interviewing techniques as tools for diagnosis and treatment, part 3 the helpful interview
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Interviewing Techniques as Tools for Diagnosis and Treatment, part 3 The Helpful Interview. The Practice of Medicine -1 Christine M. Peterson, M.D. Techniques as Tools. - PowerPoint PPT PresentationTRANSCRIPT
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Interviewing Techniques as Tools for Interviewing Techniques as Tools for Diagnosis and Treatment, Diagnosis and Treatment,
part 3part 3The Helpful InterviewThe Helpful Interview
The Practice of Medicine -1Christine M. Peterson, M.D.
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Techniques as Tools Week 2: Introduction to observing, using non-
verbal and verbal active listening skills, and giving feedback. [SG - Mentor Hospital Interviews]
Week 3: Practice observing, using active listening skills, and giving and receiving feedback.[SG - SP or Hospital Interviews]
Week 4: Become more “patient-centered” in the interview. [SG – Hospital or SP Interviews]
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Functions of the Medical Interview
Gather data and understand it Develop rapport and respond to emotions Educate and motivate
Begin both diagnostic and healing processes
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Techniques Are Not Results The true endpoint of your use of techniques
is the patient’s performance in the interview. Complete (facts, concerns & requests, context) Truthful (facts and emotions)
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The Patient-Centered Interview Focuses on the patient’s needs Activates the patient to play a larger role Is characterized by “active listening” Has a positive impact on patient outcome
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Review of techniquesReview of techniques Behavior that BEFITS a physician FOCUS on active listening PREP to obtain patient-centered information REALLY PREPARE to show empathy
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Issues from 3 x 5 cardsIssues from 3 x 5 cards *Motivating behavior change *Cultural (and other) differences *Sensitive topics *Challenging interviews / relationships *Talking with children & parents
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Issues from 3 x 5 cardsIssues from 3 x 5 cards Organizing the interview (order of inquiry, keeping
on track) Time management / efficiency Interpreting verbal and non-verbal communication
metacommunication
Dealing with emotions Note-taking / documentation Closing the interview Being a beginner
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Four “pearls”
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Active listening “Not really” actually means
“I’m not going to tell you until I really know you’ll try to understand what I’m saying.”
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Levinson w et al. JAMA 1997;277(7):553-9
Communication Behaviors of “No Claim” Primary Care Physicians
Longer visits More orienting statements More humor, more laughter More facilitating comments
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Mc Whinney’s Taxonomy of Medical Help-Seeking Behavior Limits of tolerance for symptom Limits of tolerance for anxiety about
symptom Problems of living presenting as
symptoms Preventive/routine care Administrative reasons
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History of Present Illness: “O-P-Q-R-S-T” questions
Onset and circumstances of Occurrence Provocative and Palliative factors Quality and/or Quantity of symptom Region of body and Radiation to other
areas Severity of symptom (0 to 10 scale, if
applicable) and associated Symptoms Time (duration) and Temporal associations
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Video # 8 [doc.com]“Gather Information” Characterize the symptoms
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Conclusive information Conclusive information for determining the diagnosisfor determining the diagnosis
Provided by: Per centHistory 73%
Physical examination 62%
Imaging studies 35%
Standard lab tests 22%
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Diagnostic information sourcesDiagnostic information sources
Conclusive ErroneousHistory 73% 1-2%Physical examination 62% 1-2%Imaging studies 35% 7%Standard lab tests 22%
“Inaccurate, incomplete, or misinterpreted patient histories are among the leading causes for diagnostic errors.”
Feddock C. Am J Med 2007;120(4):374-8.
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A woman presents to her doctor and requests a mammogram to find out whether she has breast cancer.
Is that a good idea?
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Why aren’t mammograms recommended for all women? Expense Reliability
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How reliable is a mammogram?How reliable is a mammogram? If she has breast cancer, the probability that
the mammogram will be abnormal is 80%. “Sensitivity” = 80%
[i.e., 80% of women with breast cancer have an abnormal mammogram, and 20% of women with breast cancer have a normal mammogram (“false negative” result) due to biology and/or interpretation.]
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How reliable is a mammogram?How reliable is a mammogram? If she does not have breast cancer,
the probability that the mammogram will be normal is 90%.
“Specificity” = 90%[i.e., 90% of normal women have a
normal mammogram and 10% of healthy women have anabnormal mammogram (“false positive” result) due to biology and/or interpretation.]
