The Medical Interview: The Three Function Approach

Front cover
Inside front cover
The Medical Interview
Copyright page
Dedication
Contributors
Foreword
Preface
What’s New?
Who is the Audience?
A Note on Language
Why Use the Three Function Approach?
References
Acknowledgments
References
Instructions for online access
Table of Contents
Unit 1 Three Functions Of The Medical Interview
1 Learning to Interview Using the Three Function Approach: Introduction and Overview
Summary
References
2 Three Functions: The Basic Model
Function One: Build the Relationship
Function Two: Assess and Understand the Patient’s Problems
Function Three: Collaborate for Management
Summary
References
3 Function One: Build
the Relationship
Nonverbal Skills
Empathy
Reflection
Legitimation
Empathic Communication to Deepen Understanding (ECDU)
Personal Support
Partnership
Respect (Affirmation)
P(E)ARLS
Summary
References
4 Function Two: Assess
and Understand
Nonverbal Listening Behavior
Questioning Style: Open-Ended Questions and the Open-to-Closed Cone
RULE #2: LET THE PATIENT COMPLETE THE OPENING STATEMENT
Facilitation
Clarification and Direction
Checking/Summarizing
RULE #3: WHEN IN DOUBT, CHECK
Survey Problems: “What Else?”
Avoid Leading (Biased) Questions
Elicit the Patient’s Perspective: Ideas, Concerns, and Expectations (“ICE”)
Explore the Patient’s Ideas about the Meaning of the Illness
Elicit the Patient’s Concerns about the Problems
Elicit the Patient’s Expectations
Explore the Impact of the Illness on the Patient’s Quality of Life
Conclusion
Summary
References
Endnotes
5 Function Three: Collaborate
for Management
Education About Illness: Use (e)TACCT
Using (e)TACCT: Elicit Baseline Understanding
Using (e)TACCT: Tell the Core Message
Using (e)TACCT: Ask About the Patient’s Knowledge of the Illness
Using (E)TACCT: Care About Patients’ Emotional Responses and Concerns
Using (e)TACCT: Counsel About the Details
Using (e)TACCT: Tell-Back to Check That the Patient Understands
Brief Action Planning
1. Question One: Elicit Ideas for Change.*
“Yes” Response
“Not Sure” Response
“Not Now” Response
2. SMART Behavioral Planning
3. Elicit the Commitment Statement
4. Question Two: Scale for Confidence
5. Question Three: Arrange Accountability
Behavioral Menus and Problem Solving
6. the Behavioral Menu
7. Problem Solving
8. Follow-Up
The Eight Core Skills of Brief Action Planning
Four Essential Attributes of a Brief Action Plan
Spirit of Motivational Interviewing
What About the Patient with Persistent Unhealthy Behavior Who Says “No” to Question One?
Conclusion
Summary
References
Endnotes
Unit 2 Meeting the Patient
6 Ten Common Concerns
1. Why Should the Patient Want to Talk to or be Examined by a Student?
2. is a Student Interview or Examination a Humiliation or Indignity for the Patient?
3. How Should I Dress? Should I Wear a White Coat Even Though I Am Not a Doctor? Doesn’t This Introduce an Artificial Separation and Inequality Into the Relationship? if I Wear a White Coat, Isn’t That Deceiving the Patient?
4. Should I Introduce Myself as “Doctor”? if I Do, Am I Not Deceiving the Patient?
5. If the Patient is in Pain or Emotional Distress, Should I Continue with the Interview?
6. Should I Shake the Patient’s Hand? Under What Circumstances is It Acceptable to Touch the Patient?
7. If the Patient Asks Me Questions, Should I Answer Them if I Know the Answers? What Should I Do if I Do Not Know the Answers?
8. What Do I Do if the Patient Starts Crying or if the Patient Gets Angry with Me?
9. What Should I Do if the Patient Promises to Tell Me Some Important Secrets if I Agree to Maintain His or Her Confidence?
10. What Should I Do if the Patient Tells Me Something His or Her Doctor Does Not Know? for Example, What if the Patient Tells Me That He or She is Depressed or Suicidal?
