Transcript Case Presentation - University of Virginia

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