Communication step II

Tutorial 1
Chapter 1
Interviewing and health history
interview
 Objectives

• Define interviewing.
• Describe the best setting to carry out an interview
• Identify types of questions.
• State use of each type.
• Describe the essentials of an interview.
• Communication skills needed for the interviewer.
 Definition
• Interviewing is the interchange of verbal and non-verbal
communication between two persons or more in intention of
exchanging information and data relevant to the topics under
consideration.
• Interviewing uses questions and statements to encourage people to
supply information
 The Use of Open-to-Closed Cone
of questions
The effective strategy to get health history is:
• Starting with open question to give rich detailed information at the
start before moving to the closed question to cover specific and
important information
• Do not move to closed questions too early in the interview
(prematurely)
"What symptoms brought you to the
hospital?"
Probing question is a form of
closed question

"Does the pain go anywhere?"

 Questions that should be avoided
• 1) Leading questions:
• Leading questions will lead the person to give only one answer.
• may suggest to the patient the desired answers.
• E.g “are you feeling a little better since starting your antibiotic?”
• How you ask this question in a non- leading way?
• “how are you feeling since you start antibiotics” (it is a probing question)
• 2) Double- barrel questions
• Double-barrel questions are two questions in one
• E.g "Do you eat fish or meat?"
 Questions that should be avoided
• 3) Double- negative questions:
• are questions that use two negatives to indicate a positive statement
• E.g "Do not you think it is not a wise policy to have a doctor in every health center?"
• 4) Embarrassing or sensitive questions:
• E.g"Did you ever have a venereal disease?“
• 5) Jargon-filled questions
• E.g"Has a physician ever done for you an abdominocentesis?“
• 6) Complex questions:
• Not simple E.g "When we collect enough data on the problems of this district and the
available resources in the community, do you think that building a center is more
preferable than organizing outreach activities?”
• 7) Inappropriate question
• E.g "How many cigarettes have you smoked since you have started smoking?" (Impossible
to answer)
 Essentials of an interview
1) Knowledge of the topic:
2) Temperament (‫)مزاج‬
avoids bias, prejudice, and bad temper.
3) Listening and observing:
Active listening to all that is being said, observes non-verbal reactions, and interprets verbal and
non-verbal messages
4) Eye contact:
5) Good interviewer:
➢ should be on time,
➢ have an objective for the interview,
➢ aware of all the prerequisites for effective communication
➢ promote a relaxed atmosphere and make the interview comfortable,
➢ accepting the person's frame of reference, his level of knowledge, past experiences and interest.
➢ He should be direct, honest, respectful, polite, friendly and empathetic showing concern and
behave according to the culture.
 The functions of the medical interview (3 functions)
• 1. Build a relation with the patient and promote it:
• 2. Determine and monitor the nature of the problem:
nature of the problem
• 3. Educate patients on: diagnostic procedures
treatment plan
compliance/adherence
improved outcome

Patient Education
Determine the problem
 1. Build a relation with the patient and promote it:

• a. Non-verbal skills and behaviors: paying attention , facial expression,

• b. Show that you are empathetic.: Empathetic look,
➢Using reflection statement (observed feeling in the patient ): Dr. "You look upset to
day".
➢Using legitimation (validation) ‫تصديق‬:Dr. " I can really understand why you were
upset".
➢Indicate your personal support: Dr.: "If you need to contact me for anything please do
so“
➢Build partnership:Dr.: "We have talked about your problem. We can now work
together to find some solutions".
➢Be respectful to the patient and his problems:
Empathetic statements versus non empathetic
Patient: “I have nothing left to live for, can't you just end this now?
Dr:“I'm so sorry, physician aid in dying is not legal in this country”

Although this answer might be correct, it does not address the

emotional content of the statement.
Patient: “I have nothing left to live for, can't you just end this now?
Dr:I know how hard you have worked to stay as healthy as possible.
this is example of empathy statement,
 The components of health history interview
• 1. Chief complaint or reasons for attending:
• 2. History of present illness: further explore the chief complaint
• 3. Review of systems: head-to- toe- questioning of presence or absence of
symptoms.
• 4. Past history: surgical history, childhood illness, obstetric history
• 5. Medication history: medications prescribed by the physician, over-the
counter drugs and herbal products.
• 6. Health maintenance/ Immunization:screening tests as Pap smear,
mammograms
• 7. Family history: to identify potential risk factors for a patient
• 8. Personal and social history: social background, housing condition, life
style and behaviors ; tobacco , alcohol and substance use.
The health history interview

Opening of the
interview…………..

