The Medical Interview: The Three Function Approach

Front cover
Inside front cover
The Medical Interview
Copyright page
Dedication
Contributors
Foreword
Preface
	What’s New?
	Who is the Audience?
	A Note on Language
	Why Use the Three Function Approach?
	References
Acknowledgments
	References
Instructions for online access
Table of Contents
Unit 1 Three Functions Of The Medical Interview
	1 Learning to Interview Using the Three Function Approach: Introduction and Overview
		Summary
		References
	2 Three Functions: The Basic Model
		Function One: Build the Relationship
		Function Two: Assess and Understand the  Patient’s Problems
		Function Three: Collaborate for Management
		Summary
		References
	3 Function One: Build
the Relationship
		Nonverbal Skills
		Empathy
			Reflection
			Legitimation
		Empathic Communication to Deepen  Understanding (ECDU)
		Personal Support
		Partnership
		Respect (Affirmation)
			P(E)ARLS
		Summary
		References
	4 Function Two: Assess
and Understand
		Nonverbal Listening Behavior
		Questioning Style: Open-Ended Questions and the Open-to-Closed Cone
		RULE #2: LET THE PATIENT COMPLETE  THE OPENING STATEMENT
		Facilitation
		Clarification and Direction
		Checking/Summarizing
		RULE #3: WHEN IN DOUBT, CHECK
		Survey Problems: “What Else?”
		Avoid Leading (Biased) Questions
		Elicit the Patient’s Perspective: Ideas, Concerns, and Expectations (“ICE”)
			Explore the Patient’s Ideas about the Meaning of the Illness
			Elicit the Patient’s Concerns about the Problems
			Elicit the Patient’s Expectations
		Explore the Impact of the Illness on the Patient’s Quality of Life
		Conclusion
		Summary
		References
		Endnotes
	5 Function Three: Collaborate
for Management
		Education About Illness: Use (e)TACCT
			Using (e)TACCT: Elicit Baseline Understanding
			Using (e)TACCT: Tell the Core Message
			Using (e)TACCT: Ask About the Patient’s Knowledge  of the Illness
			Using (E)TACCT: Care About Patients’ Emotional Responses and Concerns
			Using (e)TACCT: Counsel About the Details
			Using (e)TACCT: Tell-Back to Check That  the Patient Understands
		Brief Action Planning
			1. Question One: Elicit Ideas for Change.*
				“Yes” Response
				“Not Sure” Response
				“Not Now” Response
			2. SMART Behavioral Planning
			3. Elicit the Commitment Statement
			4. Question Two: Scale for Confidence
			5. Question Three: Arrange Accountability
		Behavioral Menus and Problem Solving
			6. the Behavioral Menu
			7. Problem Solving
			8. Follow-Up
		The Eight Core Skills of Brief Action Planning
		Four Essential Attributes of a Brief Action Plan
		Spirit of Motivational Interviewing
			What About the Patient with Persistent Unhealthy Behavior Who Says “No” to Question One?
		Conclusion
		Summary
		References
		Endnotes
Unit 2 Meeting the Patient
	6 Ten Common Concerns
		1. Why Should the Patient Want to Talk to or be Examined by a Student?
		2. is a Student Interview or Examination a Humiliation or Indignity for the Patient?
		3. How Should I Dress? Should I Wear a White Coat Even Though I Am Not a Doctor? Doesn’t This Introduce an Artificial Separation and Inequality Into the Relationship? if I Wear a White Coat, Isn’t That Deceiving the Patient?
		4. Should I Introduce Myself as “Doctor”? if I Do,  Am I Not Deceiving the Patient?
		5. If the Patient is in Pain or Emotional Distress, Should I Continue with the Interview?
		6. Should I Shake the Patient’s Hand? Under What Circumstances is It Acceptable to Touch the Patient?
		7. If the Patient Asks Me Questions, Should I Answer Them if I Know the Answers? What Should I Do if I Do Not Know the Answers?
		8. What Do I Do if the Patient Starts Crying or if the Patient Gets Angry with Me?
		9. What Should I Do if the Patient Promises to Tell Me Some Important Secrets if I Agree to Maintain His or Her Confidence?
		10. What Should I Do if the Patient Tells Me Something His or Her Doctor Does Not Know? for Example,  What if the Patient Tells Me That He or She is Depressed or Suicidal?
