Discussion of SP Case
Agenda
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Discussion of SP case
Review key principles of clinical medicine
Andrea Milam: Moral reasoning,
course/program evaluation, research
Course evaluation: Defining issues test
The Medical Interview

Not a one-way interrogation

It is a two-way collaborative and dynamic
interaction
The Medical Interview
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Most important part of the medical encounter
Functions
Structure, content, process
Requires communication and interpersonal skills
What are the functions of the
medical interview?
Functions of the Medical Interview
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Build the relationship
Assess the patient’s problems
Manage the patient’s problems (education,
negotiation, motivation)
What is the basic structure of the
medical encounter?
Structure and Tasks of the Medical
Encounter
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Initiate the session
Gather information
Explaining and planning
Closing the session
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Building the relationship
Provide structure to the
encounter
Initiating the Session
Gathering information
Providing
Structure
Building the
relationship
Physical Examination
Explanation and planning
Closing the Session
Initiating the Session: Students
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How did you initiate the session?
What were you trying to accomplish?
What steps did you take?
Initiating the Session: SPs
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How did they do?
Initiating the Session
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Preparation
Establishing initial rapport
Identifying the reason(s) for the encounter
Preparation

Puts aside last task, attends to self comfort

Focuses attention and prepares for this
encounter
Opening the Interview
Objectives
 Establish supportive environment and initial
rapport
 Awareness of pt’s emotional state
 ID all pt’s issues/problems he/she wishes to
address
 Negotiate agenda for encounter
 Develop partnership with pt
Opening the Interview
Convey
 Respect
 Empathy
 Support
 Non-judgmental/unconditional positive regard
 Interest in the patient as an individual
Opening the Interview
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Greet the patient
Verify/obtain pt’s name
Introduce self and clarify
role and goals of interview
Obtain pt’s consent for
interview
Attend to patient’s comfort
Initial rapport-building skills
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Identify the reason(s) why
the patient came to the
doctor
Negotiate priorities
Elicit the patient’s
expectations
Opening the Interview
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Greet the patient
Verify/obtain pt’s name
Introduce self and clarify
role and goals of interview
Obtain pt’s consent for
interview
Attend to patient’s comfort
Initial rapport-building skills
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Identify the reason(s) why
the patient came to the
doctor
Negotiate priorities
Elicit the patient’s
expectations
Initial Rapport Building Skills
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Initial non-verbal communication
Respect
Attending to patient’s comfort
Engage the patient
Initial Rapport Building Skills
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Initial non-verbal communication
Respect
Attending to patient’s comfort
Engage the patient
What percent of communication is
non-verbal?
What percent of communication is
non-verbal?
Around 80%
Nonverbal Communication
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Facial Expressions
Physical Environment
Territory and
Interpersonal Space
Body Language
Paralanguage
Touch
Nonverbal Communication
“You’re my doctor???!!”
Rapport
Rapport

Rapport is one of the most important features
or characteristics of human interaction.

It is commonality of perspective, being in
"sync", being on the same wavelength as the
person you are talking to.
What Are Rapport Skills?
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Start with greeting and getting to know the pt or
checking how the pt is doing
Many are nonverbal expressing interest and
concern
“Positive talk” personally supportive
Avoiding “negative talk” criticism, blaming,
arrogance
Lang
Rapport: Pros
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Shows interest in the pt as a person
Initial non-clinical talk helps calibrate the future
communication style, language, spontaneity
For non-emergent care in an emergency setting,
pts still frequently appreciate personal interest at
the beginning of the interview
Lang
Rapport: Cons
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On occasion, a pt in an ambulatory setting will
want to “get right down to business”
Frequently in emergency situations pts want
their disease taken care of first
If insincere or overdone, positive talk can
appear like “kissing up”
Lang
Barriers to Use of Rapport Building
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In an effort to be “professional”, some students may
avoid a relaxed, personally interested posture
Gender issues may create a fear that personal interest
may attract unwanted personal advances
The interviewer may have negative personal feelings or
experiences with regards to the pt or clinical situation
(counter-transference)
Lang
Genuineness and Respect are the
Key
Genuineness - "Be truthful about who you are personally
and professionally. Learn to compartmentalize your
personal and professional selves."
Respect - "Be nonjudgmental. Convey unconditional
positive regard. Value the other person as an individual
even if you don't like them."
Bayer
Initial Rapport Building Skills
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Initial non-verbal communication
Respect
Attending to patient’s comfort
Engage the patient
Rapport Building Skills:
Engage the Patient
Engage Defined
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A connection which continues throughout the
encounter
Person-to- person
Professionally, as partners
Bayer
Engagement: Techniques
Join the patient
 Use the first few minutes to build rapport
 Use a pleasant, consistent tone of voice
Bayer
Engagement: Techniques
Be as curious about the person as you are their medical
condition
“Care more particularly for the individual patient than for
the special features of the disease”
Sir William Osler
Examples of “Non-Medical”
Conversation Topics
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Begin the interview with a personal inquiry, for example:
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Ask about something in the patient’s background that catches your
interest
Identify a shared interest, experience, or background
Engage in small talk
Ask about demographic data, such as name, age, occupation, and
marital status
Ask about the patient’s general health before asking the reason
for the visit.
Find something you like about each patient
(Billings and Stoeckle,1999)
Building Rapport
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New patient:
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“Before we begin, tell me something about yourself.”
Return patient:

Mention something personal from a previous visit
Opening the Interview
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Greet the patient
Verify/obtain pt’s name
Introduce self and clarify
role and goals of interview
Obtain pt’s consent for
interview
Attend to patient’s comfort
Initial rapport-building skills


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Identify the reason(s) why
the patient came to the
doctor
Negotiate priorities
Elicit the patient’s
expectations
Identify the Reason(s) why the
Patient came to the Doctor
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Students
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Why did the patient come to the doctor?
Identify the Reason(s) why the
Patient came to the Doctor
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SPs
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Why did you come to the doctor?
Identify the Reason(s) why the
Patient came to the Doctor

Most patients have more than one concern
(mean around 3 concerns)

The first concern may not be the most
important to the patient
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Identifying all pt’s concerns allows for time
allocation
Skills: Identifying the reason(s) for the patient’s
visit
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The opening question: identifies the problems
or issues that the patient wishes to address (e.g.
“What would you like to discuss today?”)

Listening to the patient’s opening
statement: listens attentively without
interrupting or directing patient’s response
Skills:
Identifying the reason(s) for the patient’s visit

Screening: checks and confirms list of problems or
issues that the patient wishes to cover
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(e.g. “so that’s headaches and tiredness, is there anything else
you’d like to discuss today as well?”)
Agenda setting: negotiates agenda and format of
interview taking both patient’s and physician’s needs
into account
Initiating the Session
Gathering information
Providing
Structure
Building the
relationship
Physical Examination
Explanation and planning
Closing the Session
Gathering Information
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Students
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Tell us about the patient’s abdominal pain
Tell us what information you gathered on this
patient’s past and current ongoing medical
problems
What other information about this patient you feel
is pertinent?
Gathering Information
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SPs
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How did the students do?
Did they miss any pertinent information?
Did they gather information to understand your
perspective?
Content of the Medical History
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Chief complaint and survey of problems
History of present illness
Past medical history
Family history
Patient profile and social history
Review of systems
Chief complaint and survey of
problems

The one or more concerns causing the patient to
seek care.

Encourage the pt to tell you all of his/her
concerns.

You may negotiate what will be covered due to
time limitations
History of Present Illness

Amplifies each of the patients concerns.

Includes the patient’s thoughts and feelings
about the illness.

The narrative thread
History of Present Illness
Seven content items:
1.
Location: Where does it hurt?
2.
Quality: What does it feel like?
3.
Severity: How bad is it?
4.
Timing: When did it start? How long does it last?
5.
Context: What were you doing when it first began?
6.
Modifying factors: Does anything make it better or worse?
7.
Associated symptoms: What other symptoms are associated with this
problem
History of Present Illness
Patient’s perspective of the illness
FIFE
F = Function: How has this affected you?
I = Ideas: What do you think caused this problem?
F = Feelings: What concerns you about this
problem?
E = Expectations: How to you hope we can help you
with this problem?
Past Medical History
An exploration of the person’s overall health
before the present problem, including all past
medical and surgical experiences.
Past Medical History
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Hospitalizations
Surgeries
Illnesses
Trauma
Medications
Allergies
Pregnancies
Transfusions
Exposures
Past Medical History
Health Maintenance
 Periodic health examinations
 Immunizations
 Injury prevention
 Exercise
Family History
An exploration of a family’s health, past
medical experiences, illnesses, social
experiences, deaths, and genetic and
environmental circumstances
Family History

