lecture 2
DESCRIPTION
9-4-09, first hourTRANSCRIPT
V550V550
The Health Interview:The Health Interview:Facilitating QuestionsFacilitating Questions
Richard E. Meetz, OD, MSRichard E. Meetz, OD, MS20082008
Facilitating QuestionsFacilitating Questions
Questions Facilitation: Promoting Questions Facilitation: Promoting communication through verbal or communication through verbal or non-verbal meansnon-verbal means
The patient is encouraged to speak, The patient is encouraged to speak, but no direction is provided.but no direction is provided.
Facilitating QuestionsFacilitating Questions
The interviewer makes use of The interviewer makes use of gestures, facial expressions, an gestures, facial expressions, an attentive manner and a few words to attentive manner and a few words to urge the patient to continue urge the patient to continue discussion. discussion.
Facilitation: Facial ExpressionsFacilitation: Facial Expressions
Nod of the head:Nod of the head:
– Means “Go on, I’m listening”; “I heard Means “Go on, I’m listening”; “I heard you”you”
– Beware of the “Nervous Nod”Beware of the “Nervous Nod” “ “Constant Nod” or “Bobble Head Nod” -Constant Nod” or “Bobble Head Nod” -
Misleading and looks sillyMisleading and looks silly
Facilitation: Facial ExpressionsFacilitation: Facial Expressions
Perplexed Facial ExpressionsPerplexed Facial Expressions– Raised eye brow, pursed lips etc...Raised eye brow, pursed lips etc...
– Means “I don’t understand you”, “I can’t Means “I don’t understand you”, “I can’t follow you”, “Does not make sense”follow you”, “Does not make sense”
– Beware these can be interpreted as Beware these can be interpreted as disapprovaldisapproval
Facilitation: Facial ExpressionsFacilitation: Facial Expressions
Head shake:Head shake:– Can mean disapproval or unbelievableCan mean disapproval or unbelievable– ““Does not sound correct”, “Not possible” Does not sound correct”, “Not possible” – ““Not good”Not good”
Frown: aboveFrown: above
Raised eye brows:Raised eye brows:– Can mean “surprised” or “disbelief”Can mean “surprised” or “disbelief”
Types of Facilitation: Verbal HelpTypes of Facilitation: Verbal Help
ContinueContinue: encourage patient along : encourage patient along same linessame lines
– ““Yes?”Yes?”– ““Uh-huh”Uh-huh”– ““I see”I see”– ““Go on…”Go on…”
Types of Facilitation: Verbal HelpTypes of Facilitation: Verbal Help
Repeating/ReflectionRepeating/Reflection: use when more : use when more information is needed after patient has information is needed after patient has stopped.stopped.– Repeating patient’s last few words in the Repeating patient’s last few words in the
form or intonation of a questionform or intonation of a question– Repeating a phrase used earlier to change Repeating a phrase used earlier to change
a topic which was brushed over a topic which was brushed over Patient: “…and then I had this eye pain.”Patient: “…and then I had this eye pain.”Response: “You had this eye pain?”Response: “You had this eye pain?”
Types of Facilitation: Verbal HelpTypes of Facilitation: Verbal Help
ClarificationClarification: use when a word is : use when a word is ambiguous or confusingambiguous or confusing– ““Tell me what you mean by _____ “Tell me what you mean by _____ “
– Example: DizzinessExample: Dizziness
““Tell me what you mean by dizziness.”Tell me what you mean by dizziness.”
If the patient is having difficulty, give some If the patient is having difficulty, give some examples: “Does the room spin around or do examples: “Does the room spin around or do you get light headed?”you get light headed?”
Types of Facilitation: Verbal HelpTypes of Facilitation: Verbal Help
EmpathyEmpathy: Recognizing and : Recognizing and acknowledging a person’s feelings.acknowledging a person’s feelings.
– Used to show you recognize feelings and Used to show you recognize feelings and are “OK” with them.are “OK” with them.
