction to illness, depression. Solutions: Solutions: Recognize and acknowledge anger. Recognize and acknowledge anger. Accept patient’s anger, remain neutral. Acknowledge your role, if necessary. Accept patient’s anger, remain neutral. Acknowledge your role, if necessary. Explore contributing factors and identify underlying feelings. Explore contributing factors and identify underlying feelings. Be empathetic, and legitimate patient’s feelings. Be empathetic, and legitimate patient’s feelings. Discuss ways patient can deal with anger-provoking situations. Discuss ways patient can deal with anger-provoking situations.

16. The Patient With A “Crush” Potential Causes Physical attraction Physical attraction Deprivation (love, sex, support) Deprivation (love, sex, support) Personality/psychiatric disorder Personality/psychiatric disorderSolutions Recognition Recognition Acknowledgement (may be difficult to do explicitly) Acknowledgement (may be difficult to do explicitly) Exploration Exploration Legitimation/Empathy Legitimation/Empathy Refer to another physician (if all else fails) Refer to another physician (if all else fails)

17. I am fairly confident that I can handle a challenging interview? 1. Strongly Agree 2. Agree 3. Disagree 4. Strongly Disagree