Current health of parents, siblings, and
children
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History of significant illnesses in the family,
such as hypertension, diabetes, coronary artery
disease, etc.
Social History
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Information that helps in the understanding of
the patient as an individual

Helps to begin to get a view of the patient’s
illness in the context of his/her life
Social History
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Patient profile
Place of birth and upbringing, education, military,
occupations, hobbies
 Living situations, family, and relationships, residence
 Impact of illness on life
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Health-risk behaviors
Life-stress and satisfaction
Review of Systems
Assesses for the presence or absence of
common symptoms related to each major body
system
Review of Systems
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General/constitutional
Skin
Eyes
ENT
Pulmonary
Cardiovascular
Digestive
Genitourinary
Hematological
Immune
Endocrine
Musculoskeletal
Neurological
Psychiatric
History of Present Illness
Students: For this patient
Seven content items:
1.
Location: Where does it hurt?
2.
Quality: What does it feel like?
3.
Severity: How bad is it?
4.
Timing: When did it start? How long does it last?
5.
Context: What were you doing when it first began?
6.
Modifying factors: Does anything make it better or worse?
7.
Associated symptoms: What other symptoms are associated with this
problem
History of Present Illness
SPs
Seven content items:
1.
Location: Where does it hurt?
2.
Quality: What does it feel like?
3.
Severity: How bad is it?
4.
Timing: When did it start? How long does it last?
5.
Context: What were you doing when it first began?
6.
Modifying factors: Does anything make it better or worse?
7.
Associated symptoms: What other symptoms are associated with this
problem
History of Present Illness
Students: For this patient
Patient’s perspective of the illness
FIFE
F = Function: How has this affected you?
I = Ideas: What do you think caused this problem?
F = Feelings: What concerns you about this
problem?
E = Expectations: How to you hope we can help you
with this problem?
History of Present Illness
SPs
Patient’s perspective of the illness
FIFE
F = Function: How has this affected you?
I = Ideas: What do you think caused this problem?
F = Feelings: What concerns you about this
problem?
E = Expectations: How to you hope we can help you
with this problem?
Gathering Information
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Skills
Skills: Gathering information: Exploration of
Problems
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Encourages the patient to tell story (narrative)
Uses open-ended and closed-ended questions,
appropriately moving from open-ended to closed,
non-directive to directive
Avoids or explains jargon, avoids other language
“pitfalls”
Listens attentively, allowing patient to complete
statements without interruption and leaving space for
patient to think before answering or go on after
pausing
Listening
Listening

“Listening to a patient narrative is also
observing. Here, what the patient actually said
and the exact manner - words, pausing, pitch,
emphasis, and so on - in which it is said is the
observation that must be separated from what
the listener thinks the patient meant”

Eric Cassell, MD
Listening

Doctors hope they are good listeners already.
But how often do we really listen?

How often do we anticipate what is going to be
said next, and jump in with our thoughts and
ideas as soon as there is a pause?
Listening

Listening is an art, a skill, and needs to be
learned and practiced.

As listeners we need to be warm, caring and
non-judgmental.

We need to make a special effort to tune in to
the person’s feelings, and have a genuine respect
for the person calling.
Effective listening
There are three components in effective
listening:
 Attending behavior
 Effective use of silence (wait time)
 Active listening
Listening: Attending Behavior
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Eye contact
Body language
Tone of voice
Following the conversation
This means that you do not interrupt, or change the
subject or introduce new topics.
 Attending well will mean that the patient does most
of the talking, and that you don’t lecture..