– ““This must be very difficult for you.”This must be very difficult for you.”
Types of Facilitation: Verbal HelpTypes of Facilitation: Verbal Help
ConfrontationConfrontation: Observation or : Observation or statement to show discrepancies, statement to show discrepancies, especially in affect.especially in affect.
– ““You smile when you tell me that your You smile when you tell me that your mother passed away.”mother passed away.”
– ““You say all is resolved, yet you sound You say all is resolved, yet you sound angry.”angry.”
Types of Facilitation: Verbal HelpTypes of Facilitation: Verbal Help
InterpretationInterpretation: based not upon : based not upon observation but rather upon observation but rather upon inference, linking statements to inference, linking statements to imply cause.imply cause.
– ““It seems that every time you wear your It seems that every time you wear your contact lenses, your eyes are crusted contact lenses, your eyes are crusted the next morning.”the next morning.”
Types of Facilitation: Verbal HelpTypes of Facilitation: Verbal Help
ExplanationExplanation: of why a question is going : of why a question is going to be asked or has been asked.to be asked or has been asked.
– ““When the eyes are this red for this length When the eyes are this red for this length of time, we need to ask other questions of time, we need to ask other questions about your activities and about symptoms about your activities and about symptoms in other areas of the body.”in other areas of the body.”
– IMPORTANT: There is a reason for every IMPORTANT: There is a reason for every question that we as Optometrists will ask. question that we as Optometrists will ask. Know the reasons for them!!Know the reasons for them!!
Types of Facilitation: Verbal HelpTypes of Facilitation: Verbal Help
Summary: Summary:
– Condenses facts and conveys how you Condenses facts and conveys how you understand the patient’s Health/Vision understand the patient’s Health/Vision problems and/or needs.problems and/or needs.
Types of Questions and Types of Questions and StatementsStatements
Open-endedOpen-ended: unstructured, undirected: unstructured, undirected
– Allows the patient to choose own focus, Allows the patient to choose own focus, typical opening question of a case history.typical opening question of a case history.
– Starts with: “What, how, when, where…”Starts with: “What, how, when, where…”
– Example: “What brings you in for an eye Example: “What brings you in for an eye exam today?”exam today?”
Types of Questions and Types of Questions and StatementsStatements
ClosedClosed: structured, directed “Yes-No”: structured, directed “Yes-No”
– Seeks specific detailsSeeks specific details
– Starts with “Do you…, Does anyone…, Starts with “Do you…, Does anyone…, Are you…?”Are you…?”
– Example: “Are you taking any Example: “Are you taking any medications?”medications?”
Types of Questions and Types of Questions and StatementsStatements
Direct QuestionDirect Question: focuses on specific : focuses on specific informationinformation
– Short answer, can be yes-no.Short answer, can be yes-no.
– Ex: Direct Open – “What type of activities Ex: Direct Open – “What type of activities do you do at work?”do you do at work?”
– Ex: Direct Closed – “Are you currently Ex: Direct Closed – “Are you currently working?”working?”
Types of Questions and Types of Questions and StatementsStatements
Indirect QuestionIndirect Question: Open-ended : Open-ended questions that do not sound like a questions that do not sound like a questionquestion
– Ex: “Your glasses are very heavy. That Ex: “Your glasses are very heavy. That must cause you difficulty in school.”must cause you difficulty in school.”
Types of Questions and Types of Questions and StatementsStatements
Compound QuestionCompound Question: “Double Barreled”: “Double Barreled”
– Two questions at once. Confusing to the Two questions at once. Confusing to the patient, “which do I respond to?”patient, “which do I respond to?”
– Ex: “Do you ever get headaches or see Ex: “Do you ever get headaches or see double?”double?”
– AVOIDAVOID!!!!
Types of Questions and Types of Questions and StatementsStatements
Multiple ChoiceMultiple Choice: “Laundry List”: “Laundry List”
– Provides patient with a list of responses. Provides patient with a list of responses. Used to narrow down the “Time of Used to narrow down the “Time of Onset” or frequency of a Sx. Onset” or frequency of a Sx.
