MIRS
Master Interview Rating Scale
The Clinical Conversation and Interview
The Training Manual for
Standardized Patients
Copyrighted to Theresa A. Thomas Professional Skills Teaching & Assessment Center,
Eastern Virginia Medical School
Throughout this manual, pronouns are presented in the masculine gender. The authors intend no sexism.
This decision was made for the sake of ease and clarity in reading.
ACKNOWLEDGMENTS
Substantial Revisions
June 2005:
Gayle Gliva-McConvey, Director
Hilarie J. Haley, Associate Director
Jim Kiraly, Communications Trainer
Lorraine Lyman, Staff Development Coordinator
Theresa Thomas Professional Skills Teaching & Assessment Center
Eastern Virginia Medical School.
Special thanks to the following for past revisions:
July 2001:
Christine Matson M.D.
Office of Education
Eastern Virginia Medical School.
July 2002:
Joel Ladd, Communications Trainer
Theresa Thomas Professional Skills Teaching & Assessment Center
Eastern Virginia Medical School.
PURPOSE
With the increasing expectation that medical educators teach and evaluate the communication skills of health
professionals comes the need for standardized patient programs to assess these skills. Unfortunately, evaluation
instruments used by SP programs to assess communication skills are often developed and administered informally
and without attention to sound educational or psychometric practices. The Master Interview Rating Scale (MIRS)
was developed from the Arizona Clinical Interviewing Rating scale which is a reliable measure of communication
skills.1,2 It includes 28 items that can be selected to match clinical cases. Its validity and reliability are both being
established.
A critical feature of the MIRS is that it can be used by SP’s and faculty alike with adequate training. It can also be
used in the direct observation of health professionals in their clinical settings. It is also very effective as a teaching
tool for those learning to do a medical history, counsel and manage patients. This packet includes a training manual
for the MIRS, the form itself and some condensed versions of it. The original instrument was developed by Paula
Stillman, MD and the MIRS itself was developed by Gayle Gliva and colleagues at Eastern Virginia Medical School.
1.
2.
Stillman PL, et al. Construct validation of the Arizona Clinical Interview Rating Scale. Educ Psychol Measure 1977;37(4):1031-8.
Schirmer Julie M, LCSW, Mauksch Larry, Med; Lang Forrest, MD; Marvel Kim M, PhD; Zoppi Kathy, PhD; Epstein Ronald M, MD;
Brock Doug PhD; Pryzbylski Michael, PhD. Assessing Communication Competence: A Review of Current Tools. Fam Med
2005;37(3):184-92.
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BACKGROUND
Standardized Patients (SPs) have been used for medical teaching and assessment since the late 1960’s.
Originally, SPs were only required to complete checklists for scoring. Since then SPs have been trained to
give feedback to health care professionals on a variety of interview and communication skills. Eastern
Virginia Medical School implemented Standardized Patient use in January of 1994. The Director, Gayle
Gliva Mc-Convey, is in the forefront of SP education. She started her career in 1973 at McMaster
University in Hamilton, Canada. The Associate Director, Hilarie J. Haley, started working in the SP field
in 1987 at the University of Massachusetts Medical School. The Communications Trainer, Jim Kiraly,
started working with SPs in 2003 and has a diverse background in communication, video-based
instruction and computer-based instruction. Lorraine Lyman began her career as a standardized patient
and GTA in 1996 in New York. She was employed by Eastern Virginia Medical School in 1999 with field
experience and to further her career as a GTA trainer and staff development coordinator. Gliva and Haley
are recognized international trainers and speakers.
Original Manual, Arizona Clinical Interviewing Rating Scale, written by Paula L. Stillman, M.D., 1973
Note: This manual reflects further revisions proposed by Carol A. Pfeiffer, Ph.D., Director of the Clinical
Skills Assessment Program at the University of Connecticut School of Medicine.
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TABLE OF CONTENTS
PAGE
INTRODUCTION .............................................................................................................................. 4
CONTENT AND PROCESS .............................................................................................................. 5
VERBAL FEEDBACK....................................................................................................................... 6
WRITTEN FEEDBACK .................................................................................................................... 7-8
WRITTEN FEEDBACK EXAMPLES............................................................................................... 9
COMMON MISTAKES ..................................................................................................................... 10
COMMUNICATION SKILLS
Item 1.................................................................................................................... Opening
10
Item 2..................................................................................... Elicit Spectrum of Concerns
10
Item 3........................................................................... Negotiate Priorities & Set Agenda
11
Item 4.................................................................................. Eliciting the Narrative Thread
11
Item 5................................................................................................................... Timeline
12
Item 6............................................................................................................. Organization
12
Item 7............................................................................................ Transitional Statements
13
Item 8...................................................................................................Pacing of Interview
14
Item 9................................................................................................... Types of Questions
15-6
Item 10...........................................................................................................Summarizing
17
Item 11............................................................................................................. Duplication
18
Item 12........................................................................................................ Lack of Jargon
18
Item 13........................................................................ Verification of Patient Information
19
Item 14............................................................................................Interactive Techniques
20
Item 15........................................................................................ Verbal Facilitation Skills
21
Item 16................................................................................ Non-Verbal Facilitation Skills
22
Item 17............................................................ Empathy and Acknowledging Patient Cues
24
Item 18................................................................................ Patient’s Perspective (Beliefs)
25
Item 19............................................ Impact of Illness on Patient and Patient’s Self-Image
26
Item 20.................................................................................... Impact of Illness on Family
26
Item 21..................................................................................................... Support Systems
27
Item 22..................................................................... Patient Education and Understanding
28
Item 23.............................................................................. Assess Motivation for Changes
29
Item 24............................................................................... Admitting Lack of Knowledge
30
Item 25............................................. Informed Consent for Investigations and Procedures
30
Item 26............................................................................................ Achieve a Shared Plan
31
Item 27.................................................................................. Encouragement of Questions
32
Item 28................................................................................................................... Closure
33
Summary Items 28-31 (ABIM) ........................................................................................................... 34
ACGME .............................................................................................................................................. 35
Master Interview Rating Scale – Short Form ...................................................................................... 36-44
Appendix A: Outline for Medical Interview ....................................................................................... 45-50
Appendix B: Aids for Giving and Receiving Feedback ...................................................................... 51-53
Appendix C: Student Professionalism Evaluation Form ..................................................................... 54
MIRS Form 2006 ................................................................................................................................ 55-60
MIRS At-a-Glance .............................................................................................................................. 61-62
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INTRODUCTION
An effectively conducted interview is extremely important for patient care. The completeness and
accuracy of the information collected will contribute to the proper diagnosis, management, treatment, and
health outcome of the patient’s problem. The rapport established between a patient and the interviewer
allows the patient to feel comfortable about sharing information and is important in promoting a patient's
compliance with the prescribed therapy.
The development of rapport is so important to the efficiency and effectiveness of a session, that the
medical interview should actually be called the clinical conversation. The term “interview” makes one
think of a question and answer session where one person has the majority of power. In fact, the session
between a patient and a physician should be conversational, equivocal, with sharing ideas and feelings.
This manual has been designed to aid the standardized patient in evaluating a medical interview by
providing information about (1) the components of an interview, (2) techniques for evaluating interview
and communication skills and (3) the roles of the participants. This manual covers the core material
which is common to the adult, pediatric, geriatric and psychiatric interviews.
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The Medical Conversation & Interview
CONTENT AND PROCESS
There are two major components of medical interviews which can be evaluated: content and process.
Content: What doctors communicate – the substance of their questions and responses, the information
they gather and give, and the treatments they discuss. This pertinent information is contained within
several interrelated subsections of the interview: introduction, chief complaint/history of the present
illness, family and social history, and the review of systems.
Standardized patients can evaluate the amount of information obtained by the interviewer by using a
content checklist. The checklist contains all relevant aspects of the patient's case history that should be
elicited. The interviewer receives credit for each piece of relevant information he is able to obtain during
the course of the interview.
Process: How doctors communicate – the process refers to the technique, or style, that the interviewer
uses in obtaining information from the patient. The manner in which the interviewer asks questions and
interacts with the patient will greatly influence the amount of information obtained, the efficiency of the
interview, and the success of the interviewer-patient relationship.
The process component is evaluated by using a modification of the Arizona Clinical Interview Rating
Scale (ACIR). The scale lists a number of process skills which are grouped into categories. These
categories include such things as organization, timeline, transitional statements, questioning skills,
documentation of patient information, and facilitative behavior. The scale defines five optional levels of
competency for each of the skills. Each item has specific performance criteria for objective scoring on the
scale of 1 to 5. There are 27 items in the MIRS manual. Each case will have chosen items for scoring
depending on the curriculum, goals for the assessment, and case author needs. All 27 items are rarely
scored for most cases.
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VERBAL FEEDBACK
The following standard procedures are required by all Standardized Patients for a uniform presentation to
the health care providers. Remember that you may be the first SP the interviewer has worked with and
you may need to spend a little more time describing the process and items. When working with an
interviewer that has knowledge of your role and the MIRS, feedback becomes easier.
1.
Introduce yourself to the interviewer before beginning feedback. This will clearly change your role
from the patient to an evaluator/teacher. “Hi. My name is ____. I’m your standardized patient for
today. I’d like to give you feedback on some of your communication skills using the Master Interview
Rating Scale. Each item looks at a different technique and has specific criteria. If you have any
questions as we go along; feel free to ask. But first let me ask you; what did you find most
challenging about your communication skills today?”
2.
Introduce the MIRS and inquire if the interviewer has had prior experience with the process. If not,
provide education. “I’d like to give you feedback on some of your communication skills using the
Master Interview Rating Scale. Have you ever had feedback on this before?...Each item looks at a
different communication technique and has specific criteria for the interviewer.”
3.
Clearly review each item’s criteria with the interviewer. Be sure to encourage comments from the
interviewer regarding each item and specific examples from the session. “The next item is Lack of
Jargon. The criteria require you to ask questions and provide information in language, which is
easily understood; content must be free of difficult medical terms and jargon. Words must be
immediately defined for the patient. Language used should be appropriate to the patient's level of
education. Do you recall using any medical terms today? During the Family History you asked if
there was a history of MI’s in the family and I asked what that meant. You explained the term very
clearly for the patient. That would be a good example of medical jargon – words that you use every
day but that the average layperson doesn’t know.”
4.
Reinforce the learning process by asking the interviewer for specific examples. This also will help
you to gauge their understanding of the technique. “What would be a good transitional statement to
start the past medical history portion of your interview?”
5.
Encourage questions with each item before starting the next. “Do you have any questions about
using transitional statements? Would you like to try a couple more before we move on?”
6.
Always give the score at the end of the feedback for that item. That way the interviewer will give
you his full attention. This type of explanation will avoid debates over the score and will
demonstrate your objectivity as well as provide specific information.
7.
Summarize the results of the feedback by delineating both the strong points and the areas that
need improvement, and ask if there are any more questions or comments the interviewer would like
to make. This will allow the interviewer an opportunity to clarify any last-minute concerns.
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Please see Appendix B for additional information on providing feedback.
WRITTEN FEEDBACK
The following standard procedures are required by all Standardized Patients for a uniform written
presentation to the health care providers. Occasionally, the SP or Teaching Associates will be asked to
complete written feedback on the interviewer’s session. There may be times when this will follow a
verbal session or will be after an assessment. Basic steps to follow and examples are provided for you in
this section.
Basic Steps
1.
Objectify the feedback session.
 Focus on the interviewer’s behavior, rather than the interviewer.
 Focus on what the interviewer does, not who you imagine the interviewer is.
 Make observations, rather than conclusions.
 Describe rather than judge.
 Focus on reporting what actually occurred, not if it’s good or bad, right or wrong.
2.
Focus feedback for effectiveness.
 Focus on the “here and now” rather than “there and then,” on what happened today
rather than what may happen tomorrow or what did happen yesterday.
 Share ideas rather than give advice. Focus on letting the person be free to decide for
themselves, not telling them what to decide.
 Explore alternatives rather than answers or solutions. Focus on a variety of options,
not an assortment of answers.
 Focus on serving the needs of the interviewer, not the desires of the evaluator.
 Focus on the words used (what was said), not why they were used.
3.
Use direct examples.
 Stay away from vague terms like “wonderful” or “good.” Be specific as to what was
“wonderful” and why it was.
4.
Use MIRS terminology.
 Always use terminology from the MIRS manual. It will save time, be easier on you,
and be better understood by the interviewer.
5.
Be factual.
 Always avoid words or phrases the interviewer/reader may interpret as personal or
judgmental.
6.
Process, not content.
 Always focus your written comments on the process, the “how” of the session, not the
content, the “what” of the session.
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Please see Appendix B for additional information on providing feedback.
WRITTEN FEEDBACK
Examples:
ORIGINAL COMMENT
THEMES / PERCEPTIONS
Seemed flat as far as attitude
goes.
Judgmental / SP didn’t like the
student personally
OUTSTANDING!!! Besides
leaving out the drug history
she nailed everything that she
needed.
Content – not process / gives
impression student “passed” the
assessment
Did not use summarization.
No value to interviewer
Eye contact could be
improved.
Advice – no sharing of ideas or
solutions
Questions tended to be
somewhat confusing since
they were multiple choices
with a variety of possible
answers.
Theme – student didn’t make sense
– bad choice of questions.
Good closing as far as what
she thought was wrong with
me.
Interviewer may perceive the SP is
telling them the diagnosis was
wrong.
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Facilitative behavior – good eye
contact and open body language.
Tone of voice may be perceived as
uninterested in patient. Use of
empathetic statements and verbal
cueing suggested as alternatives.
Facilitation and empathy techniques
were strong throughout interview.
Eye contact and tone of voice were
warm and caring along with
establishing rapport through the
eliciting of patients feelings, ideas
and expectations of the visit.
Summarization is a technique the
interviewer may want to incorporate
into the interviewing process after
each major line of inquiry. This
technique strengthens organization,
rapport and data gathering skills for
documentation.
Rapport was established by open
body language and conversational,
friendly tone of voice. Eye contact
was interrupted a number of times
when the interviewer looked at his
watch and the clock on the wall.
Types of questions used were openended for most major lines of
inquiry but quickly became more
focused or multiple questions.
Suggest trying to keep the lines
more open-ended for the patient to
tell his story.
The closure of the interview had all
of the criteria needed – what the
interviewer will do, that I would
wait for the preceptor and that we
would talk again in a couple of
minutes. Some diagnoses and
management plans were also
discussed in a clear and easily
understood language (no jargon
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was used by the interviewer.)
COMMON MISTAKES
The following examples highlight common mistakes when providing interviewers with feedback. Each
example is coupled with a more appropriate approach to feedback and an explanation of the improvement.
1.
Incorrect Feedback:
“You needed to ask more of a family and social history – this caused you to miss the diagnosis.”
Correct Feedback:
“We have already reviewed the checklist for the items you may have forgotten to ask, let’s move on to the