Active Listening
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Facilitation - encourage client to continue; “uhhuh”
Clarification - obtain more info; “What do you
mean by -------- ?”
Restatement - repeating what was said using
different words
Active Listening
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Reflection - repeating what the patient just said
to encourage elaboration
Interpretation - used to share a conclusion
drawn from data
Summary (checking)- condenses & orders data
for sequencing events
Listening With Empathy
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Empathy is understanding
Empathy is not sympathy
Sympathy is an expression of one’s own feelings
about another’s predicament
Empathy is an attempt to fell with another
person, to understand their point of view.
Skills: Gathering information: Exploration of
Problems
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Facilitates patient’s responses verbally and nonverbally (use of encouragement, silence, repetition,
paraphrasing)
Clarifies patient’s statements which are vague or need
amplification (e.g. “Could you please explain what you
mean by ‘lightheaded’?”
Checks with patient to insure understanding
Helps the patient organize the narrative thread,
checks dates, helps establish chronology, directs
Skills: Gathering information: Understanding
the patient’s perspective
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Function: determines how each problem affects the
patient’s life
Ideas: determines and acknowledges patient’s ideas
(i.e. beliefs regarding cause) regarding each problem
Feelings and thoughts: encourages expression of the
patient’s feelings (i.e. worries)
Expectations: determines the patient’s goals, what
help the patient had expected for each problem
Cues: picks up on verbal and non-verbal cues (body
language, speech facial expressions, affect);
acknowledges and checks out as appropriate
FIFE
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Function
Ideas
Feelings
Expectations
FIFE
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Function
Ideas
Feelings
Expectations
Patient’s presents problem
Gathering Information
Parallel search of two frameworks
Illness framework
Patient’s agenda
Disease framework
Doctor’s agenda
ideas
concerns
expectations
feelings
thoughts
effects
symptoms
signs
investigations
understanding pathology
Understanding the
Patient’s unique
Experience of illness
Differential Diagnosis
Integration of the 2 frameworks
Explanation and planning: shared understanding and decision-making
Initiating the Session
• preparation
• establishing initial rapport
• identifying the reason(s) for the consultation
Gathering information
Providing
• exploration of the patient’s problems to discover the:
Structure
 biomedical perspective
• making
organisation
overt
Building the
relationship
 the patient’s perspective
 background information - context
•
using
appropriate
non-verbal
behaviour
•
developing
rapport
•
involving
the patient
Physical examination
• attending to
flow
Explanation and planning
• providing the correct amount and type of information
• aiding accurate recall and understanding
• achieving a shared understanding: incorporating the patient’s
illness framework
• planning: shared decision making
Closing the Session
• ensuring appropriate point of closure
• forward planning
AN EXAMPLE OF THE INTER-RELATIONSHIP BETWEEN CONTENT AND PROCESS
Gathering Information
Process Skills for Exploration of the Patient’s Problems
 patient’s narrative
 question style: open to closed cone
 attentive listening
 facilitative response
 picking up cues
 clarification
 time-framing
 internal summary
 appropriate use of language
 additional skills for understanding patient’s perspective
Content to Be Discovered
the bio-medical perspective (disease)
sequence of events
symptom analysis
relevant systems review
the patient’s perspective (illness)
ideas and beliefs
concerns
expectations
effects on life
feelings
background information - context
past medical history
drug and allergy history
family history
personal and social history
review of systems
Patient's Problem List
Exploration of Patient's Problems
Medical Perspective – disease
Sequence of events
Symptom analysis
Relevant systems review
Patient's Perspective - illness
Ideas and beliefs
Concerns
Expectations
Effects on life
Feelings
Background Information - Context
Past Medical History
Drug and Allergy History
Family History
Personal and Social History
Review of Systems
Physical Examination
Differential Diagnosis - Hypotheses
Including both disease and illness issues
Physician's Plan of Management
Investigations
Treatment alternatives
Explanation and Planning with Patient
What the patient has been told
Plan of action negotiated
Diagnosis of Abd Pain
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What are possible causes of abd pain in this patient?
What is you number 1 candidate?
What would you expect to find on physical exam?
What further diagnostic tests are indicated if any?
What would you tell the patient?
What are your treatment options?
How would you treat this patient?
Putting Clues Together
"Medicine is a science of uncertainty and an art of
probability."
Sir William Osler
Hypothetico-deductive method
Initial Clues/Initial Hunches
Inquiry
Differential
diagnosis
Hypothesis Generation
Case Building
Hypothesis Evaluation
Diagnostic Decision
Therapeutic Decision
Epidemiology

Does this patient have any risk factors to
predispose to a cause of abdominal pain?
Describe the patient’s abdominal pain?