– Good for patients who are unsure how to Good for patients who are unsure how to respond or to control the talkative or respond or to control the talkative or rambling patient.rambling patient.
Types of Questions and Types of Questions and StatementsStatements
Multiple ChoiceMultiple Choice cont’d: cont’d: Often used when a patient doesn’t Often used when a patient doesn’t
know an answer to onset or frequencyknow an answer to onset or frequency– Ex: “How often are your headaches? Every Ex: “How often are your headaches? Every
day? Once a week? Twice a week or a few day? Once a week? Twice a week or a few times a week?”times a week?”
– Limits responses and tends to put the Limits responses and tends to put the examiner’s word into the patient’s examiner’s word into the patient’s symptoms.symptoms.
Types of Questions and Types of Questions and StatementsStatements
Leading (Suggestive) QuestionsLeading (Suggestive) Questions::
– Suggests the “correct answer”Suggests the “correct answer”
– Ex: “You don’t smoke, do you?”Ex: “You don’t smoke, do you?”
– Judgmental! Don’t use!Judgmental! Don’t use!
Types of Questions and Types of Questions and StatementsStatements
Informing QuestionsInforming Questions::
– Asked in a way that information is given Asked in a way that information is given as to why a question was asked.as to why a question was asked.
– Ex: “This medication is usually taken for… Ex: “This medication is usually taken for… ________ is that why you are taking it?” is that why you are taking it?”
– Ex: “Side effects with that medication are Ex: “Side effects with that medication are common for…1,2,3 have you notice any common for…1,2,3 have you notice any of those?”of those?”
Types of Questions and Types of Questions and StatementsStatements
Facilitative QuestionsFacilitative Questions
– Shows attention or interest. Encourages Shows attention or interest. Encourages the patient.the patient.
– Ex: “Tell me more about that.”Ex: “Tell me more about that.”
Types of Questions and Types of Questions and StatementsStatements
Clarifying Questions and StatementsClarifying Questions and Statements:: 4 Types4 Types
– Used to confirm what was heard and to jog Used to confirm what was heard and to jog patient’s memory for more information.patient’s memory for more information.
ReflectionReflection – Repeat last statement as a – Repeat last statement as a questionquestion
ParaphrasingParaphrasing – shortening phrase in your – shortening phrase in your terms for recordterms for record
CheckingChecking – repeat last statement – repeat last statementSummarizingSummarizing – brief review – brief review
Types of Questions and Types of Questions and StatementsStatements
Validation QuestionsValidation Questions::
– To confirm meaning & accuracy. To confirm meaning & accuracy. Involves both observation & Involves both observation & interpretation of cues.interpretation of cues.
– Ex: “You seem worried about those Ex: “You seem worried about those findings…”findings…”
Types of Questions and Types of Questions and StatementsStatements
Acknowledging QuestionsAcknowledging Questions::
– Acknowledges your observation and Acknowledges your observation and asks “What would the patient like?”asks “What would the patient like?”
– Ex: “You are nervous about this test. Is Ex: “You are nervous about this test. Is there anything I can do to make you there anything I can do to make you more comfortable?”more comfortable?”
Types of Questions and Types of Questions and StatementsStatements
Confronting QuestionsConfronting Questions: : ““State the obvious”State the obvious”
– Acknowledge emotions, conflicts in Acknowledge emotions, conflicts in information, avoiding.information, avoiding.
– Ex: “You say you’re not upset but you Ex: “You say you’re not upset but you sound very angry. We need to clarify sound very angry. We need to clarify this before we go on.”this before we go on.”
