Physical Diagnosis MOD 3 Interviewing PDF

PHYSICAL DIAGNOSIS 08/24/2024. MOD 3: INTERVIEWING, COMMUNICATION, AND...

PHYSICAL DIAGNOSIS 08/24/2024. MOD 3: INTERVIEWING, COMMUNICATION, AND INTERPERSONAL SKILLS Jose Marianito T. Bautista, MD, FPCP Trans Group/s: 1B I. INTRODUCTION 9 Reassurance This chapter describes the fundamental techniques of therapeutic interviewing, the timeless skills you will 10 Appropriate Verbal Communication continue to polish as you care for your patients. This skills require practice and feedback from your 11 Appropriate Non-verbal Communication teachers so that you can monitor your progress Over time, you will learn to select the techniques best 1. ACTIVE OR ATTENTIVE LISTENING suited to the dynamics of human behaviour in your patient relationships. Lies at the heart of the patient interview It involves a number of different specific skills that help II. INTERVIEWING PROCESS facilitate, direct, and structure your interaction with the The interviewing process during a clinical encounter is: patient ○ More than a series of question Carefully attending to what the patient is communicating ○ Requires a sensitivity to the patient’s feelings Connecting to the patient’s emotional state and behavioral cues Using verbal and non-verbal skills ○ Generates a patient’s story Takes practice Different from the format of health history but have Focus on what the patient is telling you both verbally complementary purposes and non-verbally Body language tells a different story from spoken words A. STRUCTURE AND SEQUENCE OF A CLINICAL ENCOUNTER 2. GUIDED QUESTIONING This is a guide of a structure and sequence of clinical encounter we make with a patient whether this is in the Goal is to facilitate full communication in patient’s outpatient or an inpatient who is admitted to the hospital. own words, without interruption Show sustained interest in patient’s feelings and STRUCTURE AND SEQUENCE OF A CLINICAL deepest disclosure ENCOUNTER “Yes-No” questions makes the patient more restricted and passive leading to the significant loss of details 1 Initiating the Session 2.1 Techniques in Guided Questioning 2 Information Gathering Moving from open-ended to focused questions ○ Start with the most generalized question like “How 3 The Physical Exam can I help?” or “What brings you in today?” 4 Explaining and Planning ○ Then move to still open but more focused questions like “Can you tell me more about what happened 5 Closing the Session when you took the medicine?” then pose closed questions like “Did the new medicine cause any problems?” B. SKILLED INTERVIEWING TECHNIQUES ○ Open-ended questions to hear the “story of the These are the interviewing techniques that we need to symptom” in the patient’s own words master so that we may effectively communicate with the ○ Yes-no questions or “pertinent positive and patient. negatives” from the relevant section of ROS. Questions should be from general to specific SKILLED INTERVIEWING TECHNIQUES ○ The more specific questions to elicit the “seven features of every symptoms” 1 Active or Attentive Listening Begin with open-ended question Avoid leading questions 2 Guided Questioning 3 Empathic Responses TECHNIQUES IN GUIDED QUESTIONING 4 Summarization 1 Moving from Open-Ended to Focused Questions 5 Transitions 2 Questioning that Elicits a Graded Response 6 Partnering 3 Asking a Series of Questions One at a Time 7 Validation 4 Offering Multiple Choice for Answers 8 Empowering the Patient 5 Clarifying What the Patient Means Physical Diagnosis - Mod 3 Interviewing, Communication, and Interpersonal Skills 1 of 7 The use of trans, practice questions, and evals ratio must be used discreetly and social media/public exposure of the aforementioned shall be strictly prohibited.  6 Encouraging with Continuers As patients talk with you, they may convey in their words or facial expressions the feelings they haven’t 7 Echoing consciously acknowledged. For the response to be empathic, it must convey that you feel what the patient is feeling. 2.1.1 Moving from Open-Ended to Focused Questions Capacity to identify with the patient and feel the pain Seven features of every symptom will help the patient as your own, then respond in a supportive manner. to describe what they are feeling to the clinician. One must recognize the patient’s feelings, then actively move toward and elicit emotional content. SEVEN FEATURES OF EVERY SYMPTOM May also be non-verbal. OPQRST OLD CARTS 4. SUMMARIZATION 1. Onset 1. Onset Giving a capsule summary of the patient’s story during 2. Precipitating and 2. Location the course of the interview serves to communicate that Palliating Factors 3. Duration you have been listening carefully. 