In this three-part series, EMS World columnist Mike Rubin discusses interviewing techniques. Part 2 focuses on patient Q&A.
“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 communication skills—not the kind that leads to long discourses on cerebral topics in rooms full of people, but the kind that allows the interviewer to effortlessly connect with the subject in an engaging and efficient manner, yielding an exceptional ratio of useful information per minute of conversation.
Good interviewing also requires humility—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 interviewing the interviewer!
Interviewing patients in the field requires flexibility because there are two broad categories 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 nonemergent cases, we can usually take more time to learn about the patient and the environment 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 seated 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 wearing sunglasses. Talk about condescending, particularly indoors!
Next it’s time for some high-frequency listening—by us, not by our subjects. Remember, this isn’t about us.
High-frequency listening means focusing on our patients and absorbing their answers, not just with our ears but with our eyes, too. Every expression, every gesture, every movement 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 subject’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 previous 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 valuable 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 assessment,” 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 training to consistently diagnose and treat illnesses 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 interview that is a better use of limited time than front-loaded SAMPLE, but still consistent with the philosophy of primary and secondary 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 nontraditional 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 community-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 progressively 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 members 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.
As community paramedicine and other nonemergent initiatives become commonplace in EMS, caregivers are going to need communication skills that go beyond SAMPLE 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 interventions 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.
Mike Rubin is a paramedic in Nashville, TN, and a member of EMS World’s editorial advisory board. Contact him at firstname.lastname@example.org.