process or communication skills.”
Explanation:
The content and the process are two different things. Standardized Patients may be asked to review a
checklist with a student. This will show the student which items were considered important by the case
author. It is not the SP’s job to discuss if a student was thorough in the completion of the checklist or to
discuss the diagnosis, only a MD can discuss these with the students.
2.
Incorrect Feedback:
“I didn’t like the way you came into the room and started firing questions at me.”
Correct Feedback:
“One of the techniques I would like to review with you is the opening of a session…. Let’s move on to the
pacing of the interview…”
Explanation:
The student hears “I didn’t like you.” Feedback should not be personalized. Keep in mind that you are
portraying a patient and should react as the patient in role, but be very professional and detached from the
role during feedback. Don’t take student mistakes personally, remember that they are here to learn from
you and are nervous about their performance. Starting feedback in a negative fashion will cause any
person to shut down and put up defenses. Always start feedback with a positive comment.
3.
Incorrect Feedback:
“All in all, I think you did great – you were really wonderful.”
Correct Feedback:
“You have a lot of great strengths in the techniques of the interview. Your types of questions elicited
information and built rapport..”
Explanation:
The first statement is too vague. The student will leave the room thinking that they have “aced” that
session. Unless the SP is also the case author and statistician, they can not truly know how a case checklist
and MIRS is being scored. Don’t give the students the wrong information. If you feel a student is
“wonderful” stop and think first why you feel that way. Which items from the MIRS did they excel at? Be
sure to give that feedback to the students but be specific to the MIRS items.
4.
Incorrect feedback:
“You got a lot more information from me than any other student.”
Explanation:
Never compare students. This is not a competitive nor a comparative “sport” but an individual
performance. Comments are to be specific and non-comparative.
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COMMUNICATION SKILLS
ITEM 1 - OPENING
The opening of the visit begins with the introduction of self, clarification of roles, and inquiry of how to
address patient. The interviewer uses a combination of non-verbal approaches such as a handshake, eye
contact and smile plus a suitable verbal greeting, putting the patient at ease, using small talk or inquiring
about the patient’s physical comfort (addressing dress, temperature, and light), and privacy.
The opening question identifies the problems or issues that the patient wishes to address (i.e.: what would
you like to discuss today?).
Example: “Hello, I’m Carol Redding, (shaking patient’s hand) a medical student working with Dr. Lee;
I’m learning how to interview patients. We haven’t met before – which would you prefer, Mrs. Black or
Phyllis? Are you comfortable right now? What would you like to discuss today?”
ITEM 2 - ELICITS SPECTRUM OF CONCERNS
It is very important for the interviewer to elicit the patient's full spectrum of concerns other than those
expressed in the chief complaint within the first 3-5 minutes of the interview.
Criteria Statements:
5. The interviewer elicits the patient's full spectrum of concerns within the first few minutes of the
interview. The interviewer specifically questions for hidden concerns.
3. The interviewer elicits some of the patient's concerns on his chief complaints but misses some of
his hidden concerns and/or does not follow through with addressing concerns.
1. The interviewer fails to elicit the patient's concern, OR to address any hidden concerns.
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COMMUNICATION SKILLS
ITEM 3 - NEGOTIATES PRIORITIES & SETS AGENDA AT INTERVIEW ONSET
The interviewer negotiates priorities of concerns and establishes the purpose of the visit. An agenda is
negotiated between the interviewer and the patient. In negotiating priorities, a balance may need to be
struck between the patient’s concerns and the doctor’s medical understanding of which problems might be
more immediately important. In agenda setting and negotiating, the patient is not just told what is going
to occur, but is invited to participate in making an agreed plan.
Criteria Statements:
5.
The interviewer fully negotiates priorities of patient concerns, listing all of the concerns and
sets the agenda for the interview onset. The patient is invited to participate in making an
agreed plan.
3.
The interviewer elicits only partial concerns and therefore does not accomplish the complete
patient agenda for today’s visit. The interviewer sets the agenda.
1.
The interviewer does not negotiate priorities or set an agenda. The interviewer focuses only
on the chief complaint and takes only the physician’s needs into account.
ITEM 4 - ELICITING THE NARRATIVE THREAD or the “PATIENT’S STORY”
At the beginning of the visit, the interviewer should encourage the patient to talk about their problem(s),
in their own words. The interviewer listens attentively without interrupting, except for encouragement to
continue until the patient has finished talking about their problem(s).
Criteria Statements:
5. The interviewer encourages and lets the patient talk about their own problem(s). They do not stop
the patient or introduce new information.
3. The interviewer begins to let the patient tell their story but either interrupts with focused questions
or introduces new information into the conversation.
1. The interviewer fails to let the patient tell their story, OR the interviewer sets the pace with Q & A
style, not conversation.
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COMMUNICATION SKILLS
ITEM 5 - TIMELINE
The timeline pertains to the information contained in the chief complaint and history of the patient's
current illness. To obtain a timeline, the interviewer should inquire when the patient was last free of this
problem, and then follow the progression of the first signs and symptoms to the present. By carefully
following the chronological progression of the complaint, the interviewer will avoid missing important
information. If several symptoms are reported, it is important that their chronological relationship to each
other be determined. The interviewer need not gather the information in a chronological order or all at
once, as long as the information needed is obtained during the interview.
Example: A 56-year-old male presents with chest pain on the left for two hours. The patient's
chest pain first occurred two years ago but only upon exertion and disappeared after a few
minutes. One year ago the pain increased and was diagnosed as angina pectoris. Nifedipine (l0
mg) qid was taken and the pain disappeared one month later. The patient continued to take
Nifedipine (l0) bid and is currently doing so. Two hours ago the patient experienced chest pain on
the left and one hour ago the patient experienced sweating, faintness, palpitations, and the pain
radiated to the left shoulder.
Criteria Statements:
5. The interviewer obtains sufficient information so that a chronology of the chief complaint and
history of the present illness can be established. The chronology of any associated symptoms is
also established.
3. The interviewer obtains some of the information necessary to establish a chronology. He may fail
to establish a chronology for any associated symptoms.
1. The interviewer fails to obtain information necessary to establish a chronology.
ITEM 6 - ORGANIZATION
The organization category refers to the structure and organization of the entire interview. This
encompasses the information gathered in the introduction (during which the student introduces himself
and explains his role), the body of the interview, (chief complaint and history of present illness, past
medical history, family history, social history, review of systems), and the closure (or the end of the
interview, but not quality of the closure).
Questions in the body of the interview follow a logical order to the patient. The interviewer imposes
structure by systematically following a series of topics.
Criteria Statements:
5. Questions in the body of the interview follow a logical order to the patient.
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3. The interviewer seems to follow a series of topics or agenda items; however, there are a few
minor disjointed questions.
1. Asks questions that seem disjointed and unorganized.
COMMUNICATION SKILLS
ITEM 7 - TRANSITIONAL STATEMENTS OR “SIGNPOSTS”
Transitional statements are two-part statements used (including what and why) between subsections of
the interview to inform the patient that a new topic is going to be discussed. For example, "We've been
talking about why you came to see me today. Now I'd like to get some information about your own past
medical history (what), to see if it has any bearing on your present problem (why). We will begin with
your earliest recollections of what you have been told about your childhood health and progress to the
present time." (Pause) "How was your health as a child?" With this type of transition, the patient is not
confused about why you are changing the subject and why you are seeking this information.
Transitional statements are also important for good communication skills. Poor quality or complete lack
of transitional statements can hinder the development of rapport between patient and interviewer, and can
even result in the creation of a hostile or uncooperative patient. An example of a transitional statement
that would meet a standard of excellence is: Transition to family history: (What) "Now I'd like to talk to
you about your family's history. (Why) As you know, there are some diseases that tend to run among
blood relatives, and in order to have as complete a picture of your medical history as possible and be able
to anticipate and treat future problems, it is important that we have this information. Let's begin with
your parents. How is their health?"
Criteria Statements:
5. The interviewer utilizes full transitional statements when progressing from one subsection to another.
3. The interviewer sometimes introduces subsections with effective transitional statements but fails to do
so at other times. OR
Some of the transitional statements used are lacking in quality.
1. The interviewer progresses from one subsection to another in such a manner that the patient is left
with a feeling of uncertainty as to the purpose of the questions. No transitional statements are made.
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COMMUNICATION SKILLS
ITEM 8- PACING OF INTERVIEW
The pacing of the interview should flow in a smooth and comfortable manner. The interviewer should be
attentive to the patient and allow him ample time to complete his answers without interruption. Some
delays, however, are necessary [such as in reflective thinking] and are an indication of good interviewing
skills. A well-placed period of silence may encourage the patient to provide additional relevant data or to
talk about sensitive issues that he might otherwise omit. For example, if the patient exhibits behavior
indicating a need to gather his composure or to ponder certain points, a delay can be beneficial to an
interview. Silence is a double-edged sword. It can be detrimental or a powerful interviewing technique,
depending on how it is used. A helpful way to assess pauses in the interview is to judge your feeling for
that pause. If you feel embarrassed for the interviewer, he probably has lost his train of thought. If you
feel that you should be giving more information, the pause should be considered an effective interviewing
technique.
Interruptions may be necessary when a patient moves the conversation off the topic. In this case, the
interviewer should politely stop the patient by saying something to the effect, “I understand you’re desire
to let me know more about you, but let’s focus on what we were talking about for just a moment then we’ll
move on.”
A good teaching point for the feedback session should include information for helping the interviewer jog
his memory in the event that he should lose his train of thought. Summarizing the information (Item #28)
previously obtained from the patient may help the interviewer to regain his train of thought. To buy time,
he might have some stock questions available, i.e., "Can you tell me about a typical day for you?"
It is also important to note that a good interviewer does not fire questions at the patient so fast that the
patient has little or no time to consider his answers.
Criteria Statements:
5. The interviewer is attentive to the patient's responses and listens without interruption. The
interview progresses smoothly with no awkward pauses. Silence may be used deliberately.
3. The pace of the interview is comfortable most of the time, but the interviewer occasionally
interrupts the patient and/or allows awkward pauses to break the flow of the interview.
1. The interviewer frequently interrupts the patient and there are awkward pauses, which break the
flow of the interview.
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COMMUNICATION SKILLS
ITEM 9 - QUESTIONING SKILLS - TYPES OF QUESTION
An open-ended question is a general question that allows the interviewer to obtain a large amount of
information about a particular area. It allows the patient to tell the interviewer "his story.” This type of
question should be used to begin a line of inquiry. (For example, "What brings you here today?" or "Tell
me about your general health.”) After the interviewer has obtained information, he should follow up with
more focused and direct questions.
Direct or specific questions are used to gather specific pertinent information. (For example, "How old
were you when you had your tonsils removed?" or "When did your abdominal pain begin?" or "How long
have you had abdominal pain?" These questions are used to focus in on pertinent information that needs
to be more specific. Other types of direct questions typically elicit a "yes" or "no" answer from the
patient, or a response to a choice that the interviewer has provided.
To gain accurate information in an organized and efficient manner, the interviewer should follow a line of
inquiry that progresses from the open-ended to the specific (e.g., starting with, "Tell me about the things
that are stressful to you," followed with specific questions).
Here is an example of a line of inquiry utilizing the various types of questions, which begins with openended questions and then focuses on more specific questions.
Interviewer (I): "Tell me about your problem." (Open-ended)
Patient (P): "For two weeks, I've been having a constant pain in my stomach,
Right here (patient points), above my navel."
I:
"Tell me about the pain." (Open-ended)
P: "Well, it's really bad."
I:
"What does the pain feel like?" (Direct)
P: "It's a burning sensation."
I:
"Is it a deep pain or does it feel like it's on the surface?" (Direct)
P: "It's a very deep one."
I:
"Does the pain seem to travel around?" (Direct)
P: "No."
I:
"What makes the pain feel worse?" (Direct)
The interviewer should avoid using direct or (particularly) forced choice questions in beginning a line of
inquiry because it restricts the possible flow of information and makes obtaining the necessary
information a tedious task.
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For example, rather than beginning with an open-ended question:
interviewer might inefficiently have asked several direct questions.
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I:
P:
I:
P:
I:
P:
"Does the pain feel like an ache?"
"No."
"Is it a stabbing pain?"
"No."
"Is it a dull pain?"
"No."
Furthermore, incorrect use of questions may result in erroneous information or omission of pertinent data.
The interviewer should avoid these kinds of questions:
Leading questions are questions that tend to supply a particular answer for the patient. The desired
answer is implied by the way the question is phrased. They should also be avoided because acquiescent
respondents may tend to agree with the leading questions rather than contradicting the interviewer. (For
example, "You haven't had any nausea, have you?" or "No headaches?")
"Why" questions often put the patient on the defensive and should be avoided. (For example, "Why
haven't you come in before now when you've had the problem for six weeks?")
Multiple questions are a series of short questions asked in succession without allowing the patient to
answer each individually. The patient can then become confused about which questions to answer. (For
example, "What does the pain feel like after dinner? Is it different than before dinner? Is it sharp? Is it
dull?”) Multiple questions can also be one question listing many options (For example, "Has anyone in
your family ever had cancer, diabetes, heart disease, or high blood pressure?").
Criteria Statements:
5.
The interviewer begins information gathering with an open-ended question. This is followed
up by more specific or direct questions. Each major line of questioning is begun with an
open-ended question. No poor questions types are used.
3.
The interviewer often fails to begin a line of inquiry with open-ended questions but rather
employs specific or direct questions to gather information.
OR
The interviewer uses a few leading, why or multiple questions.
1.
The interviewer asks many why questions, multiple questions, or leading questions. (For
example, "Your child has had diarrhea, hasn't he?" or "You want your child to have a
tetanus shot, don't you?")
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ITEM 10 - QUESTIONING SKILLS – SUMMARIZING
When summarizing the Chief Complaint and History of Present Illness it is important to provide a detailed
summarization to the patient. When summarizing the Family History, a brief general statement may be
sufficient, especially for a negative or non-complex positive family history.
When summarizing the Review of Systems, it is appropriate to summarize only the positives discovered
(e.g., "Other than a few headaches each month and the constipation that you treat by increasing the
roughage in your diet, you appear to be fairly healthy. So it seems that our main task is to clear up the
problem you're having with your back. Is this how you see the problem?")
Summarizing data at the end of each subsection of the interview serves several communication purposes:
a) It can be a way for the interviewer to "jog" his memory in case he has forgotten to ask a
question.
b) It allows the patient to hear how the interviewer understands the information.
c) It provides an opportunity to verify what the patient has told the interviewer (For example,
"You've also stated the pain in your lower back is a deep, nagging pain, while the pain on
the outside of your leg seems more superficial. Is that correct?" Verifying is often done
during summarization, but may also be utilized if the patient seems reluctant to interrupt, or
in an effort to involve the patient in active listening.
d) It provides an opportunity to clarify information obtained by the interviewer (e.g., "I'm not
sure I understand how much your problem has been interfering with your attendance at
school. Could you tell me how many days you've missed since the onset of your problem?").
e) Summarizing also shows the patient that the interviewer has been listening; thus
strengthening interview and relationship.
Criteria Statements
5. The interviewer summarizes the data obtained at the end of each major line of inquiry or
subsection to verify and/or clarify the information or as a precaution to assure that no important
data are omitted.
3. The interviewer summarizes the data at the end of some lines of inquiry but not consistently or
completely or attempts to summarize at the end of the interview and it is incomplete.
1. The interviewer fails to summarize any of the data obtained. No attempt to summarize.
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ITEM 11 - QUESTIONING SKILLS – DUPLICATION
Duplication is defined as the seeking of information that has been previously provided. Avoiding
duplication is important in signaling to the patient that the interviewer has been attentive. A question
should only repeated if it is to clarify or summarize.
Criteria Statements
5. The interviewer does not repeat questions, seeking duplication of information that has previously
been provided, unless clarification or summarization of prior information is necessary.
3. The interviewer only rarely repeats questions. Questions are repeated not for the purpose of
summarization or clarification of information, but as a result of the interviewer’s failure to
remember the data.
1. The interviewer frequently repeats questions seeking information previously provided because he
