Core and Advanced Skills of Family Interviewing

Interviewing with Family Members Present

Special attention should be given to privacy and confidentiality while interviewing an adolescent in the presence of a family member.
There may be ethical dilemmas involving confidentiality and privacy when family members are present with a patient of any age.
Family members might have additional questions or concerns about the patient’s health. The physician must make sure they avoid a potential breach of HIPPA: Patients should agree and not object to their relevant health care information being disclosed.
The patient should have time to communicate privately with the physician at some point during the visit.
There could be legal issues whenever a third party is involved in making financial and legal decisions for the patient, such as the mother of a child or the guardian of an adult who is impaired or has dementia.
Family members can be a valuable source of information and can help in the implementation of a treatment plan, which can result in better patient outcomes.
A family member strengthens the alliance between the physician and the patient without lengthening the office visit.
Family involvement may have a positive influence on medical encounters.

Core family interviewing skills are used routinely during interviews in which another person accompanies the patient. Core skills are sufficient when family members communicate effectively and when the differences between the family members, patient, and physician are minimal.

Using these skills, the physician can conduct an efficient and productive interview that involves everyone present. They include:

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Greet and build rapport
Identify each person’s agenda
Check each person’s perspective
Allow each person to speak
Recognize and acknowledge feelings
Avoid taking sides
Respect privacy and maintain confidentiality
Interview the patient separately, if needed
Evaluate agreement with the plan

Advanced family interviewing skills are useful in situations where the family exhibits ineffective communication, as a result of a conflict and intense emotions.

The advanced family interviewing skills will help the family communicate or manage conflicts to address the immediate patient care issues; however, unlike therapy, these skills are not intended to create a permanent change in the family’s interaction patterns.

The physician may use the following skills:

Guide communication
Manage conflict
Reach common ground
Consider referral for family therapy

All students can be expected to learn and practice the core skills. The advanced skills are generally learned during residency training and are described in more detail in the article by Lang, et al., listed in the References section, below.

You enter the exam room and find Andrew lying down in an uncomfortable position on the exam table. His mother, Ms. Hailey, is sitting next to her son visibly worried and anxious.

You introduce yourself and explain, “I understand you are not feeling well. Would it be okay if I get some information about how you’re feeling? First, I would like to talk with you and your mom; then I would like to talk to you by yourself for a bit.”

You ask,

“Can you tell me more about your pain?”

You note that Andrew has already told you the location, quality, character, onset, and duration of his pain. You still have a few more questions to ask:

“Do you have other concerns, like nausea, sweating, chills, vomiting, or fever?”

TEACHING POINT

Important Features of the History for a Patient in Pain

The following acronym can be helpful: LAQ CODIERS:

Location
Associated symptoms
Quality
Character
Onset
Duration
Intensity
Exacerbating factors
Relieving factors
other Symptoms

You have a few more questions:

“How bad is the pain? On a scale from 1-10, with 1 being the slightest pain and 10 being the worst pain you have ever felt?”

Andrew grunts, “It is the worst pain I have ever had. I would give a score of 10.”

“Does anything make it worse? What happens if you . . .?”

Andrew getting annoyed with these multiple questions and interrupts “It is already worse.”

You reply, “I am very sorry for bothering you with all these questions. I need this information to find out what is going on with you.

“Has anything made it better?”
“Nothing is relieving the pain.”

Ms. Hailey interjects, “He had similar pain few months ago and it was relieved without any treatment.” She looks worried, “I hope he didn’t hurt himself while playing.”

You complete the history. Andrew denies any increased urinary frequency, dysuria, urethral discharge, abdominal pain, or vomiting.

Ms. Hailey wants to know, “Could you tell me what is going on with Andrew?”

You respond, “Well, I have to ask Andrew a few more questions and then examine him before I could tell you anything. Can you please excuse us for now and I will call you back as soon as we are done.”

After obtaining information about his pain you want to inquire about his sexual history.

Before Mrs. Hailey leaves the room, you reassure Andrew by saying, “What you and I talk about is confidential, which means that I am not going to tell your mother anything we talk about unless I am worried that you are hurting yourself, hurting someone else, or someone is hurting you.”

Mrs. Hailey leaves the room, and you begin your conversation:

“You must be in eleventh grade. How is school going?”

Andrew responds, “My schoolwork is going pretty well. I am getting As and Bs. Next month I am going to take the SAT.”

“Do you have a romantic or sexual relationship with anyone?”

Andrew reports that he has been sexually active with a single female partner for the past year and uses condoms sometimes for protection.

“Have you ever been pressured to do something sexually that you didn’t want to do?”

Andrew denies being subjected to any kind of pressure.

On further questioning, he denies past history of sexually transmitted diseases, urological/surgical procedures (aside from the appendectomy), or congenital anomalies.

You ask him about his diet and he tells you that he maintains a healthy diet and feels satisfied with his current weight and shape. He adds, “I have never experimented with dietary supplements or steroids, although I know of some kids on the football team that have tried them.”

Core and Advanced Skills of Family Interviewing