		Summary
Unit 3 Structure of the Interview
	7 Opening the Interview
		Establishing Goals of the Interview
		Obtaining Patient Consent to Your Interview Plan
		Establishing Initial Rapport
		Establishing Patient Comfort
			Steps for an Effective Opening
		Summary
		References
	8 Chief Complaint, Problem Survey, Patient’s Perspective, and  Agenda Setting
		1. Eliciting the Chief Complaint
			Responding to Emotions
			Initial Facilitation
			Checking
		2. The Problem Survey
			Probing to Completeness
		3. Elicit Patient’s Perspective: Ideas, Concerns,  and Expectations (“ICE”)
			Explore Patient Ideas About the Meaning of the Illness
			Explore Patient Concerns About the Illness
			Explore Patient Expectations
		4. Agenda Setting
		Summary
		References
	9 History of Present Illness
		Narrative Thread and Open-to-Closed Questioning
		Problem Exploration: WW, QQ, AA, LC, I
			Where (Location)
			When (Timing)
			Quality
			Quantity (Severity)
			Aggravating and Alleviating Factors  (Modifying Factors)
			Associated Signs and Symptoms
			Life Context
			Impact on Patient’s Quality of Life
		Respond to Emotions Throughout
		Complete the Narrative Thread
		Complete This Process for Every Problem
		Summary
		References
		Endnotes
	10 Past Medical History
		Hospitalizations
		Surgeries
		Illnesses
		Injuries
		Medications
		Allergies
		Pregnancies
		Exposures
		Health Maintenance Practices
		Summary
		Reference
	11 Family History
		Summary
		Reference
	12 Patient Profile and Social History
		Patient Profile
		High-Risk Health Behaviors
		High-Risk Life Situations (High Stress  and Low Support)
		Summary
		References
	13 Review of Systems
		Summary
		References
	14 Mental Status
		Why Every Medical Workup Should Include a Mental Status Evaluation
		Brief Mental Status Examination
			1. General Appearance/Behavior
			2. Speech/Language
			3. Mood/Affect
			4. Thought/Perception
			5. Cognition/Sensorium
			6. Insight/Judgment
		Conclusion
		Summary
		References
Unit 4 Presentation and Documentation
	15 Presentation and Documentation
		Chief Complaint
		History
		Medications
		Past Medical History
		Family History
		Social History
		Review of Systems
		Examination
		Data
		Assessment
		Plan
		Some Pearls for the Presentation
		Guideline for the New Patient Presentation
		Guideline for the Follow-Up Presentation
		Summary and Conclusion
		Reference
Unit 5 Understanding Patients' Emotional Responses to Chronic Illness
	16 Understanding Chronic Illness: Normal Reactions
		Common Stresses of Illness
			1. Threat to Efficacy
			2. Threat of Separation
			3. Threat of Loss of Love
			4. Threat of Loss of Body Function
			5. Threat of Loss of Body Parts
			6. Threat of Loss of Rationality
			7. Threat of Pain
		Adaptive Tasks of Illness
			1. Coping with Symptoms, Pain, and Disability
			2. Coping with Treatment
			3. Adapting to a Variety of Health Care Providers
			4. Managing Emotions
			5. Relating to Family Members and Friends
			6. Preserving a Positive Self-Image
			7. Coping with the Unknown
		“Normal” Emotional Reactions to Illness and Mechanisms of Defense
			Regression
			Denial, Suppression, and Repression
			Anxiety
			Anger
			Sadness
		Summary
		References
	17 Understanding Chronic Illness: Maladaptive Reactions
		Persistent Anger
		Adjustment Disorder with Depressed Mood and Major Depression
		Adjustment Disorder with Anxious  Mood/Anxiety Disorders
		Interviewing Strategies for Patients with Maladaptive Emotional Responses
			Persistently Angry Patients
			Patients Who Have an Adjustment Disorder with Depressed Mood or Major Depression
			Patients Who Have an Adjustment Disorder with Anxious Mood or an Anxiety Disorder
		Summary
		References
Unnit 6 Advanced Applications
	18 Stepped-Care Advanced Skills for Action Planning
		A: Why Are Advanced Skill Necessary?
		B. Overview: The SAAP Model
			Step One: Respond to Distress or Discord to Meet Relational Challenges
			Step Two: Understand Benefits or Obstacles to Change to Meet Exploratory Challenges
			Step Three: Use Higher-Order Motivational Interviewing Skills to Meet Complex  Motivational Challenges