3. Quality 4. Character It identifies what you know and what you don’t 4. Region or Radiation 5. Aggravating or know. 5. Severity Alleviating factors Allows the patient to add other information and 6. Timing or Temporal 6. Radiation correct any misunderstanding. characteristics 7. Timing Furthermore, it allows you to organize your clinical 8. Setting reasoning and convey your thinking to the patient, making the relationship more collaborative. It also helps learners to draw a blank on what 2.1.2 Questioning that Elicits a Graded Response questions to ask next. Ask questions that can elicit a graded response, instead of a yes or no question. 5. TRANSITIONS “How many steps can you climb before you get shortness of breath?” instead of “Do you get short of “SignPosting” helps transition the patient with what breath climbing the stairs?” comes next. Orient patient with brief transitional phrases 2.1.3 Asking a Series of Questions One at a Time ○ As you move on from the history to the physical Make sure to ask questions one at a time. exam, orient the patient with brief transitional Be sure to pause and establish eye contact as you phrases like “Now, I’d like to ask some question listen to each of the patient’s problem about your past health.” Make clear what the patient should expect or do next. 2.1.4 Offering Multiple Choice for Answers Sometimes patients need help in describing their 6. PARTNERING symptoms. Express our commitment to an ongoing relationship. To minimize bias, we can offer multiple choice for Make patients feel that no matter what happens you answers. will continue to provide their care. For example: ○ “Which of the following words describes your pain? 7. VALIDATION Is it aching? Is it sharp? Is it pressing? Is it burning or shooting?” Another way to validate the patient is to validate the legitimacy of their emotional experience. 2.1.5 Clarifying What the Patient Means Always validate that their response is legitimate and Sometimes the patient’s history is difficult to understand. understandable. It is better to ask for clarifications than to pretend the story makes sense. 8. EMPOWERING THE PATIENT Taking time for clarifications reassures the patient that you want to understand their story and build a Ultimately, patients are responsible for their own care therapeutic relationship. Empower patients to ask questions, express their concerns, and probe your recommendations → more 2.1.6 Encouraging with Continuers likely to adapt to your advice, make lifestyle changes, Non-verbal encouragement (postures, gestures) to or take medications as prescribed encourage the patient to say more. Reinforces patients’ responsibility for their own For example: leaning forward, making eye contact, health pausing and nodding your head, remaining quiet yet attentive and relaxed 8.1 Techniques to empower patients You can also say words such as “uh-huh”, “go on, I’m a. Evoke the patient’s perspective listening.” b. Convey interest in the person, not just the problem c. Follow the patient’s leads 2.1.7 Echoing d. Elicit and validate emotional content Repeating the patient’s last words encourages the e. Share information with the patient patient to elaborate on details and feelings. f. Make your clinical reasoning transparent to the It also demonstrates careful listening and subtle patient connection with the patient. g. Reveal the limits of your knowledge 3. EMPATHIC RESPONSES Vital to patient rapport and healing. Physical Diagnosis - Mod 3 🏠 Interviewing, Communication, and Interpersonal Skills 2 of 7 The use of trans, practice questions, and evals ratio must be used discreetly and social media/public exposure of the aforementioned shall be strictly prohibited. 9. REASSURANCE 4 Head nodding with gesture. First step is to identify and acknowledge the patient’s 5 Posture feelings Reassurance is more appropriate when the patient 6 Tone and Use of Voice feels that the problems have been fully understood and are being addressed 7 Use of Silence Meaningful reassurance comes later ○ Completed the interview 8 Use of Touch ○ Thorough physical exam ○ Laboratory tests Pay close attention to: eye contact, facial expression, posture, head position and movement (i.e., shaking or 10. APPROPRIATE VERBAL COMMUNICATION nodding), interpersonal distance, and placement of the arms or legs (i.e., crossed, neutral or open). As clinicians, important that we are careful in what we Be aware that some forms of nonverbal say and cautious in how we say things communication are universal, but many are The effectiveness of a clinical encounter rests on the culturally-bound. use of appropriate language. Enhances patient rapport Use understandable language C. BROACHING SENSITIVE TOPICS Avoid medical jargon Discussions on sensitive topics can be awkward when you're inexperienced or assessing patients you don’t 10.1 Ask Me Three Approach know well. Clinicians can be inhibited by societal constraints Ideally, your patient encounter should focus on 1 to 3 when discussing certain subjects, including: key points. ○ Abuse of Alcohol or Drugs As a clinician, we should repeat the points often. ○ Sexual Practices One way to narrow in on the key message is with the ○ Death and Dying ask me three approach. ○ Financial Concerns This is