1. Interviewing and the Health History Practicum of Health Science Technology 2011 - 2012

2. Objectives At the end of this unit students will be able to:  Understand the importance of establishing a trusting and supportive relationship with patients  Develop the skills to gather pertinent information from patients  Acquire the ability to convey information to patients regarding their medical conditions

3. Health History  The health history format is a structured framework for organizing patient information in written or verbal form for other health care providers; it focuses on the clinician’s attention on specific kinds of information that must be obtained from the patient.

4. Interview Process  The interviewing process that actually generates the pieces of information is more fluid and demands effective communication and relational skills.  It requires not only the knowledge of data that you need to obtain, but also the ability to elicit accurate information and the interpersonal skills that allow you to respond to the patient’s feelings and concerns.

5. Health History Formats  Comprehensive  Problem-oriented  Focused

6. Interviewing Milestones  Getting Ready: The Approach to the Interview  Learning About the Patient: The Sequence of the Interview  Building the Relationship: The Techniques of Skilled Interviewing  Adapting Your Interview to Specific Situations  Sensitive Topics that Call for Special Skills  Societal Aspects of Interviewing

7. Getting Ready: The Approach  Self Reflection  Reviewing the Medical Record  Setting Goals for the Interview  Reviewing Your Clinical Behavior and Appearance  Adjusting the Environment  Taking Notes

8. Learning About the Patient: The Sequence  Greeting the Patient and Establishing Rapport  Establishing the Agenda  Inviting the Patient’s story  Identifying and Responding to the Patient’s Emotional Cues  Expanding and Clarifying the Patient’s Story

9. Learning About the Patient: The Sequence  Generating and Testing Diagnostic Hypothesis  Creating a Shared Understanding of the Problem  Negotiating a Plan  Planning for Follow-Up and Closing

10. Expanding and Clarifying the Patient’s Story: OLD CART  O = Onset  L = Location  D = Duration  C = Character  A = Aggravating/Alleviating Factors  R = Radiation  T = Timing

11. The Seven Attributes of a Symptom  Location  Quality  Quantity or Severity  Timing  Setting in which it occurs  Remitting or exacerbating factors  Associated manifestations

12. Generating and Testing Diagnostic Hypothesis First, open-ended questions to hear “the story of the symptom” in the patient’s own words. More specific questions to elicit the “seven features of every symptom” “Pertinent positives and negatives” from the relevant section of the review of systems

14. Disease  The explanation that the clinician brings to the symptoms.  It’s the way the clinician organizes what he or she learns from the patient that leads to a clinical diagnosis

15. Illness  Can be defined as how the patient experiences all aspects of the disease, including its effects on relationships, function, and sense of well-being.  Many factors shape this experience, including prior personal or family health, the effect of symptoms on everyday life, individual outlook and style of coping, and expectations about medical care.

16. Exploring the Patient’s Perspective  The patient’s feelings, including fears or concerns, about the problem  The patient’s ideas about the nature and the cause of the problem  The effect of the problem on the patient’s life and function  The patient’s expectations of the disease, of the clinician, or of the health care, often based on prior personal or family experiences.

17. Negotiating a Plan  Learning about the patient’s disease, and developing the ability to understand the patient’s illness give you and the patient the opportunity to create a complete picture of the problem and develop a plan of care on how you will address the problem (ie. Physical examination, diagnostic testing, laboratory tests, specialist consultations)

18. Planning for Follow-Up and Closing  May be difficult, patient’s often have lots of questions  Let the patient know that the end of the interview is coming and that this is their opportunity to ask any final questions  Make sure the patient comprehends the plan of care you have developed  Remind patient of follow-up and reaffirm your continued commitment to their health care management

19. Building a Therapeutic Relationship: The Techniques of Skilled Interviewing  Active Listening  Guided questioning  Non-Verbal Communication  Empathetic responses  Validation  Reassurance  Partnering  Summarization  Transitions  Empowering the Patient

20. Active Listening  The process of closely attending to what the patient is communicating, being aware of the patient’s emotional state, and using verbal and nonverbal skills to encourage the speaker to continue and expand  This allows you to understand precisely at multiple levels of the patient’s experience.

21. Guided Questioning  Moving from open-ended to focused questions  Using questioning that elicits a graded response  Asking a series of questions, one at a time  Offering multiple choices for answers  Clarifying what the patient means  Encouraging with continuers  Using echoing

22. Nonverbal Communication  Communication that does not involve speech occurs continuously and provides important clues to feelings and emotions.  Pay close attention to eye contact, facial expressions, posture, head position, and movement such as shaking or nodding, interpersonal distance, and placement of the arms or legs – crossed, neutral, or open.  Be aware that some nonverbal language is universal and some is culturally bound.

23. Nonverbal Communication  Mirroring your position can signify the patient’s increasing sense of connectedness, matching your position to the patient’s can increase rapport.  Mirroring the patient’s paralanguage, or qualities of speech, such as pacing, tone, and volume, to increase rapport are also effective.  Moving closer to the patient or physical contact like placing your hand on the patient’s arm can convey empathy or help the patient gain control of difficult feelings.

