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 Step-By-Step Guide
Tips and Traps
Resources
Step-By-Step Guide
How to Critique an Interview and Examination
Dr. Lee Mendoza, the attending physician in your department, has asked you to assist in the case review process and has sent you your first case to review. You will begin to critique a case handled by one of your fellow interns, Dr. Jessica Chang. Dr. Mendoza would like you to carefully observe what was done (or not done) in the handling of this case and to write a critique of each part of the diagnosis and treatment process for this patient.
Your first task is to write a critique of the patient interview and the physical examination. To do this, you will examine the video and notes documenting Dr. Chang's interview and examination of the patient, Jenny Anderson, and then you will fill out Lakeshore Hospital's standard critique template.
Remember, the purpose of the interview and examination is to find out details about the patient's present illness or condition, to gather a variety of data about the patient that will help in diagnosis, and to establish a positive working relationship with the patient. In the case of a sports injury, the physician gathers information about such things as pain and tenderness, swelling, and limitation of motion in the joints. You will be looking to see whether Dr. Chang accomplished this in a thorough manner, while also remaining focused on the main goals for this visit.
Getting Started
- Before meeting with your teammates, prepare for your work on this task.
- First, go to the second email sent to you by Dr. Mendoza, and locate and/or download the attachments. You will need the following throughout the task:
- Video of the Interview and Examination- Use this video to closely observe everything that took place during the patient visit.
- Patient Interview and Physical Examination Form - This form contains Dr. Chang's notes recording her findings from the visit with Jenny Anderson.
- Critique Template of the Interview and Examination - This is the form that physicians at Lakeshore Hospital use to write up the first part of a case review; it covers the key elements of a good interview and examination. Use this form to write your critique.
- Plan a time to meet with your team for your first work session.
- With your teammates, review the email from Dr. Mendoza to become familiar with your task. You may find it helpful to restate in your own words what you are being asked to do.
- Together, start reading the document titled Diagnosis and Treatment Process.
- This document describes the process that health care professionals typically use to diagnose what is wrong with their patients and to develop treatment plans to help them. You will learn and apply this process in your role as an intern. (An intern is a first-year physician who has completed medical school.)
- Read about the first step in the process: Determine available and relevant clinical findings and risk factors. Pay close attention to the section under Easy and inexpensive first steps; these are the steps to focus on in your critique.
- Watch the video of the interview and examination, and skim Dr. Chang's notes about Jenny Anderson's condition (on the Patient Interview and Physical Examination Form). As you view these materials for the first time, note your first impressions.
- What did you notice about the intern's interview and history-taking? What did you notice about the physical examination? Did anything stand out or surprise you?
- Was there anything you especially liked or disliked about what Dr. Chang did?
- Note any questions about interviewing and examination you may have that you would like answered as you complete this task. Taking note of these questions might help you to focus your thinking in this task.
- Familiarize yourself with the template you will use to critique Dr. Chang's interview and examination (Critique Template of the Interview and Examination).
- Read the general instructions in the beginning of the template so you'll understand how to use it and be aware of the questions you'll need to answer. You will follow a similar process for each of the subsections on the critique template.
- Read through the template to preview the different parts of the interview and examination that you will be expected to critique. Within each section, there are specific elements listed that typically are present in a good medical interview and physical examination. Read to preview the elements that you will be looking for in Dr. Chang's work. You will learn more about these elements as you do your critique.
- Organize your team to do the critique.
- It is up to your team to decide how to organize the work in this task. You may want to use the strategy of “divide and conquer” so that team members split up the work, or you may want to help each other cover the same ground. If you decide to divide the work, it is important for you to meet regularly to touch base on your progress and share the information you have found. Regardless of how you decide to break up the work, each team will need to submit a single, unified document to the mentor for review.
- For help with working as a team, managing your time, and managing a project (managing the work in a task is similar to managing a project), see the sections on Teamwork and Project Management in the General Skills Resources in the left menu.
Completing Section I: Patient Interview and History
Interview Style and Process
In this section, you will critique Dr. Chang's interviewing style and process. You will be looking at the physician's manner of handling the patient and going about the process of gathering information. You will evaluate whether she used techniques that helped in the exchange of important information. You will also judge whether she helped to form a positive relationship with the patient since this can be important in creating a positive outcome for the patient.
Note: It may be necessary to watch the video and read the notes several times as you go through in order to cover all of the required elements.
- First, read about how to conduct an effective interview with a patient. Focus especially on the style and process elements that you find. In other words, for now, focus less on what questions to ask and more on how to ask them.
- Visit the Resources section (above) and explore the materials listed under Conducting a Patient Interview and History. It may be helpful to take notes on some of the key points that you find.
- Read the Tips and Traps (above) for more advice about conducting a patient interview.
- Reread the first section in the Critique Template for the style and process elements to be focused on when you critique Dr. Chang.
- Watch the video, looking for evidence as to whether those elements are present or not.
- Follow the instructions below to complete the Critique Template.
- In the second column of the table, indicate whether the element indicated is present in the interview (video).