intended to make the patients more active ○ Racial and Ethnic Bias members of their healthcare, encourage patients to ○ Psychiatric Illness ask and clinicians to answer three main questions ○ Physical Deformities during the clinical encounter. Examples: ○ What is my main problem? GUIDELINES FOR BROACHING SENSITIVE TOPICS ○ What do I need to do? ○ Why is it important for me to do this? The following are strategies that will help make you feel more comfortable when discussing sensitive areas. If 10.2 Use Non-Stigmatizing Language possible, listen to experienced clinicians as they The language we use to reference people should reflect approach these issues with patience and practice their full identities and acknowledge their capacity similar techniques in your discussion. Over time, your to change and grow. level of comfort will grow and expand. The use of stigmatizing language can distance and 1 The single most important rule is to be traumatize patients, create barriers to patients seeking non-judgemental. Our role is to learn from the help or accessing treatment. patient, and help the patient achieve health. A step to avoid the use of stigmatizing language involves the use of “people-first” language. 2 Explain why you need to know certain ○ For example: Saying “drug abusers” can imply that information. the person is the problem. Instead, we can say “person who uses drugs or person with a substance 3 Find opening questions for sensitive topics. abuse problem.” 4 Consciously acknowledge whatever discomfort 11. APPROPRIATE NON-VERBAL COMMUNICATION you are feeling. Consciously or not, you send messages both through your words or behaviour. D. INFORMED CONSENT As we carefully observe the patient, the patient is also A patient’s consent to a procedure or treatment is more carefully observing us. than simply signing a form. Posture, gestures, eye contact and tone of voice will convey the extent of interest, attention, acceptance and REQUIRED ELEMENTS FOR THE DOCUMENTATION understanding. OF THE INFORMED CONSENT First step is to notice non-verbal behaviours and bring them to a conscious level. 1 Nature of the Procedure or Treatment 2 Risks and Benefits of the Procedure or Treatment FORMS OF NONVERBAL COMMUNICATION 3 Reasonable Alternatives 1 Body orientation toward and physical proximity to patient. 4 Risks and Benefits of Alternatives 2 Gaze orientation (eye contact) towards patients. 5 Assessment of the Patient’s Understanding of the First 4 Elements 3 Head nodding with facial animation. Physical Diagnosis - Mod 3 🏠 Interviewing, Communication, and Interpersonal Skills 3 of 7 The use of trans, practice questions, and evals ratio must be used discreetly and social media/public exposure of the aforementioned shall be strictly prohibited.  Clinicians have a legal and ethical duty to follow the Establish a healthcare proxy or healthcare power of process of obtaining an informed consent WITHOUT attorney who can act as the patient’s health decision leaving any of the core elements. maker Every patient with decisional capacity has the right Identifies what is important to the patient, makes life to consent or decline procedures or treatments after worth living, and when living would no longer be they have been properly informed. worthwhile ○ Ensure that the patient has decisional capacity. Explore the patient’s religious or spiritual beliefs so ○ If not, discuss with the person whom the patient has that the patient can make the most appropriate assigned as the healthcare proxy. decisions about healthcare. E. WORKING WITH A MEDICAL INTERPRETER 1. MEDICAL ORDER FORM When you work with an interpreter, begin by establishing rapport and reviewing the information Completion of the medical order form starts with a that would be most useful. conversation whereby the patient discusses his/her An ideal interpreter is one who is neutral and trained in values, beliefs, and goals for care; and the clinician both languages and cultures. presents the patient’s diagnosis, prognosis, and Family members as translators is hazardous. It may treatment alternatives. violate confidentiality, and information gathered may be ○ This includes the benefits and burdens of life incomplete, misleading or harmful. sustaining treatment. Ask the interpreter to translate everything and NOT to ○ Failing to facilitate end-of-life decision making is condense or summarize. a flaw in clinical care. It is important to make your questions clear, short, For patients who are acutely ill and in the hospital, and straightforward. discussions about how to respond to cardiac or After going with your plans, arrange the setting so you respiratory arrest are usually mandatory. can have and maintain an easy eye contact with the patient and speak directly to the patient. MEDICAL ORDER FORM POLST/MOLST is an actionable medical order form that GUIDELINES FOR WORKING WITH A MEDICAL tells others the patient’s medical orders for life sustaining INTERPRETER treatment. 