interviewing techniques as tools for diagnosis and treatment, part 3 the helpful interview

Interviewing Techniques as Tools for Interviewing Techniques as Tools for Diagnosis and Treatment, Diagnosis and Treatment,

part 3part 3The Helpful InterviewThe Helpful Interview

The Practice of Medicine -1Christine M. Peterson, M.D.

Techniques as Tools 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

Gather data and understand it Develop rapport and respond to emotions Educate and motivate

Begin both diagnostic and healing processes

Techniques Are Not Results The true endpoint of your use of techniques

is the patient’s performance in the interview. Complete (facts, concerns & requests, context) Truthful (facts and emotions)

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

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

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

Issues from 3 x 5 cardsIssues from 3 x 5 cards Organizing the interview (order of inquiry, keeping

on track) Time management / efficiency Interpreting verbal and non-verbal communication

metacommunication

Dealing with emotions Note-taking / documentation Closing the interview Being a beginner

Four “pearls”

Active listening “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

Longer visits More orienting statements More humor, more laughter More facilitating comments

Mc Whinney’s Taxonomy of Medical Help-Seeking Behavior Limits of tolerance for symptom Limits of tolerance for anxiety about

symptom Problems of living presenting as

symptoms Preventive/routine care Administrative reasons

History of Present Illness: “O-P-Q-R-S-T” questions

Onset and circumstances of Occurrence Provocative and Palliative factors Quality and/or Quantity of symptom Region of body and Radiation to other

areas Severity of symptom (0 to 10 scale, if

applicable) and associated Symptoms Time (duration) and Temporal associations

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

Conclusive information Conclusive information for determining the diagnosisfor determining the diagnosis

Provided by: Per centHistory 73%

Physical examination 62%

Imaging studies 35%

Standard lab tests 22%

Diagnostic information sourcesDiagnostic information sources

Conclusive ErroneousHistory 73% 1-2%Physical examination 62% 1-2%Imaging studies 35% 7%Standard lab tests 22%

“Inaccurate, incomplete, or misinterpreted patient histories are among the leading causes for diagnostic errors.”

Feddock C. Am J Med 2007;120(4):374-8.

A woman presents to her doctor and requests a mammogram to find out whether she has breast cancer.

Is that a good idea?

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

How reliable is a mammogram?How reliable is a mammogram? If she has breast cancer, the probability that

the mammogram will be abnormal is 80%. “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?How reliable is a mammogram? If she does not have breast cancer,

the probability that the mammogram will be normal is 90%.

“Specificity” = 90%[i.e., 90% of normal women have a

normal mammogram and 10% of healthy women have anabnormal mammogram (“false positive” result) due to biology and/or interpretation.]

Breast cancer risk varies by ageBreast cancer risk varies by age

Risk of breast cancer in women at current age is: age 20: 1 in 1,837 (0.054%) age 30: 1 in 234 (0.42%) age 40: 1 in 70 (1.4%) age 50: 1 in 40 (2.5%) age 60: 1 in 28 (3.6%) 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 2007-2008

Over a lifetime: 1 in 8 (12.5%)

Prevalence of breast cancerPrevalence of breast cancer In the population as a whole

what per cent of women 20 and older have breast cancer today?

1 %

Random mammogramRandom mammogramBreast cancer

Yes No Total Abnormal

Mammogram result

Normal

Total 10 990 1000

Random mammogramRandom mammogramBreast cancer

Yes No Total Abnormal

Mammogram result

Normal

?

Total 10 990 1000

Random mammogramRandom mammogramBreast cancer

Yes No Total Abnormal

Mammogram result

Normal

10 x 80%

8

Total 10 990 1000

Random mammogramRandom mammogramBreast cancer

Yes No Total Abnormal

Mammogram result

Normal

10 x 80%

8

2

Total 10 990 1000

Random mammogramRandom mammogramBreast cancer

Yes No Total Abnormal

Mammogram result

Normal

10 x 80%

8

2 ?

Total 10 990 1000

Random mammogramRandom mammogramBreast cancer

Yes No Total Abnormal

Mammogram result

Normal

10 x 80%

8

2990 x 90%

891

Total 10 990 1000

Random mammogramRandom mammogramBreast cancer

Yes No Total Abnormal

Mammogram result

Normal

10 x 80%

899

2990 x 90%

891

Total 10 990 1000

Random mammogramRandom mammogramBreast cancer

Yes No Total

Abnormal

Mammogram result

Normal

10 x 80%

899 107

2990 x 90%

891893

Total 10 990 1000

Random mammogramRandom mammogramBreast cancer

Yes No Total

Abnormal

Mammogram result

Normal

10 x 80%8

True pos99

False pos107

2False neg

990 x 90%891

True neg893

Total 10 990 1000

Random mammogramRandom mammogramBreast cancer

Yes No Total

Abnormal

Mammogram result

Normal

10 x 80%8

True pos99

False pos107

2False neg

990 x 90%891

True neg893

Total 10 990 1000

Positive predictive value of random mammogram = 8 / 107 = 7.5%

Interpreting mammogram resultsInterpreting mammogram resultsCancer; 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.

For which women are mammograms recommended? Risk factors:

Previous breast cancer Genetic mutations (BrCA-1, BrCA-2) Breast mass Age Etc.

Breast cancer risk varies by ageBreast cancer risk varies by age

Risk of breast cancer in women at current age is: age 20: 1 in 1,837 (0.054%) age 30: 1 in 234 (0.42%) age 40: 1 in 70 (1.4%) age 50: 1 in 40 (2.5%) age 60: 1 in 28 (3.6%) age 70: 1 in 26 (3.8%)

Source: American Cancer Society Breast Cancer Facts and Figures 2007-2008

Mammogram at age 50Mammogram at age 50(prevalence = 2.5%)(prevalence = 2.5%)

Breast cancer

Yes No Total

Abnormal

Mammogram result

Normal

25 x 80%20

True pos97.5

False pos117.5

5False neg

975 x 90%877.5

True neg882.5

Total 25 975 1000

Positive predictive value of mammogram at age 50 = 20 / 117.5 = 17%

Mammogram at age 50 Mammogram at age 50 with masswith mass(prevalence ~ 50%)(prevalence ~ 50%)

Breast cancer

Yes No Total

Abnormal

Mammogram result

Normal

500 x 80%400

True pos50

False pos450

100False neg

500 x 90%450

True neg550

Total 500 500 1000

Positive predictive value of mammogram at age 50 with mass = 400 / 450 = 89%

A thorough history and physical exam = more accurate assessment of “prior probability” that the patient has a particular disease.

This helps guide appropriate choice and interpretation of lab and imaging tests.

And leads to better diagnosis and more effective treatment.

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

Video # 8 Mr. Dade

Patient-Centered Interview Allows patients to express their concerns Seeks patients’ specific requests Elicits patients’ explanations of their illnesses Facilitates patients’ expression of feeling Gives patients information Involves patients in developing a plan for

evaluation and treatment IMPROVES OUTCOME AND SATISFACTION.

A good physician can talk to anyone…

But a great physician can listen to anyone.

Doc.com #13: Responding to Strong Emotions