		C. What Is Change Talk? Why Is It Important?
		D. SAAP and Change Talk: How Elicitation, Recognition, and Response to Change Talk  Drive the Model
			1. Respond to Distress or Discord to Meet Relational Challenges (Advanced Application of Function  One Skills)
			2. Understand Benefits or Obstacles to Change to Meet Exploratory Challenges (Advanced Application of Function Two Skills)
			3. Use of Higher-Order Motivational Interviewing Skills to Meet Complex Motivational Challenges (Advanced Application of Function Three Skills)
		E. Skills and Case Study of SAAP Step One: Responding to Discord or Distress
		F. Skills and Case Studies of SAAP Step Two: Understanding Benefits or Obstacles to Change
		G. Skills and Case Study of SAAP Step Three: Using Higher-Order Motivational Interviewing Skills
		Elicit and Resolve Ambivalence
		Develop the Discrepancy
		Conclusion
		Summary
		References
		Endnotes
	19 Communicating with Patients with Chronic Illness
		Application of the Three Function Model  to Chronic Illness
			Function One: Build (and Maintain) the Relationship
			Function Two: Assess and Understand the Patient
			Function Three: Collaborate for Management
			Eliciting a Goal:
			Action Planning:
		Summary
		References
		Endnotes
	20 Health Literacy and Communicating Complex Information for Decision Making
		Why Health Literacy Matters
		Health Literacy and the Three Function Model
			Function One: Build the Relationship
				Conveying Respect
			Function Two: Assess and Understand the Patient
			Function Three: Collaborate to Manage
		Communicating Complex Information  for Decision Making
			Function One: Build the Relationship
			Function Two: Assess and Understand the Patient
				Elicit Expectations
			Function Three: Collaborate to Manage
		Special Considerations Using Written Materials
		References
	21 Sexual Issues in the Interview
		Why Are Sexual Issues Important?
		Function One: Build the Relationship
		Function Two: Assess and Understand the Problem
			Basic Evaluation of Risk
			Impact of Chronic Illness on Sexual Quality of Life
		Function Three: Collaborate for Management
		Managing Your Own Anxiety or Attitudinal Barriers
		Managing Specific Problems
		Conclusion
	22 Interviewing Elderly Patients
		Function One: Build the Relationship with the Elderly Patient
		Function Two: Assess and Understand  the Elderly Patient
		Function Three: Collaborate for Management
		Conclusion
		Addendum
		10 Tips from the Literature for Improving Communication with Older Patients
		References
	23 Culturally Competent  Medical Interviewing
		The Culture Concept
		Importance of Understanding the Patient’s Explanatory Model and Social Context
		Strategies for Eliciting Explanatory Models
		Continuum of Illness Beliefs
		Working with Interpreters in the Medical Encounter
		Enhancing the Patient-Interpreter-Physician Interaction
		Guidelines for Language Use When Working  with Interpreters
		Collaborative Management and the Negotiation of Culturally Appropriate Treatment Plans
		Conclusion
		References
	24 Family Interviewing
		Situations in Which Family Members  Are Often Present
		The Three Functions of Family Interviewing
		Function One: Build the Relationship
		When There Is Conflict in the Family
		Function Two: Assess and Understand the Patient and Family
		Function Three: Collaborate to Manage
		Delivering Information
		Using the Family as a Resource in Motivating Patients to Change
		Special Circumstances When Interviewing Families
			When to Convene the Family
			Avoiding Taking Sides or Triangulation
			When the Customer is Not the Patient
			Dealing with Strong Affect during  the Family Interview
			Violence in the Family
			Mental Health Referral
		Family-Oriented Interview with the Individual Patient
		Conclusion
		References
	25 Troubling Personality Styles  and Somatization
		Compulsive Patients
			General Characteristics
			Inner Conflicts and Needs
			Stresses of Illness and Illness Behavior
			Interviewing Strategies
		Dependent Patients
			General Characteristics
			Inner Conflicts and Needs
			Stresses of Illness and Illness Behavior
			Interviewing Strategies
		Histrionic Patients
			General Characteristics
			Inner Conflicts and Needs
			Stresses of Illness and Illness Behavior
			Interviewing Strategies
		Self-Defeating Patients
			General Characteristics
			Inner Conflicts and Needs
			Stresses of Illness and Illness Behavior
			Interviewing Strategies
		Borderline Patients
			General Characteristics
			Inner Conflicts and Needs
			Stresses of Illness and Illness Behavior
			Interviewing Strategies
		Narcissistic Patients
			General Characteristics
			Inner Conflicts and Needs
			Stresses of Illness and Illness Behavior
			Interviewing Strategies
		Somatization
			General Characteristics
			Inner Conflicts and Needs
			Stresses of Illness and Illness Behavior
			Interviewing Strategies
			Develop Rapport
			Changing the Agenda
			Seeing the Patient Regularly
			“Don’t Just Do Something, Stand There!”