fails to remember the data already obtained.
ITEM 12 - QUESTIONING SKILLS – LACK OF JARGON
Jargon is defined as "the technical or secret vocabulary of a profession." Since one of the skills of an
interviewer is the ability to communicate with the patient, it is necessary to substitute jargon or difficult
medical terms with terms known to lay persons. The interviewer may make erroneous assumptions about
the patient's level of sophistication on the basis of one or two medical terms that the patient uses during
the interview. For example, a patient may be familiar with "otitis media" if he has had problems with his
ears, but may know nothing about what the term "palpitations" means. However, because the patient used
the term "otitis media", the interviewer may assume that it is safe to use medical terminology in
questioning the patient. Jargon may also be misleading to a patient who does not want to admit to the
doctor that he doesn't understand the question, (i.e., "productive cough"). Therefore, the interviewer
should define questionable terms. Interviewer must also be aware of communication and different age and
educational levels (i.e., slang terms).
Criteria Statements:
5. The interviewer asks questions and provides information in language, which is easily
understood; content is free of difficult medical terms and jargon. Words are immediately
defined for the patient. Language is used that is appropriate to the patient's level of
education.
3. The interviewer occasionally uses medical jargon during the interview failing to define the
medical terms for the patient unless specifically requested to do so by the patient.
1. The interviewer uses difficult medical terms and jargon throughout the interview.
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ITEM 13 - QUESTIONING SKILLS – VERIFICATION OF PATIENT INFORMATION
In the interest of gaining as accurate a case history as possible, the interviewer must verify and clarify the
information given to him by the patient. Use of clarification of statements that are vague or need further
amplification is a vital information-gathering skill. After an initial response to an open-ended question, the
interviewer may need to prompt the patient for more precision, clarity or completeness.
Clarifying is often open in nature but may be closed.
Example:
Open: “can you explain what you mean by weak.”
Closed: “What did you mean by ‘dizzy’ exactly?”
Clarification may also address apparent inconsistencies.
Example:
“I’m confused; you said you’d never been short of breath before, but now you said
this suffocating feeling feels like when you were short of breath last year. Can you
clear that up for me?”
Verification is also a vital information-gathering skill. If responses from the patient include specific
diagnoses or medications, it is the task of the interviewer to ascertain if the patient knows how the
diagnosis was made or determine the quantity of medication.
Example:
You said you were allergic to penicillin. How do you know that?
Criteria Statements
5.
The interviewer always seeks clarification, verification and specificity of the patient’s
responses.
3.
The interviewer will seek clarification, verification and specificity of the patient’s responses
but not always.
1. The interviewer fails to clarify or verify the patient’s responses, accepting information at face
value.
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ITEM 14 – INTERACTIVE TECHNIQUES
Use patient-centered interviewing techniques during the entire interview. The patient-centered approach
promotes a collaborative partnership between patient and doctor. The collaborative partnership promotes
a more equal relationship between patient and doctor.
The interviewer progresses from patient-centered to physician-centered technique to elicit all required
information, but returns the lead to the patient whenever appropriate.
Criteria Statements:
5. The interviewer consistently uses the patient-centered technique. The interviewer mixes
patient-centered and physician-centered styles that promotes a collaborative partnership
between patient and doctor.
3.
1.
The interviewer initially uses a patient-centered style but reverts to a physician-centered
interview at the end (rarely returning lead to the patient).
OR
The interviewer uses all patient-centered interviewing and fails to use physician-centered
style and therefore does not accomplish the negotiated agenda.
The interviewer doesn’t follow the patient’s lead, uses only physician-centered technique
halting the collaborative partnership.
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ITEM 15 – VERBAL FACILITATION SKILLS & ENCOURAGEMENT
It is important to actively encourage patients to continue their story-telling. Any behavior that has the
effect of inviting patients to say more about the area that they are already discussing is a facilitative
response. The interviewer follows up patient’s initial story with focusing facilitation skills to broaden and
complete the story. The use of short statements and echoing can be used to facilitate the patient to say
more about a topic, indicating simultaneously that the interviewer is interested in what the patient is
saying and that the interviewer wants them to continue. Additionally, the interviewer should use verbal
encouragement to motivate the patient toward a cooperative relationship and continued health care
throughout the interview. By providing intermittent verbal encouragement, the interviewer is responding
to the patient's statements in such a way that the patient feels encouraged starting or continuing proper
health care techniques.
 Verbal Encouragement & use of occasional social praises such as: "You've quit smoking?
That's excellent; I bet it certainly took willpower on your part!" Or "I'm glad you're doing
a breast self-exam every month--it's very important as most women detect lumps
themselves at home..." go a long way towards increasing rapport and continued health care
with the patient.
 The interviewer should use short statements such as, “I see,” “Go on,” Uh-huh,” and
“Tell me more,” to encourage the patient to continue talk about their problem.
 Use of echoing (using a few words of the patient's last sentence) to encourage patient to
elaborate on a topic.
Patient: “I just couldn’t take a good breath.”
Interviewer: “You felt as if you couldn’t get your breath?” Suffocating?”
Criteria Statements:
5. The interviewer uses facilitation skills throughout the interview. Verbal encouragement, use of
short statements and echoing are used regularly when appropriate.
3. The interviewer uses some facilitative skills but not consistently or at inappropriate times. Verbal
encouragement could be used more effectively.
1. Interviewer fails to use facilitative skills to encourage the patient to tell his story.
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ITEM 16 - NON-VERBAL FACILITATION SKILLS
Facilitative behavior can also be defined as how comfortable the interviewer makes the patient feel. This
is done with verbal communications (Item 13), and non-verbal communications.
Non-verbal communication.
The interviewer demonstrates appropriate non-verbal behavior:
1.
2.
3.
Eye contact
Body language
Facial expression
4. Physical barriers
5. Physical contact
As with many other mannerisms or traits, there is a fine balance between too much and too little eye
contact. "Good" eye contact means that amount of eye contact that is comfortable for the patient. In other
words, the interviewer should be paying attention to the patient, while avoiding staring or conducting the
interview as if it were an interrogation. The interviewer should not place a physical barrier between
himself and the patient. He should lean forward in a listening posture when the conversation becomes
intense. On the other hand, if the interviewer crosses his arms while the patient relates his sexual history,
this suggests something about the interviewer's receptivity to the patient and his problem. Physical
contact is sometimes appropriate during the interview. If a patient receives bad news or becomes upset,
the interviewer may want to show support by touching the patient’s hand or shoulder. They may also
establish the same support by offering a tissue or a drink of water.
Use of notes. This is the interviewer’s choice. Some interviewers like to ensure accuracy by making
notes while speaking with the patient. If he chooses to read a chart, write notes or uses a computer, he
does so in a manner that does not interfere with dialogue or rapport. However it has been demonstrated
that loss of eye contact decreases efficiency in the interview. Patients withhold their initial reply to the
doctor’s solicitation until eye contact is given; some pause in mid-utterance when the doctor looks at the
notes and resume when eye contact is regained. Doctors frequently miss or forget information given to
them while they are reading their notes.
Criteria Statements:
5.
The interviewer puts the patient at ease and facilitates communication by using good eye contact,
relaxed, open body language, appropriate facial expressions, and by eliminating physical barriers.
Appropriate, physical contact is made with the patient.
3.
The interviewer makes some use of facilitative techniques but could be more consistent. One or two
techniques are not used effectively. (For example, frequency of eye contact could be increased or
some physical barrier may be present.)
1. The interviewer makes no attempt to put the patient at ease. Body language is negative or closed, or
any annoying mannerism (foot or pencil tapping) intrudes on the interview. Eye contact is not
attempted, or uncomfortable.
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ITEM 17 – EMPATHY & ACKNOWLEDGING PATIENT CUES
One of the key skills in building the doctor-patient relationship is the use of empathy. Of all the skills in
consultation, this is the one most often thought by learners to be a matter of personality rather than skill. Although
some of us may naturally be better at demonstrative empathy than others, the skills of empathy, like any other
communication skill, can be learned.
The key to empathy is not only being sensitive but also demonstrating that sensitivity to the patient so that they
appreciate understanding and support. To display empathy, the interviewer must actively acknowledge and followup on verbal patient cues, demonstrating to the patient that they have been heard and understood. The patient is
actively encouraged to express emotion. It is not good enough to think empathetically, but it must be
demonstrated. Empathic statements are supportive comments that specifically link the “I” of the doctor and the
“you” of the patient. They both name and appreciate the patient’s affect or predicament.
NURS is an active technique used to demonstrate empathy and acknowledgement of patient cues.
 Naming emotion
“It must be very frustrating to not be able to work right now”
 Express Understanding
"That must have been very difficult for you. I’d have felt that way too!”
[The goal here is to normalize or validate a patient’s feelings or experience.]
 Showing Respect
“I can appreciate how difficult it is for you to talk about this.”
 Offering Support
“You don’t have to face this alone. [partnering/assistance] I’ll be working with you each step of
the way.”
“I’m worried about you attempting to drive while taking this medication.
[showing concern] Is there someone who can drive for you this week?”
“I’m sorry this is so uncomfortable for you. I’ll be as brief as possible.” [sensitivity]
Criteria Statements:
5.
The interviewer uses empathetic & supportive techniques actively acknowledging the patient’s
emotions. The interviewer uses NURS.
3.
A few empathetic statements are used. The interviewer is neutral, neither overly positive nor
negative in demonstrating empathy.
1.
No empathetic statements were used or empathy demonstrated. He uses a negative emphasis or
openly criticizes the patient, (e.g., “I can't believe you smoked three packs a day.” or “Why are you
letting your husband’s headaches affect your work?”).
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ITEM 18 - PATIENT'S PERSPECTIVE (BELIEFS)
It is very important for the interviewer to elicit the patient's perspective on his illness in order for it to be
effectively diagnosed and treated. The patient's beliefs about the beginning of his illness may affect his
ability to talk about his symptoms or to understand the diagnosis.
One method of eliciting patient’s beliefs is to encourage the patient to discuss FIFE:
Feelings: addresses the patient’s feelings about each of the problems
Ideas: determines and acknowledges patient’s ideas (belief of cause) for each of the problems
Function: determines how each problem affects the patient’s life
Expectations: determines patient’s goals, what help the patient had expected for each problem
Here is an example of a patient’s hidden concern:
Example:
Patient - "I have stomach pain."
Interviewer - "What do you think is going on?" (Idea)
Patient - "I think I may have cancer."
Interviewer - "What makes you think it may be cancer?"
Patient - "My uncle died of gastric cancer one year ago."
Note: If a case has a hidden concern it will be discussed during case training. A SP should not add in a
hidden concern on their own.
Criteria Statements:
5. The interviewer elicits the patient's perspective on his illness, including his beliefs about its
beginning, Feelings, Ideas of cause, Function and Expectations (FIFE).
3. The interviewer elicits some of the patient's perspective on his illness and/or does not follow
through with addressing beliefs.
1. The interviewer fails to elicit the patient's perspective.
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ITEM 19 - IMPACT OF ILLNESS ON PATIENT AND PATIENT’S SELF-IMAGE
The interviewer must address the impact on self-image that certain illnesses may have. For example, a
patient who has had a mastectomy may have a different self-image after this surgical procedure.
Immediately after a heart attack, a patient may need to change his sexual and physical activity. This could
certainly affect the way he views himself. The interviewer must explore these issues in depth to the
satisfaction of the patient. The interviewer also addresses counseling or recommends resources after
discussing impact and self-image.
Criteria Statements:
5. The interviewer inquires about the patient’s feelings about his illness, how it has changed his life.
Then the interviewer explores these issues and offers counseling or resources to help.
3. The interviewer partially addresses the impact of the illness on the patient’s life or self-image
and/or offers no counseling or resources to help.
1. The interviewer fails to acknowledge any impact of the illness on the patient’s life or self-image.
ITEM 20 - IMPACT OF ILLNESS ON FAMILY
Depending on the diagnosis, as well as the information obtained during the personal history, there could
be a tremendous impact of the patient's illness on the family and the family's lifestyle. An example of this
would be a patient with a diagnosis of cancer. This would certainly affect family members and family
lifestyle because of the need for frequent treatment, side effects of drugs, potentially decreased family
income, etc. The interviewer must address this issue and explore it in depth to the patient’s satisfaction.
Example:
Interviewer: “You have told me that your child cries all through the day and
night. Who else is at home and is affected by this?”
Patient: “My husband and my mother. They cannot sleep and my husband is
starting to miss work.”
Interviewer: “OK, let’s discuss ways to relieve this stress at home...”
Criteria Statements:
5.
The interviewer inquires about the structure of the patient's family. He addresses the impact
of the patient's illness and/or treatment on family. He then explores these issues.
3.
The interviewer recognizes the impact of the illness or treatment on the family members
and on family lifestyle but fails to explore issues adequately.
1.
The interviewer fails to address the impact of the illness or treatment on the family
members and on family lifestyle.
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ITEM 21 - SUPPORT SYSTEMS
To explore the patient’s means of financial and emotional support. These support systems might include
other family members, friends, and the organization in which he works. These are current resources,
which could be used immediately. The interviewer may suggest other community resources including
charitable organizations, self-help groups, etc., not yet thought of or known to the patient.
Example:
Interviewer: “You have told me that your child cries all day and night and that
your husband and your mother are losing sleep and work time. Is there someone
who can help you take care of your child so that you can rest?”
Patient: “Yes, my sister could come in and help me.”
Interviewer: “Is she available to do so?”
Criteria Statements:
5. The interviewer determines what emotional support and what financial support the patient feels he
has now. The interviewer inquires about other resources available to the patient and family and
suggests appropriate community resources.
3. The interviewer may determine some of the available support OR may assume support without
determining if it is actually available (e.g. “I’m sure your sister could help.”).
1. The interviewer fails to determine what support is currently available to the patient.
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ITEM 22 - PATIENT EDUCATION & UNDERSTANDING
Many times, patients who are labeled non-compliant may in fact not understand the information that is
given to them. There are several ways to check the patient's understanding. The interviewer can ask the
patient to repeat the information directly back to him, demonstrate techniques, or the interviewer may
pose hypothetical situations to see if the patient will react appropriately. It is vital when the patient must
continue therapy on his own without direct supervision that he understands how to successfully carry out
that task. For example, when prescribing medications, it is important that the patient understand what the
medication is for, the schedule that should be followed, and what effect it will have on his body. This is
also true if the interviewer must communicate certain findings to the patient.
If the patient does not fully understand, or understands the information incorrectly, this must be clarified
immediately.
Examples:
Interviewer: “Now that I’ve shown you how to test the level of sugar in your blood with this monitor, will
you show me how to use this so I can be sure that I explained it clearly?”
Interviewer: “Will you repeat back to me how to take your medicine so I know I have given you the
correct information?”
Criteria Statements:
5. The interviewer uses deliberate techniques to check the patient's understanding of information
given during the interview including diagnosis. Techniques may include asking the patient to
repeat information, asking if the patient has additional questions, posing hypothetical situations, or
asking the patient to demonstrate techniques. When patient education is a goal, the interviewer
determines the patient’s level of interest and provides education appropriately.
3. The interviewer asks the patient if he understands the information but does not use a deliberate
technique to check. Some attempt to determine the interest in patient education but could be more
thorough.
1. The interviewer fails to assess patient's level of understanding and does not effectively correct
misunderstandings when they are evident and/or fails to address the issue of patient education.
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ITEM 23 - ASSESS MOTIVATION FOR CHANGES
It is important that the interviewer assesses how the patient feels about lifestyle/behavioral changes
(taking medicine, changing diet and exercise, and smoking cessation). Many interviewers assume a
patient will change behavior without discussing it with them, this lack of communication may lead to
return visits or incompliant issues. Asking the patient about previous experiences, the patient’s view of
importance to change and their confidence in ability to change will help to establish guidelines. Then the
interviewer can provide information as appropriate based on the patient’s needs. Offer a menu of options,
emphasize the patient’s ability to choose and anticipate and plan for obstacles.
ACKNOWLEDGMENT:
Dr. Daniel Duffy, American College of Physicians
Stages of Readiness to Change
STAGE
DESCRIPTION
Precontemplation
Not considering change
Contemplation
Ambivalent to changing
Preparation
Relapse
Cognitively committed to make the
change
Involved in change (began changing
behaviors)
Involved in sustaining change
(behavioral strategies are well
learned and almost automatic)
Undesired behavior returns
Termination
Change is no longer an issue
Action
Maintenance
TECHNIQUES











