Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 Week 2: Introduction to observing, using nonverbal 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] 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 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) The Patient-Centered Interview 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 Focuses Review of techniques Behavior that BEFITS a physician FOCUS on active listening PREP to obtain patient-centered information REALLY PREPARE to show empathy Issues from 3 x 5 cards *Motivating behavior change *Cultural (and other) differences *Sensitive topics *Challenging interviews / relationships *Talking with children & parents Issues 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 Four “pearls” 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.” Communication Behaviors of “No Claim” Primary Care Physicians Longer visits More orienting statements More humor, more laughter More facilitating comments Levinson w et al. JAMA 1997;277(7):553-9 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 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 Video # 8 [doc.com] “Gather Information” Characterize the symptoms Conclusive information for determining the diagnosis Provided by: Per cent History 73% Physical examination 62% Imaging studies 35% Standard lab tests 22% Diagnostic information sources History Physical examination Imaging studies Standard lab tests Conclusive 73% 62% 35% 22% Erroneous 1-2% 1-2% 7% “Inaccurate, incomplete, or misinterpreted patient histories are among the leading causes for diagnostic errors.” Feddock C. Am J Med 2007;120(4):374-8. A woman presents to her doctor and requests a mammogram to find out whether she has breast cancer. Is that a good idea? Why aren’t mammograms recommended for all women? Expense Reliability 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.] 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 an abnormal mammogram (“false positive” result) due to biology and/or interpretation.] Breast 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%) Over a lifetime: 1 in 8 (12.5%) Source: American Cancer Society Breast Cancer Facts and Figures 2007-2008 Prevalence of breast cancer In the population as a whole what per cent of women 20 and older have breast cancer today? 1 % Random mammogram Breast cancer Yes No Total 10 990 1000 Abnormal Mammogram result Normal Total Random mammogram Breast cancer Yes Abnormal No Total 990 1000 ? Mammogram result Normal Total 10 Random mammogram Breast cancer Yes No Total 10 x 80% Abnormal Mammogram result 8 Normal Total 10 990 1000 Random mammogram Breast cancer Yes No Total 10 x 80% Abnormal Mammogram result Normal Total 8 2 10 990 1000 Random mammogram Breast cancer Yes No Total 10 x 80% Abnormal Mammogram result Normal Total 8 2 ? 10 990 1000 Random mammogram Breast cancer Yes No Total 10 x 80% Abnormal Mammogram result 8 990 x 90% Normal 2 891 Total 10 990 1000 Random mammogram Breast cancer Yes No Total 10 x 80% Abnormal Mammogram result 99 8 990 x 90% Normal 2 891 Total 10 990 1000 Random mammogram Breast cancer Yes No Total 10 x 80% Abnormal Mammogram result 99 8 107 990 x 90% Normal 2 891 Total 10 990 893 1000 Random mammogram Breast cancer Yes No Total 10 x 80% Abnormal Mammogram result 8 99 True pos False pos 107 990 x 90% Normal Total 2 891 False neg True neg 10 990 893 1000 Random mammogram Breast cancer Yes No Total 10 x 80% Abnormal Mammogram result 8 99 True pos False pos 107 990 x 90% Normal Total 2 891 False neg True neg 10 990 893 1000 Positive predictive value of random mammogram = 8 / 107 = 7.5% Interpreting mammogram results Cancer; 80% pos mammo Healthy; positive mammo Healthy; negative mammo Each box = 10 women. Mammogram sensitivity = 80%; specificity = 90. Breast cancer overall prevalence = 1% (varies with risk!) For which women are mammograms recommended? Risk factors: Previous breast cancer Genetic mutations (BrCA-1, BrCA-2) Breast mass Age Etc. Breast 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 Mammogram at age 50 (prevalence = 2.5%) Breast cancer Yes No Total 25 x 80% Abnormal Mammogram result 20 97.5 True pos False pos 117.5 975 x 90% Normal Total 5 877.5 False neg True neg 25 975 882.5 1000 Positive predictive value of mammogram at age 50 = 20 / 117.5 = 17% Mammogram at age 50 with mass (prevalence ~ 50%) Breast cancer Yes No Total 500 x 80% Abnormal Mammogram result Normal 400 50 True pos False pos 100 False neg 500 x 90% 450 450 550 True neg Total 500 500 1000 Positive predictive value of mammogram at age 50 with mass = 400 / 450 = 89% 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. An accurate history and physical exam are essential for arriving at the correct diagnosis. Video # 8 Mr. Dade 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. A good physician can talk to anyone… But a great physician can listen to anyone. Doc.com #13: Responding to Strong Emotions