Where is it located?
Differential Diagnosis
Location of pain
Differential Diagnosis
Epigastric pain
 Peptic ulcer disease
 Gastroesophageal reflex disease
 Gastritis
 Pancreatitis
 Myocardial infarction
 Ruptured aortic aneurysm
Describe the patient’s abdominal pain?
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Location, radiation
Quality
Severity
Timing: onset, duration, frequency
Setting or context
Modifying factors: aggravating, alleviating
Associated symptoms
Diagnosis Epidemiology
Etiology
Presentation
Physical
examination
Peptic
ulcer
May be associated
with Helicobacter
pylori infection.
Risk factors
include COPD,
NSAID use,
tobacco and
alcohol use.
Nonradiating
epigastric pain that
starts 1–3 hours after
eating and is relieved
by food or antacids.
Pain frequently
awakens patient at
night.
Epigastric
tenderness without
rebound or
guarding.
Perforation or
bleeding leads to
more severe
clinical findings
Occur in all age
groups. Peak at age
50. Men affected twice
as much as women.
Severe bleeding or
perforation in less
than 1% of patients.
Pathophysiology of Peptic Ulcer
Disease
Is this the whole story of abdominal
pain in this patient?
Describe this patient’s peptic ulcer
disease “illness”
Make a Problem List for This Patient
Make a Problem List for This Patient

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Peptic ulcer disease
Stress
Depression
Insomnia
Back pain
Smoking
Alcohol problem
Other Aspects of Encounters With
This Patient

Depression
Diagnosis
 Therapy

Office-based counseling
 Medications
 Refferal

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
Stress
Negotiation
Other Aspects of Encounters With
This Patient
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Rapport and trust
Empathy
Dealing with emotions
Health behavior change
Smoking cessation
 Alcohol

Determine degree of problem: CAGE
 Alcohol counseling

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Prevention and health promotion
End of Case Discussion
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
Questions?
Comments?
Evolution of a Physician:
How Do We Get There?
First-Year
Medical Student
Practicing
Physician
Where You Are Now





Knowledge
Skills
Attitudes
Experiences
Personal development
Where do you want to be?
Evolution of a Physician:
How Do We Get There?
Professional Development
•Knowledge
•Skills
•Attitudes
First-Year
Medical Student
Practicing
Physician
Who are physicians accountable to?
Who are physicians accountable to?


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
Patients
Other healthcare professionals
Communities
Accreditation boards and medical societies
Healthcare system
Society in general
Themselves and their families
What do these stakeholders expect
of physicians?

That we are competent
Defining Professional Competence

The habitual and judicious use of
communication, knowledge, technical skills,
evidence-based decision-making, emotions,
values and reflection to improve the health of
the individual patient and the community.
Epstien
What Patients Want

Most patients take our technical expertise for
granted.

What they evaluate, however, is the art of the
care, the human side of how the care is
delivered, and the compassion and concern
for their welfare exhibited by physicians.
John J. Gartland, MD
“Mastery of the broad spectrum of knowledge,
skills, and attitudes necessary to accurately and
compassionately perform our role defines what
it means to be a physician and not just a
technician.”
Trainer and Kirug
ACGME Competencies






Patient care
Medical Knowledge
Interpersonal and communication skills
Professionalism
Systems-based practice
Practice-based learning and improvement
Where You Want to Be
Component in:

Patient care

Medical Knowledge

Interpersonal and communication skills

Professionalism

Systems-based practice

Practice-based learning and improvement
The Evolution of a Physician is Never
Complete
?
“The hardest conviction to get into the mind
of a beginner is that the education upon
which he is engaged is not a college course,
not a medical course, but a life course, for
which the work of a few years under teachers
is but a preparation.”
Sir William Osler
Questions

What is the most powerful diagnostic and
therapeutic tool in medicine?
Healthcare Professionals
Healthcare Professionals

Teams are more effective than individuals

Must exhibit professionalism
Questions

What is the most crucial knowledge one needs
in medicine?
Self-Knowledge

Self-assessment
What you know and what you don’t know
 What you know about the way you make decisions:
moral reasoning
 Biases



Life-long learning and improvement
Reflection
Questions

What is the most important skill one needs in
medicine?
Communication


Communicating with patients and their families
Communicating about the patient
Oral and written communication
 Team communication


Communicating about medicine and science

Teaching
Questions

What is the one most important attitude one
needs in medicine?
Caring
“One of the essential qualities of the clinician
is interest in humanity, for the secret in the
care of the patient is caring for the
patient.”
Francis W. Peabody, MD. JAMA, March 19, 1927