1 Introductions INSTRUCTIONS ON RESPONSE TO CARDIAC OR 2 Note Goals RESPIRATORY ARREST 3 Transparency 1 DNR (DO NOT Resuscitate) 4 Ethics 2 DNI (DO NOT Intubate) 5 Respect Beliefs H. DISCLOSING SERIOUS NEWS 6 Patient-Focus Complex task of disclosing serious news to patients such as illnesses with poor survival outcomes, disease 7 Retain Control recurrence, or failure of treatments requires advanced communication skills. 8 Explain Requires responding to the patient's emotional reactions, shared decision-making, stress created by 9 Thanks the patient's expectations, involvement of family members, and how to provide hope despite the bleak F. INTERPRETING BY TELEPHONE situation Telephone interpreting is provided when an interpreter, who is usually based in a remote location, provides SPIKES PROTOCOL interpretation via telephone for two or more individuals who do NOT speak the same language. 1 Setting up the interview DO NOT REPLACE the need for on-site medical interpretation. 2 Assessing the patient’s perception Large amounts of nonverbal information can be lost. 3 Obtaining the patient’s invitation SITUATIONS BEST SUITED FOR FACE-TO-FACE 4 Giving knowledge and information to the patient INTERPRETER 5 Addressing the patient’s emotions with empathic 1 Serious Diagnoses or Bad News responses 2 When the patient is hard of hearing. 6 Strategy and summary 3 Family Group or Group Discussions I. MOTIVATIONAL INTERVIEWING 4 Interaction requires visual elements. A set of well-documented techniques to improve health outcomes, especially for patients with substance 5 Complicated or Personal Medical News abuse. A lot of patients will close with a discussion of behavior G. ADVANCE DIRECTIVES changes, either to optimize health or treat illness. Important to encourage any adult who are older or chronically ill to have an advance directive. Physical Diagnosis - Mod 3 🏠 Interviewing, Communication, and Interpersonal Skills 4 of 7 The use of trans, practice questions, and evals ratio must be used discreetly and social media/public exposure of the aforementioned shall be strictly prohibited.  ○ These could be diet, exercise habits, cessation of Give the patient FREE reign for the first 5 or 10 smoking or drinking, adherence to medication minutes, while listening carefully. regimens or self-management strategies ○ Maybe the patient simply needs a good listener and Encourages your patients to discover their interest in is expressing pent-up concerns or enjoying telling considering and making changes in their behaviors stories. Is there a flight of ideas or a disorganized thought III. INTERPROFESSIONAL COMMUNICATION process? As a trainee in the clinics you will often find yourself Part of our task is structuring the interview. caring for patients with other trainees and clinicians from “What is your concern today?” various fields Avoid showing impatience. Working as a team using effective communication If needed, explain the need for a second visit. provides efficient quality care that leads to excellence in patient outcomes 3. PATIENT WITH A CONFUSING NARRATIVE Collaboration is critical in minimizing the risks of errors Some patient stories are confusing and do not seem to in patient care make sense Mutual respect is essential for interprofessional Put up a coherent story by using skills of guiding communication questions, clarification, and summarizing ○ It helps facilitate a positive environment for If symptoms seem bizarre, there maybe a mental setting shared goals, creating collaborative plans, status change like psychosis or delirium making decisions, and sharing responsibilities Acute confusional state = acutely ill or intoxicated patient A. SBAR FRAMEWORK Dementia = older patient One of the framework used to improve Focus on the level of consciousness, orientation, interprofessional communication and teamwork memory and capacity to understand A shared mental model which provides a clear, concise, and organized framework for communication 4. PATIENT WITH ALTERED LEVEL OF COGNITION between clinicians This framework facilitates active listening and Some patients cannot provide their own histories provides all interprofessional team members a because of delirium, dementia, or mental health constructive and standardized approach to openly conditions discuss patient issues they may have Others are unable to remember certain parts of history such as events related to a febrile illness or a COMPONENTS OF SBAR FRAMEWORK seizure As clinicians we need to obtain historical information 1 Situation from others such as family members or caregivers ○ Always seek the best informed source 2 Background Some patients can provide history but CANNOT make informed health care decisions. 