Patient-centered interviewing skills; Data Gathering For Health Professional , Patient-centered interviewing skills are used at the beginning of the interaction to obtain the patient’s perspective. They elicit unique symptom, personal, and emotional information from the patient. They are also used throughout the interview to continue building and maintaining the clinician-patient relationship. Clinician-centered skills may be used sparingly during patient -centered interviewing but, mainly, are used in the middle portion of the interview to provide more control for the clinician. They elicit information the clinician needs to know that has not already arisen during the initial patient -centered portion. In this chapter, both skills are discussed with the emphasis on using the more difficult patient-centered skills.
Patient -centered interviewing assists patients in expressing what is most important to them, recognizing the importance of personal concerns, thoughts, feelings, and emotions. A useful analogy is to view each piece of new information during the interview, as being placed on a table between the clinician and patient.
The clinician succeeds in being patient -centered when the information on the table has been placed there by the patient. When the clinician places new ideas “on the table;’ this defines clinician-centered interviewing. Regardless of effort to not introduce new topics, clinicians using patient -centered skills can still influence the type and amount of information patients disclose through gestures, comments, and selectively attending to certain topics. Used prematurely during the beginning of the interview, clinician-centered skills can contaminate the patient’s story with what is on the clinician’s mind, creating a cognitive bias. This is sometimes referred to as premature hypothesis testing by focusing only on the initial piece of information to make subsequent judgments.
This can lead to an inaccurate or skewed view of the problem(s) and therefore lead to erroneous treatment.2 Individualized care relies on an accurate patient report of symptoms and, especially, their context in the history of the illness. Contextual errors occur when elements of the patient’s environment, behavior, or emotions are not considered when making diagnosis and treatment plans.
- Open-Ended Skills
Open-ended skills encourage the patient to freely express what is on his/her mind. There are two types of open-ended skills: (1) nonfocusing skills (silence, nonverbal encouragement, and continuers) and (2) focusing skills (echoing, open-ended requests, summaries). When the patient’s narrative becomes hard to follow, gets off-track, or overwhelming, focusing skills are used to help restore structure and balance to the interview-to focus the patient’s story
- Open-Ended Nonfocuslng Skills
Nonfocusing skills encourage the patient to put more and more information “on the table”.
Remaining silent-saying nothing-while continuing to be nonverbally attentive and responsive (using appropriate eye contact and an open body posture, leaning forward with legs and arms uncrossed) prompts the patient to continue talking and signals that you are interested in what s/he is saying.
- Nonverbal encouragement
Nonverbal encouragement often paired with silence, urges patients to talk freely. Typically; the clinician makes a sympathetic facial expression (expectation to continue), nods, or simply indicates by body language that the patient should continue speaking.
Integrated with silence and nonverbal encouragement, continuers are brief, noncommittal statements such as ‘1 see;’ llh-huh,”‘ “Yes:· or “Mmm” that encourage the patient to talk without directing the conversation; they let the patient know you are following what slhe is saying.
- Open-Ended Focusing Skills ,Focusing skills encourage the patient to expand on specific parts of the information they have already “placed on the table”. In essence, the clinician uses these skills to pick things up “off the table” in order to learn more about them.
- Echoing , Echoing is a type of reflection, accomplished by repeating a word or phrase “placed on the table” by the patient; this not only lets the patient know slhe is heard, but also provides encouragement to focus, expand, and elaborate on the word or phrase.
- Open-ended requests, Open-ended requests are used to focus the patient on an already mentioned area that the clinician wants to expand upon, such as “Tell me more about the daughter you mentioned.Like other focusing skills, open-ended requests move the patient to deeper levels of his/her story by focusing on something that the patient has already mentioned. They should not be used to direct the patient to a topic they have not already mentioned, for example, “Tell me about your family” when the patient has not said anything about her or his family. Remember the table analogy? Family was not on the table, so the clinician should not introduce a new topic.
- Summarizing paraphrasing , Summarizing by paraphrasing what the patient said invites the patient to focus on and expand the material provided, but also is an accuracy check. Basically, summarizing allows the patient to know that the clinician has followed the conversation, heard the details, and is ready for more information. With open -ended focusing skills the clinician can refocus the patient on an important topic that may have slipped by too quickly. Often patients mention an emotionally loaded topic, such as death, but rapidly move away from it. You can return to the topic by saying, for example, “You mentioned death a minute ago, tell me more about that:’ Because the patient initially introduced the topic of death by “placing it on the table; the clinician can comment on it, even though it may interrupt the immediate thread of conversation. Using these open-ended skills, the clinician learns information, feelings, and thoughts important to the patient-patient-centered material-with less contamination from the clinician
- Closed-Ended Data-Gathering Skills (Used In the Middle Portion of Interview) , Closed-ended questions, typically answered with yes, no, or a choice among provided answers, are used primarily to confirm or refute specific issues, rather than expand the conversation in the way that open-ended questions do. Close-ended questions imply that the clinician knows what is important to the patient, and possibly that the patient’s concerns are trivial. Patients who are chronically exposed to this type of questioning during the encounter are less satisfied with the clinician and the interaction.
- Integrating Open-Ended and Closed-Ended Skills, Open- and closed-ended skills complement each other. During the patientcentered beginning of the interview, open-ended skills predominate and are used repeatedly, primarily for developing information about symptoms and personal and emotional concerns expressed by the patient. Closed-ended questions are used sparingly during the beginning of the interview to clarify the patient’s utterances. As you will learn in Chapter 3, at the end of the patient-centered part of the interview a clear transitional statement is made alerting the patient to a change in interview style. Then, during the cliniciancentered middle of the interview, open-ended questions are fewer and used primarily at the start of each step for brief but repeated scanning purposes. Closed-ended questions predominate and are used to pin down details and often place new information “on the table.” Thus far, we have described the fundamental communication skills used for data-gathering. Next, we will discuss how to use these and other skills to build positive, strong relationships with patients. Then, we will show how to integrate these skills into a method to conduct a patient-centered interview in a systematic manner.