Identify patient’s goals
Provide information
Bolster self-efficacy
Develop discrepancy between goals and behavior
Elicit self-motivational statements
Strengthen commitment to change
Provide a menu of options for change
Identify new barriers
Offer menu of options for reinforcing change
Check status
Recognize relapse or impending relapse
 Identify relapse
 Reestablish self-efficacy and commitment to change
 Learn from experience, develop new behavioral strategy
None
Criteria Statements:
5. The interviewer inquires how the patient feels about change and offers options and plans for the
patient to choose from.
3. The interviewer inquires how the patient feels about changes but does not offer options or plans.
OR assumes the patient will follow the suggested change without assessing change but does offer
options and plans.
1. The interviewer fails to assess patient's level of motivation to change and does not offer any
options or plans.
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ITEM 24- ADMITTING LACK OF KNOWLEDGE
The interviewer must be aware of his own level of experience as related to the information he is able to
give to the patient. When asked for information or advice that he is not equipped to provide, he admits his
lack of experience in that area. For example, a physician referring a patient to a cardiologist may lack
knowledge about specialized cardiovascular testing. When questioned by the patient, he must admit lack
of experience and immediately offer to seek a resource to answer the patient's questions.
Criteria Statements:
5. The interviewer, when asked for information or advice that he is not equipped to provide,
admits to his lack of knowledge in that area but immediately offers to seek resources to answer
the question(s).
3. The interviewer, when asked for information or advice that he is not equipped to provide,
admits lack of knowledge, but rarely seeks other resources for answers.
1. The interviewer, when asked for information, which he is not equipped to provide, makes up
answers in an attempt to satisfy the patient's questions, but never refers to other resources.
ITEM 25- INFORMED CONSENT FOR INVESTIGATIONS & PROCEDURES
In discussing investigations and procedures, the interviewer should walk the patient through the basic
elements of informed consent: the purpose and nature of the investigation or procedure (What is going to
be done and why?), the probable risks and foreseeable benefits (How will this help? Is there potential
pain or harm involved? How much? How long?), and potential alternatives (What are the other
options?). Taking no action is always considered an alternative, the interviewer should always objectively
explain the consequences of taking no action. The patient should be told when and how he will be
informed of the meaning of results. The interviewer relates procedures to treatment plan, value and
purpose. He encourages discussions of potential anxieties or negative outcomes.
Criteria Statements:
5. The interviewer discusses the purpose and nature of all investigations and procedures,
reviews foreseeable risks and benefits, and discloses alternatives and their relative risks
and benefits. Taking no action is considered always considered an alternative.
3. The interviewer discusses some aspects of the investigations and procedures but omits some
elements of informed consent.
1. The interviewer fails to discuss investigations or procedures.
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Eastern Virginia Medical School
COMMUNICATION SKILLS
ITEM 26- ACHIEVE A SHARED PLAN
A shared understanding is achieved with the patient, including nature and significance of the problem. The
patient's understanding about his prognosis also plays a role in treatment; someone whose uncle died from
a perforated ulcer may well see a diagnosis of peptic ulcer as far more life threatening than the
interviewer.
The interviewer involves the patient by making suggestions and encourages the patient to contribute their
own thoughts, ideas, suggestions and preferences. A mutually acceptable plan is negotiated, and the
interviewer checks with the patient to see if the plan is acceptable and addresses the patient’s concerns.
To achieve a shared understanding several questions are answered:
1. What is the diagnosis (“What has happened to me?”)
2. Etiology of the problem (“Why has it happened to me?”)
3. Prognosis of the problem (“What is going to happen to me?”)
Criteria Statements:
5. The interviewer discusses the diagnosis and/or prognosis and negotiates a plan with the patient.
The interviewer invites the patient to contribute his own thoughts, ideas, suggestions and
preferences.
3. The interviewer discusses the diagnosis and/or prognosis and plan but does not allow the patient to
contribute. Lacks full quality.
1. The interviewer fails to discuss diagnosis and/or prognosis.
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COMMUNICATION SKILLS
ITEM 27 - ENCOURAGEMENT OF QUESTIONS
It is important that the interviewer allow the patient an adequate opportunity to express questions during
the interview. Oftentimes during an interview, a patient may think of pertinent information that was not
obtained by the interviewer during a specific line of inquiry, or the patient may have questions that still
need to be addressed by the interviewer.
The interviewer should encourage the patient to discuss these additional points and ask questions by
clearly providing an opportunity to do this. For example, the interviewer should state that if the patient has
a question or is able to offer additional information that may be pertinent to the topic being discussed, he
should do so. This is usually done at the end of a major subsection of the interview, and repeated at the
end of the interview.
Criteria Statements:
5. The interviewer encourages the patient to ask questions at the end of a major subsection, about
the topics discussed. He also gives the patient the opportunity to bring up additional topics or
points not covered in the interview. (For example, “We’ve discussed many things. Are there
any questions you might like to ask concerning your problem? Is there anything else at all
that you would like to talk about?”) This is particularly important at the end of the interview.
3. The interviewer provides the patient with the opportunity to discuss any additional points or
ask any additional questions but neither encourages nor discourages him. (For example, "Do
you have any questions?")
1. The interviewer fails to provide the patient with the opportunity to ask questions or discuss
additional points. The interviewer may discourage the patient’s questions. (For example,
“We’re out of time.”)
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COMMUNICATION SKILLS
ITEM 28- CLOSURE
It is important that the patient feel that there is some closure at the end of the interview. This closure
should include describing future plans, making clear the interviewer's role and obligations and the
patient's role and obligations, explaining what the interviewer expects the patient to do, or planning for the
next interview or follow-up communication.
The patient must be left with a definite feeling about what will happen next, what the interviewer will do,
what the patient should do, and the time frame for the next communication.
Closure will vary in detail according to the level of an interviewer.
Example of first-year medical student:
“I will go speak to Dr. Perone (what). If you want to change into a gown
(what). We will be back together in a few minutes (when) to discuss your
concerns.”
Example of third-year medical student:
“I will give you a prescription for some antibiotics (what) and I would like
the nurse to take some blood tests today (what). I would like to see you again
in one week (when).”
Criteria Statements:
5. At the end of the interview the interviewer clearly specifies the future plans: what the
interviewer will do (make referrals, order tests), what the patient will do (make diet changes,
go to Physical Therapy), when the time of the next communication or appointment is.
3. At the end of the interview, the interviewer partially details the plans for the future (e.g.,
“Sometime you should bring in the name of the medicine you received.” or “Call my secretary
when you gather the information.” or “Go get x-rays.” “We need some tests.” (1 out of 3
requirements)
1. At the end of the interview, the interviewer fails to specify the plans for the future and the
patient leaves the interview without a sense of what to expect. There is no closure whatsoever.
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ABIM
The following four items were taken from the American Board of Internal Medicine Patient Satisfaction
Questionnaire and have been included in the interview rating scale. There is no special training given on
how to score these items; standardized patients are asked to respond to these items as if they were actual
patients. These items are not addressed in feedback sessions, nor are the scores shown to the interviewer
during verbal feedback.
Would you do what this doctor asks you to do?
[5]
Definitely
Yes
[4]
Probably
Yes
[3]
Not
Sure
[2]
Probably
No
[1]
Definitely
No
Would you recommend this doctor to a friend who
wanted a doctor with excellent communication skills?
[5]
Definitely
Yes
[4]
Probably
Yes
[3]
Not
Sure
[2]
Probably
No
[1]
Definitely
No
Would you make a special effort to see this doctor?
[5]
Definitely
Yes
[4]
Probably
Yes
[3]
Not
Sure
[2]
Probably
No
[1]
Definitely
No
How would you compare the personal manner
(courtesy, respectfulness, sensitivity, friendliness)
of this doctor to other doctors you have seen?
[5]
One of the
Best
(10%)
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[4]
Above
Average
(20%)
[3]
About
Average
(40%)
[2]
Below
Average
(20%)
[1]
One of the
Worst
(10%)
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Eastern Virginia Medical School
ACGME
The following items were taken from the Accreditation Counsel for Graduate Medical Education
(ACGME).
Unsatisfactory
1. Patient Care:
Incomplete, inaccurate
medical interview and
review of other data; fails
to analyze clinical data and
consider patient
preferences when making
medical decisions
2. Medical Knowledge:
Minimal interest in learning
new knowledge
1
2
3
4
Superior
5
6
7
9
8
9
Exceptional interest in
learning new knowledge
8
9
Excellent insight to self,
receptive to feedback
8
9
Establishes a highly
effective therapeutic
relationship with patient;
demonstrates excellent
relationship building
through listening,
nonverbal skills;
excellent education and
counseling of patient
8
9
 Performance needs attention
1
2
3
4
5
6
7
Superb, accurate,
comprehensive medical
interview, review of other
data. Made a diagnostic
and therapeutic decision
based on available
evidence, sound judgment
and patient preferences
8
 Performance needs attention
3. Practice-Based Learning
Improvement:
Lacks insight, initiative;
resists or ignores feedback
4. Interpersonal and
Communication skills:
Does not establish even
minimally effective
therapeutic relationships
with patient; does not
demonstrate ability to build
relationship through
listening, poor non-verbal
skills; does not provide
education or counseling to
patients
5. Professionalism:
Lacks respect, compassion,
integrity, honesty;
disregards need for selfassessment, fails to
acknowledge errors or lack
of knowledge; does not
consider needs of patient;
does not display responsible
behavior
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1
2
3
4
5
6
7
 Performance needs attention
1
2
3
4
5
6
7
 Performance needs attention
1
2
3
4
5
6
7
 Performance needs attention
Always demonstrates
respect, compassion,
integrity, honesty;
displays responsible
behavior; total
commitment to selfassessment; willingly
acknowledges lack of
knowledge; considers
needs of patient
35
Copyrighted to Theresa A. Thomas Professional Skills Teaching & Assessment Center,
Eastern Virginia Medical School
MIRS FORM 2005
Interviewer Name:
Date:
SP Name:
Program/Case:

[5]
The interviewer introduces himself,
clarifies his roles, and inquires how
to address patient.

ITEM 1 – OPENING
[3]
The interviewer introduces himself,
clarifies his roles, or inquires how
to address patient but does not
achieve all tasks.

[1]
The interviewer fails to introduce
himself, clarify his roles, or inquire
how to address patient.
Comments:

ITEM 2 – ELICITS SPECTRUM OF CONCERNS
[5]
[3]
[1]
The interviewer elicits the patient’s
 The interviewer elicits some of the
 The interviewer fails to elicit the
full spectrum of concerns within the
patient’s concerns on his chief
patient’s concern.
first 3-5 minutes of the interview.
complaint.
Comments:
SCORE:


ITEM 3 – NEGOTIATES PRIORITIES & SETS AGENDA
[5]
[3]
[1]
The interviewer fully negotiates
 The interviewer elicits only partial
 The interviewer does not negotiate
priorities of patient concerns, listing
concerns and therefore does not
priorities or set an agenda.
all of the concerns and sets the
accomplish the complete patient
 The interviewer focuses only on
agenda at the onset of the interview.
agenda for today’s visit.
the chief complaint and takes only
The patient is invited to participate
 The interviewer sets the agenda.
the physician’s needs into account.
in making an agreed plan.
Comments:
SCORE:
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

ITEM 4 – ELICITING THE NARRATIVE THREAD or the “PATIENT’S STORY”
[5]
[3]
[1]
The interviewer encourages and lets  The interviewer begins to let the
 The interviewer fails to let the
the patient talk about their problem.
patient talk about their problem but
patient talk about their problem.
either interrupts with focused
OR
The interviewer does not stop the
questions or introduces new
patient or introduce new
 The interviewer sets the pace with
information into the conversation.
information.
Q & A style, not conversation.
Comments:
SCORE:


[5]
The interviewer obtains sufficient
information so that a chronology of
the chief complaint and history of
the present illness can be
established.
The chronology of all associated
symptoms is also established.


ITEM 5 - TIMELINE
[3]
The interviewer obtains some of the
information necessary to establish a
chronology.
He may fail to establish a
chronology for all associated
symptoms.

[1]
The interviewer fails to obtain
information necessary to establish a
chronology.
Comments:
SCORE:

[5]
Questions in the body of the
interview follow a logical order to
the patient.

ITEM 6 – ORGANIZATION
[3]
The interviewer seems to follow a
series of topics or agenda items;
however, there are a few minor
disjointed questions.

[1]
The interviewer asks questions that
seem disjointed and unorganized.
Comments:
SCORE:

[5]
The interviewer utilizes full
transitional statements when
progressing from one subsection to
another.
ITEM 7 – TRANSITIONAL STATEMENTS
[3]
 The interviewer sometimes

introduces subsections with
effective transitional statements but
fails to do so at other times.
OR
 Some of the transitional statements

used are lacking in quality.
[1]
The interviewer progresses from one
subsection to another in such a
manner that the patient is left with a
feeling of uncertainty as to the
purpose of the questions.
No transitional statements are
made.
Comments:
SCORE:
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



[5]
The interviewer is attentive to the
patient’s responses.
The interviewer listens without
interruption.
The interview progresses smoothly
with no awkward pauses.
Silence may be used deliberately.
ITEM 8 – PACING OF INTERVIEW
[3]
 The pace of the interview is
comfortable most of the time, but
the interviewer occasionally
interrupts the patient and/or allows
awkward pauses to break the flow
of the interview.