3 Assessment Ability to understand information, weigh choices and their consequences, reason through the options 4 Recommendation and communicate a choice B. CHALLENGING PATIENT SITUATIONS AND 5. PATIENT WITH EMOTIONAL LABILITY BEHAVIORS May mean strong emotions ranging from sadness to Some patients are more difficult to interview than others anger or frustration Being aware of your reaction helps develop your Crying is therapeutic, as is your quiet acceptance of clinical skills patient’s distress Take into account your own stressors ○ Offer tissue and wait for the patient to recover Self care is vital in caring for others As clinicians, we have to learn how to accept displays Even if patient is challenging, always remember the of emotions so you can support patients importance of listening to the patient and clarifying his concerns 6. PATIENT WHO IS ANGRY OR AGGRESSIVE 1. PATIENT WHO IS SILENT Many patients have reasons to be angry ○ They are ill, they have suffered a loss, they have Silence has many meanings lost control of their health, or they feel overwhelmed Periods of silence usually seem longer to the clinician by the healthcare system than the patient Displace their anger onto the clinicians as a reflection of ○ Be attentive and respectful and encourage the their frustration or pain patient to continue when ready Learn to accept angry feelings from patients Being comfortable with periods of silence maybe WITHOUT getting angry in return therapeutic, prompting him to reveal more profound If they get out of control, alert the security staff, ensure feelings. a safe environment “You seem quiet. Have I said something that has upset Stay calm and avoid being confrontational you?” 7. PATIENT WHO IS FLIRTATIOUS 2. PATIENT WHO IS TALKATIVE Clinicians occasionally find themselves physically Faced with limited time to get the whole story, you may attracted to their patients. grow impatient and even exasperated Similarly patients may make sexual overtures or exhibit No perfect solution flirtatious behavior Physical Diagnosis - Mod 3 🏠 Interviewing, Communication, and Interpersonal Skills 5 of 7 The use of trans, practice questions, and evals ratio must be used discreetly and social media/public exposure of the aforementioned shall be strictly prohibited.  Any sexual romantic relationship is unethical. Spend more time on verbal explanations because Keep your relationship with the patient within postures and gestures are unseen professional bounds Calmly but firmly set clear limits that your relationship 11. PATIENT WITH LIMITED INTELLIGENCE is professional, NOT personal. Seek help if you need it If disability is suspected, pay attention to the patient's school record and ability to function independently 8. PATIENT WHO IS DISCRIMINATORY If you are unsure, transition to the MSE, assess simple calculations, vocabulary, memory and abstract thinking Conflict will arise about your course of action, due to For patients with severe mental retardation, turn to the your duty to care for patients, your obligation as a family or caregivers for the history but always show clinician to your hospital, and your duty to care for interest in the patient first yourself Establish rapport, make eye contact, and engage in Discriminatory patient behavior should be named and simple conversation processed appropriately, since such interactions with the patient may undermine one’s resilience. 12. PATIENTS BURDENED WITH PERSONAL PROBLEMS Unacknowledged discriminatory behaviors towards trainees and clinicians can lead to increased anxiety, Patients may ask you for advice about personal avoidance of certain patients, and a change in career problems that fall outside your clinical expertise interests Instead of responding, ask about what alternatives Options include continuing care for your patient, that the patient has considered, related pros and reaching out to another team member for cons, and others who have provided advice assistance, or removing yourself from the situation Letting the patient talk through the problem with you You should be empowered to state your discomfort is more therapeutic than giving your opinions with continuing an encounter with a discriminatory patient to your supervisor 13. PATIENTS WHO IS NON-ADHERENT You can seek to cultivate a therapeutic alliance with Adherence is preferred over compliance, it is not fair to your patient, but under the guidance of your assume that the patient is always at fault supervising clinician ○ Studies show that several factors lead to patient It is the role of your supervisor to establish a non-adherence supportive learning environment for you on the Factors that lead to non adherence include patient clinical team cognitive abilities, emotional status, socioeconomic conditions, cultural attitudes and beliefs as well as 9. PATIENT WITH HEARING LOSS their disease condition, therapy and systems of In the US, approximately 10% of the population is deaf medical care or hard of hearing Strategies for better adherence include the use of According to WHO, > 5% of the world's population has information handouts, positive feedback to the patient disabling hearing loss, defined as >40 decibels in the Steps to minimize monitoring discomfort and better hearing