Summary
Unit 3 Structure of the Interview
7 Opening the Interview
Establishing Goals of the Interview
Obtaining Patient Consent to Your Interview Plan
Establishing Initial Rapport
Establishing Patient Comfort
Steps for an Effective Opening
Summary
References
8 Chief Complaint, Problem Survey, Patient’s Perspective, and Agenda Setting
1. Eliciting the Chief Complaint
Responding to Emotions
Initial Facilitation
Checking
2. The Problem Survey
Probing to Completeness
3. Elicit Patient’s Perspective: Ideas, Concerns, and Expectations (“ICE”)
Explore Patient Ideas About the Meaning of the Illness
Explore Patient Concerns About the Illness
Explore Patient Expectations
4. Agenda Setting
Summary
References
9 History of Present Illness
Narrative Thread and Open-to-Closed Questioning
Problem Exploration: WW, QQ, AA, LC, I
Where (Location)
When (Timing)
Quality
Quantity (Severity)
Aggravating and Alleviating Factors (Modifying Factors)
Associated Signs and Symptoms
Life Context
Impact on Patient’s Quality of Life
Respond to Emotions Throughout
Complete the Narrative Thread
Complete This Process for Every Problem
Summary
References
Endnotes
10 Past Medical History
Hospitalizations
Surgeries
Illnesses
Injuries
Medications
Allergies
Pregnancies
Exposures
Health Maintenance Practices
Summary
Reference
11 Family History
Summary
Reference
12 Patient Profile and Social History
Patient Profile
High-Risk Health Behaviors
High-Risk Life Situations (High Stress and Low Support)
Summary
References
13 Review of Systems
Summary
References
14 Mental Status
Why Every Medical Workup Should Include a Mental Status Evaluation
Brief Mental Status Examination
1. General Appearance/Behavior
2. Speech/Language
3. Mood/Affect
4. Thought/Perception
5. Cognition/Sensorium
6. Insight/Judgment
Conclusion
Summary
References
Unit 4 Presentation and Documentation
15 Presentation and Documentation
Chief Complaint
History
Medications
Past Medical History
Family History
Social History
Review of Systems
Examination
Data
Assessment
Plan
Some Pearls for the Presentation
Guideline for the New Patient Presentation
Guideline for the Follow-Up Presentation
Summary and Conclusion
Reference
Unit 5 Understanding Patients' Emotional Responses to Chronic Illness
16 Understanding Chronic Illness: Normal Reactions
Common Stresses of Illness
1. Threat to Efficacy
2. Threat of Separation
3. Threat of Loss of Love
4. Threat of Loss of Body Function
5. Threat of Loss of Body Parts
6. Threat of Loss of Rationality
7. Threat of Pain
Adaptive Tasks of Illness
1. Coping with Symptoms, Pain, and Disability
2. Coping with Treatment
3. Adapting to a Variety of Health Care Providers
4. Managing Emotions
5. Relating to Family Members and Friends
6. Preserving a Positive Self-Image
7. Coping with the Unknown
“Normal” Emotional Reactions to Illness and Mechanisms of Defense
Regression
Denial, Suppression, and Repression
Anxiety
Anger
Sadness
Summary
References
17 Understanding Chronic Illness: Maladaptive Reactions
Persistent Anger
Adjustment Disorder with Depressed Mood and Major Depression
Adjustment Disorder with Anxious Mood/Anxiety Disorders
Interviewing Strategies for Patients with Maladaptive Emotional Responses
Persistently Angry Patients
Patients Who Have an Adjustment Disorder with Depressed Mood or Major Depression
Patients Who Have an Adjustment Disorder with Anxious Mood or an Anxiety Disorder
Summary
References
Unnit 6 Advanced Applications
18 Stepped-Care Advanced Skills for Action Planning
A: Why Are Advanced Skill Necessary?
B. Overview: The SAAP Model
Step One: Respond to Distress or Discord to Meet Relational Challenges
Step Two: Understand Benefits or Obstacles to Change to Meet Exploratory Challenges
Step Three: Use Higher-Order Motivational Interviewing Skills to Meet Complex Motivational Challenges