- In the third column of the table, comment on the importance of the element indicated to this particular visit. Indicate whether you think the element was necessary and provide your reasoning. For each element, you'll need to address the following:
- Do you think that the element was necessary to include in this particular instance? (Answer yes or no.)
- It is possible that your opinion on a particular element may be different from the choice Dr. Chang made. (That is, you may think the element was necessary to this case but Dr. Chang left it out, or you may think it was irrelevant but he included it.) If this is the case, note your disagreement, explain your reasons, and then explain what you think Dr. Chang should have done instead.
- Remember, if a certain element would be unlikely to prove critical to this case and would take up time, it may be the right decision to leave it out.
- Justify each answer with your own thinking and with ideas from the resources you read.
- For those elements that Dr. Chang chose to include, use the last column to comment constructively on her performance. Consider the following:
- What did she do well?
- What could she do to improve her performance next time?
History of the Present Illness and Patient's Medical History
These are the two areas a physician generally covers when taking a patient interview and history.
- First, read about the specific content a physician should seek when interviewing a patient. To do this, see the section on Conducting a Patient Interview and History in the Resources (above).
- Research what information a physician typically includes when taking a history, and read about some ways to draw out this information.. This part of the interview covers the background and details related to the patient's main problem.
- Research what information a sports medicine physician typically includes when recording the patient's past medical history.
- Read the “History of the Present Illness” and “Patient's Medical History” tables in the critique template for an overview of what you should see in the video of the case and in Dr. Chang's notes. As you read, take preliminary notes on any ideas you have about what you might want to look for when reviewing the video and notes.
- Review the video and the notes to determine if Dr. Chang gathered the appropriate content in the interview.
- Complete the tables in the Critique Template covering the History of the Present Illness and the Medical History, following the template instructions.
- In the second column, indicate whether a discussion of this content was present.
- For the “History of the Present Illness” section check to see that Dr. Chang included all potentially relevant details about the main symptoms.
- For the “Medical History” section, check to see that Dr. Chang asked about all factors that might have a bearing on the present problem.
- In the third column, comment on the importance of each element to this particular visit. Indicate whether you think each element was necessary and provide your reasons why.
- As in the interview style and process section, your opinion may be different from the choice Dr. Chang made. If this is the case, note where your thoughts diverge from Dr. Chang and give the reasoning behind your answers.
Completing Section 2: The Physical Examination
General Orthopaedic Exam Guidelines and Ankle Examination Guidelines
- First, read some background information to prepare to critique the physical examination.
- In order to understand the examination of the ankle and foot, you will first need to be familiar with the structures found there. Consult the section on Ankle Anatomy in the Resources section (above).
- For information on conducting a physical exam in cases of injury to the ankle and foot, see the sections on Physical Examination of the Ankle in the Resources section (above).
- Read Section 2 of the Critique Template for the elements you will focus on when you critique Dr. Chang's physical examination. As you read, take preliminary notes on any ideas you have about what you might want to look for when reviewing the video and notes.
- Watch the video and review Dr. Chang's notes, looking for evidence as to whether those elements are present or not.
- Complete the tables related to the physical examination, following the instructions in the template.
- Fill in yes or no to indicate whether each element was present.
- Comment on whether you agree with Dr.Chang's choice to include or omit that part of the physical exam. Justify your opinion with specific facts from your research and your own ideas.
In order to determine whether each element of the physical examination is called for in this case, you need to understand what that element is and why physicians do it. It is likely that you'll need to revisit the Resources (above) in order to read more about certain elements. It may help to consider the following questions:
- What is the meaning of the medical terms used? If you don't know, look them up in the Resources (above). The Sports Medicine Orthopaedic Glossary will be especially helpful.
- What is the purpose of performing this test or action? What can it tell you?
- Does this test or action provide information the physician needs to know about this patient?
- Can this test or action be done successfully at this time, or would it be inappropriate due to the patient's present condition?
- For the elements Dr. Chang did perform, comment on what she did well and what she could improve. Consider whether Dr. Chang performed each test or action correctly, based on your research.
- To know whether Dr. Chang performed each test correctly, you'll need to know how each test is normally done by an experienced sports medicine physician. For guidance, use details provided in the section on Physical Examination of the Ankle in the Resources (above).
- Also refer to the Tips and Traps related to physical examination.
Meeting to Exchange Feedback
- Meet with your cohort (made up of all teams participating in the rotation) to discuss your findings and ideas. Your team will be assigned one or more sections of the critique form at the beginning of the meeting; your team will present the key ideas and lead the discussion of that section with the cohort.
- Edit your work. Make any additions or changes.
- Now that you have had the chance to discuss with your peers, you may have new insights to add to your critique.
- Remember that there is not necessarily a “right” answer, so your comments may not always be identical to those from other teams. Whatever your responses, be sure that you have provided a thorough rationale to support your opinions.
- Submit your work to your mentor. Be sure to save all of your work, regardless of whether you submit it to the mentor.
Tips and Traps
Interview Style and Process
- Physicians do use proper names or titles when referring to the patient and family members.
- Physicians are friendly and show sincere interest in a patient's life.
