Introduction to Medical

Interviewing Skills
Semester 1
2018
Dr. Selfridge
Chair, Department of Clinical Medicine
Dr. Helgoe
Associate Professor, Behavioral Science
Department
Introduction to Interviewing Skills

“History taking, the most clinically sophisticated

procedure of medicine, is an extraordinary
investigative technique: in few other forms of
scientific research does the observed object talk.”
Alvan Feinstein, Clinical Judgment
1925-2001
 Medical Interviewing Training at
RUSM
• Semester 1 – Introduction to Medical Interviewing
Guided Clinical Skills Activity (IMIGCS)
• Semester 2 – Small Group Learning-Interview Skills
Training (SGL-IST)
• Semester 3, 3X, 04 –Enhance Standardized Patient
Program (ESP), Special Interviews (SIST)
• Semester 4X, 5 – Advanced Interview Skills Training (AIST)
 Medical Interviewing Skills

IMIGCS SGL-IST ESPP AIST

Enhanced Standardized
Introduction to Small Group Patient Program Advanced
Medical Learning-
Interviewing - Interview Skills
SIST Interview Skills
Training
Guided Clinical Training Special Interview Skills
Training
Skills
 Objectives
• Recognize and describe the differences between process and content
in the medical interview and how they influence each other
• Recognize or list specific processes which create a successful interview:
making an appropriate introduction, using empathy and non-verbal
communication, using open-ended questions, actively listening,
summarizing and checking for understanding
• Recognize or describe the structure of the medical history and
demonstrate where to place relevant data: the chief complaint, the
history of present illness, the past medical history, the family history,
the social history, the review of systems, the physical exam and the
assessment of the patient
 WHY?
Medical interviewing skills are an integral part of
becoming an effective physician and are used
daily in the work of a physician.

Excellent interview skills influence the quality and

effectiveness of the care you provide.
Masterful physicians are masterful interviewers.
 Sherlock Holmes was a Detective
“Perhaps I have trained
myself to see what others
overlook. If not, why should
you come to consult me?”

Pay attention to details!

Sir Arthur Conan Doyle was a physician!

Why else do I need to learn this?

Step 2 Clinical Skills grading:

• ICE (Integrated Clinical Encounter):
– Includes assessments of both data gathering and data interpretation
skills
• CIS (Communication and Interpersonal Skills):
– Assessment of the important communication skills of fostering the
relationship, gathering information, providing information, helping
the patient make decisions, and supporting emotions
• SEP (Spoken English Proficiency)
 Process and Content
Process - (“How”)
• Setting stage
• Developing rapport
• Empathy
• Active listening and facilitation
• Open-ended questions
• Closed-ended questions
• Transitions & segues
Content - (“What/Why”)
• ID-Identifying data
• CC-Chief Complaint
• HPI-History of Present Illness
• PMH-Past Medical History
• FMH-Family History
• SH-Social History
• ROS-Review of Systems
• PE-Physical Exam
• A-Assessment; P-Plan
• Closing the encounter
 Setting the Stage
• “Setting the stage” can refer to
both the physical environment
as well as the relationship
• Is the physical setting
comfortable, secure?
• Is the dynamic of the setting
calm? Chaotic?
• First impressions? Why does it
matter to the interview?
 Developing Rapport
• Rapport from the French root
“to bring/carry back”
• Greeting/Introduction
• Conveying trust, interest,
concern, commitment
• The very beginning of a
reciprocal relationship between Robert Young
physician and patient as
Marcus Welby, MD
 Video Demonstration
Beginning the Interview
Discussion
 Empathy
Definition: To be in the
psychological frame of
reference of another and
to understand their
thinking/feeling/behavior

Comprehensive Textbook of Psychiatry-Kaplan and Sadock

 Do these statements convey empathy?
YES: NO:
“I can see how “I know exactly how you
difficult this is for feel”
you”

“That must be so “Don’t cry, things will

tough…” work out”
 Active Listening
• Technique used in communication, with
the following elements:
– Comprehending
– Retaining
– Responding
• Accomplished by facilitating techniques:
– Attending to both verbal and non-verbal cues
– Repeating (their words-watch ‘inflection’)
– Paraphrasing (similar words)
– Reflecting (your words)
– Silence
 Facilitating Techniques
• Reflection of Content / Repeating
Patient: “I’m just so tired”
Doctor: “You’re so tired”

• Reflection of Emotion / Paraphrasing

Patient: “I’m just so tired”
Doctor: “You’re really wiped out”

• Reflection of Meaning
Patient: “I’m just so tired”
Doctor: “You’re trying to burn the candle at both
ends, and it’s catching up with you…”
 Communication and Cues
Verbal and Nonverbal

