Are We There Yet? A Road Map to the Clinical Interview
Ms. Swanson, her 2 Pembroke Welsh corgis, and twin daughters are waiting for you in the exam room. Judging from how Sampson, the older of the 2 corgis, walked into the clinic your first thought is degenerative myelopathy.
As you enter the exam room, Ms. Swanson hurriedly explains her diagnosis of hip dysplasia and proposed treatment plan that she researched on the internet. You take a deep breath and smile. After all, you have a secret weapon, your communication toolbox, and you know what tools to use to respectfully guide the conversation.
Think of the clinical interview as a road trip. Imagine that the client is in the driver’s seat and you are riding shotgun with a map in your hands. Getting to the destination requires a collaborative effort with much of the responsibility resting on you as the navigator. After all, how does the driver know where to go without some form of direction from you? In the context of a clinical interview, structure acts as the road map. It is a tool that helps you organize the interview in a logical sequence so the client (or driver, in this case) can easily follow along.
Map the Route Using Structure
Providing structure happens throughout the entire clinical interview, as illustrated in The Calgary-Cambridge Guides. Structure acts as the highlighted route between point A and point B on the map. The service areas along the way are the phases of initiation, gathering information, physical examination, explanation and planning, and closing the session. Structural statements build bridges to transition effectively between each of these interview sections.
Structuring the clinical interview in a logical sequence is beneficial to both you and the client. It provides a clear route while attending to the flow of where you’ve been and where you’re going. Providing an overt logical progression also helps the client follow the route. Think of it this way—Ms. Swanson is trying to follow your directions while driving on the interstate during rush hour. Zigzagging through traffic and zipping on and off exit ramps is far from efficient and could result in literally and figuratively losing the client.
Laying out a route and referring to the road map frequently during the visit ensure that you stay on track and arrive at the destination successfully. Furthermore, following a logical sequence fosters a complete and systematic approach to gathering information, client education, and diagnostic and treatment planning.
"Thanks for coming in Ms. Swanson; it’s great to see you again. You certainly have your hands full [empathy]! Would it be okay if we worked with one dog at a time [asking permission]?"
"Let’s start off by talking about how they’re doing at home, then I’ll perform their physical exam, and together we can come up with a plan that addresses your concerns [sign posting]. How does that sound [check-in]?"
Tools of a Skilled Navigator
Use these 3 key tools to help navigate the clinical interview:
1. Structure: Organizes the interview in a logical sequence.
2. Sign Posting: Provides a smooth transition between topics.
3. Internal Summary: Confirms understanding and accuracy of information with the client.
Using Sign Posting as GPS
Providing structure through the use of sign posting draws a distracted client back into the interview, keeps the visit on track, and allows you to share your thoughts and needs with the client. Sign posting also builds rapport, as it asks the client permission to move between topics or sections of the interview and assesses whether the client is ready to move on.
"Ms. Swanson, if it’s all right with you and the twins [asking permission], I’d like to start by getting some information about Sampson [sign posting]."
Sign posting introduces and draws attention to what you are about to say and then provides the client with the rationale behind the direction you’re headed. It’s like GPS telling you to turn left in 2.5 miles and then reminding you again when you’re within a mile.
"You mentioned hip dysplasia, which is a valid concern. Is it okay if we start by talking through Sampson’s medical history [asking permission], so I can get a sense of his overall health? Then we can dive into your concern about his hind end [sign posting]?"
Sign posting allows Ms. Swanson to smoothly exit the interstate to the next topic with you rather than pulling off and asking for directions—or worse, becoming completely lost. It lets her know that you will dedicate time to discuss her concerns, allowing her to focus on what you’re saying. It saves time, energy, and allows her to take an active part in the process. Letting the client know where you are going and why you are heading there reduces unnecessary uncertainty, stress, and anxiety during the visit.
"Thanks for sharing Sampson’s story. Is it okay if I place Sampson on the table now [asking permission]? I’m going to do a thorough physical exam and pay particular attention to his back legs [sign posting]."
Exit to the Left in 1 Mile—Use Sign Posting to: 1
• Transition from initiation to information gathering.
• Move from open to closed questions.
• Shift from one topic to the next.
• Explore the client’s ideas, concerns, and expectations
• Switch between current problems and past medical history.
• Start the physical exam.
• Delve into explanation and planning.
• Delineate the key steps of the diagnostic or treatment plans.
• Close the interview.
Use Summary to Check Directions
We’ve all had times in our lives when we should have stopped to ask for directions. This would have saved time, gas, and frustration. The use of summary to provide structure to the clinical interview is like stopping to ask for directions. If you are unsure about what the client said or what you should say next, summary is an outlet to check the map and gain agreement of “where you are” with the client. Internal summary allows you to summarize at the end of a specific line of questioning or discussion in order to check your understanding before moving on to the next topic.
Using sign posting as an introduction to your summary provides even more direction for the client and may give you more “bang for your buck.”
"Ms. Swanson, I’d like to make sure I understand your main concerns [sign posting]. You’ve noticed that Sampson isn’t as active as he was in the past and you feel that he’s put on some weight [summary]."
Summary also serves as a clinical reasoning skill to integrate and synthesize the data that have been gathered. Following open-ended inquiry, summary aids the clinician in itemizing, organizing, and prioritizing the clues to the case. It helps discover missing information and areas that need further clarification and is a method to pull it all together. Sometimes as the navigator you can get lost—summary helps identify where to go next and how to get back on course.
"Okay, so it all started with Sampson’s slowing down on walks and has progressed to his having difficulty climbing stairs and getting up from lying down. What really scared you this week was when he lost his balance and went down on his hind end [summary]. Do I have that right?"
Summary pulls together and reviews what you heard. It creates an opportunity to check with the client as to whether you received and understood the information accurately, closing the feedback loop. Through summary we engender confidence in the client that his or her message has been interpreted appropriately. Summary allows you to obtain accurate information and lets the client know that you heard and understood his or her concerns.
Pulling Into the Destination
As the navigator, you structure the route and help guide clients to the destination through the use of sign posting and summary, allowing them to stay in the driver’s seat. This leads to efficient use of time, increased compliance, and a clinician and client both headed in the same direction. Can you say road trip? | EVT
The Communication Toolbox is based on the framework of the Calgary-Cambridge Guide. Each issue, we’ll teach you a new exam step and add evidence-based skills to your toolbox!
1. Skills for Communicating with Patients. Silverman J, Kurtz SA, Draper J—Arbingdon, UK: Radcliffe Medical Press, 2005.