Linda GaskUniversity of Manchester

Problem-Based interviewinga modelDevelopment by Art Lesser in Canada in

1980s.One of several models!

Key featuresSimple- minimal theory!Active- videofeedbackBased on real material‘Problems’ not symptoms.Process not outcome.Extensively evaluated.

Three key sources of informationWhat the patient says: the ‘History’- but also

verbal cuesWhat the doctor ‘sees’ and ‘hears’: nonverbal

and vocal cues.What the doctor feels.

Problem detection skillsBeginning the interviewPicking up/responding to verbal cuesPicking up/responding to non-verbal cuesDemonstrating empathyAsking about health beliefs/concernsControlling the interview

Picking up/responding to verbal cues

Open questionClarificationExample

Problem Management skillsVentilating feelingsInformation/educationMaking linksNegotiationMotivating change/promoting self-

managementConjoint interviewing

Skills needed in trainingPutting trainee at easeSelection of materialSetting the agendaStopping tape to teach: ‘decision points’

Skills needed in trainingFocus on skillsConstructive criticismHierarchy of prompts

Impossible patients?Much of the published literature is about

problem patients.Is the problem really one of problematic

interactions rather than problem patients?

Complex interactionsDemanding problems?

Multiple problemsSocial difficulties ‘not medical’‘Medically unexplained symptoms’Unmet emotional needs

Complex interactionsComplex communication

Physical barriers (eg. deafness)Communication styleLinguistic barriersCultural barriersEmotional tone

Atypical balance of power‘Expert’ patientsConsulting with fellow professionals

Complex interactionsPotential for disagreement

Physical or psychological?Having treatment or not?Changing behaviour or not?

Complex dynamicsCouplesFamiliesParents and children

I came to medical school with the idea that really got reinforced in my training, that if you really learn everything and you really do care about your patients, if you really are a great doctor then you can take care of it all….. (From Gerber 1983)

Factors that predict our resistance to stressCharacterChallengeCommitmentControl

What do you get out of your work?What does your work get out of you?

Recognising and tackling problemsReflection- awareness of our thoughts,

feelings, reactionsAcknowledgementOwnershipMotivation to changeAction

Breaking the problem downHelps with clearer definitionEnables sense of control and achievement

earlierFact or assumption?What, when, where, who and how?

Establish achievable goalsWhat are the key sources of support that I

have?Can I make use of them?If not, why not?

What sources of relevant training do I have access to?Can I make use of them?If not, why not?

Establish achievable goalsAre the expectations that I have of myself

realistic or unrealistic in this case?Am I guilty of undervaluing what I have

achieved so far?

Generating solutions to problems‘Brainstorming’The more the merrierMix and combineAvoid judgement

KEY SLIDE 22

Challenging the way we think about complex interactions with our patientsShare your difficultiesChallenge your attitudes but

Also be prepared toBe clear about your boundariesConfront hopelessness in yourself but also be

prepared toAccept your own powerlessness when

necessary(Getting the balance right between the two)