Calgary-Cambridge Guide to the Medical Interview - Gathering Information

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Gathering Information: Psychosocial assessment

Introduction

The third step of the medical interview according to the Calgary-Cambridge model is the gathering of information.[1] In the previous step, the main reason for the patient’s visit was established and a basic background has been provided. Questions were open-ended and the patient was given a chance to reveal his/her main complaint. Information gathering involves further exploration on the patient’s problem from a biomedical perspective, but also from the patient’s perspective, all within the patient’s unique context and background. During this section of the interview, the clinician gains as much information as possible to formulate a well-supported clinical hypothesis.

Traditionally, the gaining of biomedical information forms the basis of the medical interview; however, of equal importance is the investigation of the patient’s perspective on his/her symptoms, and the role that it plays/will play in their road to recovery. In this document, the psychosocial approach necessary during gathering of information will be discussed and investigated, while specific detail on the biomedical side of the interview will be covered in a follow-up session.

Disease vs Illness

The terms “disease” and “illness” both refer to ill-health. From a medical anthropological perspective, these words convey different meanings and contexts:

Disease refers to the structural or functional abnormality of body organs or systems. It entails the pathological entities responsible for ill-health, and are identifiable in form, progress and content. Aspects such as signs and symptoms, natural history, specific physiological parameters, treatment and prognoses of any identified disease is similar universally [2]. Examples are conditions such as asthma, bone fractures, tendinosis or multiple sclerosis.

Illness encompasses an individual’s specific response to being unwell and the effect that ill-health has on life experience. It can include their view on the origin of the condition, personal significance or an existing framework thereof, the effect of the condition on their behaviour or relationships, as well as any steps taken to manage the condition. Illness thus provides meaning to the experience of ill-health, rather than focusing on the pathological parameters of a diagnosis. The emotional impact of illness can be significantly influenced by social and cultural backgrounds as well as personality traits[2].

The shaping of illness and the subsequent behaviour is often determined by a patient’s perception of the specific occurring incident. Either consciously or subconsciously, patients usually ask six questions in making sense of their ill-health [2]. These questions are explored in Box 1 using an example of nonspecific back pain in an office worker. His thought processes will be shaped by the answers to the six mentioned questions (potential answers added in italics).

  1. What has happened? (My back hurts badly and is getting worse.)
  1. Why has it happened?  (Maybe I lifted something heavy, maybe my mattress or office chair is faulty, maybe there is a problem with the spine?)
  1. Why to me? (My mom had a bad back, it must be hereditary. And I am an office worker, so I sit all day, which is bad for my back. I also don’t have a strong core.)
  1. Why now? (I am middle-aged, maybe there is degeneration?)
  1. What would happen if nothing is being done? (It can become worse, and what if something serious is wrong? I could become decapacitated or even end up in a wheelchair like my mom.)
  1. What steps should I take to manage it? (Should I self-medicate? I know my core is weak and I am overweight, so maybe I should exercise more. Maybe I must consult the doctor?)

Box 1: Questions determining extent of illness to patients[2]

Cassell (1978) summarised the difference between disease and illness:  “Illness is what a man has when he goes to the doctor. Disease is what he has when he returns from the doctor’s office. Disease, then, is something and organ has. Illness is something a man has.”[3] Therefore, disease focuses on the biomedical aspect of ill-health, where illness include personal, cultural and social factors which describes how a patient experiences ill-health. Illness and disease mostly co-occur, but can also present in the absence of each othe[4] . Also, they can have a circular effect on each other[2]. For example, a patient may be suffering from undiagnosed upper cervical joint pain with a referred headache (disease). Stress and anxiety surrounding possible origin and prognosis of disease (illness) can lead to clenching and subsequent muscle spasm, resulting in a tension headache which will exacerbate the original headache.

Considering disease and illness in the medical interview

Healthcare professionals are well-equipped to deal with disease and the acute presentation thereof. They have been taught how to make diagnoses on clinical signs and symptoms and physiological parameters, and tend to much better understand the concept of peripheral pain mechanisms than central pain mechanisms [5]. Although the investigation of disease is truly important in the interview, the neglect to regard the role of central pain-processing mechanisms (attributing to illness) will lead to an incomplete gathering of information and a failure to achieve a true patient-centred approach. Also, when a healthcare professional focuses mostly on the biomedical aspect of a condition without regrading potential perception and fears around the symptoms, the possibility exists that medical management can actually exacerbate symptoms rather than treat them.  For example, explaining joint pain as a result of ‘some wear and tear’ may be well-intended to put the patient at ease and encouraging return to normal activity. However, the interpretation of ‘wear and tear’ may exacerbate the idea of vulnerability in certain patients and lead to fear avoidance of movement, which is the opposite of what was initially intended by the healthcare professional [5].

