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