[1]
The interviewer frequently
interrupts the patient and there are
awkward pauses, which break the
flow of the interview.
Comments:
SCORE:




ITEM 9 - QUESTIONING SKILLS – TYPES OF QUESTIONS
[5]
[3]
[1]
The interviewer begins information
 The interviewer often fails to begin
 The interviewer asks many why
gathering with an open-ended
a line of inquiry with open-ended
questions, multiple questions, or
question.
questions but rather employs
leading questions.
specific or direct questions to gather
This is followed up by more
information.
specific or direct questions.
OR
Each major line of questioning is
begun with an open-ended question.  The interviewer uses a few leading,
why or multiple questions.
No poor question types are used.
Comments:
SCORE:


ITEM 10 – QUESTIONING SKILLS - SUMMARIZING
[5]
[3]
[1]
The interviewer summarizes the
 The interviewer summarizes the
 The interviewer fails to summarize
data obtained at the end of each
data at the end of some lines of
any of the data obtained.
major line of inquiry or subsection
inquiry but not consistently or
 The interviewer constantly repeats
to verify and/or clarify the
completely or attempts to
questions.
information or as a precaution to
summarize at the end of the
assure that no important data are
interview and it is incomplete.
omitted.
 The interviewer rarely repeats
The interviewer occasionally
questions.
repeats or duplicates questions only  Questions are repeated as a result of
for purposes of clarification or
the interviewer’s failure to
summarization.
remember the data rather than for
purposes of clarification or
summarization.
Comments:
SCORE:
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
ITEM 11 – QUESTIONING SKILLS – DUPLICATION
[5]
[3]
[1]
The interviewer does not repeat
 The interviewer only rarely repeats
 The interviewer frequently repeats
questions, seeking duplication of
questions. Questions are repeated
questions seeking information
information that has previously
not for the purpose of
previously provided because he fails
been provided, unless clarification
summarization or clarification of
to remember the data already
or summarization of prior
information, but as a result of the
obtained.
information is necessary.
interviewer’s failure to remember
the data.
Comments:
SCORE:




ITEM 12 - QUESTIONING SKILLS – LACK OF JARGON
[5]
[3]
[1]
The interviewer asks questions and
 The interviewer occasionally uses
 The interviewer uses difficult
provides information in language
medical jargon during the interview
medical terms and jargon
which is easily understood.
failing to define the medical terms
throughout the interview.
for the patient unless specifically
Content is free of difficult medical
requested to do so by the patient.
terms and jargon.
Words are immediately defined for
the patient.
Language is used that is appropriate
to the patient’s level of education.
Comments:
SCORE:

ITEM 13 - QUESTIONING SKILLS – VERIFICATION OF PATIENT INFORMATION
[5]
[3]
[1]
The interviewer always seeks
 The interviewer will seek
 The interviewer fails to clarify or
clarification, verification and
clarification, verification and
verify patient’s responses, accepting
specificity of the patient’s
specificity of the patient’s responses
information at face value.
responses.
but not always.
Comments:
SCORE:
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

[5]
The interviewer consistently uses
the patient-centered technique.
The interviewer mixes patientcentered and physician-centered
styles that promote a collaborative
partnership between patient and
doctor.
ITEM 14 –INTERACTIVE TECHNIQUE
[3]
 The interviewer initially uses a

patient-centered style but reverts to
physician-centered interview at the

end (rarely returning the lead to the
patient).
OR
 The interviewer uses all patientcentered interviewing and fails to
use physician-centered style and
therefore does not accomplish the
negotiated agenda.
[1]
The interview does not follow the
patient’s lead.
Uses only physician-centered
technique halting the collaborative
partnership.
Comments:
SCORE:



ITEM 15 – VERBAL FACILITATION SKILLS
[5]
[3]
[1]
The interviewer uses facilitation
 The interviewer uses some
 The interviewer fails to use
skills through the interview.
facilitative skills but not
facilitative skills to encourage the
consistently or at inappropriate
patient to tell his story.
Verbal encouragement, use of short
times.
statements, and echoing are used
regularly when appropriate.
 Verbal encouragement could be
used more effectively.
The interviewer provides the patient
with intermittent verbal
encouragement, such as verbally
praising the patient for proper
health care technique.
Comments:
SCORE:






ITEM 16 – NON-VERBAL FACILITATION SKILLS
[5]
[3]
[1]
The interviewer puts the patient at
 The interviewer makes some use of
 The interviewer makes no attempt to
ease and facilitates communication
facilitative techniques but could be
put the patient at ease.
by using:
more consistent.
 Body language is negative or
Good eye contact;
 One or two techniques are not used
closed.
effectively.
OR
Relaxed, open body language;
OR
 Any annoying mannerism (foot or
Appropriate facial expression;
 Some physical barrier may be
pencil tapping) intrudes on the
Eliminating physical barriers; and
present.
interview.
Making appropriate physical
 Eye contact is not attempted or is
contact with the patient.
uncomfortable.
Comments:
SCORE:
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

ITEM 17 – EMPATHY AND ACKNOWLEDGING PATIENT CUES
[5]
[3]
[1]
The interviewer uses supportive
 A few empathetic statements are
 No empathy is demonstrated.
comments regarding the patient’s
used.
 The interviewer uses a negative
emotions.
 The interviewer is neutral, neither
emphasis or openly criticizes the
The interviewer uses NURS or
overly positive nor negative in
patient.
specific techniques for
demonstrating empathy.
demonstrating empathy.
Comments:
SCORE:

ITEM 18 – PATIENT’S PERSPECTIVE (BELIEFS)
[5]
[3]
[1]
The interviewer elicits the patient’s
 The interviewer elicits some of the
 The interviewer fails to elicit the
perspective on his illness, including
patient’s perspective on his illness
patient’s perspective.
his beliefs about its beginning,
AND/OR
Feelings, Ideas of cause, Function
 The interviewer does not follow
and Expectations (FIFE).
through with addressing beliefs.
Comments:
SCORE:



ITEM 19 – IMPACT OF ILLNESS ON PATIENT AND PATIENT’S SELF-IMAGE
[5]
[3]
[1]
The interviewer inquires about the
 The interviewer partially addresses
 The interviewer fails to
patient’s feelings about his illness,
the impact of the illness on the
acknowledge any impact of the
how it has changed his life.
patient’s life or self-image.
illness on the patient’s life or selfAND/OR
image.
The interviewer explores these
issues.
 The interviewer offers no
counseling or resources to help.
The interviewer offers counseling or
resources to help.
Comments:
SCORE:
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


ITEM 20 – IMPACT OF ILLNESS ON FAMILY
[5]
[3]
The interviewer inquires about the
 The interviewer recognizes the

structure of the patient’s family.
impact of the illness or treatment on
the family members and on family
The interviewer addresses the
lifestyle but fails to explore these
impact of the patient’s illness and/or
issues adequately.
treatment on family.
The interviewer explores these
issues.
[1]
The interviewer fails to address the
impact of the illness or treatment on
the family members and on family
lifestyle.
Comments:
SCORE:



[5]
The interviewer determines what
emotional support the patient feels
he has now.
The interviewer determines what
financial support the patient feels he
has now.
The interviewer inquires about other
resources available to the patient
and family and suggests appropriate
community resources.
ITEM 21 – SUPPORT SYSTEMS
[3]
 The interviewer may determine
some of the available support.
OR
 The interviewer may assume
support without determining if it is
actually available.

[1]
The interviewer fails to determine
what support is currently available
to the patient.
Comments:
SCORE:



ITEM 22 – PATIENT’S EDUCATION & UNDERSTANDING
[5]
[3]
[1]
The interviewer uses deliberate
 The interviewer asks the patient if
 The interviewer fails to assess
techniques to check the patient’s
he understands the information but
patient’s level of understanding and
understanding of information given
does not use a deliberate technique
does not effectively correct
during the interview including
to check.
misunderstandings when they are
diagnosis.
evident.
 Some attempt to determine the
AND/OR
Techniques may include asking the
interest in patient education but
patient to repeat information, asking
could be more thorough.
 The interviewer fails to address the
if the patient has additional
issue of patient education.
questions, posing hypothetical
situations or asking the patient to
demonstrate techniques.
When patient education is a goal,
the interviewer determines the
patient’s level of interest and
provides education appropriately.
Comments:
SCORE:
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
ITEM 23 – ASSESS MOTIVATION FOR CHANGES
[5]
[3]
[1]
The interviewer inquires how the
 The interviewer inquires how the
 The interviewer fails to assess
patient feels about the
patient feels about changes but does
patient’s level of motivation to
lifestyle/behavioral change and
not offer options or plans.
change and does not offer any
offers options and plans for the
OR
options or plans.
patient to choose from to encourage  The interviewer assumes the patient
and/or support the change.
will follow the suggested change
without assessing change but does
offer options and plans.
Comments:
SCORE:

ITEM 24 – ADMITTING LACK OF KNOWLEDGE
[5]
[3]
[1]
The interviewer, when asked for
 The interviewer, when asked for
 The interviewer, when asked for
information or advice that he is not
information or advice that he is not
information, which he is not
equipped to provide, admits to his
equipped to provide, admits lack of
equipped to provide, makes up
lack of knowledge in that area but
knowledge, but rarely seeks other
answers in an attempt to satisfy
immediately offers to seek
resources for answers.
the patient’s questions, but
resources to answer the question(s).
never refers to other resources.
Comments:
SCORE:



ITEM 25 – INFORMED CONSENT FOR INVESTIGATIONS & PROCEDURES
[5]
[3]
[1]
The interviewer discusses the
 The interviewer discusses some
 The interviewer fails to discuss
purpose and nature of all
aspects of the investigations and
investigations or procedures.
investigations and procedures.
procedures but omits some elements
of informed consent.
The interviewer reviews foreseeable
risks and benefits of the proposed
investigation or procedure.
The interviewer discloses
alternative investigations or
procedures and their relative risks
and benefits. Taking no action is
considered always considered an
alternative.
Comments:
SCORE:
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

[5]
The interviewer discusses the
diagnosis and/or prognosis and
negotiates a plan with the patient.
The interviewer invites the patient
to contribute his own thoughts,
ideas, suggestions and preferences.
ITEM 26 – ACHIEVE A SHARED PLAN
[3]
 The interviewer discusses the

diagnosis and/or prognosis and plan
but does not allow the patient to
contribute.
 Lacks full quality.
[1]
The interviewer fails to discuss
diagnosis and/or prognosis.
Comments:
SCORE:

ITEM 27 – QUESTIONING SKILLS - SUMMARIZING
[5]
[3]
[1]
The interviewer summarizes the
 The interviewer summarizes the
 The interviewer fails to summarize
data obtained at the end of each
data at the end of some lines of
any of the data obtained. No
major line of inquiry or subsection
inquiry but not consistently or
attempt to summarize.
to verify and/or clarify the
completely or attempts to
information or as a precaution to
summarize at the end of the
assure that no important data are
interview and it is incomplete.
omitted.
Comments:
SCORE:




[5]
At the end of the interview the
interviewer clearly specifies the
future plans:
What the interviewer will do
(make referrals, order tests);
What the patient will do (make
diet changes, go to Physical
Therapy);
When (the time of the next
communication or appointment.)

ITEM 28 – CLOSURE
[3]
At the end of the interview, the
interviewer partially details the
plans for the future.