Conducting the
interview…………..

Closing the
interview……………….
 I- Opening the interview

• 1. Introduce yourself.
• 2. Establishing aims of the interview.
• 3. Obtain patient consent.
• 4. Establish initial rapport.
• 5. Establish patient comfort.
• 6. Remove barriers to communication
1- Introducing your -self to a patient and your role
2. Establishing aims of interview
3. Obtaining patient consent
Statement:
-Good morning. My name is ……… I am in charge of
this center . I need to take a detailed history of your
condition
-Well do you have few minutes to answer a couple of
questions?

- Good morning. My name is ……… I am a medical

student. Please to meet you The Professor asked
me to take a detailed medical history from you
- -Can we talk for a few minutes?
 4. Establish initial rapport
Using reflection and legitimation statement
5. Establishing patient's comfort.

Statements:
• Before we start talking, let me raise the head of
the bed.
• Before I ask you about your illness, I want to be
sure that you are comfortable.
Questions:
• How are you feeling right now?
• Are you fine?
 II-Conducting main body of the interview
How to conduct your interview
1. Elicit the chief concern (complaint).
2. Ask about other complaints or problems.
3. Obtain additional data from nonverbal messages.
4. Elicit the patient’s perspectives.
5. Explore the impact of illness on the patient.
6. Clarify and direct.
7. Check and summarize.
Indicated the time available for the interview
“We have 30 minutes together today"
1. Elicit chief concern. Use open-to close end cone approach
Questions:
• What kind of problems brought you to the clinic today?
• Please tell me more about your (headache, pain, cough)
Facilitative statements:
• "Tell me more about your pain or go on
• You say you do not want another pregnancy: Repeating
patients` words (Echoing)
• Facilitative Questions:
• What else?
• Facilitative Behavior: nodding of the head ,eye contact
Relying too heavily on directed, closed questions.
This style discourages the patient's associations
and spontaneous report of symptoms
• A "closed-ended-question" is one that can be answered with a "yes"
or a "no."
• "Are you having difficulty breathing?" is a closed-ended-question.
• "open-ended-questions."
• "How's your breathing?" or
• "How does your chest feel?“
• Which question is better?
• Open-ended-questions require the patient to actually describe his
complaints.
Use the patient's words, and only the patient's
words, when referring to - or reporting - his
complaints (facilitation)
• If a patient says, "My chest feels really tight!"
• × Dr . "Are you short of breath?" ...patient: "Well, now that you
mention it ... yeah!" vs.
• Suggesting complaints leads patients to complain of something
they're not experiencing.
• ✓"How's your breathing?" ... "My breathing's fine! It's this tightness
that's bothering me!"
2. Ask about other complaints.
Questions:

- Are there any other thing you want to tell me?

- Do you have other complaints?

- What other problems do you have?

 [Link] the patient's perspective: ideas, concerns and
expectations (ICE Model):

