Patient-Centered Narrative Interviewing
Impact on Perceptions of Primary Care Clinicians
Michael Terry 2
Section I: Clinical Problem
Problems with a Provider-Centered Approach To Err is Human and Crossing the Quality Chasm
Problems with a Patient-Centered Approach Identifying the Essential Elements of Patient-
Centered Interviewing Making the Personal Transformation
Michael Terry 3
Section II: Clinical Solution
Components of Evidence-Based Patient-Centered Interviewing
Patient-Centered Interviewing in a Narrative Mode
Michael Terry 4
Components of Evidence-Based Patient-Centered Interviewing Skills Used Simultaneously
Rapport building and the relationship maintenance Mindful practice Topic tracking Acknowledging social or emotional clues with
empathy
Skills Used Sequentially Up-front, collaborative agenda setting Exploring the patient’s perspective Co-creating a plan
Michael Terry 5
Patient-Centered Interviewing in a Narrative Mode History and basic concepts
Application in Patient-Centered Interviewing Skills Rapport building and the relationship maintenance Mindful practice Topic tracking Acknowledging social or emotional clues with empathy Up-front, collaborative agenda setting Exploring the patient’s perspective Co-creating a plan
Michael Terry 6
Section III: Project Implementation Purpose
Conduct a project using consultants to interview patients and provide information to their medical providers, and evaluate its impact and suitability as a small test of change in order to improve and expand this approach to improving patient-centered care in primary care settings.
Rationale and Assumptions PCPs likely employ medical model; provider-
centered approach PCPs unlikely to seek training but may be open to
others performing services
Michael Terry 7
Section III: Project ImplementationOverall Design and Objectives Provide a process for the PCP to identify frustrating
and/difficult patients. Collect quality and adequate biopsychosocial data using
the patient-centered narrative interviewing process. Organize and effectively present this case to the PCP. Assess changes in the clinical decision-making, level of
frustration, and other general perceptions of the PCP. Evaluate information for the purposes of modifying the
approach in order to improve its value and acceptability. Determine how, when, and where to re-implement and/or
expand the implementation of this project the future.
Michael Terry 8
Section III: Project Implementation Outcomes Evaluated
PCP perceptions of patient’s condition, diagnosis and treatment plans
Value of information provided to PCP PCP frustration Differences between clinician and interviewer
assessments of patient problems
Setting Contracted w/ UCSF; preceptors established Student roles and expectations established
Michael Terry 9
Section III: Project Implementation Training Approach and Method
12-week period from January through April, Approx. 10 hours of classroom instruction and 30
hours of reading, practice, and other assignments. Methods of instruction included
assigned articles, viewing videos, participating in discussions, developing individual and group create presentations, performing and rating each other’s practice. Final check-out
https://moodle.ucsf.edu/course/view.php?id=821
Michael Terry 10
Section III: Project Implementation
Intervention and Data Collection PCPs invited Patients selected; Clinician Problem Assessment form
completed Interviews performed; and Interviewer Problem
Assessment form completed Cases presented Information discussed Surveys completed, Forms collected and submitted
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Section IV: Project Evaluation Results
Participant Characteristics (n=16) Profession
MD 6% PA 12% NP 81%
FNP 31%
ANP 44%
PNP 6%
Medical + Psychiatric Scope- 31%
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Section IV: Project Evaluation Results
Sites (n=16) 44% Primary Care only
VA, CHC, Pvt practice, HMO, elder care
31% Psych is primary PES, Psych hospitals
25% PC + Psych Correctional center, mobile van, community care,
residential care
Michael Terry 13
Section IV: Project Evaluation Results
Diagnostic range:psychiatric conditions - substance abuse,
bipolar disorder, anxiety, depression and suicide attempt, schizoaffective disorder, psychotic disorder, somatization disorder, schizophrenia, dementia,
medical conditions - chronic back pain, stomach pain, celiac disease, cellulitis, hypertension, dyslipidemia, emphysema, arthritis, gastroesophageal reflux disease, medication side effects, asthma
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Value of Interview Information to the PCP
0
Somewhat10
Very
11
Info Value to PCP
Not at all 0
Somewhat 10
Very 11
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Section IV: Project Evaluation Results
Positive Value of information provided to PCP 100% (48%+ 52%++) Characteristics attributed to information:
50% encouraging 31% hopeful 12% enthusiastic 6% ambivalent 3% indifferent
Readiness to make change: Confidence: 83% very, 17% somewhat Act within: 50% now, 33% <6 mo., 27% 30 days
Michael Terry 16
Section IV: Project Evaluation Results
Positive Value of information provided to PCP Specifically helpful in these ways: “Helps me with overall understanding and treatment planning,” “To put a plan together that will anticipate the patient’s needs prior to
presenting with a health decline,” “Helpful in giving additional information and another perspective,” “Helped me think about the case from a broader perspective,” “Reinforced diagnostic impression,” “Mental health is as important as the medical issues presented,” “It gives me good insight into the patient’s behavior,” “This information made her more approachable and more
straightforward to deal with,” “Provided me with alternative insight and viewpoints on approach
and technique with his patient,” “Found impressions very helpful to my end decision,” “Knowing history of drug use will guide me in deciding interventions
for enhancing client motivation and self esteem.”
