Profession Comm. 7

How to Conduct the

Patient Inter view

PATIENT COMMUNICATION

“What seems to be the problem?”

I can’t tell you how many patient interviews I started

that way—hundreds, at least—probably because that’s

how doctors and nurses spoke to me when I was growing

up. Then one day I decided my opening sounded a little

patronizing, as if “the problem” only seems to be one to

the patient and, in fact, isn’t much of a problem at all.

Yes, I know that’s a lot of analysis for a pretty common

expression, but the way we approach patients is just

one aspect of assessment that can be enhanced easily

without rewriting protocols or going back to school.

We’re going to cover lots more about evaluating patients

but first, let’s consider what effective interviewing is

and is not.

Interviewing is a bit like selling. A good interviewer

(salesperson) tries to get the subject (buyer) to part with

something of value: information instead of money. Doing

that requires strategy and practice. More important,

though, a successful interviewer needs specialized com-

munication skills—not the kind that leads to long dis-

courses on cerebral topics in rooms full of people, but the

kind that allows the interviewer to effortlessly connect

Communicating successfully with patients requires strategy, fexibility and practice By Mike Rubin

In this three-part

series, EMS World

columnist Mike

Rubin discusses

interviewing

techniques. Part 2

focuses on patient

Q&A.

28 OCTOBER 2015 | EMSWORLD.com

iS to c k /T h in k s to c k

ABOUT THE

AUTHOR

Mike Rubin is a

paramedic in

Nashville, TN,

and a member

of the EMS

World editorial

advisory board.

Contact him at

mgr22@prodigy.

net.

with the subject in an engaging and efficient

manner, yielding an exceptional ratio of use-

ful information per minute of conversation.

Good interviewing also requires humil-

ity—the ability to subordinate one’s ego to

the task at hand. Interviewers who make

themselves the focal point of interviews—

and there are many—waste both their time

and their subject’s time by augmenting

dialog with observations and anecdotes of

their own instead of with good follow-up

questions. Such self-serving digressions can

almost sound as if the subject were inter-

viewing the interviewer!

Interviewing patients in the field requires

flexibility because there are two broad cat-

egories of cases presenting in modern-day

EMS, emergent and nonemergent, that

require different intelligence-gathering

approaches.

In emergent scenarios with verbal

patients, minute-long assessment-driven

interviews are still the norm. In nonemer-

gent cases, we can usually take more time

to learn about the patient and the environ-

ment behind the complaint, or even try to

anticipate the next complaint.

Let’s start with similarities between

emergent and nonemergent interviews.

The Initial Encounter

Meeting anyone for the first time should

involve, at the very least, a commonsense

goal of polite, non-threatening discourse.

Begin by trying to put the subject at ease.

When “What seems to be the problem?”

wasn’t working for me, I switched to “So

why did you call us today?” Direct, but also

a bit condescending, don’t you think? Some

of my patients did—at least one for sure, who

looked at me with disgust and answered with

as much sarcasm as his COPD would allow,

“Why, do you have something better to do?”

I wasn’t happy with my opening until

I started greeting patients the way I did

almost everyone else: “How’s it going?” It

didn’t seem to matter that an honest answer

from sick people would almost always have

been “Not too well.” Patients seemed to

value informality over precision.

As important as our first words is our

posture. You’ll often get better information

faster by making eye contact at eye level,

which usually means kneeling beside a seat-

ed or recumbent subject not too close and

not too far away. Dr. Judith Orloff, author

of Emotional Freedom, suggests an “arms-

length bubble” as an “invisible border that

surrounds us and sets our comfort level.”

Don’t forget the part about eye contact. I

think the biggest mistake many responders

make is to approach their patients wear-

ing sunglasses. Talk about condescending,

particularly indoors!

Next it’s time for some high-frequency lis-

tening—by us, not by our subjects. Remem-

ber, this isn’t about us.

High-frequency listening means focusing

on our patients and absorbing their answers,

EMSWORLD.com | OCTOBER 2015 29

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PATIENT COMMUNICATION

not just with our ears but with our eyes, too.

Every expression, every gesture, every move-

ment can be part of the information we’re

looking for. This isn’t the time to be thinking

about our next call or our next meal.