Types of Questions and Types of Questions and StatementsStatements
““Why” QuestionsWhy” Questions::– Requires the patient to account for Requires the patient to account for
behavior.behavior.– Ex: “Why didn’t you take your Ex: “Why didn’t you take your
medication?”medication?” BEWARE:BEWARE:
Shows Dr’s feelings of helplessness or Shows Dr’s feelings of helplessness or frustrationfrustration
Overtones of accusationsOvertones of accusationsCan antagonize the patientCan antagonize the patientPatient can feel like Dr is finding faultPatient can feel like Dr is finding fault
Types of Questions and Types of Questions and StatementsStatements
““Why” QuestionsWhy” Questions cont’d: cont’d:– Typical response: “because” or alibi, Typical response: “because” or alibi,
excuses and rationalizationexcuses and rationalization
– Avoid!Avoid!Shuts down communicationShuts down communication
– Suggestive alternative: “I’m not clear on Suggestive alternative: “I’m not clear on why…”why…”
Types of Questions and Types of Questions and StatementsStatements
Patient’s QuestionsPatient’s Questions::
– ClarificationClarification (terms, treatment) (terms, treatment)
Know lay explanation for any jargon you use.Know lay explanation for any jargon you use.May need to write out patient instructions.May need to write out patient instructions.
Types of Questions and Types of Questions and StatementsStatements
Patient’s QuestionsPatient’s Questions cont’d: cont’d:
– InformationInformation (Dx, treatment progression, (Dx, treatment progression, risks)risks)
Dr must know the reason for all questions Dr must know the reason for all questions asked.asked.
Dr must be familiar with many different Dr must be familiar with many different diseases/treatments of both ocular disorders diseases/treatments of both ocular disorders and systemic disorders.and systemic disorders.
Types of Questions and Types of Questions and StatementsStatements
Patient QuestionsPatient Questions cont’d: cont’d:– Personal questionsPersonal questions
May just wish to know your background as a May just wish to know your background as a personperson
– Best to keep answers to “Yes/No”Best to keep answers to “Yes/No”
ManipulationsManipulations– Patient seeking special care, “your friend”Patient seeking special care, “your friend”– If get more questions after your 1If get more questions after your 1stst “Yes/No,” “Yes/No,”
don’t ask, “Why?” Say: “I believe we are don’t ask, “Why?” Say: “I believe we are here to discuss your eyes and vision….”here to discuss your eyes and vision….”
Communication Patterns andCommunication Patterns andApproaches to InterviewingApproaches to Interviewing
We will use these different question We will use these different question styles to open up a patient to give us styles to open up a patient to give us the information we need. the information we need.
By changing or combining these By changing or combining these question types we will be able to question types we will be able to focus a general complain down to the focus a general complain down to the essential information needed to essential information needed to make a diagnosis. make a diagnosis.
Communication Patterns andCommunication Patterns andApproaches to InterviewingApproaches to Interviewing
Funnel ApproachFunnel Approach Inverted Funnel ApproachInverted Funnel Approach Tunnel ApproachTunnel Approach Repeated Funnel ApproachRepeated Funnel Approach Hourglass ApproachHourglass Approach Diamond ApproachDiamond Approach
Communication Patterns andCommunication Patterns andApproaches to InterviewingApproaches to Interviewing
Funnel ApproachFunnel Approach This is the standard approach to This is the standard approach to
most patientsmost patients– We start off with a very broad “open” We start off with a very broad “open”
questionquestion– Then we slowly change to more closed Then we slowly change to more closed
questions as we focus down to the questions as we focus down to the details of the problemdetails of the problem
Communication Patterns andCommunication Patterns andApproaches to InterviewingApproaches to Interviewing
Inverted Funnel ApproachInverted Funnel Approach– Is used for patients who are closed or Is used for patients who are closed or
not sure what or if they have a problemnot sure what or if they have a problem– We start out closed “yes-no” questions We start out closed “yes-no” questions
then to open as the patient opens upthen to open as the patient opens up
Communication Patterns andCommunication Patterns andApproaches to InterviewingApproaches to Interviewing
Tunnel ApproachTunnel Approach– Is used for those closed patients who Is used for those closed patients who
never open up and for those overly never open up and for those overly talkative patientstalkative patients
– We use a series of repeated closed, We use a series of repeated closed, “yes-no” and list questions“yes-no” and list questions
Communication Patterns andCommunication Patterns andApproaches to InterviewingApproaches to Interviewing
Repeated Funnel ApproachRepeated Funnel Approach– Is used for patients whom have multiple Is used for patients whom have multiple
problemsproblems– We often have to start over with the We often have to start over with the
open to close questioning for each open to close questioning for each symptomsymptom
Communication Patterns andCommunication Patterns andApproaches to InterviewingApproaches to Interviewing
Hourglass ApproachHourglass Approach– This is more typical of the approach we This is more typical of the approach we
will take with most of our patientswill take with most of our patients– We start open then focus them down. We start open then focus them down.