Michael Terry 17
PCP Understanding of Patient Condition/Situation Changed
Unchanged4
Somewhat12
Definitely5
Changed Understanding
Unchanged 4
Somewhat 12
Definitely 5
Michael Terry 18
Information Changed Diagnostic Impression:
11
8
2
0
2
4
6
8
10
12
Changed Dx
Not at all 11
Somewhat 8
Definitely 2
Michael Terry 19
Information Changed Treatment Options:
Not at all3
Somewhat13
Definitely5
Changed Tx
Not at all 3
Somewhat 13
Definitely 5
Michael Terry 20
Information Changed Treatment Options:
11
89
6
4
0
6
Changed Tx Type
Approach 11
Sequence 8
Referral 9
Rx 6
Eval 4
Test 0
Other 6
Michael Terry 21
Section IV: Project Evaluation Results
Outcomes PCP perceptions of patient’s condition,
diagnosis and treatment plans Condition/Situation: 81% (57% + 24% ++) Dx: 48% (38% + 9%++) vs. 52% - Tx: 86% (62% + 24% ++) vs. 14% - Areas:
29% general approach 21% sequence/timing 24% referrals 16% Rx 11% further eval/testing
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Change in PCP Frustration
Unchanged10
More1
Less10
0
1
2
3
4
5
6
7
8
9
10
Change in PCP Frustration
Unchanged More Less
Unchanged 10
More 1
Less 10
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Section IV: Project Evaluation Results
PCP frustration Less: 48% Unchanged 48% More 4% Reasons: Lack of responsibility for actions, manipulative behaviors, medication seeking behaviors, attention seeking behaviors, “needy patient,” chronic pain problems, refusal of care, refusal of referrals patient lack of insight, evasiveness, lack of motivation, Multiple comorbid conditions, high level of complexity, complex patient but
limited time, non-adherence, noncompliant, “says one thing and does another,” inconsistency of information provided, demanding, controlling, frequency of service use, “irritable and difficult to communicate with,” patient distrust of system, evasiveness, “hyperactive and hyper verbal patient,”, “poor temper,” somatization
Michael Terry 24
Section IV: Project Evaluation Results
Differences between clinician and interviewer assessments of patient problems
PCP: medical dx + biopsyhosocial problems Primary care dx + psychiatric dx
Interviewer: Co-morbidity & co-occurring disorders Situational elaboration Patient’s perspective on problem
Michael Terry 25
Section IV: Project Evaluation Analysis
Participants and Sites Over 80% NPs Over-representation of psychiatric diagnoses and settings Substantial mental health expertise in PCPs
Outcomes PCP perceptions of patient’s condition, diagnosis and
treatment plans Treatment > Diagnosis change is expected Scale and Direction of treatment changes unanticipated
Value of information provided to PCP Highly appreciated and committed to action
PCP frustration Similar to expectations based on literature
Differences between clinician and interviewer assessments of patient problems
Overlap of biomedical & biopsychosocial approach Condition elaboration; fostered acceptability
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Section IV: Discussion – lessons learned
Would clinicians involved in this project want to do it again? Would they take advantage of other opportunities to use
consultants in similar ways? As a result of this experience, are any of them interested in
pursuing this kind of training themselves? Should be provided routinely? What patients do they feel would
benefit from this approach? When might this approach be considered to be essential? Did a nursing background of the interviewer affect the results? Did the nursing background of the PCP have an effect? If this project were repeated in strictly outpatient primary care
medical clinics, would we see the same results? Did interviewers actually perform patient-centered narrative
interviewing as trained?
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Section V: Next Steps
CQI and EBP – ideal applicationProblem with Patient Preferences & Shared
Medical Decision-MakingSimilar problems as biomedical +
biopsychosocial intersection
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Section V: Next Steps
This project’s iterative development history Directions forward:
Repeat with lessons-learnedExpand to PCP training approachEvolve to Primary Behavioral Health
Consultation Services
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Section VI: Implications for Advanced Practice Nursing
Concurrence with Nursing Theory
Concurrence with DNP Competencies
Michael Terry 30
Concurrence with Nursing Theory
Newman’s Health as Expanding Consciousness (HEC)Meaning & Emergent PatternsDialectic & Transforming PresenceShared Narrative
Michael Terry 31
Concurrence with Nursing Theory
Ways of KnowingPatterns
Empiric (Positivist), logico-scientific, biomedical approach
Aesthetic, narrative, biopsychosocial approach
Relationship Independent Dependent Interdependent
Michael Terry 32
Concurrence with DNP Competencies Independent Practice Scientific Foundation Leadership Quality Practice Inquiry Technology & Information Literacy Policy Health Delivery System Ethics