		Conclusion
		References
	26 Communicating with the  Psychotic Patient
		Psychotic Patients
			General Characteristics
			Inner Conflicts and Needs
			Stresses of the Illness and Illness Needs
		Strategies
			Self Management
			Cognitive Support
			Affect Management
			Reality Orientation
		Conclusion
		References
	27 Breaking Bad News
		Preparing to Break Bad News
		Breaking the News
			Tell
			Ask
			Care
			Counsel
			Tell-Back
		Importance of Physician Self-Awareness
		Special Challenges in Breaking Bad News
			Breaking Bad News From a Distance
			Don’t Break the News
			Denial of Bad News
		Honest Disclosure and Realistic Hope
		Teaching How to Give Bad News
		Conclusion
		References
			Books
			Websites
	27A Sharing Difficult or Bad News:
		The Recipient’s Experience of Receiving Difficult  or Bad News
		The Biggest Trap into Which Clinicians Fall
			An Ineffective Sharing of Difficult News
			A More Effective Way to Share Difficult News
		Thoughts for Medical Students
		Nine Steps to Sharing Difficult or Bad News
		References
	28 Disclosure of Medical Errors  and Apology
		Learning Context
		Preparing for the Initial Conversation
			Examples of denial:
			Examples of anger:
			Examples of bargaining:
			Examples of depression:
			Examples of acceptance:
		The Conversation
		The Aftermath
		The Follow-up
		Conclusion
		References
	29 Risky Drinking and Interviewing About Alcohol Use
		Definitions
			A drink
			Normal or healthy or moderate drinking
			Risky or hazardous drinking
			Alcohol abuse
			Alcohol dependence
		Function One: Build the Relationship
			Introduction
			Conversation
		Function Two: Assess and Understand  the Patient’s Problems
			Introduction
			Definitions
				Intoxication
				Tolerance
				Blackout
				Withdrawal syndrome
				Denial
			Are You Worried About the Patient’s Drinking?
			Prescreen
			Screening
			Red Flags
			Continue the Conversation
		Function Three: Collaborative Management
			Initial Steps
			Readiness for Change Matters
			Provocation
			Brief Intervention
			Education
			(e) Elicit Baseline Knowledge
			(T)(Tell) Present Information in Focused  and Succinct Statements
			(A)(Ask) Check Understanding
			(C) (Care) Respond To Emotions
			(T) (Tell-Back) and Invite Questions
			Brief Action Planning
			Some Specific Communication Strategies for Patients at Different Levels of Readiness
			Some Possible Dialogues with Patients Who Have Low Readiness for Change
		Summary
		References
		Endnote
Unit 7 Higher Order Skills
	30 Nonverbal Communication
		Basic Behavior
			Safety
			Fight
			Flight
			Conservation-Withdrawal
		Nonverbal Skills
			Developing Nonverbal Rapport
			Shaping Space
			Addressing Mixed Messages
		Application to the Three Function Approach
			Function One: Build the Relationship
			Function Two: Assess and Understand  the Patient’s Problems
			Function Three: Collaborate for Management
		Conclusion
		References
	31 Use of the Self in Medical Care
		Physician Personal Awareness
		Personal Growth
		Self-Care
		Summary
		References
	32 Using Psychological Principles  in the Medical Interview
		The Psychodynamic Model: Basic Concepts
			Psychic Conflict
			Mechanisms of Defense
			Resistance and Management of Resistance
			Support
			Transference
			Countertransference
		Cognitive-Behavioral Model: Basic Concepts
			Primacy of Cognition
			Arbitrary Inference
			Operant Conditioning
		George: A Case Study Integrating Psychodynamic and Cognitive-Behavioral Interventions
			Psychodynamic Understanding and Interventions
			Cognitive-Behavioral Understanding and Interventions
		Conclusion
		Summary
		References
	33 Integrating Structure and Function: Diagnostic Reasoning, Clinical
Inference, Communication
Flexibility, and Rules
		Higher-Order Processes and Skills
			Clinical Reasoning
			Clinical Inference and Flexibility
		Six Rules of Integrative, Higher-Order Functioning
			1. Observe Your Patient
			2. Observe Yourself
			3. When in Doubt, Check
			4. When the Patient Demonstrates an Emotion, Respond to It
			5. Don’t Answer Every Question Immediately
			6. Understand That Patients are Usually Forgiving of Mistakes in the Interview
		Conclusion
		Summary
		References
Appendix 1 The Medical Interview: The Three Function Approach Table of Skills
Appendix 2 The Brief Action Planning Guide
Appendix 3 Learning How to Interview
	Readings
	Lectures
	Demonstration
	Practice
	Observation and Feedback
	Re-Practice
	Videotape
	Standardized Patients
	Role-Play
	Modified Live Patient Interviews
	Small Groups
	Learner-Centered Methods
	References
Index
	A
	B
	C
	D
	E
	F
	G
	H
	I
	J
	K
	L
	M
	N
	O
	P
	Q
	R
	S
	T
	U
	V
	W
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