Skillset for gaining psychosocial information

A shift from a ‘disease model’ to a ‘biopsychosocial model’ in the patient interview is integral for a comprehensive clinical picture. The term” biopsychosocial” refers to a combination of a biomedical investigation, understanding social background and context, and regarding a person’s potential psychological connections to their illness. When placing equal emphasis on all three these factors, the clinician will conduct a well-balanced interview, gaining information holistically and specific to the individual.

A psychosocial approach “tells the patient’s illness story”,  and explains and predicts the individual’s experience and response to illness[4]. Different to biomedical information, which is based on pathophysiology and mostly peripheral pain mechanisms, the gaining of psychosocial information is often abstract and not quantitative. This, together with the fact that clinicians often have a poor understanding of central pain mechanisms underlying illness, makes the gaining of psychosocial information challenging to many health care professionals[5].  Certain skills can be learned and engaged in the medical interview to effectively gauge the psychosocial influence on the presenting condition, as discussed below:

Active listening

Active listening puts patients at ease, signals interest from the clinician’s side and thereby facilitates disclosure of information without feeling pressured. It involves both verbal and non-verbal behaviour. In terms of non-verbal behaviour, the listener should be seated, facing the patient at a comfortable distance, leaning slightly forward and making good eye contact. The clinician should also allow the patient to talk without interrupting, and leave space for the patient to think before answering [6].

Verbal behaviour includes appropriate questioning techniques, such as the use of the open-to-closed cone, facilitation and summarising. The open-to-closed cone describes the initial use of open-ended questions, followed by more close-ended questions to verify information. Facilitation refers to comments or behaviour by the interviewer that will encourage the patient to continue talking along the same lines. Summarising takes place when the clinician offers a concise repeat of information gathered thus far to the patient[7]. This ensures that all information is understood correctly and provides the patient with an opportunity to clarify details, make corrections or add more information[6] .

Explore belief systems

Medical belief systems are influenced by various aspects, under which culture, religion, community and education. Patient health beliefs may differ vastly from scientific medicine. An example is the health belief system of traditional Aboriginal Australians, who attributes ill-health to nature, environmental forces, supernatural forces or Western influences[8] rather than following a pathophysiological model. Another well-known and controversial example is the religion-based prohibition of certain medical procedures, some of which may be life-saving [9].

It is essential for the clinician to explore and respect their patients’ health belief systems, regardless whether it differs from the clinician’s personal viewpoints. This is significant for a number of reasons. Firstly, the acknowledgement of health belief systems provides the clinician with a more complete idea of the patient as a person, contributes to patient-centred medicine and may predict how certain patients will act in response to illness or suggested treatment[4] .  Secondly, certain health beliefs involve preferences in terms of medical management. This may include aspects such as the clinician being the same sex as the patient, the involvement of family in decision making[8] or the carrying out of certain medical procedures[10]. Thirdly, regarding spirituality, a positive link has been established between religion and patient well-being and recovery. Therefore, optimal spiritual support can contribute to better recovery rates[9] .

The exploration of the patient’s medical belief system can be a potentially sensitive issue, but should not be avoided or omitted to prevent an awkward situation. When investigating the patient’s belief systems, remain open and objective. Ask if you do not completely understand and adapt an attitude of acceptance and willingness to learn more about the patient’s background. Avoid any non-verbal communication that may come across as disapproving or judgemental, such as frowning or shaking the head[11].

Explore patient perceptions and concerns, and setting the agenda

Empathy is defined as the cognitive understanding of a patient’s experiences, concerns and perspectives, and the ability to communicate this understanding in order to help alleviate any form of suffering or discomfort[12]. An empathic clinician creates a space where a patient feels comfortable to disclose sensitive information without fearing judgement or breach in confidentiality. The clinician also needs to thoroughly understand the patient’s perceptions, concerns and biases regarding the presenting condition. Asking a patient what he/she thinks the problem is, not only provides a comprehensive viewpoint of patient perception, but may also encourage the patient to share any deeper emotions and fears regarding a potential diagnosis[6] .