Albert Mehrabian, PhD, UCLA

This research was focused on limited communication rather than whole conversations;
however, the message is clear
that we tend to underestimate the impact of nonverbal communication!
 Communication and Cues
Verbal communication, ideally:

• Will be understandable
• Will not contain jargon
• Will be non-technical
• Allows for expression
• Is tolerant of emotions and differences
• Avoids interrupting
• Uses open-ended questions appropriately
• Uses closed-ended questions effectively
 Communication and Cues
Nonverbal consists of the following elements:

•Facial expression
•Body language and posture
•Personal space
•Gestures
•Vocal tone and inflection (para-linguistics)
•Dress and appearance
•Eye contact
Richard Chamberlain
•Concept of mirroring as
Doctor Kildare
So, what happens when we use
–Telephone
–Sign language
–Interpreters
?
https://www.youtube.com/watch?v=RjEY99zcslg
Dirie Waris . Desert Flower [DVD]. Germany: Desert Flower Filmproductions; 2009.
 Communication-Interruptions
• Study of Family Practitioners: 75% solicited patient
concerns, 25% did not. If not, the concerns were late-
breaking or missed.
• Average: After 23 seconds, the patient was redirected.
And if so, communication of patient concerns was
rarely completed.
• Waiting how much longer would have allowed for
completion?
• 6 seconds!
Not Interrupting – How Well Do We Do?
Table 1. Relationship Between Interruption and Elapsed Time for 52
Interrupted Opening Statements.

Concerns Expressed Encounters Mean Time to

Before Interruption Interruption (seconds)

0 6 6.83
1 28 16.48
2 8 25.00
3 7 37.50
4 3 37.00
 PLEASE!
At the beginning of every patient interview
– Start with an open-ended question or
statement
– Use “continuers” as needed
– Try not to interrupt for 30 seconds!
– When done effectively, this technique
prevents “late-breaking” concerns
 Open-Ended Questions
• Are less leading and tend to allow for more genuine
information
• Allow the patient to present the problem in his/her
own words
• Usually begin with “Tell me about”, “Why” or “How”
• If interviewer is not adept, can lead to a long or less
productive interview
 Open Ended vs. Leading Question
• Open-ended: “Tell me about
your smoking.”
VS

• Leading: “You don’t smoke do

you?”
The answer is implied and anticipated in the question.
This tends to make the patient feel judged or coerced!
 Closed-Ended Questions
• Are much more interviewer directed
• Are convergent, that is, they lead to more specific
information
• Usually “Yes or no?”, “Who?”, “What?”, “Where?”,
“When?”
• If the “right” question is not asked, patient may feel his
concerns and reason for the visit have not been heard
• Use these judiciously and strategically
Example of a Closed-Ended Question
“How many cigarettes do you smoke?”
Discussion
 Transitions and Segues
• Purpose
o Help control the interview
o Help calibrate the interview
• Transitional statements
o Help prepare the patient for changes in
direction
• “OK, Mrs. Smith, from what I understand…so, now,
what I’d like to do is…”
Demonstration
 Content
• When taking a patient history, stay organized
and on task
• The following slides detail the order you use
to pursue medical history information
 Content: Patient Demographics
Usually taken by medical assistant or receptionist before patient sees physician.
Will include:
o Age
o Gender
o Race
o Marital status
o Next of Kin
o Address
o Phone number
o Insurance information

