A Model for guiding the Pharmacist Patient Interview

Stages
1

Initiating the session

Gathering Information Physical Examination Explanation and Planning

2
3 4

Closing the session

Initiating the session

Establish initial rapport By Greeting the patient Introduce yourself Role and nature of interview Obtain consent Identify reasons for Consultation Open Ended Question ( I understand that you would like to speak to me- how can I help?) Properly listen to the answer Check and confirm the list of problems and queries Pick up any verbal and non verbal behavior clues Agenda for interview

For example: so would you like me to recommend a medicine to help relieve your cough that doesnt make you drowsy?

Gathering Information
Patients ideas and concerns Effects on patients life of each problem Expectations of the patients Patients feeling and thoughts about the problem

Gathering Information
Acronyms The Funneling Technique

Clinical Reasoning

Acronyms
Have been developed to help pharmacist which questions should be asked? WWHAM
Who is the patient? What are the symptoms? How long the symptoms been present? Actions Taken? Medications Taken?

 ENCORE

Explore No medications Care Observe Refer Explain

 ASMETHOD

Age/Appearance Self/Someone else Extra Medicines Medications

Time Persisting

History
Danger symptoms

Other symptoms

 SIT DOWN SIR

Site/location Intensity/severity Type/nature Duration Onset With (other symptoms) Incidence/ Frequency pattern Annoyed or aggravated?

Spread /radiation

Relieved By


Acronyms can be helpful in gaining some information But pharmacist should not rely on them only Each patient is different, and it is unlikely that an acronym can be fully applied

The Funneling Technique

1. 2. Allow direction and focusing of ideas on specific point It involves Initially asking open ended background questions Then specific closed questions to provide specific details and clarify points paraphrasing is important to ensure that the information obtained is accurate This minimizes misinterpretation More than one funnel can be used For ex: establishing a patients current medication and then going on to suggest appropraite action or medication availability Where TIME is a limiting factor, this technique is useful for directing and focusing a conversation to enable an end point to achieved more quickely

Clinical Reasoning
Relates to decision making process It is a thinking process directed towards enabling the practitioner to take appropriate action in a specific context Various models have been used : 1. Hypothetico-deductive reasoning 2. Pattern recignition

Hypothetico-deductive reasoning

A number of hypothesis are genrated w/c are then used to guide subsequent information retrieval from the patient Each hypothesis can be used to predict what additional findings ought to be present if it were true. The practitioner tests hypothesis by asking relevent questions Answer to each question allows the practitioner to narrow down the possible diagnosis by either eliminationg particular condition or conforming suspicions


Hypothesis generation and testing involves: 1. Inductive Reasoning: Moving from a set of observations to generalization 2. Deductive Reasoning: Moving from generalization to a conclusion in relation to a specific case. Therefore;
Induction is used to generate hypothesis Deduction is used to test hypothesis

Pattern recognition
Relies on inductive processes than deduction For example, when a newly qualified pharmacist and a experienced pharmacist see the same patient with the same problem, both might arrive at the same point, but how this was achieved will probably be different. Much of the daily practice will consist of seeing new cases that strongly resemble previous encounters. For this reason expert reasoning in non problematic situations tends to be drawn form pattern recognition from previous knowledge and clinical experience.

Example
A man in his early sixties (slightly over weight) wants something for his cough. 1. Visual Clues: age, sex, & overweight 2. Conditions to consider;
1. Most likely cause of cough in any age patient is viral infection
A. LIKELY: postnasal drip, allergies, acute bronchitis B. UNLIKELY: Croup, chronic bronchitis, asthma, pneumonia, ACE C. VERY UNLIKELY: heart failure, bronchitis, tuberculosis, cancer, pneumothorax, lung absecess

 In this case patient is approx 60 yrs so certain conditions can be eliminated

Croup Pneumothorax Heart failure and lung abscess

This leaves possible 12 conditions


3. Formation of Hypothesis
Initial questions needs to narrow down the no of conditions
Duration of cough Sputum production Presence of systemic symptoms

If we take duration 4-5 weeks

This eliminates acute causes of cough upto 3 weeks duration


1. 2. 3. 4. 5. 6. 7. 8. 9. Now 9 possibilities remains Chronic bronchitis Asthma Bronchiectasis Tuberculosis Cancer Nocardiosis Post nasal drip? Allergy? Medications?


Chronic bronchitis is worse in the morning Asthma is worse in the evening Bronchiectasis is worse in the morning & evening Tuberculosis shows no variation Cancer shows no variation Nocardiosis shows no variation
Patient says that the cough is always worse in the morning Therefore, this tends to point chronic bronchitis


Diagnosis is tentative Now ask supplementry questions( closed) To support differential diagnosis

Explanation and Planning

To provide the correct amount and type of information

To give comprehensive & appropriate information To assess each individual patients information needs & to neither restricts nor onerload To make information easier for the patient to remember and understand


To achieve a shared understanding: incorporating the patients illness framework
To provide explanations/ plans that relate to the patients perspective of the problem To discover the patients thoughts and feelings about the information given To encourage an interaction rather than one way transmission


To plan: shared decision making
To allow the patient to understand the decision making process To involve the patient in decision making to the level they wish To increase patients commitment to plan made

Closing the session

Summarize what has taken place & the joint decision made Inform the patient about the next stage(Follow up) Ensure the patient knows what to do if the problem do not resolve Check weather the patient agrees and feels comfortable with the chosen plan or needs to discuss any other issues