- Physicians do not react in a negative way (e.g. showing impatience, disgust, disapproval, or boredom) while in the room with the patient or while discussing the patient with colleagues.
- Physicians do not make comments that are judgmental or critical about what happened to put the patient in this condition or how the patient or family handled the condition before this point. Physicians do show empathy with what the patient is going through.
- Physicians do not prematurely reassure the patient by saying, “Everything is going to be just fine.” Along the same lines, physicians do not prematurely upset the patient and family by giving a diagnosis that is not yet confirmed (for example, jumping to the conclusion that a patient has cancer). Physicians do use great caution not to say things that might not be correct.
- When physicians do not have the answer to a patient's question, they do not give an opinion right then and there. However, physicians need to maintain the patient's confidence and to let the patient know how his/her concerns will be addressed. One way to handle this situation is to explain that you need more information before you can give a comprehensive answer. Patients often are comforted by the knowledge that you are in pursuit of that information. Another way is to tell the patient your area of practice and indicate that you may need the help of other specialists. This is acceptable, since no one physician today is an expert in all areas of medicine. For example, a physician in the emergency room might schedule a patient to see a specialist in a certain area. A medical student or intern who is unsure about an issue can say, “I'd like to confirm this with my attending physician.” A physician in a hospital may need a radiologist or other expert to help read test results but may be alone in the middle of the night. The physician can inform the patient that s/he will be contacted during the day, after the specialist reads the results. While physicians do not need to be omniscient (all-knowing), the patient needs to feel confident that s/he is in good hands.
Interview Content
- Physicians do record the chief complaint(s) in the patients own words, whenever possible. For example, “I feel feverish and weak.”
- Physicians do ask open-ended questions that will help in diagnosing the patient's condition. Physicians do not jump to conclusions ahead of time, but are aware of what the possibilities are, and use those to guide their questioning.
- Physicians are guided primarily by what the patient says and does, rather than by the interview form or a rigid format. For example, it may be better for the physician to ask follow-up questions and to allow the patient to keep talking about something s/he brought up rather than to jump too quickly to the next question or topic. By being too abrupt or directive, a physician might prevent the patient from giving additional important information.
- Physicians do not ask about too many items at once, e.g. “any allergies, asthma, bronchitis, sinusitis, or pneumonia?” Patients will not be able to respond to everything at once, and they might skip one of the questions. Instead, physicians ask one question at a time.
- Physicians do not use medical jargon that is unfamiliar to the patient. For example, a physician says “shortness of breath” instead of “dyspnea” in order to be clearly understood and to avoid intimidating the patient.
Orthopaedic Physical Examination
- Physicians are clear about the nature of the patient's problem from the interview and history. Physicians determine whether the pain is coming from an acute (sudden) injury or whether the pain started spontaneously (on its own, without explanation); this will affect the examination. Many different tissues and organs, when inflamed or injured, can cause pain that seems to come from the musculoskeletal system, even when it doesn't. If the pain is mistaken for muscular pain, another disease in the body could be missed. However, if there is history of a recent injury, and there was no pain previous to that injury, physicians can feel confident that they are dealing with an orthopaedic problem.
- Physicians do observe the joint while the patient attempts to perform normal motions and activities. They focus on the following questions: What can't the patient do? What is limiting him/her?
- Physicians do not ignore an increase in the mobility or range of motion of a joint. Excessive mobility can mean there is a problem with the stability of the joint. Physicians look for both limitations in mobility and unusual increases.
- Physicians do examine the unaffected side to compare their observations from visual inspection, palpation, and tests of range of motion with the patient's normal condition.
- When palpating (touching), physicians do try to determine the specific anatomical structure that is tender.
- Physicians do palpate the joint line medially and laterally. They also palpate areas that influence the symptomatic part, including the joint above and the joint below the area.
- Physicians do not force the patient to go through tests that cause a lot of pain if those tests are unnecessary at that particular time. Whenever it wouldn't risk further harm to the patient, waiting for acute symptoms such as swelling and pain to subside is acceptable.
Meeting to Exchange Feedback
When it is your team's turn to present:
- Rather than reciting everything that you wrote, pick a few key ideas that you would like to bring to the group. For example, you can focus on places in the interview and examination where you strongly agreed or disagreed with Dr. Chang's choices.
- Be sure to back up the points you make with research or with strong, logical arguments.
- Be open to hearing disagreement or different ideas from other teams and be open to listening to those ideas. If your points generate some debate, then you know you have done your job well and hit upon an interesting issue. Both your team and other teams can learn from the discussion.
When you are listening to other people present:
- Listen carefully to the thoughts the other teams are sharing, and note how they are the same or different from your own.
- Be aware that you'll have an opportunity to revise your work following the discussion, so it is in your interest to pay close attention. The discussion may help to clarify parts of the interviewing and examination process that you weren't sure of, or it may bring up new ideas that hadn't occurred to you.
- It may be helpful to jot down notes to record what you learn in the discussion.
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Diagnosis and Treatment Archive - Sports Medicine
What is the purpose of interviewing the patient?