ear in adults inconvenience include simplifying dosing schedule, Factors include degree of hearing loss, age of onset, disease monitoring to alter management, obtaining preferred language and psychological issues counseling Communication and trust are particular challenges and the risk of miscommunication is high 14. PATIENT WITH LOW LITERACY ○ Even hearing-impaired patients who use english In the US, 30 million Americans are unable to read basic may not follow standard english usage documents It is important to know the patient's preferred method Low literacy may explain why the patient has not taken of communication medications or followed your recommendations Learn whether the patient belonged to the deaf BEFORE giving written instructions, assess the culture or the hearing culture when the hearing loss patient’s ability to read occurred relative to the development of speech and Many patients are embarrassed about reading poorly language ○ Be sensitive to their quandary and do not Handwritten questions and answers may be the only confuse their degree of literacy to their level of solution. intelligence Partial hearing deficits may vary Explore the reasons for impaired literacy (e.g., Check if patient has hearing aid and if it is working language barriers, learning disorders, poor vision, or For patients with unilateral hearing loss, sit on the level of education) hearing side. ○ A person who is hard of hearing may not be aware 15. PATIENT WITH LOW HEALTH LITERACY of the problem; a situation you would have to address tactfully Affects about 80M Americans Eliminate background noise from televisions or Goes beyond reading. hallways Includes practical skill the patient need to navigate the Face patients who can read lips directly in good light healthcare environment ○ Patients should put on their glasses to see cues ○ Print literacy: the ability to interpret information in that help them understand documents Speak at a normal volume and rate ○ Numeracy: the ability to use quantitative information like understanding food labels or 10. PATIENT WITH LOW OR IMPAIRED VISION adhering to medication regimens ○ Oral literacy: the ability to speak and listen Shake hands to establish contact and explain who you effectively are and why you are there Encourage patients to wear glasses Physical Diagnosis - Mod 3 🏠 Interviewing, Communication, and Interpersonal Skills 6 of 7 The use of trans, practice questions, and evals ratio must be used discreetly and social media/public exposure of the aforementioned shall be strictly prohibited. 16. PATIENT WITH LIMITED LANGUAGE PROFICIENCY Nothing makes the importance of the history more evident than being unable to communicate with the patient. These individuals are less likely to have regular primary or preventive care, and more likely to experience dissatisfaction and worse outcomes from clinical errors. More than 60M Americans speak a language other than English at home, of these 20% have limited English proficiency Learning to work with qualified interpreters is essential for optimal outcomes and cost effective care. 17. PATIENT WITH TERMINAL ILLNESS/WHO IS DYING Even as beginning students, working through your own feelings about death and dying and acquiring necessary skills to ensure excellent communication are essential, as you will come into contact with patients of all ages near the end of their life. For those facing death and their survivors, there are overlapping and sometimes prolonged phases of anticipatory grief and bereavement Denial, anger, bargaining, depression, and acceptance ○ These stages may occur sequentially or in any order According to WHO, our goal is "the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual” C. LEARNING COMMUNICATION SKILL FROM STANDARDIZED PATIENTS (SP) Best teaching is that taught by the patient himself — William Osler Although clinical training has traditionally relied on patient contact, often alternative approaches to using “real” patients augment clinical learning for many reasons: ○ Patient with conditions required for learning are unavailable ○ Patients with unpredictable behavior ○ Patients in situations that may be inappropriate Concept of SP for learning teaching and assessment, is predicated on their reliable, repeatable portrayals of a broad range of clinical cases with predictable behaviors, where students can practice skills in a safe learning environment They provide examples for teaching and assessment TIPS FOR MAKING THE MOST OUT OF LEARNING FROM STANDARDIZED PATIENTS 1 Take the SP encounter seriously 2 Trust your patient 3 Ask specific instructions 4 Make your patient comfortable 5 Build a connection 6 Keep your cool 7 Summarize the encounter 8 Enjoy the experience Physical Diagnosis - Mod 3 🏠 Interviewing, Communication, and Interpersonal Skills 7 of 7 The use of trans, practice questions, and evals ratio must be used discreetly and social media/public exposure of the aforementioned shall be strictly prohibited.