[1]
At the end of the interview, the
interviewer fails to specify the plans
for the future and the patient leaves
the interview without a sense of
what to expect.
There is no closure whatsoever.
Comments:
SCORE:
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Appendix A
OUTLINE FOR MEDICAL INTERVIEW
A. INTRODUCTION
Introduce yourself
Explain role and position
Address patient as “Mr.” or “Mrs.” unless directed by patient to use first name
Talk a little to get interview started and to put the patient at ease
B. HISTORY OF THE PRESENT ILLNESS
Detailed documentation of patient’s current problem. Use open-ended questions to begin interview: e.g.,
“What brings you here today, Mrs. Smith?” “What can I do for you today, Mrs. Jones?”
Onset
Duration
Progression
Frequency
Location
Radiation
Quality
Quantity (severity, functional impairment)
Alleviating Factors
Aggravating Factors
Precipitating Events / Setting (context of illness)
Associated Symptoms
Current Medications (include Rx, over-the-counter, vitamins, herbal remedies)
Risk Factors / Pertinent Negatives
Patient’s attributions or understanding of illness (beliefs and concerns)
FIFE: Feelings, Ideas, Function, and Expectations
Summarize, clarify, and document missing information
Transitional statement into next subject of questioning
C. PAST MEDICAL HISTORY
Past illnesses: serious childhood/ adult illnesses including: Psychiatric, Hospitalizations,
Surgical Procedures, Injuries,
Accidents
Allergies (drugs, foods, environmental agents)
Menstrual / Obstetrical History (if female)
Immunizations / Exposures (travel history)
Screening Tests (TB, Pap Smear, Mammograms, Cholesterol, PSA, etc.)
Other Health Care Providers regularly seen (Ophthalmologists, Dentist, Therapists, etc.)
Summarize, clarify and document missing information
Transitional statement into next subject of questioning
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D. FAMILY HISTORY
Ages and health status of parents
Ages and health status of grandparents
Ages and health status of siblings
Ages and health status of spouse/children
Summarize, clarify and document missing information
Transitional statement into next subject of questioning
E. SOCIAL HISTORY
Patient Profile:
Occupation
Marital Status
Educational Background
Religion
Risk Factors: (Habits)
Alcohol Use:
Quantity
Frequency
Ever had a drinking problem?
Effect on function, i.e. CAGE Questions:
Do you feel you need to Cut down on your drinking?
Do you get Annoyed with criticism about your drinking?
Do you feel Guilty about your drinking?
Do you need an Eye-opener in the morning?
Tobacco Use:
Type
Frequency (PPD/How long)
Drug Use:
Type (Recreational, Sleeping pills, Diet pills, Pain killers)
Frequency (How long, How many)
Ever been dependent on Rx drugs/medications?
Nutritional:
History / Current
Appetite / Diet (24 hour recall)
Intake (Caffeine, Restrictions, Supplements)
Sexual History:
Satisfaction (Pain, Problems)
Sexual Preference
Age first active
Number of lifetime partners
Number of partners in last 6 months
Sexual activity (frequency and type)
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History of molestation / abuse
Health / Drug use of partners
Contraceptive methods
Knowledge of safe sex: Condom/barrier use
Ever treated for STD’s?
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Physical Violence:
How are disagreements handled at home?
Do you feel safe in relationships / Concerned for your (or your children’s) safety?
Guns in the home?
Ever been hurt or abused?
Risk Factors (use of seatbelts, sunscreen, etc.)
Recreational / Leisure Activities / Hobbies
Daily Activities / Exercise / Sleep Patterns / Energy Level
Relationship with:
Marital / Other significant relationships
Family
Professional
Living Arrangements
Support Systems (Financial and Emotional, Sense of Well-being / Stress)
Cultural & Health Beliefs (Ideas, Concerns, Expectations)
Summarize, clarify and document missing information
Transitional statement into next subject of questioning
F. REVIEW OF SYSTEMS (Students may be permitted to use a copy of the ROS for this section.)
If any general items for a system are positive, the interviewer should inquire about the system in
detail. If any item has been previously mentioned in HPI or PMH, repetition should be avoided or
explained to the patient. Record significant positives and negatives.
Skin
Hematopoietic
Head
Eyes
Ears
Nose
Pharynx & larynx
Breasts
Respiratory system
Cardiovascular system
Urinary system
Genital system
Menstrual reproductive
system
Endocrine system
Bones, muscles, joints
Neurological system
Psychiatric
Summarize, clarify and document missing information (only positives)
Ask the patient how he views the problem
G. CLOSURE OF THE INTERVIEW (Specific to level of interview)
Initial diagnostic impressions
Follow-up tests / consultations
Initial management plans
Discusses time frame for tests / plans
Patient education/counseling
Ensure patient understanding of any instructions, plans or treatment.
Allow the patient to discuss any additional questions or concerns (current complaint, appointments,
other concerns).
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Appendix B
AIDS FOR GIVING AND RECEIVING FEEDBACK
George F. J. Lehner, Ph.D., Professor of Psychology
University of California, Los Angeles
Some of the most important data we can receive from others (or give to others) consists of
feedback related to our behavior. Such feedback can provide learning opportunities for each of
us if we can use the reactions of others as a mirror for observing the consequences of our
behavior. Such personal data feedback helps to make us more aware of what we do and how we
do it, thus increasing our ability to modify and change our behavior and to become more effective
in our interactions with others.
To help us develop and use the techniques of feedback for personal growth, it is necessary to
understand certain characteristics of the process. The following is a brief outline of some factors
that may assist us in making better use of feedback, both as the giver and the receiver of
feedback. This list is only a starting point. You may wish to add further items to it.
1.
Focus feedback on behavior rather than the person
It is important that we refer to what a person does rather than comment on who we imagine he is.
This focus on behavior further implies that we use adverbs (which relate to qualities) when
referring to a person. Thus, we might say a person “talked considerably in this meeting,” rather
than that this person “is a loudmouth.” When we talk in terms of “personality traits” it implies
inherited, constant qualities difficult, if not impossible, to change. Focusing on behavior implies
that it is something related to a specific situation that might be changed. It is less threatening to a
person to hear comments about his behavior than his “traits.”
2.
Focus feedback on observations rather than inferences
Observations refer to what we can see or hear in the behavior of another person, while inferences
refer to interpretations and conclusions that we make from what we see or hear. In a sense,
inferences or conclusions about a person contaminate our observations, thus clouding the
feedback for another person. When inferences or conclusions are shared and it may be valuable
to have this data, it is important that they be so identified.
3.
Focus feedback on description rather than judgment
The effort to describe represents a process for reporting what occurred while judgment refers to
an evaluation in terms of good or bad, right or wrong, nice or not nice. The judgments arise out
of a personal frame of reference or values, whereas description represents neutral (as far as
possible) reporting.
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4.
Focus feedback on descriptions of behavior which are in terms of “more or less”
rather than in terms of “either-or”
The “more or less” terminology implies a continuum on which any behavior may fall, stressing
quantity, which is objective and meaningful rather than quality, which is subjective and
judgmental. Thus, participation of a person may fall on a continuum from low participation to
high participation, rather than “good” or “bad” participation. Not to think in terms of “more or
less” and the use of continua is to trap ourselves into thinking in categories, which may then
represent serious distortions of reality.
5.
Focus feedback on behavior related to a specified situation, preferably to the “here
and now” rather than to behavior in the abstract, placing it in the “there and then”
What you and I do is always tied in some way to time and place, and we increase our
understanding of behavior by keeping it tied to time and place. Feedback is generally more
meaningful if given as soon as appropriate after the observation or reactions occur, thus keeping
it concrete and relatively free of distortions that come with the lapse of time.
6.
Focus feedback on the sharing of ideas and information rather than on giving advice
By sharing ideas and information we leave the person free to decide for himself, in the light of
his own goals in a particular situation at a particular time, how to use the ideas and the
information. When we give advice, we tell him what to do with the information, and in that
sense we take away his freedom to determine for himself what is for him the most appropriate
course of action.
7.
Focus feedback on exploration of alternatives rather than answers or solutions
The more we can focus on a variety of procedures and means for the attainment of a particular
goal. The less likely we are to accept our particular problem. Many of us go around with a
collation of answers and solutions for which there are no problems.
8.
Focus feedback on the value it may have to the recipient, not on the value or
“release” that it provides the person giving the feedback
The feedback provided should serve the needs of the recipient rather than the needs of the giver.
Help and feedback need to be given and heard as an offer, not an imposition.
9.
Focus feedback on the amount of information that the person receiving it can use,
rather than on the amount that you have which you might like to give
To overload a person with feedback is to reduce the possibility that he may use what he receives
effectively. When we give more than can be used we may be satisfying some need for ourselves
rather than helping the other person.
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10.
Focus shared feedback on the time and place so that personal data can be shared at
appropriate times
Because the reception and use of personal feedback involves many possible emotional reactions,
it is important to be sensitive to when it is appropriate to provide feedback. Excellent feedback
presented at an inappropriate time may do more harm than good.
11.
Focus feedback on what is said rather than why it is said
The aspects of feedback which relate to the what, how, when, where, of what is said are
observable characteristics. The why of what is said takes us from the observable to the inferred,
and brings up questions of “motive” or “intent.”
It is maybe helpful to think “why” in terms of a specifiable goal or goals which can then be
considered in terms of time, place, procedures, probabilities or attainment, etc. To make
assumptions about the motives of the person giving feedback may prevent us from hearing or
cause us to distort what is said. In short, if I question “why” a person gives me feedback, I may
not hear what he says.
In short, the giving (and receiving) of feedback requires courage, skill, understanding and respect
for self and others.
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Appendix C
STUDENT PROFESSIONALISM EVALUATION FORM
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MIRS FORM 2006
MASTER INTERVIEW RATING SCALE
2/12/16
[5]
The
interviewer
introduces
himself, clarifies his roles, and
inquires how to address patient.
Uses patient name.
[4]
ITEM 1 – OPENING
[3]
The interviewer’s
introduction is missing a
critical element (s)
[2]
[1]
There is no introduction.
ITEM 2 – ELICITS SPECTRUM OF CONCERNS
[5]
[4]
[3]
[2]
[1]
The interviewer elicits the patient’s full
The interviewer elicits some of the
The interviewer fails to elicit the
spectrum of concerns within the first 3-5 patient’s concerns on his chief complaint.
patient’s concern.
minutes of the interview.
ITEM 3 – NEGOTIATES PRIORITIES & SETS AGENDA
[5]
[4]
[3]
[2]
[1]
The interviewer fully negotiates
The interviewer elicits only partial
The interviewer does not negotiate
priorities of patient concerns, listing all
concerns and therefore does not
priorities or set an agenda.
of the concerns and sets the agenda at
accomplish the complete patient agenda
The interviewer focuses only on the
the onset of the interview.
for today’s visit.
chief complaint and takes only the
The patient is invited to participate in
The interviewer sets the agenda.
physician’s needs into account.
making an agreed plan. (communication
cases)
ITEM 4 – ELICITING THE NARRATIVE THREAD or the “PATIENT’S STORY”
[5]
[4]
[3]
[2]
[1]
The interviewer encourages and lets the
The interviewer begins to let the patient
The interviewer fails to let the patient
patient talk about their problem.
talk about their problem but either
talk about their problem.
The interviewer does not stop the patient interrupts with focused questions or
OR
or introduce new information.
introduces new information into the
The interviewer sets the pace with Q &
conversation.
A style, not conversation.
ITEM 5 - TIMELINE
[5]
[4]
[3]
[2]
[1]
The interviewer obtains sufficient
The interviewer obtains some of the
The interviewer fails to obtain
information so that a chronology of the
information necessary to establish a
information necessary to establish a
chief complaint and history of the
chronology.
chronology.
present illness can be established.
He may fail to establish a chronology for
The chronology of all associated
all associated symptoms.
symptoms is also established.
ITEM 6 – ORGANIZATION
[5]
[4]
[3]
[2]
[1]
Questions in the body of the interview
The interviewer seems to follow a series The interviewer asks questions that seem
follow a logical order to the patient.
of topics or agenda items; however,
disjointed and unorganized.
there are a few minor disjointed
questions.
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ITEM 7 – TRANSITIONAL STATEMENTS
[5]
[4]
[3]
[2]
[1]
The interviewer utilizes transitional
The interviewer sometimes introduces
The interviewer progresses from one
statements that explain the reasons for
subsections with effective transitional
subsection to another in such a manner
progressing from one subsection to
statements but fails to do so at other
that the patient is left with a feeling of
another (only in a complete history)
times.
uncertainty as to the purpose of the
OR
questions.
Some of the transitional statements used No transitional statements are made.
are lacking in quality.
ITEM 8 – PACING OF INTERVIEW
[5]
[4]
[3]
[2]
[1]
The interviewer is attentive to the
The pace of the interview is comfortable The interviewer frequently interrupts the
patient’s responses.
most of the time, but the interviewer
patient and there are awkward pauses,
The interviewer listens without
occasionally interrupts the patient and/or which break the flow of the interview.
interruption.
allows awkward pauses to break the
The interview progresses smoothly with
flow of the interview.
no awkward pauses.
Silence may be used deliberately.
ITEM 9 - QUESTIONING SKILLS – TYPES OF QUESTIONS
[5]
[4]
[3]
[2]
[1]
The interviewer begins information
The interviewer often fails to begin a
The interviewer asks many why
gathering with an open-ended question.
line of inquiry with open-ended