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Breast cancer risk varies by ageBreast cancer risk varies by age
Risk of breast cancer in women at current age is: age 20: 1 in 1,837 (0.054%) age 30: 1 in 234 (0.42%) age 40: 1 in 70 (1.4%) age 50: 1 in 40 (2.5%) age 60: 1 in 28 (3.6%) age 70: 1 in 26 (3.8%)
Current entire ♀ population (20 to 80): 1 in 100 (1%)
Source: American Cancer Society Breast Cancer Facts and Figures 2007-2008
Over a lifetime: 1 in 8 (12.5%)
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Prevalence of breast cancerPrevalence of breast cancer In the population as a whole
what per cent of women 20 and older have breast cancer today?
1 %
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Random mammogramRandom mammogramBreast cancer
Yes No Total Abnormal
Mammogram result
Normal
Total 10 990 1000
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Random mammogramRandom mammogramBreast cancer
Yes No Total Abnormal
Mammogram result
Normal
?
Total 10 990 1000
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Random mammogramRandom mammogramBreast cancer
Yes No Total Abnormal
Mammogram result
Normal
10 x 80%
8
Total 10 990 1000
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Random mammogramRandom mammogramBreast cancer
Yes No Total Abnormal
Mammogram result
Normal
10 x 80%
8
2
Total 10 990 1000
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Random mammogramRandom mammogramBreast cancer
Yes No Total Abnormal
Mammogram result
Normal
10 x 80%
8
2 ?
Total 10 990 1000
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Random mammogramRandom mammogramBreast cancer
Yes No Total Abnormal
Mammogram result
Normal
10 x 80%
8
2990 x 90%
891
Total 10 990 1000
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Random mammogramRandom mammogramBreast cancer
Yes No Total Abnormal
Mammogram result
Normal
10 x 80%
899
2990 x 90%
891
Total 10 990 1000
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Random mammogramRandom mammogramBreast cancer
Yes No Total
Abnormal
Mammogram result
Normal
10 x 80%
899 107
2990 x 90%
891893
Total 10 990 1000
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Random mammogramRandom mammogramBreast cancer
Yes No Total
Abnormal
Mammogram result
Normal
10 x 80%8
True pos99
False pos107
2False neg
990 x 90%891
True neg893
Total 10 990 1000
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Random mammogramRandom mammogramBreast cancer
Yes No Total
Abnormal
Mammogram result
Normal
10 x 80%8
True pos99
False pos107
2False neg
990 x 90%891
True neg893
Total 10 990 1000
Positive predictive value of random mammogram = 8 / 107 = 7.5%
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Interpreting mammogram resultsInterpreting mammogram resultsCancer; 80% pos mammo
Healthy; positive mammo
Healthy; negative mammo
Mammogram sensitivity = 80%; specificity = 90.Breast cancer overall prevalence = 1% (varies with risk!)
Each box = 10 women.
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For which women are mammograms recommended? Risk factors:
Previous breast cancer Genetic mutations (BrCA-1, BrCA-2) Breast mass Age Etc.
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Breast cancer risk varies by ageBreast cancer risk varies by age
Risk of breast cancer in women at current age is: age 20: 1 in 1,837 (0.054%) age 30: 1 in 234 (0.42%) age 40: 1 in 70 (1.4%) age 50: 1 in 40 (2.5%) age 60: 1 in 28 (3.6%) age 70: 1 in 26 (3.8%)
Source: American Cancer Society Breast Cancer Facts and Figures 2007-2008
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Mammogram at age 50Mammogram at age 50(prevalence = 2.5%)(prevalence = 2.5%)
Breast cancer
Yes No Total
Abnormal
Mammogram result
Normal
25 x 80%20
True pos97.5
False pos117.5
5False neg
975 x 90%877.5
True neg882.5
Total 25 975 1000
Positive predictive value of mammogram at age 50 = 20 / 117.5 = 17%
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Mammogram at age 50 Mammogram at age 50 with masswith mass(prevalence ~ 50%)(prevalence ~ 50%)
Breast cancer
Yes No Total
Abnormal
Mammogram result
Normal
500 x 80%400
True pos50
False pos450
100False neg
500 x 90%450
True neg550
Total 500 500 1000
Positive predictive value of mammogram at age 50 with mass = 400 / 450 = 89%
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A thorough history and physical exam = more accurate assessment of “prior probability” that the patient has a particular disease.
This helps guide appropriate choice and interpretation of lab and imaging tests.
And leads to better diagnosis and more effective treatment.
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An accurate history and physical exam are essential for arriving at the correct diagnosis.
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Video # 8 Mr. Dade
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Patient-Centered Interview Allows patients to express their concerns Seeks patients’ specific requests Elicits patients’ explanations of their illnesses Facilitates patients’ expression of feeling Gives patients information Involves patients in developing a plan for
evaluation and treatment IMPROVES OUTCOME AND SATISFACTION.
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A good physician can talk to anyone…
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But a great physician can listen to anyone.
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Doc.com #13: Responding to Strong Emotions