PCM1: The Medical Interview: Communication Skills II

=The Medical Interview: Communication Skills II=

Describe how the doctor-patient relationship maximizes quantity/quality of information obtained from the patient, and fosters patient commitment to treatment.
Patients who feel at ease and who are listened to will be more likely to talk freely about their symptoms, giving you many clues to diagnosis. Patients who are listened to, without unneeded interruption, will feel respected by their doctor. (Average time physicians let patients talk before interruption – 18 seconds in one study, and 23 seconds in another!) Also, studies have shown that good communication improves both patient satisfaction, as well as clinical outcomes (i.e. compliance).

Describe how the "science" of medicine leads to applying reliable diagnostic standards and predicts the necessary care to be provided.
The US preventive services task force has taken a strong leadership position on defining the quality of experimental evidence for particular routine screening practices. They review the scientific literature and boil it down to a recommendation of when a physician should use a particular test. The use of algorithms to predict the prognosis of a patient is increasingly important in the practice of clinical medicine.

Demonstrate the ability to gather sufficient information needed to establish a differential diagnosis in a well-organized and efficient medical interview.
OK, use open-ended questions. – Questions that don’t have a yes/no answer. i.e. “Tell me about your symptom” – and use the OPQRST to elicit information about the chief complaint Use more specific or closed ended questions for the Review of Systems, to cover possible differential diagnoses. i.e. “Any Headache, fever, weight loss?” (There is a time and place for yes/no questions, but maybe not in the beginning of the interview) Pay attention to both what the patient says (be a good listener), as well as what the patient doesn’t say. Silence is a clue. Mengel states that it’s important to not only get information about the patient’s chief complaint, but to also get a sense of the patient’s perception of the illness. This will go a long way in establishing a good relationship with the patient, letting them know you are also interested in their psychosocial health, and that it is a partnership you are developing in their journey to health. == Describe how everyone—no matter how openly accepting of diversity—possesses cultural biases or blind spots, and how one’s own “mind set” can influence the course of an interview and one’s diagnostic reasoning.==

Probably hard to imagine that we are not all perfectly loving altruistic human beings, but we are human, and have biases. Some examples I have seen in the clinic so far – judgment towards patients who use a lot of pain medication, judgment or disappointment towards patient’s who drink or smoke, or who don’t take their medications correctly. Then of course there are the stereotypes we have towards certain races, or religious cultures, or ethnicities. The most important thing to remember is that everyone is doing the best that they can in the current moment, and they trust you to take care of them, both physically and emotionally.

== Describe the role of “trust” in the patient-physician relationship vis-à-vis cross cultural medical encounters and explain why the ability to assess a patient’s cultural issues vis-à-vis health behavior is an important skill for medical students.==

Did you ever read “The Spirit Catches You and You Fall Down”? Great book documenting the struggles between family of the Hmong culture and the physician’s who were trying to take care of a young Hmong child who had epilepsy. Tragic how much pain was caused from both sides not understanding the other, and making assumptions based on this lack of understanding. So cultural issued are important as we cannot separate the mind from the body, or the patient from his or her culture. Be sensitive to different cultures, and the patient will trust you, even though you may not be from the same culture.

Demonstrate cultural assessment techniques of developing rapport/building mutual agenda with patient through basic listening skills

 * Respectful attention to story, - (give them time and space to disclose, without interruption)
 * Paraphrasing to acknowledge patient's concerns / feelings/ ideas of what is causing illness, - (repeating what they have told you, or summarizing helps both them, to know that you have been listening, but it can also help you, since it will make clear what direction you may need to go)
 * Using perception check and behavior description in responding to patient's affect, social context, and experience of illness. – How does the patient sit? Does the patient make eye contact? Smile?

The LEARN guidelines for cross-cultural assessment may also be used.


 * ETHNIC Questionnaire – A framework for Culturally Competent Clinical Practice


 * E – Explanation – Why do you think you have these symptoms? What do friends, family, and others say? Do you know others with this problem? Have you seen it on TV, heard about it on the radio, or read about it in the newspaper?


 * T – Treatment – Do you take any treatments, medicines, or home remedies to treat the illness or to stay health? What kinds of treatment are you seeking from me?


 * H – Healers – Have you sought advice from friends, alternative folk, healers, or other non-doctors?


 * N- Negotiate – Negotiate mutually acceptable options, and incorporate patient’s beliefs. Ask results patient hopes to receive from intervention.


 * I – Intervention – Determine an intervention with your patient. May include incorporation of alternative treatments, spirituality, healers, or other cultural practices (i.e. foods to be eaten or avoided)


 * C - Collaborate – Collaborate with the patient, family, health team members, healers, and community resources.

== Describe how attending to and utilizing nonverbal cues can improve doctor-patient communication: the way a person uses his or her body; paralinguistic (e.g., pressure of speech, dead voice tone); use of personal and social space; appearance and grooming; eye contact.==

Does the patient face you, or is their body turned to the side? Does the patient make eye contact? Does the patient cross their arms over their chest? Do they pick at their fingernails? What is the intonation of the patient’s voice? Can you tell if they are sad, anxious, neutral, angry, relieved, or happy? How are they dressed? Clean? Hair washed? Well-groomed?

And I’m sure you can come up with some other things to note – the important thing – pay attention!

Describe and utilize components of a spiritual history (i.e. FICA).
SPIRIT questionnaire:


 * S – Spiritual Belief System – What is your formal religious affiliation? Name or describe your spiritual belief system.


 * P – Personal Spirituality – Describe the beliefs and practices of your religion or the spiritual system that you personally accept. Describe the beliefs or practices you do not accept. Do you accept or believe (specific tenet or practice)? What does your spiritual/religion mean to you? What is the importance of your spirituality/religion in daily life?


 * I – Integration with a Spiritual Community – Do you belong to any spiritual or religious group or community? What is your position or role? What importance does this group have to you? Is it a source of support? In what ways? Does or could this group provide help in dealing with health issues?


 * R – Ritualized Practices and Restrictions – Are there specific practices that you carry out as part of your religion/spirituality (i.e. prayer or mediation?) Are there certain lifestyles activities or practices that your religion/spirituality encourages or forbids? Do you comply? What significance do these practices and restrictions have to you? Are there specific elements of medical care that you forbid on the basis of religious/spiritual grounds? (i.e. I witnessed my preceptor ask her patient if she was catholic and whether she believed that life began at conception, when they were discussing the IUD as a form of birth control)


 * I – Implications for Medical Care – What aspects of your religion/spirituality would you like me to keep in mind as I care for you? Would you like to discuss religious or spiritual implications of health care? What knowledge or understanding would strengthen our relationship as physician-patient? Are there any barriers to our relationship based on religious or spiritual issues?


 * T - Terminal Events Planning – As we plan for your care near the end of your life, how does your faith affect your decisions? Are there particular aspects of care that you wish to forgo or have withheld because of your faith?