• Patient`s perspectives: thoughts ,feelings, ideas concerns , expectations

,support system and previous experiences, this influence the physical effect
of an illness itself
Ideas what the patient believes or think is the cause or effect of the
problem.
Concerns patient’s fears and anxieties surrounding the situation. Concerns
can relate to the seriousness of the issue, Addressing concerns can help with
adherence to treatment plan.
Expectations: the doctor should know what the patient expects and wants
therapeutic options (e.g. prescribing a medication), advice or referral to
satisfy patient . Doctors should elicit what outcomes are the patients looking
for or what are their goals .
 [Link] the patient's perspective: ideas,
concerns and expectations (ICE Model):
• Example of Questions
• A 52-year-old man, employed as a postman, presents to the GP with progressively
worsening knee pain.
• Ideas
• “I’ve been thinking that it might be some kind of arthritis. My mother, during her later
years, had to get a hip replacement due to severe joint pain and she really limited
movement in her hands.”
• Concerns
• “I’ve been worrying about the impact on my work. I spend all day on my feet, and this
knee pain is making it incredibly difficult. I worry that I need time off work or even have
to change job. The pain is almost unbearable after a full day of walking and standing”
• Expectations
• “I’m hoping that you could arrange an X-ray or some other tests? Having a diagnosis
would give me some peace of mind and help me plan for the future.”
5. Explore the impact of illness on the patient's life.
Questions:

• How did this new pregnancy affect your

life at home?

• Did this pregnancy affect your work?

6. Clarify and direct.
Clarifying the information
Questions:

Dr.:"Mrs. Aida you say you have more

headaches now. Can you describe these
headaches to me?"
Patient: "They are usually affecting one side CLARIFICATION: the act of
making a statement or
of my head. They are so severe that I usually situation less confused and
more easily
vomit. I cannot tolerate noise or even light." comprehensible.
6. Clarify and direct.
Clarifying the terminology used by the patient
Questions:

• You say that you have asthma. Can you

tell me what do you mean by Asthma?

• You say you suffer from allergies. Can

you tell me what you mean by
allergies?"
6. Clarify and direct.
Finding the chronology of the problem
Questions:

Dr.: "Can you tell me when these headaches

started?"
Patient: "I have been having them all my
life. They started when I was 14 years old.
But they are worse in the last 6 months."
6. Clarify and direct.
Directing to find the cause of the problem (life context of
illness)
Questions:
• Patient: "Yes. I got married and I am
working in a Bank from 8.0 Am-5.0 Pm.
• Dr.: "Do you think that the burden of
your marriage and work are putting you
under a stress?"
7. Check and summarize.
Periodically and at the end of interview
Statements:

• Dr.: "Let me check to see if I understand

what you have just told me. You are
allergic since you were fourteen years
old. These allergies are worse this year."
12. Closing the interview and thanking the patient.

Statements:
• Well thank you for all the information you
have given me…
Questions:
• Do you have anything else to add?
• "What question do you have for me?"
 Exercise I
Identify the type of question
Identify the type of question

1- Do not you feel that exclusive breast feeding should be

recommended?
Type:
This is a leading question and should be avoided.
Identify the type of question

2. Do you prefer to play basketball or football?

Type:
This is a double barreled question and should not be used
Identify the type of question

3. Please tell me about your views as regards the communication

course?
Type:
This is an open-ended question that leads to open comments.
Identify the type of question
4. Do not you think it is not right for a pregnant woman not to attend
for antenatal checkups?
Type:
This is a double negative questions that should be avoided.
Identify the type of question

5. Have you ever thought of applying for social aid for the poor?
Type:
An embarrassing sensitive question that can be avoided
Identify the type of question

6. Are nurses overworked, or they are just inefficient?

Type:
This is double-barreled questions and can be avoided
Identify the type of question
7-Have you ever been told that your child have PEM or rickets?
Type:
This is double-barreled questions and can be avoided.
The medical terms used may be unfamiliar to the mother so
it can be a jargon filled question.
Identify the type of question

8. Where did you receive your antenatal care?

Type:
A simple direct question (closed question)
Identify the type of question
9. How many eggs did you eat in the past year?
Type:
A simple direct question (closed question).
However, the person cannot accurately respond to
the question (inappropriate question)
Identify the type of question