24. Empathetic Response  To provide empathy, you must first identify the patient’s feelings  Once you have identified the patient’s feelings, respond with understanding and acceptance  For a response to be empathetic, it must reflect a precise understanding of what the patient is feeling

25. Validation  Another important way to make a patient feel affirmed is to validate or acknowledge the legitimacy of his or her emotional experience.

26. Reassurance  Don’t give false hope  Don’t downplay the patient’s feelings  Always first determine what the patient’s feelings are, which promotes a feeling of connectedness  Actual reassurance comes after the interview and physical examination have been completed  At this point you can interpret for the patient what you believe is going on and deal openly with expressed concerns  The reassurance comes from conveying information in a confident manner, making the patient feel confident that problems have been understood, and will be addressed

27. Partnering  When building your relationships with patients, make explicit your desire to work with them in an ongoing way  Always convey that you are working together  This is not a dictatorship!

28. Summarization  Giving an abbreviated summary of the patient’s story during the course of the interview serves several different functions  It communicates to the patient that you have been listening carefully  It identifies what you know and what you don’t know  This allows the patient the ability to correct any misinformation or misunderstanding on the part of the clinician

29. Transitions  Notify the patient when you are changing directions during the interview  As you move from one part of the history to the next and on to the physical examination, orient the patient with brief transitional phrases  Make clear what the patient should expect or do next

30. Empowering the Patient  Share the Power  Evoke the patient’s perspective  Convey interest in the person, not just the problem  Follow the patient’s leads  Elicit and validate emotional content  Share information with the patient, especially at transition points during the visit  Make your clinical reasoning transparent to the patient  Reveal the limits of your knowledge

31. Adapting Your Interview to Specific Situations  The Silent Patient  The Confusing Patient  The Patient with Altered Capacity  The Talkative Patient  The Crying Patient  The Angry or Disruptive Patient  The Interview Across A Language Barrier  The Patient with Low Literacy  The Patient with Impaired Hearing  The Patient with Impaired Vision  The Patient with Limited Intelligence  The Patient with Personal Problems

32. The Interview Across a Language Barrier: Guidelines for Working With an Interpreter  Choose a trained interpreter  Use the interpreter as a resource for cultural information  Orient the interpreter to the components you plan to cover in the interview; include reminders to translate everything the patient says  Arrange the room so that you and the patient have eye contact and can read each other’s nonverbal cues; Seat the interpreter next to the patient

33. The Interview Across a Language Barrier: Guidelines for Working With an Interpreter  Allow the interpreter and the patient to establish a rapport  Address the patient directly. Reinforce your questions with nonverbal behaviors  Keep sentences short and simple. Focus on the most important concepts to communicate  Verify the mutual understanding by asking the patient to repeat back what he or she has heard  Be patient. The interview will take more time and may provide less information than usual.

34. Sensitive Topics That Call for Specific Approaches  Sexual History  Mental Health History  Alcohol and Illicit Drug Use  Family Violence  Death and Dying Patient

35. Guidelines for Broaching Sensitive Topics  The single most important rule is to be nonjudgmental.  Explain why you need to know certain information  Find opening questions for sensitive topics and learn the specific kinds of information needed for your assessments  Consciously acknowledge whatever discomfort you are feeling. Denying your discomfort may lead you to avoid the topic altogether.

36. Sensitive Topics That Call for Specific Approaches  Sexual History  Mental Health History  Alcohol and Illicit Drug Use  Family Violence  Death and Dying Patient

37. The CAGE Questionnaire  Have you ever felt the need to Cut down on drinking?  Have you ever felt Annoyed by criticism of your drinking?  Have you ever felt Guilty about drinking?  Have you ever taken a drink first thing in the morning (Eye – Opener) to steady your nerves or get rid of a hangover?

38. The CAGE Questionnaire: Results  Two or more affirmative answers to the CAGE Questionnaire suggest alcohol misuse and have a sensitivity that ranges from 43% to 94% and specificity that ranges from 70% to 96%. If you detect misuse, you need to ask about blackouts (loss of memory about events during drinking), seizures, accidents or injuries while drinking, job or school problems, conflict in personal relationships, or legal problems.  Also ask specifically about drinking while operating machinery or driving.

