Guest Post: Improve Your Subjective Interviewing | Modern Manual Therapy Blog

Guest Post: Improve Your Subjective Interviewing

Today's Guest post is from Dr. Ryan Balmes, DPT, OCS, FAAOMPT. I love the history, it's your chance at establishing rapport, setting the stage, and some important patient education. Thanks to Ryan for the great guest post!

As a new physical therapist, what aspect of your clinical practice should you improve upon the most? There are plenty to improve upon, and as a new grad, naturally you’d want to improve upon them all. But if you had to pick one aspect to improve upon first what would it be?

Your manual therapy skills?
Your knowledge of all the special tests?
Your progression of therapeutic exercises?

Have you ever thought about your subjective interviewing skills? Your subjective interviewing skills are the first aspect of clinical practice that happens between you and your patient. If you were like me, your subjective interviewing skills were likely very raw and undeveloped. Sure you passed well enough to make it through your clinicals, but think about it - how critical were you about your subjective interviewing skills?

Studies show that expert clinicians utilize pattern recognition during their subjective, which is derived from their years of clinical experience (Hobus et al, 1987). Yes, expert clinicians can get away with this, but as a new grad you absolutely can not.

You have no experience to draw from. Absolutely none.

Yeah you had that awesome long-term orthopaedic clinical affiliation for 8 plus weeks, but that is just not enough to make the right clinical decisions that can significantly affect the life of a 70 year old patient with shoulder pain that has persisted for half a year.

(For this blog post, our patient’s name is Ms. Alberta.)

So what do you do as a new grad?
The answer will seem simple, but it will truly transform how clinical practice.

Let the patient tell you all the answers.

That’s it! Seriously, the patient will, if you let them, tell you all the answers during your subjective exam. All you have to do is allow the patient to talk. I want to cover the basics of a thorough subjective examination with you, so that you can better serve your patients.

1. “Could it Be” vs. “It Will Be”

“Could it Be” and “It Will Be” are two potential mindsets to have going into your subjective examination. You do not want to have the “It Will Be” mindset, and if you already practice this way, you've probably run into frustration when attempting to confirm your bias during your objective exam and subsequently focus on an incorrect treatment emphasis. Get out of the “It Will Be” mindset now. The “It Will Be” mindset is, simply put, arrogant and does a huge disservice to your patients.

“Could It Be” is a mindset that allows you to approach your subjective exam with an open mind and no bias towards a certain diagnosis. When meeting a patient for the first time, or even a return patient with a brand new injury, you want to have that open mindset so that you can consider every possibility. You may wonder if expert clinicians really practice this way, because at times it seems like they practice with a “It Will Be” mindset. I’d bet that their still have the “Could It Be” mindset, but that their thought processes move much faster to a hypothesis.

2. Funnel Down Approach

I have to credit my amazing residency mentor for teaching me the Funnel Down approach. With the Funnel Down approach, you start with open ended questions that’s broad and evokes a storytelling-type response. Your skilled evaluation begins with the first words you utter:

“Thank you for coming in today! So tell me, Ms. Alberta, how can I help you today?”

Once said, you shut up, listen, and take notes.

You’ll be surprised at all the answers your patient will reveal.

Depending on your style and personality, your opening line can vary, but the key elements for beginning the Funnel Down approach is that it’s welcoming, defines your role to serve the patient, remains open-ended, and evokes the patient to reveal his/her story.

What happens if you started your subjective exam the opposite way?

“Hi Ms. Alberta, tell me about the pain in your shoulder.”

What a terrible opening line. This is as closed-ended as you can get. Even if Ms. Alberta was coming in with a script or direct access of shoulder pain, asking immediately about pain in the shoulder, will evoke a response that’s direct to the shoulder, but ignores any other possible contributing factors such as chest pain she’s felt at night or neck pain that’s occurred once. Sure you could ask all those specific questions to follow-up, but you’re doing way too much work.

By starting with an open-ended question, and listening to the entire story, most of the important clinical information will be told without you having to ask a million specific questions. As the patient reveals the problem, takes notes on clinically important details. Details would include elements like:
  • chronicity
  • aggravating factors and easing factors
  • mechanism of injury
  • functional difficulties
  • nature and description of the pain 
As the patient’s story unfolds, you’ll want to funnel down, which is asking further clarifying questions that digs deeper for more details. Some examples would be “Does your shoulder hurt more with activity or at rest?” or “Tell me more about that neck injury you experienced 6 months ago.” Your Funnel Down questioning will begin to be more closed-ended. Also, your Funnel Down questions can probe for any clinically important details that were not freely revealed during the patient’s previous answers.

Red-flag questions and past medical history clarifying questions would go near the end of your Funnel Down process too. So in the case of Ms. Alberta’s shoulder pain, an example question could be, “Ms. Alberta do you experience any pain at night?” You definitely want to make sure that patient is even appropriate for PT!

3. Patient Goals

You’ll want to finish out your subjective examination by asking your patients what their goals are with physical therapy. Since you and your patient started the subjective examination with what the current problem is and how its affecting their life, what better way to finish the subjective exam that with what the patient wants to regain back in their life.

4. List Out the Possible Clinical Presentations

When starting out, it’s best to list out all the possible clinical presentations after your subjective examination, especially after scanning through all the notes you've taken. As you improve, you’ll be able to write down possible clinical presentations onto the side of your paper while taking notes during the subjective exam.

You could list all all the possibilities, but that’s what rookies do. You’re not a rookie. You’re a smart well-read rookie that reads PT blogs. List out the top three possibilities that makes sense from the information you just heard during your subjective exam. Order them from most likely to least likely.

As the case with Ms. Alberta, our shoulder patient, an example of the top 3 possible clinical presentations could be: 
  • Primary shoulder impingement
  • Rotator cuff tendinopathy
  • Cervical radiculopathy 
These three possibilities, which are hypotheses, are what you’ll be seeking to confirm or refute in your objective examination. Your objective examination just got much more concise!

You’ll find that with your improved subjective examination, the rest of your initial evaluation, specifically your objective examination, will be easier to conduct because you’re working on answers freely given to you. This will take practice, so incorporate these steps out in clinic!

For more of Ryan's posts, check out his newly launched site here!

Keeping it Eclectic...

1 comment:

  1. Andrew Banh, PT, DPT, OCSJuly 7, 2014 at 2:31 PM

    Great points about how the essentials and organization of a subjective, and how such contributes to efficient patient management. Though time consuming at times with certain patients, I agree it is important to spend such time extracting and revealing such details related to patient's chief complaint. Simply makes the treatment more guided, specific, minimizes second-guessing and backtracking. Majority of patients also appreciate the level of detail with the questions that they often mention another healthcare professional may have breezed over, so an excellent opportunity to build rapport as well with such an approach to the subjective exam. As a recent grad of a residency program, I remember the challenges with the subjective were with the more "chaotic patients" who did not directly answer questions or went off on tangents. I felt that while the structured subjective they emphasized in residency was nice, it was also important to be flexible and flow one's subjective with what the patient was trying to indirectly tell a clinician first, furthermore underscoring why active listening, open-ended communication, and collaboration with the patient can put you on a path of telling you everything you need to know to address what is meaningful to the patient.