Is the patient sick, scared or in pain? Are

they hiding something? The answer to all of

those questions is probably yes, but watch

for the ways questions are answered. A sub-

ject’s words plus tone plus body language

equals a whole lot of feedback.

Some crews double- or even triple-team

patient interviews. That just makes it harder

for interviewers to progress in an orderly way

from the general to the specific and ramps

up the intimidation factor for the subject.

The most challenging of all interviewing

skills is absorbing verbal and nonverbal cues

while formulating new questions—open-

ended, whenever possible—based on pre-

vious answers. It’s easy to let experience or

fatigue overwhelm high-frequency listening

and make us resort to a mental script of

practiced questions, but it’s the ability to

vector toward unanticipated, possibly valu-

able information that earns an interviewer

exceptional results.

Now that we’ve covered all-purpose

patient interviewing techniques, it’s time

to discuss the differences between emergent

and nonemergent patients.

The Emergent Patient Setting aside scene safety for the moment,

if recognizing how urgently a patient needs

care is the first step of a “doorway assess-

ment,” the second step would arguably be

deciding how effectively we can deal with

serious illness outside of a hospital.

Except for when we encounter a clear case

of treat right now, such as cardiac arrest or

profound hypoglycemia, we need to concede

that we have neither the tools nor the train-

ing to consistently diagnose and treat ill-

nesses correctly, and that hospitals are good

places to get help. Once we buy into that,

our efforts on scene should be focused on

initiating transport, which means the clock

is ticking as soon as we start our patient

interview.

When I was in EMT class I learned to

use the mnemonic SAMPLE as a guide for

that interview. That isn’t always the best

approach. Not only are A (allergies), M

(meds), L (last meal) and E (precipitating

events) often not as important as other

questions during our first 60 seconds with

a patient but, as EMS educator Dan Limmer

points out, SAMPLE is too much of a rote

process that doesn’t encourage vectoring

toward a chief complaint’s likely cause.

With experience, many field providers

employ a two-step emergent patient inter-

30 OCTOBER 2015 | EMSWORLD.com

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DON’T HESITATE TO CLARIFY ANSWERS TO YOUR QUESTIONS.

view that is a better use of limited time than

front-loaded SAMPLE, but still consistent

with the philosophy of primary and second-

ary assessment:

• Spend the first minute discovering

what you need to know to make treatment

decisions.

• Finish the interview en route while

assembling a background-rich presentation

you’ll give the receiving facility.

The Nonemergent Patient A distinctive aspect of working in a nontra-

ditional EMS environment—entertainment,

in my case—is that many patients present

with nonemergent conditions that make

transport less of a priority and permit more

comprehensive interviews.

As our industry assimilates the com-

munit y-paramedicine paradigm, we’ ll

hear more and more vague complaints

with subtle clues like mild pain or minor

GI upset. A willingness to go into detective

mode and conduct an unhurried interview,

for the sake of both diligence and customer

service, should be as much a part of our

prehospital practice as rapidly treating and

transporting unstable patients.

A good way to proceed during interviews

with nonemergent patients, many of whom

have multiple chronic illnesses, is to pro-

gressively update an “inventory” of their

complaints. For example, “Any discomfort

besides your headache and sore knee?”

shows you understand what the subject told

you so far, and are considering that there is

more useful information to come. Prompts

like “discomfort” or “odd feelings” are more

open-ended than “pain”; to some people, a

sensation such as chest pressure isn’t pain.

Don’t hesitate to clarify answers to your

questions. A patient whose head “feels

funny” might have a cold or an intracranial

bleed. Sometimes friends or family mem-

bers can help patients answer questions,

but beware of bystanders who repeatedly

interrupt your interview. Ask them to let

the subject try to answer. Even better, put

them to work doing something useful, like

collecting the patient’s meds.

Summary As community paramedicine and other

nonemergent initiatives become common-

place in EMS, caregivers are going to need

communication skills that go beyond SAM-

PLE checklists. A minimalist approach to

dialogue with patients, considered preferred

if not essential in what was once almost

exclusively a light-and-sirens environment,

isn’t acceptable when prehospital interven-

tions require a thorough understanding not

only of chief complaints, but also how the

physical part of illness and injury is framed

by the patient’s environment.

Be considerate, be as thorough as time

permits, and pay attention!

Next time we’ll talk about interviewing

prospective employees.

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