39. Sensitive Topics That Call for Specific Approaches  Sexual History  Mental Health History  Alcohol and Illicit Drug Use  Family Violence  Death and Dying Patient

40. Clues to Possible Physical Abuse  If injuries are unexplained, seem inconsistent with the patient’s story, are concealed by the patient, or cause embarrassment  If the patient has delayed in obtaining treatment for trauma  If there is a past history of repeated injuries or “accidents”  If the patient or person close to the patient has a history of alcohol or drug abuse  If the partner tries to dominate the interview, will not leave the room, or seems unusually anxious or solicitous

41. Sensitive Topics That Call for Specific Approaches  Sexual History  Mental Health History  Alcohol and Illicit Drug Use  Family Violence  Death and Dying Patient

42. Kubler – Ross Model of Death and Dying  Denial and isolation  Anger  Bargaining  Depression or sadness  Acceptance

43. TIPS for Practice  Work through your own feelings regarding death and dying  Utilize reading and discussion to explore these feelings  Utilize active listening with patients and provide opportunity for them to discuss their feelings  Understand the patient’s wishes regarding end of life treatment  Ask specific questions

44. Societal Aspects of Interviewing  Demonstrating Cultural Humility  Sexuality in the Clinician – Patient Relationship  Ethics and Professionalism

45. Demonstrating Cultural Humility  Cultural competence has been viewed as the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by patients and their communities

46. Culture  Defined as the system of shared ideas, rules, and meanings that influences how we view the world, experience it emotionally, and behave in relation to other people

47. Cultural Humility  Defined as the process that requires humility as individuals continually engage in self – reflection and self – critique as lifelong learners and reflective practitioners  Involves the difficult work of examining cultural beliefs and cultural systems of both patients and providers to locate points of cultural dissonance or synergy that contribute to patient’s health outcomes

48. Cultural Humility  Calls for clinicians to “bring into check” the power imbalances that exist in the dynamics of the clinician – patient communication and maintain mutually respectful and dynamic partnerships with patients and communities

49. Three Dimensions of Cultural Humility  Self – Awareness: Learn about your own biases.  Respectful Communication: Work to eliminate assumptions about what is “normal”.  Collaborative Partnership: Build your patient relationships on respect and mutually acceptable plans.

50. Societal Aspects of Interviewing  Demonstrating Cultural Humility  Sexuality in the Clinician – Patient Relationship  Ethics and Professionalism

51. Clinician – Patient Relationship  Any sexual contact or romantic relationship with patients is unethical  Keep you relationship with the patient within professional bounds, and seek help if you need it.  Protect yourself.

52. Societal Aspects of Interviewing  Demonstrating Cultural Humility  Sexuality in the Clinician – Patient Relationship  Ethics and Professionalism

53. Ethics  Are a set of principles crafted through reflection and discussion to define right and wrong

54. Medical Ethics  Principles and moral values of proper medical conduct  Guide professional behavior,

55. Building Blocks of Professional Ethics in Patient Care  Nonmaleficence – First Do No Harm  Beneficence – Do Good for the patient  Autonomy – Patients have the right to determine what is in their best interests  Confidentiality – Protecting the patient’s right to privacy regarding medical information

56. The Tavistock Principles  Rights: People have a right to health and health care  Balance: care of the individual patient is central, but the health of the populations is our concern  Comprehensiveness: In addition to treating illness, we have an obligation to ease suffering, minimize disability, prevent disease, and promote health

57. The Tavistock Principles  Cooperation: Health care succeeds only if we cooperate with those we serve, each other, and those in other sectors  Improvement: Improving health care is a serious and continuing responsibility  Safety: Do No Harm  Openness: Being open, honest, and trustworthy is vital in health care

58. Medical Terminology

59. Instructions Define the following terms in your interactive note book. Utilize KIM technique with the K = Key word/ key term; I = Information/ Definition; and M = Memory Cue – something that will help you to remember the term. Maybe a picture, word, or phrase.

60. Terms  Health History Format  Comprehensive Health History  Problem – Oriented History  Focused Health History  Open – Ended Questions  Disease  Illness  Code Status  Active Listening  Guided Questioning  Leading questions  Empathy  Sympathy  Validation  Reassurance  Partnering  Summarization

61. Terms  Surrogate Informant  Durable Power of Attorney  Health Care Proxy  Decision – Making Capacity  Cultural Competence  Cultural Humility  Culture  Values  Biases  Ethics  Medical Ethics  Principalism  Utilitarianism  Feminist Ethics  Casuistry  Communitarianism  Nonmaleficence  Beneficence  Autonomy  Confidentiality  Informed Consent

62. Medical Abbreviations

63.  OLD CART – Onset, Location, Duration, Character, Aggrravating/Alleviating Factors, Radiation, and Timing  HIPAA – Health Insurance Portability and Accountability Act  STD – Sexually Transmitted Disease  STI – Sexually Transmitted Infection  HIV – Human Immunodeficiency Virus  AIDS – Acquired Immunodeficiency Syndrome  OB/GYN – Obstetric/Gynecology  CAGE – Cut down, Annoyed, Guilty, Eye – Opener  DNR – Do Not Resuscitate  CPR – Cardiopulmonary Resuscitation

64. VIP of the Week

65. Sigmund Freud Instructions: Research this person and write the following in your interactive notebook.  Who is he? Describe him as a person.  What significance did he have to medicine, science, or health care?  How can you utilize his contribution in your profession?  How did his contribution affect the world?