The Clinical Interview

Skills for More Effective Patient Encounters

Scott Simpson, Anna McDowell

• Publisher: Routledge
• Year: 2019
• ISBN:
  9780429793455
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The Clinical Interview offers a new perspective on the patient encounter. Interpreting decades of evidence-based psychotherapy and neuroscience, it provides 60 succinct techniques to help clinicians develop rapport, solicit better histories, and plan treatment with even the most challenging patients.

This book describes brief skills and techniques for clinical providers to improve their patient interactions. Although evidence-based psychotherapies are typically designed for longer specialized treatments, elements of these psychotherapies can help clinicians obtain better patient histories, develop more effective treatment plans, and more capably handle anxiety-provoking interactions. Each chapter is brief and easily digestible, contains sample clinical dialogue, and provides references for further reading. These skills help clinicians practice more effectively, more efficiently, and with greater resilience. Whatever your clinical specialty or role, whether you are a trainee or an experienced clinician, The Clinical Interview offers practical wisdom and an entirely new way to think about the clinical encounter.

The Clinical Interview will be of great use to any student in a health-related field of study or a healthcare professional interested in refining their interviewing skills. It will help anyone from emergency medical technicians, nurses, and physician assistants, to nurse practitioners and physicians to build more meaningful patient relationships.

I
Building Rapport

1
Elicit One Goal

Be More Efficient by Learning the Patient’s Agenda

Setting

Clinicians are busy. Healthcare systems demand productivity through short outpatient appointments and ever-present pressure to discharge from the hospital or emergency department. On one hand, this productivity maintains access to care for more people. But clinicians are challenged to maintain a focus on any individual patient. The resulting haste would come across as rude in any other human interaction: the average clinician does not ask the patient their goals for the appointment and interrupts the patient after 11 seconds.¹ Clinicians must balance efficiency with the need to understand the patient’s goals in a compassionate, thorough manner.

The Technique

Elicit the patient’s one most important goal at the outset of the appointment with an open-ended question. Patients who provide multiple, competing goals should be asked to prioritize their needs for the appointment, after which the patient and clinician may negotiate what secondary issues can be covered in the available time. When patients have difficulty identifying a single goal, ask for a short list of possibilities and the patient’s best guess as to the most important item. The clinician can then ask the patient why they think that one item would be the most important to address.

Sample Dialogue

Patient: I have so much going on—my stomach is upset, and my back is really hurting. My sleep feels off a little, too. And I need refills for my medication. I think that’s all, but maybe not!

Clinician: That does sound like a lot! What is the one most important thing that we should discuss today?

Just one thing? I have a whole list!

I imagine we can talk about much of this, but let’s prioritize what is most important to you in the time we have.

I guess the one thing I really need is a medication refill. But then if we have time, let’s talk about my stomach.

OK, the most important thing we need to discussion is your medication refill. Then your stomach issues. And then we can work on those other issues or schedule another appointment if we need. What made you think the medication refill is most important?

Because if I don’t take my medications, my blood sugars get really high, which is dangerous.

Why This Works

Interrupting the patient early does not make the encounter more efficient.² Early interruptions make it more likely that the patient brings up new concerns later in the visit or that their most significant concern goes unaddressed entirely. Eliciting the patient’s one most important agenda item early on enables the clinician to anticipate how to spend time during the encounter and best address the patient’s preeminent needs. Most patients are able to prioritize their needs, and they will communicate quickly. Left uninterrupted, patients disclose their agenda in an average of 6 seconds.¹

If early interruptions don’t save time, opening with the wrong questions does not, either. Opening an encounter with vague, open-ended questions such as, “How are you today?” is helpful in building rapport but inefficient in assembling a clinical agenda. The sample dialogue lays out clear ground rules for this encounter: What one thing is most important to discuss? Even quite ill patients are good at triaging their own medical needs,³ and for some conditions self-triage is as accurate as that done by a professional.⁴ Notwithstanding the need for clinicians’ expert judgment in urgent cases, following the patient’s lead in agenda-setting generally improves efficiency and safety.⁵

Many patients have multiple complaints as in the sample dialogue. The clinician can validate the patient’s concerns and distress before reframing the agenda. The clinician is not closing any doors to the patient’s concerns—only opening doors more selectively. Patient-centered communication demands that clinicians consider patient’s preferences in addressing medical needs but does not abrogate the need for clinical effectiveness.⁵ In the absence of a unifying diagnosis accounting for myriad complaints, the clinician needs to address a number of concerns and will only be able to do so with some control over the encounter’s agenda. Neither solely adopting the clinician’s priorities nor proceeding with an unfocused appointment benefits the patient.