10. Can you tell me more about these headaches?

Type:
This is an open-ended question that leads to
open comments
 Exercise II

Identify the communication skills carried out in the

following statements:
• Hello, my name is dr Samir. Thank you for speaking with me today. This
interview will take about 30 minutes to complete. The purpose of this interview
is to learn about your experience with the disease from the time before you got a
diagnosis up until today
• Communication skills carried out are:
• ----Introduce self--------------------------------------
• -----building rapport--------------------------------------
• -------indicating time----------------------------------
• -------achieving aim of interview-----------------------------------
• What communication skills are missing in this statement?
• -------Role of the doctor -------------------------
• --------Obtain patient`s consent -----------------------
• You said you noticed something was different and didn’t feel right. Could you
please tell me more about that?
• What is the use of this question?
• Repeating the patient`s words (facilitating comment)
• for clarification of information

• How did your symptoms affect your daily routine, work, family?
• What is the use of this question?
• -explore impact of illness on patient`s life -------------------------------------------

• Which outcomes are most important to you when it comes to your condition?
• What is the use of this question?
• -------Explore expectations of patient----------------------------------------
• Doctor is asking a patient if it is okay to take a blood pressure reading, and the
patient replies “Yes”.?
• What is the use of this question?
• -----obtain consent of patient --------------------------------------------

• “I can imagine how frustrating this is for you.”

• What is the use of this statement?
• ----------legitimation -----------------------------

• “Most people in your position would feel the same way. ”

• What is the use of this statement?
• ----------legitimation --------------------------------
• "How are you feeling?" "Are you comfortable now?" "Do you feel well enough to
talk now?"
• What is the use of this question?
• ------------- Establish patient comfort --------------------------------

• Dr "What problems brought you to the hospital today?"

• Patient "My chest feels really tight!
• Dr: your chest feeling tight (repetition)
• What are communication skills used?
• a.---------------- Elicit the chief concern (complaint -----------------------
• b.------------------------Facilitative statement for clarification ----------------
• Which terms of ICE are the following statements?
• What were you hoping to get out of today’s appointment?”
• Expectation---------------
• “What do you think might be causing your chest pain?”
• Ideas ------------------
• “What are you most concerned about?”
• Concerns------------------------------
• “Let’s start by getting a list of topics you would like to talk about
today. What is most important to you?”
• Concerns--------------------------------
• I’m not sure I understand. Can you explain it to me?”
• What is the use of this question?
• -------------clarification--------------------------------

• During the past half hour we have talked about ----

• What is the use of this statement?
• ----------Summarizing---------------------------------
Exercise III

Dialogue
• Dr.: "Now, what kind of problems brought you to the center to-day?"
• Patient: "I am having terrible headaches".
• -What information did the doctor receive?
• Stating the main complaint---------------------------------
• Dr.: "Please tell me some more about your headaches?"
• Patient: "Well they are really severe. But they come and go. They come on slowly
and get worse over several days. They come worse during this season. You know I
have allergy."
• -What is the use of the doctor `s question?
• With facilitative questions the patient described more the problem and helping
the doctor to develop diagnostic hypotheses.
• Dr.: "What else?"
• Patient: "They only started a month ago".
• -What is the use of the doctor `s question?
• --------With facilitative questions the patient is talking more about her problem
• Dr.: "You say that your headache started a month ago?"
• Patient: "Yes. You know we are in the spring. Spring and autumn are the months
that allergies and headaches do occur."
• -What is the use of the doctor `s question?
• -----------The doctor is applying facilitative skills by repeating the patient's own
words (Echoing)---------------------------------
• Dr.: "What else happened during this month?"
• Patient: "Well I changed my job a month ago. Everything is new and I have to
adapt to new things. Also I have to work at night".
• -What type of information did the doctor receive?
• -----With facilitative questions the patient is providing the doctor information
about the environment context and stress factors
• Patient: "The headache was so severe that I wished to die!!"
• Dr.: "I am sure that the pain was unbearable."
• -what communication skill did the doctor use?
• The patient expressed emotions and the doctor responded empathetically
• Dr: "Is Headache intermittent?"
• - What is the type of question?
• ---------------closed question-------------------------
• Dr.: "Now that you have told me about your headaches, I would like to know
what else is bothering you."
• Dr.: "What other problems do you have?"
• Dr.: "Are there any other thing you want to tell me?"
• -What is the use of these questions?
• Asking about other complaints ---------------------------------------
Exercise IV