C. What Is Change Talk? Why Is It Important?
D. SAAP and Change Talk: How Elicitation, Recognition, and Response to Change Talk Drive the Model
1. Respond to Distress or Discord to Meet Relational Challenges (Advanced Application of Function One Skills)
2. Understand Benefits or Obstacles to Change to Meet Exploratory Challenges (Advanced Application of Function Two Skills)
3. Use of Higher-Order Motivational Interviewing Skills to Meet Complex Motivational Challenges (Advanced Application of Function Three Skills)
E. Skills and Case Study of SAAP Step One: Responding to Discord or Distress
F. Skills and Case Studies of SAAP Step Two: Understanding Benefits or Obstacles to Change
G. Skills and Case Study of SAAP Step Three: Using Higher-Order Motivational Interviewing Skills
Elicit and Resolve Ambivalence
Develop the Discrepancy
Conclusion
Summary
References
Endnotes
19 Communicating with Patients with Chronic Illness
Application of the Three Function Model to Chronic Illness
Function One: Build (and Maintain) the Relationship
Function Two: Assess and Understand the Patient
Function Three: Collaborate for Management
Eliciting a Goal:
Action Planning:
Summary
References
Endnotes
20 Health Literacy and Communicating Complex Information for Decision Making
Why Health Literacy Matters
Health Literacy and the Three Function Model
Function One: Build the Relationship
Conveying Respect
Function Two: Assess and Understand the Patient
Function Three: Collaborate to Manage
Communicating Complex Information for Decision Making
Function One: Build the Relationship
Function Two: Assess and Understand the Patient
Elicit Expectations
Function Three: Collaborate to Manage
Special Considerations Using Written Materials
References
21 Sexual Issues in the Interview
Why Are Sexual Issues Important?
Function One: Build the Relationship
Function Two: Assess and Understand the Problem
Basic Evaluation of Risk
Impact of Chronic Illness on Sexual Quality of Life
Function Three: Collaborate for Management
Managing Your Own Anxiety or Attitudinal Barriers
Managing Specific Problems
Conclusion
22 Interviewing Elderly Patients
Function One: Build the Relationship with the Elderly Patient
Function Two: Assess and Understand the Elderly Patient
Function Three: Collaborate for Management
Conclusion
Addendum
10 Tips from the Literature for Improving Communication with Older Patients
References
23 Culturally Competent Medical Interviewing
The Culture Concept
Importance of Understanding the Patient’s Explanatory Model and Social Context
Strategies for Eliciting Explanatory Models
Continuum of Illness Beliefs
Working with Interpreters in the Medical Encounter
Enhancing the Patient-Interpreter-Physician Interaction
Guidelines for Language Use When Working with Interpreters
Collaborative Management and the Negotiation of Culturally Appropriate Treatment Plans
Conclusion
References
24 Family Interviewing
Situations in Which Family Members Are Often Present
The Three Functions of Family Interviewing
Function One: Build the Relationship
When There Is Conflict in the Family
Function Two: Assess and Understand the Patient and Family
Function Three: Collaborate to Manage
Delivering Information
Using the Family as a Resource in Motivating Patients to Change
Special Circumstances When Interviewing Families
When to Convene the Family
Avoiding Taking Sides or Triangulation
When the Customer is Not the Patient
Dealing with Strong Affect during the Family Interview
Violence in the Family
Mental Health Referral
Family-Oriented Interview with the Individual Patient
Conclusion
References
25 Troubling Personality Styles and Somatization
Compulsive Patients
General Characteristics
Inner Conflicts and Needs
Stresses of Illness and Illness Behavior
Interviewing Strategies
Dependent Patients
General Characteristics
Inner Conflicts and Needs
Stresses of Illness and Illness Behavior
Interviewing Strategies
Histrionic Patients
General Characteristics
Inner Conflicts and Needs
Stresses of Illness and Illness Behavior
Interviewing Strategies
Self-Defeating Patients
General Characteristics
Inner Conflicts and Needs
Stresses of Illness and Illness Behavior
Interviewing Strategies
Borderline Patients
General Characteristics
Inner Conflicts and Needs
Stresses of Illness and Illness Behavior
Interviewing Strategies
Narcissistic Patients
General Characteristics
Inner Conflicts and Needs
Stresses of Illness and Illness Behavior
Interviewing Strategies
Somatization
General Characteristics
Inner Conflicts and Needs
Stresses of Illness and Illness Behavior
Interviewing Strategies
Develop Rapport
Changing the Agenda
Seeing the Patient Regularly
“Don’t Just Do Something, Stand There!”