Furthermore, this technique simplifies the patient’s treatment goals. When a patient presents with so many concerns, the clinician is soon as overwhelmed as the patient. Clinicians can alleviate themselves of this burden by sharing responsibility for the encounter’s agenda with the patient. Identifying goals is an important part of life but does not come easily for everyone. (After all, some persons seek therapy because they have difficulty understanding their personal and professional goals.) Understanding the patient’s choices is helpful in planning further treatment; in this sample dialogue, it is clear that the patient has a sense of the dangers of medication non-adherence. In a sense, this technique is a variant of the technique described in chapter 47, except that the time horizon for the patient’s goals is the end of the encounter rather than several weeks out. Both techniques are designed to aid in forming concrete priorities for treatment.

Final Thoughts

Identifying and pursuing the patient’s agenda improves patient satisfaction, a common metric used in many healthcare systems’ quality and pay-for-performance programs.⁶ Clinicians often feel that trying to address satisfaction and productivity while maintaining safety is a losing battle. Remember also that follow-up encounters will not necessarily follow the same agenda as the first initial visit.⁷ Clinicians should be prepared to re-examine the patient’s goals every encounter. Patients whose desired treatment goals are unrealistic may benefit from a discussion around agenda setting (chapter 34).

References

1. Singh Ospina N, Phillips KA, Rodriguez-Gutierrez R, et al. Eliciting the patient’s agenda-secondary analysis of recorded clinical encounters. J Gen Intern Med. 2018;34(1):36–40.

2. Hashim MJ. Patient-centered communication: basic skills. Am Fam Physician. 2017;95(1):29–34.

3. Miyamichi R, Mayumi T, Asaoka M, Matsuda N. Evaluating patient self-assessment of health as a predictor of hospital admission in emergency practice: a diagnostic validity study. Emerg Med J. 2012;29(7):570–575.

4. Eijk ES, Busschbach JJ, Monteban H, Timman R, Bettink-Remeijer MW. Towards patient self-triage in the ophthalmic emergency department: sensitivity and specificity of a self-triage instrument. Acta Ophthalmol. 2014;92(7):697–700.

5. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy of Sciences; 2001.

6. Boissy A, Windover AK, Bokar D, et al. Communication skills training for physicians improves patient satisfaction. J Gen Intern Med. 2016;31(7):755–761.

7. Rey-Bellet S, Dubois J, Vannotti M, et al. Agenda setting during follow-up encounters in a university primary care outpatient clinic. Health Commun. 2017;32(6):714–720.

2
Validate Three Different Ways

Be Authentic in Your Validation by Expanding the Ways in Which You Can Agree With the Patient

Setting

Validating patients’ feelings and thoughts are an essential part of building a treatment alliance. Successful validation requires the clinician to be authentic—even when you do not entirely agree with the patient. It is important to be adaptable while interviewing in order to deliver effective validating statements.

The Technique

The simplest form of validation is to agree with what the patient is saying. When this proves too difficult, the clinician can agree with how the patient is feeling about a situation. And if that does not feel authentic, validate the likelihood that any patient would feel similarly given the circumstances.¹

Sample Dialogue

Patient: You are not treating me fairly. I don’t think you care about me at all!

Clinician: I understand that you feel you are being mistreated.

Do you? Because you don’t act like it.

I think anyone who felt they weren’t getting what they needed would feel like they were being treated unfairly. And I understand that you feel this way. But I do not feel comfortable prescribing that medication for you.

Well, then perhaps I just need to see a different doctor.

I can appreciate why you would want to see someone else. Let’s talk about the treatment options I can offer you.

Why This Works

What is validation, and why is it important? Validation is the act of affirming a person’s viewpoint, including how they think and feel. Giving validation is a way of giving value to others’ opinions, perspectives, and decisions. For the patient, hearing validating statements reminds them of their own self-worth and personal value. Our need for validation begins at a young age, when our caregivers provide affirmation of our basic needs, thereby reminding us how our own opinions and wants matter. Across cultures, persons who grow up without the validating support of loving caregivers are prone to anxiety and interpersonal difficulties later in life.²,³

As important as validation is for the clinical encounter, validating statements should always be delivered by the clinician from a genuine, authentic position. False affirmation is easily detected by the patient. Patients who have a history of trauma are often highly sensitive to inauthentic validation, and upon hearing it become upset.

The clinician is thus in the position of having to find some way to validate the patient’s stance without appearing inauthentic even in situations when there is disagreement. In the sample dialogue, the patient posits that they are ...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• Foreword
• Preface
• List of Contributors
• Introduction: A New Approach to the Clinical Encounter
• I Building Rapport
• II Taking a History
• III Making an Assessment
• IV Planning Treatment
• Index