script
Dr. Sobhy: "Good morning Mrs. Abeer. You are always on time. Your daughter Lyla looks just
fine. She is now 4 months of age."
Mrs. Abeer: "Yes, she is four months and fifteen days" Mrs. Abeer leans forward and smiles
Dr. Sobhy: "She is four months and half. What are you giving her now?
Mrs. Abeer: "Only my breast."
Dr. Sobhy: "Well it is best to keep breast feeding her as long as possible. But now she will need
other foods to help her to continue to grow well. You can introduce her to cereals. What types of
cereals do you have at home?"
Mrs. Abeer: "Well I have rice and wheat."
Dr. Sobhy: "Good, you can use either to make the first food for her. Do you know how to make
porridge? "
Mrs. Abeer: "Yes, I can. (Abeer smiles) My family loves the thick porridge I do?"(Dr. Smiles)
Dr. Sobhy: "Excellent, but for Lyla you have to make it very soft first by adding water. As Lyla
grows older, you increase gradually the thickness of the porridge.
Question: What function(s) of the medical interview did Dr. Sobhy fulfill?
The 3 functions: building rapport, determine the problem and educate the patient
 Exercise V
Compare and comments on the following scripts
• Script 1 • Script 2
• hello mrs. hala I'm dr fady I'm your doctor I'm here to learn about your • hi I'm dr fady and I'm your doctor I'm here to meet you and learn
health what brings you here today about your current health what brings you here today Chief
complaint
• patient : I've been having really bad stomach pain Chief • you've had a lot of stomach pain what do you mean by a lot of
complaint stomach pain
• Dr: what do you mean by a lot of pain clarification clarification
• Patient: well for the last week after I eat I can have stomach pain that
• Patient: well I have this pain every time I eat for about the last week and will last up to two hours
it's lasts for at least a couple of hours
• Dr : have you had any changes in your diet clarification
• dr: okay I have some other questions I need to ask you do you have
any other illnesses or health problems • Patient :well no but I noticed I know I'm not eating regular meals
• patient : no • Dr: so you've been having pain for about a week and it's worse after you
eat and it's even worse when you don't have regular meals what do you
• Dr: have you ever had any major surgeries Left the main mean by regular meals Summarizing
complaint and
• Patient: oh I have my tonsils out long time ago ask for other • Patient: well like if I don't eat breakfast I skip it and then I have lunch it's
• Dr: have you ever been diagnosed with allergies complaints really bad after lunch if I've skipped a meal

• Patient: no doctor • Dr: I can tell you're having pain right now on a scale of zero to ten with
zero meaning no pain and ten meaning the worst pain you've ever had
• dr: okay are you taking any medications what number best describes your pain
• patient no I don't think I can stand this pain much longer • Patient: eight and I don't think I can take much more of this you know
• dr: anything else you like to tell me • Dr: sometimes stress makes your stomach pain worse is there anything
going on in your life right now Asking about
• patient :well I lost my job I live alone my daughter's been diagnosed life problems
with cancer I try to hope for as much as I can with my ten kids • Patient:well I lost my job I live alone and my daughter has cancer and
I've been trying to help her as much as I can with my grandchildren
• dr:don't worry about it ,it will all work out
• Dr :I know you'd have a lot of worries right now with losing your job
Dr did not take time to understand and taking care of your daughter and your grandchildren
the patient`s feelings
• Dr :I'm really impressed by what you're doing I can tell it's been really
Did not build rapport hard we're going to figure out what's causing your pain and we're
going to make you more comfortable Empathy
Affirmative
Which script is positive and which is negative statement
 Feedback questions
Question 1
• Case: “I don’t want an HIV test. I don’t want to know if I have AIDS. If
there is nothing I can do about it, what’s the point in knowing?”

• How would you reflect this statement?