Conclusion
References
26 Communicating with the Psychotic Patient
Psychotic Patients
General Characteristics
Inner Conflicts and Needs
Stresses of the Illness and Illness Needs
Strategies
Self Management
Cognitive Support
Affect Management
Reality Orientation
Conclusion
References
27 Breaking Bad News
Preparing to Break Bad News
Breaking the News
Tell
Ask
Care
Counsel
Tell-Back
Importance of Physician Self-Awareness
Special Challenges in Breaking Bad News
Breaking Bad News From a Distance
Don’t Break the News
Denial of Bad News
Honest Disclosure and Realistic Hope
Teaching How to Give Bad News
Conclusion
References
Books
Websites
27A Sharing Difficult or Bad News:
The Recipient’s Experience of Receiving Difficult or Bad News
The Biggest Trap into Which Clinicians Fall
An Ineffective Sharing of Difficult News
A More Effective Way to Share Difficult News
Thoughts for Medical Students
Nine Steps to Sharing Difficult or Bad News
References
28 Disclosure of Medical Errors and Apology
Learning Context
Preparing for the Initial Conversation
Examples of denial:
Examples of anger:
Examples of bargaining:
Examples of depression:
Examples of acceptance:
The Conversation
The Aftermath
The Follow-up
Conclusion
References
29 Risky Drinking and Interviewing About Alcohol Use
Definitions
A drink
Normal or healthy or moderate drinking
Risky or hazardous drinking
Alcohol abuse
Alcohol dependence
Function One: Build the Relationship
Introduction
Conversation
Function Two: Assess and Understand the Patient’s Problems
Introduction
Definitions
Intoxication
Tolerance
Blackout
Withdrawal syndrome
Denial
Are You Worried About the Patient’s Drinking?
Prescreen
Screening
Red Flags
Continue the Conversation
Function Three: Collaborative Management
Initial Steps
Readiness for Change Matters
Provocation
Brief Intervention
Education
(e) Elicit Baseline Knowledge
(T)(Tell) Present Information in Focused and Succinct Statements
(A)(Ask) Check Understanding
(C) (Care) Respond To Emotions
(T) (Tell-Back) and Invite Questions
Brief Action Planning
Some Specific Communication Strategies for Patients at Different Levels of Readiness
Some Possible Dialogues with Patients Who Have Low Readiness for Change
Summary
References
Endnote
Unit 7 Higher Order Skills
30 Nonverbal Communication
Basic Behavior
Safety
Fight
Flight
Conservation-Withdrawal
Nonverbal Skills
Developing Nonverbal Rapport
Shaping Space
Addressing Mixed Messages
Application to the Three Function Approach
Function One: Build the Relationship
Function Two: Assess and Understand the Patient’s Problems
Function Three: Collaborate for Management
Conclusion
References
31 Use of the Self in Medical Care
Physician Personal Awareness
Personal Growth
Self-Care
Summary
References
32 Using Psychological Principles in the Medical Interview
The Psychodynamic Model: Basic Concepts
Psychic Conflict
Mechanisms of Defense
Resistance and Management of Resistance
Support
Transference
Countertransference
Cognitive-Behavioral Model: Basic Concepts
Primacy of Cognition
Arbitrary Inference
Operant Conditioning
George: A Case Study Integrating Psychodynamic and Cognitive-Behavioral Interventions
Psychodynamic Understanding and Interventions
Cognitive-Behavioral Understanding and Interventions
Conclusion
Summary
References
33 Integrating Structure and Function: Diagnostic Reasoning, Clinical
Inference, Communication
Flexibility, and Rules
Higher-Order Processes and Skills
Clinical Reasoning
Clinical Inference and Flexibility
Six Rules of Integrative, Higher-Order Functioning
1. Observe Your Patient
2. Observe Yourself
3. When in Doubt, Check
4. When the Patient Demonstrates an Emotion, Respond to It
5. Don’t Answer Every Question Immediately
6. Understand That Patients are Usually Forgiving of Mistakes in the Interview
Conclusion
Summary
References
Appendix 1 The Medical Interview: The Three Function Approach Table of Skills
Appendix 2 The Brief Action Planning Guide
Appendix 3 Learning How to Interview
Readings
Lectures
Demonstration
Practice
Observation and Feedback
Re-Practice
Videotape
Standardized Patients
Role-Play
Modified Live Patient Interviews
Small Groups
Learner-Centered Methods
References
Index
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
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