Then we open them back up to Then we open them back up to complete the rest of their medical complete the rest of their medical history ending with the summery and history ending with the summery and asking is there anything else to add.asking is there anything else to add.
Communication Patterns andCommunication Patterns andApproaches to InterviewingApproaches to Interviewing
Diamond Approach Diamond Approach – Is with the Inverted Funnel Approach on Is with the Inverted Funnel Approach on
patients who where initially closed who patients who where initially closed who then opened up we then refocused them then opened up we then refocused them down to find our WDx.down to find our WDx.
TrapsTraps
Ten Traps of InterviewingTen Traps of Interviewing
Nonproductive, defeating verbal Nonproductive, defeating verbal messages that restrict the patient’s messages that restrict the patient’s response:response:
1) Providing Assurance or 1) Providing Assurance or Reassurance Reassurance
– ““Don’t worry, I’m sure it will be all Don’t worry, I’m sure it will be all right.”right.”
Trivializes anxiety and problems.Trivializes anxiety and problems.
Ten Traps of InterviewingTen Traps of Interviewing
2) Giving Advice2) Giving Advice– ““If I were you, I’d do……”If I were you, I’d do……”– Shifts accountability for decisions to Shifts accountability for decisions to
you. Increases YOUR liability.you. Increases YOUR liability.
3) Using Authority3) Using Authority– ““Your doctor knows best”Your doctor knows best”– Promotes feelings of inferiorityPromotes feelings of inferiority
Ten Traps of InterviewingTen Traps of Interviewing
4) Using Euphemisms or Language of 4) Using Euphemisms or Language of AvoidanceAvoidance
– “…“…passed on…”passed on…”– Avoids realityAvoids reality
5) Engaging in Distancing5) Engaging in Distancing– use of impersonal language/speech “We use of impersonal language/speech “We
find…” to erect barriers between you and find…” to erect barriers between you and your patientyour patient
Ten Traps of InterviewingTen Traps of Interviewing
6) Use of Professional Jargon6) Use of Professional Jargon– sounds condescending, excludes sounds condescending, excludes
patient, makes them feel like you are patient, makes them feel like you are talking over their head.talking over their head.
7) Leading or Biased Questions7) Leading or Biased Questions– ““You don’t smoke, do you?”You don’t smoke, do you?”– Judgmental Judgmental – Implies that one answer is “better”Implies that one answer is “better”
Ten Traps of InterviewingTen Traps of Interviewing
8) Talking Too Much/Teaching 8) Talking Too Much/Teaching During HistoryDuring History
– Patient loses train of thoughtPatient loses train of thought– Wastes time Wastes time
most will forget informationmost will forget information
– If exam takes long even due to their If exam takes long even due to their questions the patient still sees you as questions the patient still sees you as inefficient…Competent?inefficient…Competent?
Ten Traps of InterviewingTen Traps of Interviewing
9) Interrupting9) Interrupting– The most common trap doctors fall intoThe most common trap doctors fall into– Cuts patient off, seen as rude?Cuts patient off, seen as rude?– Discourages elaborationDiscourages elaboration
10) Using “Why” Questions10) Using “Why” Questions– Implies blame, condemnationImplies blame, condemnation
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