Patients then often fill out a detailed form with components of the medical history,
such as review of systems (to follow!)
Content: Chief Complaint (CC)
• What is the chief complaint?
– The reason for the patient visit
• Where is it placed in written documentation?
– At the beginning of the documentation, after patient
demographics
• How is it documented?
– Usually reported in the patient’s own words, using
quotation marks
 CC - Remember!
• Don’t interrupt patients before they tell us their main
complaint(s)/concern(s)!
• There is sometimes a difference between when
patients REVEAL the chief complaint to us, and where
we place it in our written documentation!
• It should be written in your documentation using the
patient’s own words
• At some point early in the interview, ask if the patient
has ANY other concerns
 Content: History of Present Illness (HPI)
• What is the HPI?
– The full “story” of the patient’s reason for the visit, usually reported in
an organized narrative format
• What is it comprised of?
– Includes the patient’s answers to relevant and strategic closed-ended
questions that are hypothesis driven
– In written documentation this section also includes the answers to
questions related to appropriate systems (e.g. questions about bowel
habits, appetite, nausea and vomiting in a patient complaining of
abdominal pain)
• Where is it placed in written documentation?
– After the Chief Complaint
 HPI - Remember!
For a write-up
• Include clear predisposing factors from the SH or PMH such as a
long history of smoking, or previous lung surgery, if relevant to
the HPI
• Try to ask questions relevant to the chief complaint based upon
what you think might be causing the patient’s problems
• When patients give the history, it is rarely linear, logical and
chronological, but when we record it, we are putting it in an
order that would communicate to other health care providers
that we are already considering the medical problems that might
be causing the chief complaint!
 Content: HPI
• What kinds of questions to ask about the CC?
– Chronology: onset, duration, periodicity
– Prior episodes
– Nature of symptom: intensity, quality, location,
radiation (when relevant)
– Associated symptoms
– Alleviating or aggravating factors
 Discussion
What are the importance, components,
and proper placement of:
–Past Medical History
–Family Medical History
–Social History
 Content: Past Medical History
• Childhood illnesses
• Medical diagnoses
• Hospitalizations
• Surgeries/traumas/transfusions
• Obstetric/Gynecologic
• Psychiatric
• Allergies
– Medication allergies
– Environmental allergies (e.g. “hay fever”)
• Medications (OTC and CAM)
• Immunizations
 Content: Family History
• Consider placing data in a genogram
• Ask about (and document) 3-4 generations: both
parents, siblings, children/grandparents
• If parents deceased, ask about age and cause of death
• Ask about:
– Genetically transmitted diseases, hypertension, coronary
artery disease, elevated cholesterol, stroke, diabetes,
thyroid disease, renal disease, arthritis, Tb, asthma, lung
disease, headache, seizures, mental illness, suicide,
substance abuse, and cancers (breast, ovarian, colon &
prostate)
 Content: Social History
• Marital or partner status, home situation
• Sexual history (5 P’s)
• Employment, education, important life experiences (military
service)
• Alcohol use - estimate of amount used (CAGE questions)
• Tobacco use – amount used
• Illegal/Illicit (recreational) drugs, including use of prescription
drugs for recreational use
• Baseline level of functioning (elderly, disabled)
• Lifestyle habits (diet, exercise, stress management)
 Content: Review of Systems (ROS)
• A systematic inquiry to discover symptoms not covered by other
parts of the history (you must ask relevant system questions in the
HPI and record them in the HPI, though!)
• At some point, every student of medicine has to simply memorize
these symptoms/questions
• There is a list of symptoms/questions for you to practice with posted
in the CS folder in eCollege “The Review of Systems”
• The list will “follow you” through your semesters in Dominica. We
will expect you to work on memorizing this list through 1st and 2nd
semesters!
• You’ll have a check list to use for your first interviewing skills sessions
this semester
 Review of Systems - Important
• When you discover the CC try to ask those ROS, PMH, FH
and SH questions relevant to the CC in the HPI and place
these relevant answers in your written history EVEN IF YOU
COLLECTED THE DATA DURING OTHER PARTS OF THE
HISTORY
• For example, patient with cough, ask:
– Fever, weight loss, night sweats, wheezing, chest pain, sputum
production and character, travel history, allergies, exposure to
TB, work exposures, last PPD, smoking history
 Demonstration-The Review of
Systems
• Content

• Process
 Content: Physical Examination
• Vital signs (often collected and recorded by nursing staff):
– Blood pressure
– Pulse or heart rate
– Respiratory rate
– Temperature
• General survey/inspection
• Head and neck
• Heart and CVS and peripheral vascular
• Lungs
• Abdomen
• Musculoskeletal, skin and neurological examinations
• Pelvic, breast, male genital and rectal exams
 Content: Assessment
• A summary of your impressions as the interviewing and
examining physician
• May include your differential diagnoses (the various
diseases/disorders that might be the cause of the chief
complaint)
• May also include a problem list:
– Risk factors for disease
– Mood or stress issues
– Any chronic diseases still being dealt with
– Supplement, vitamin or alternative medicine use
– ETC
 Content: Plan
A list, summary or discussion of your plans to
evaluate/investigate precisely what is causing your
patient’s problem. May include additional exams, labs
tests, imaging studies.

May also include plans for evaluation or management

of other problems noted in your assessment.
 Process: Closing the Patient Encounter
• Give working diagnosis and explain your reasoning in lay terms
• Explain how the tests will done and what you expect to find
• Assure follow-up with patient as soon as results are available
• Address possibility of any concerns mentioned by patient
• Discuss preventive health care, such as further evaluation for
coronary risk factors in this patient, mammography, seasonal
influenza vaccine
• Summarize visit and check for understanding
• Inquire if there are any other questions or concerns
• Close out with empathy/concern/reassurance
Demonstration of Interview Closure
 Beware of Assumptions
• Study of hospital discharge planning after M.I./
Pneumonia
• Physicians felt 89% of patients understood medication
side effects risks upon discharge
• But only 57% of patients actually did
• Physicians felt 95% of patients understood directions
about resuming normal activities
• But only 58% of patients did
 Resources
• Handout
• Practice Questions
• Both on eCollege in Introduction to Medical
Interview Skills under FM course
• Resources for the IMIGCS activity on eCollege
in the CS course