There is often a mismatch between patient and clinician agendas in the medical interview. The clinician’s agenda tends to focus on the gaining of information with the end goal of a clinical hypothesis, and is mostly driven by a more biomedical approach. Patient agendas focus more on conveying their problems and concerns to the clinicians and mostly include psychosocial aspects which can easily be missed by clinicians[13] . Patients provide certain clues in communication regarding life circumstances or emotions that may contribute significantly to the clinical image. If such clues are ignored, the clinician fails to integrate the patient as a person, and subsequent medical management may not address patient concerns in their entirety [14]. For this reason, clinicians need to be able to listen holistically rather than simply gaining biomedical information.

Underlying concerns and biases are often expressed subtly or in a by-the-way manner in conversation. Patients may seemingly deviate from the line of conversation, mentioning factors or concerns that provides insight into their circumstances or affect towards their symptoms. The clinician will need to prioritise topics that emerges from conversation which may need further exploration. However, when a clinician misses a concern that the patient deems significant, the patient will be likely to repeat the concern later in the conversation. Such an issue should then be acknowledged and addressed [14].

Determine patient expectations

Similar to agenda setting, clinicians and patients often have different expectations from a medical interview. Patient expectations are often more complex than the relief of symptoms. Expectations can include aspects such as the exploration of alternative treatment options, diagnostic clarity, reassurance and verification, or even the opportunity to voice frustration and anger. Conversely, the clinician might have a different set of expectations, such as performing or requesting certain tests to confirms or negate a diagnosis, to provide immediate symptomatic treatment or to determine the appropriateness of interventions requested by the patient. Where there is a mismatch between clinician and patient expectations, this needs to be negotiated between the two parties [5].

An example: A patient who sustained a whiplash injury a decade ago reads about Pilates-based rehabilitation to optimally strengthen her neck muscles. She suffers from occasional low-grade headache that she manages symptomatically, but she is now keen to engage in rehabilitation to address the neuromuscular control issue. She decides to visit a physiotherapist to find out more about the rehabilitation.  On learning about the whiplash injury and occasional headaches, the physiotherapist focuses all her attention on manual therapy to assist with headache relief, without offering an explanation as to how she plans to link her manual therapy approach with rehabilitation and motor learning. The contrast between clinician and patient expectation is evident: where the patient’s expectation is the provision of Pilates-based exercises, the physiotherapist’s expectations are to provide relief from headaches. While none of the two parties are clinically wrong, the mismatch in their expectations will likely lead to poor patient buy-in and poor addressing of her main concern. A better approach may have been education by the physiotherapist to the patient on the adverse role of pain in neuromuscular control and the importance of addressing pain before rehabilitation of movement, and then realign their expectations collectively.

Explore the impact of symptoms on the patient’s life

Functional impairment is a major threat to many patients, especially if their regular income or normal functioning is at stake. Clinicians need to explore the extend of functional impairment due to the presenting condition, but also how this impairment affects the patient on an emotionally and psychologically. Threat value can influence illness in many ways, often subconsciously. For example, if a patient fears that a presenting condition can result in loss of occupational function, he may ignore or deny symptoms out of fear for losing his job. Unresolved pathology can lead to even more complications and exacerbate the patient’s condition[4] . Where possible and applicable, the physiotherapist should seek to council and provide patient support to optimise occupational and functional ability, or alternatively, to refer the patient to other social or occupational professionals for optimal management and return to regular function.

Conclusion

The role of the psychosocial assessment in the medical interview should never be underestimated. A thorough psychosocial evaluation will provide a holistic view of the patient and condition and assist the clinician to devise an all-encompassing management plan. Also, proper focus on the psychosocial aspects of the patient enhances the therapeutic alliance and improves patient compliance as an active participant in the process of treatment and rehabilitation. Picking up on psychosocial cues and clues as opposed to the acquisition of concrete pathological information is often challenging for health care workers. However, psychosocial evaluation is a skill that can (and should) be learned and improved, and an investment in gaining the complete clinical image necessary for holistic and comprehensive patient management.


References

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