questions, multiple questions, or leading
This is followed up by more specific or
questions but rather employs specific or
questions.
direct questions.
direct questions to gather information.
Each major line of questioning is begun
OR
with an open-ended question.
The interviewer uses a few leading, why
No poor question types are used.
or multiple questions.
ITEM 10 – QUESTIONING SKILLS - SUMMARIZING
[5]
[4]
[3]
[2]
[1]
The interviewer summarizes the data
The interviewer summarizes the data at
The interviewer fails to summarize any
obtained at the end of each major line of the end of some lines of inquiry but not
of the data obtained.
inquiry or subsection to verify and/or
consistently or completely or attempts to
clarify the information (complete hx,
summarize at the end of the interview
focused history: one summary is
and it is incomplete.
sufficient)
ITEM 11 – QUESTIONING SKILLS – DUPLICATION
[5]
[4]
[3]
[2]
[1]
The interviewer does not repeat
The interviewer only rarely repeats
The interviewer frequently repeats
questions, seeking duplication of
questions. Questions are repeated not
questions seeking information previously
information that has previously been
for the purpose of summarization or
provided because he fails to remember
provided, unless clarification or
clarification of information, but as a
the data already obtained.
summarization of prior information is
result of the interviewer’s failure to
necessary.
remember the data.
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ITEM 12 - QUESTIONING SKILLS – LACK OF JARGON
[5]
[4]
[3]
[2]
[1]
The interviewer asks questions and
The interviewer occasionally uses
The interviewer uses difficult medical
provides information in language which
medical jargon during the interview
terms and jargon throughout the
is easily understood.
failing to define the medical terms for
interview.
Content is free of difficult medical terms the patient unless specifically requested
and jargon.
to do so by the patient.
Words are immediately defined for the
patient.
Language is used that is appropriate to
the patient’s level of education.
ITEM 13 - QUESTIONING SKILLS – VERIFICATION OF PATIENT INFORMATION
[5]
[4]
[3]
[2]
[1]
The interviewer always seeks
The interviewer will seek clarification,
The interviewer fails to clarify or verify
clarification, verification and specificity verification and specificity of the
patient’s responses, accepting
of the patient’s responses.
patient’s responses but not always.
information at face value.
ITEM 14 –INTERACTIVE TECHNIQUES
[5]
[4]
[3]
[2]
[1]
The interviewer consistently uses the
The interviewer initially uses a patientThe interview does not follow the
patient-centered technique.
centered style but reverts to physicianpatient’s lead.
The interviewer mixes patient-centered
centered interview at the end (rarely
Uses only physician-centered technique
and physician-centered styles that
returning the lead to the patient).
halting the collaborative partnership.
promote a collaborative partnership
OR
between patient and doctor.
The interviewer uses all patient-centered
interviewing and fails to use physiciancentered style and therefore does not
accomplish the negotiated agenda.
ITEM 15 – VERBAL FACILITATION SKILLS
[5]
[4]
[3]
[2]
[1]
The interviewer uses facilitation skills
The interviewer uses some facilitative skills
The interviewer fails to use
through the interview.
but not consistently or at inappropriate
facilitative skills to encourage the
Verbal encouragement, use of short
times.
patient to tell his story.
statements, and echoing are used
Verbal encouragement could be used more
regularly when appropriate.
effectively.
The interviewer provides the patient
with intermittent verbal encouragement,
such as verbally praising the patient for
proper health care technique.
ITEM 16 – NON-VERBAL FACILITATION SKILLS
[5]
[4]
[3]
[2]
[1]
The interviewer puts the patient at ease
The interviewer makes some use of
The interviewer makes no attempt to put
and facilitates communication by using:
facilitative techniques but could be more the patient at ease.
Good eye contact;
consistent.
Body language is negative or closed.
Relaxed, open body language;
One or two techniques are not used
OR
Appropriate facial expression;
effectively.
Any annoying mannerism (foot or pencil
Eliminating physical barriers; and
OR
tapping) intrudes on the interview.
Making appropriate physical contact
Some physical barrier may be present.
Eye contact is not attempted or is
with the patient.
uncomfortable.
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ITEM 17 – EMPATHY AND ACKNOWLEDGING PATIENT CUES
[5]
[4]
[3]
[2]
[1]
The interviewer uses supportive
The interviewer is neutral, neither overly No empathy is demonstrated.
comments regarding the patient’s
positive nor negative in demonstrating
The interviewer uses a negative
emotions.
empathy.
emphasis or openly criticizes the patient.
The interviewer uses NURS (name,
understand, respect, support) or specific
techniques for demonstrating empathy.
ITEM 18 – PATIENT’S PERSPECTIVE (BELIEFS)
[5]
[4]
[3]
[2]
[1]
The interviewer elicits the patient’s
The interviewer elicits some of the
The interviewer fails to elicit the
healing practices and perspectives on his patient’s perspective on his illness
patient’s perspective.
illness, including his beliefs about its
AND/OR
The interviewer does not follow through
beginning, Feelings, Ideas of cause,
with addressing beliefs.
Function and Expectations (FIFE).
ITEM 19 – IMPACT OF ILLNESS ON PATIENT AND PATIENT’S SELF-IMAGE
[5]
[4]
[3]
[2]
[1]
The interviewer inquires about the
The interviewer partially addresses the
The interviewer fails to acknowledge any
patient’s feelings about his illness, how
impact of the illness on the patient’s life impact of the illness on the patient’s life
it has changed his life.
or self-image.
or self-image.
The interviewer explores these issues.
AND/OR
The interviewer offers counseling or
The interviewer offers no counseling or
resources to help. This is used in
resources to help.
communication cases.
ITEM 20 – IMPACT OF ILLNESS ON FAMILY
[5]
[4]
[3]
[2]
[1]
The interviewer inquires about the
The interviewer recognizes the impact of The interviewer fails to address the
structure of the patient’s family.
the illness or treatment on the family
impact of the illness or treatment on the
The interviewer addresses the impact of
members and on family lifestyle but fails family members and on family lifestyle.
the patient’s illness and/or treatment on
to explore these issues adequately.
family.
The interviewer explores these issues.
[5]
The interviewer determines what
emotional support the patient has.
The interviewer determines what
financial support the patient has and
learns about health care access
The interviewer inquires about other
resources available to the patient and
family and suggests appropriate
community resources.
(will be focused in focused histories)
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[4]
ITEM 21 – SUPPORT SYSTEMS
[3]
[2]
[1]
The interviewer determines some of the
The interviewer fails to determine what
available support.
support is currently available to the
patient.
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ITEM 22 – PATIENT’S EDUCATION & UNDERSTANDING
[5]
[4]
[3]
[2]
[1]
The interviewer uses deliberate
The interviewer asks the patient if he
The interviewer fails to assess patient’s
techniques to check the patient’s
understands the information but does not level of understanding and does not
understanding of information given
use a deliberate technique to check.
effectively correct misunderstandings
during the interview including diagnosis. Some attempt to determine the interest
when they are evident.
If English proficiency is limited an
in patient education but could be more
AND/OR
interpreter is offered.
thorough.
The interviewer fails to address the issue
Techniques may include asking the
of patient education.
patient to repeat information, asking if
the patient has additional questions,
posing hypothetical situations or asking
the patient to demonstrate techniques.
When patient education is a goal, the
interviewer determines the patient’s
level of interest and provides education
appropriately.
ITEM 23 – ASSESS MOTIVATION FOR CHANGES
[5]
[4]
[3]
[2]
[1]
The interviewer inquires how the patient The interviewer inquires how the patient The interviewer fails to assess
feels about the lifestyle/behavioral
feels about changes but does not offer
patient’s level of motivation to
change and offers options and plans for
options or plans.
change and does not offer any
the patient to choose from to encourage
OR
options or plans.
and/or support the change.
The interviewer assumes the patient will
follow the suggested change without
assessing change but does offer options
and plans.
ITEM 24 – ADMITTING LACK OF KNOWLEDGE
[5]
[4]
[3]
[2]
[1]
The interviewer, when asked for
The interviewer, when asked for
The interviewer, when asked for
information or advice that he is not
information or advice that he is not
information, which he is not
equipped to provide, admits to his lack
equipped to provide, admits lack of
equipped to provide, makes up
of knowledge in that area but
knowledge, but rarely seeks other
answers in an attempt to satisfy the
immediately offers to seek resources to
resources for answers.
patient’s questions, but never refers
answer the question(s).
to other resources.
ITEM 25 – INFORMED CONSENT FOR INVESTIGATIONS & PROCEDURES
[5]
[4]
[3]
[2]
[1]
The interviewer discusses the purpose
The interviewer discusses some aspects
The interviewer fails to discuss
and nature of all investigations and
of the investigations and procedures but
investigations or procedures.
procedures.
omits some elements of informed
The interviewer reviews foreseeable
consent.
risks and benefits of the proposed
investigation or procedure.
The interviewer discloses alternative
investigations or procedures and their
relative risks and benefits. Taking no
action is considered always considered
an alternative.
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ITEM 26 – ACHIEVE A SHARED PLAN
[5]
[4]
[3]
[2]
[1]
The interviewer discusses the diagnosis
The interviewer discusses the diagnosis
The interviewer fails to discuss
and/or prognosis and negotiates a plan
and/or prognosis and plan but does not
diagnosis and/or prognosis.
with the patient.
allow the patient to contribute.
The interviewer invites the patient to
Lacks full quality.
contribute his own thoughts, ideas,
suggestions and preferences.
[5]
The interviewer
encourages the patient
to ask questions at the
end of a major
subsection.
The interviewer gives
the patient the
opportunity to bring up
additional topics or
points not covered in
the interview.
ITEM 27 – ENCOURAGEMENT OF QUESTIONS
[4]
[3]
[2]
The interviewer
The interviewer does
The interviewer fails to provide the patient with the
provides the patient
not specifically ask if
opportunity to ask questions or discuss additional points.
with the opportunity
there are questions, but
The interviewer may discourage the patient’s questions.
to discuss any
the climate and the pace
additional points or
of the interview allow
ask any additional
them
questions but neither
encourages nor
discourages him.
ITEM 28 – CLOSURE
[5]
[4]
[3]
[2]
[1]
At the end of the interview the
At the end of the interview, the
At the end of the interview, the
interviewer clearly specifies the future
interviewer partially details the plans for interviewer fails to specify the plans for
plans:
the future.
the future and the patient leaves the
interview without a sense of what to
What the interviewer will do (leave
expect.
and consult, make referrals)
There is no closure whatsoever.
What the patient will do (wait, make
diet changes, go to Physical Therapy);
When (the time of the next
communication or appointment.)
An online module for MIRS training is available at http://fitsweb.uchc.edu/PCMLogin/login.asp
2/12/16
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Eastern Virginia Medical School
MASTER INTERVIEW RATING SCALE (MIRS) AT-A-GLANCE
1.) Opening
introduces self, clarifies role, and inquires how to address patient
2.) Elicits Spectrum of Concerns elicits full spectrum of patient concerns at interview onset
in first few minutes of encounter (2-4)
3.) Negotiates Priorities and Sets Agenda
purpose, agenda, plan, and patient agreement
4.) Eliciting the Narrative Thread or the “Patient’s Story”
tell the story without interruption at interview onset
gives patient the opportunity to
5.) Timeline chronological progression of all of the symptoms from onset to present time
6.) Organization
the interview follows a logical order; does not jump from section to section
7.) Transitional Statements
8.) Pacing of Interview
alert patient to change from one topic to another with reasons
neither too fast nor too slow with no interruptions or long pauses
9.) Types of Questions begins with open-ended question (describe, tell me about), followed
by direct questions; avoids leading, negative, and multiple questions
10.) Summarizing data is summarized by the end of the interview (focused) or at end of each section
(complete)
11.) Duplication
12.) Lack of Jargon
questions are not repeated, except for clarification or summarization
lay vocabulary is used; medical terms are explained immediately
13.) Verification of Patient Information pursue/verify the details of symptoms, events, meds
(dates, dosages, quantities)
14.) Interactive Techniques uses a patient-centered approach throughout the interview
15.) Verbal Facilitation Skills
verbally encourages patient to tell the story; gives verbal
reinforcement for positive behaviors
16.) Non-Verbal Facilitation Skills encouraging and supportive gestures, body language,
and appropriate eye contact are used; no physical barriers
17.) Empathy and Acknowledging Patient Cues empathetic approach, responds to concerns, helps
to seek solutions; Name: I hear that you are afraid; Understand: it is something to be worried about;
Respect: I would feel the same way; Support: I will do what I can to help= NURS (2 or more of these
equals a score of 5)
18.) Patient’s Perspective (Beliefs) patient is asked about perception of problems/issues
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Copyrighted to Theresa A. Thomas Professional Skills Teaching & Assessment Center,
Eastern Virginia Medical School
19.) Impact of Illness on Patient and Patient’s Self-Image explores impact of illness on
activities of daily living, finances/work, and social function; explores feelings about illness
20.) Impact of Illness on Family explores impact of illness/treatment on family members
21.) Support Systems inquires about friends, family, social services, support groups,
finances and spiritual resources
22.) Patient’s Education and Understanding patient is given a comfortable amount of
information; deliberate techniques to check understanding (have patient demonstrate/repeat the plan)
23.) Assess Motivation for Changes inquires about patient patient’s readiness for
behavioral change
24.) Admitting Lack of Knowledge when not equipped to provide specific information,
admits this and offers to seek information to answer the question
25.) Informed Consent for Investigations and Procedures discusses purpose of
procedure/treatment, risks and benefits, and alternatives
26.) Achieve a Shared Plan negotiates plan with patient and invites him to contribute ideas
27.) Encouragement of Questions
asks patients if they have questions or additional concerns
28.) Closure clearly specifies future plans (what interviewer will do, what patient should do,
next communication date)
C. Pfeiifer, B. Palten, S. Derochers, T. McNally, D. Aloi, 10/10/08
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