• Answer
• “It sounds like the HIV-testing process may be scary for you
 Question 2
• How can silence indicate you are actively listening?

• Answer
• It allows the case an opportunity to think and to answer the
questions
 Question 3
• In the following scenario identify the problems in communication:
• Doctor, I have some pain in my heart', said Mrs. Mona,
• DR Ahmed: 'where is your pain, is it gripping in character and does it
radiate to your left arm?'
• Mrs. Mona replied negatively to Dr. Ahmed`s questions,
• Dr. Ahmed fired another five questions at Mrs. Mona in order to confirm his
provisional diagnosis of angina, he was a bit puzzled but thought angina
could not be ruled out, so he ordered an ECG just to make sure.
• Mrs. Mona was going to tell the doctor that her pain in the chest came on
whenever she had a quarrel with her daughter-in-law and worried that she
would choke from the intense anger, but she was not given a chance.
• [Link] left the Doctor's clinic with an ECG appointment neither feeling
any better in her heart nor had she told the doctor what she wanted
 Answer
Problems
• No active listening
• Asking many questions in the same time
• Interruption of the patient story
• Failure to get accurate diagnosis
• Unnecessary ECG test
• Bad clinical outcome
 Question 4: give your comments on transcript 1 and transcript 2
and choose the positive transcript

TRANSCRIPT 1 TRANSCRIPT 2
Dr: So, what brings you in today? Dr: So, what brings you in today?
Pt: My back has been bothering me. Pt: My back has been bothering me.
Dr: What kind of work do you do? Dr: How so?

Pt: Um, well, I was an administrative Pt: When I bend over, it hurts, and I'm stiff in the
assistant as of the beginning of January, morning.
but I got laid off, so -
Dr: So, recently laid off. Dr: Do you remember when it started?

Pt: Yes. Pt: Yes. I was moving boxes in my house.

Dr: OK. OK. And when was your last Dr: What did it feel like when your hurt it?
physical exam, like pelvic exam, breast
exam and all that?
 Answer
• COMMENT on Transcript 1 • COMMENT on Transcript 2
• "Cut-off": Physician does not inquire further about • Physician explores concern further
concern and changes the topic.
• Patient describes the concern in more
detail.
• Physician stays on topic but does not give patient
the chance to elaborate. Physician offers no • Physician initiates further
empathy in response to distressing event. exploration
• Patient gives more relevant
• Patient answer suggests that the patient is in a information.
passive mode
• Physician offers validation
(legitimation) (empathy).
• Physician changes topic.
• Patient confirms that she felt
understood.
The positive transcript is transcript 2
 Question 5

• A patient came to the clinic in with a lump, and the doctor examined it.
• The doctor asked the appropriate questions as he carefully went over the lump, and then told her
it needs a minor surgery.
• Then the doctor asked, Do you have any questions?
• and the patient replied, Yes, could this be cancer
• It was never the doctor`s perspective so he did not explain to the patient , but it was the main
reason the patient called to see the doctor in the first place. And if the doctor hadn`t asked the
previous question , the patient would have left the clinic without any answer and she will not be
satisfied
• Questions
• What perspective had the women according to ICE Model?(ideas, concern, expectations)
• Answer; concerns
• What was the doctor mistake ?
• Answer: he did not inform the woman about her diagnosis before she asks the question
 Question 6
• “So as I understand it, you’ve been getting headache and dizziness but
have also been feeling rather irritable and a bit low, and your concern is
that you might be anemic, did I get that right? ”
• What is The skill carried out ?
• Answer
• Summarizing
 Question 7
• Encouragement : ‘
uh-huh’, ‘okay’, ‘go on’, ‘I see’
• Silence :
brief silence or pause
• Repetition or echoing :
e.g ‘Pain on your chest?’
• Paraphrasing :
restating in our word
e.g. I think I might have cancer, doctor. I feel so tired…’, said the patient
‘You’re worried that tiredness might be caused by cancer’(restating)
• Question
• In all of the previous statements what type of responses is the doctor giving?
• Answer
• Facilitative responses