Vignette 1: Introduction to a Preventive Services Visit

Charles is a 16 year old boy who has come to an outpatient clinic for a routine preventive services visit and physical exam. It is his first appointment with this provider. This vignette covers the initial moments of the preventive services visit. Adolescent boys generally respond to a personal and friendly greeting. They appreciate eye contact, a smile, and a handshake. They want their provider to begin by asking questions about their lives and activities, and show interest in them as individuals. They express difficulty with a provider who is stiff and has a “checklist approach”. They may not like the provider to write or type when he/she is conducting the interview. The patient may be more accepting of a computer if the provider tells him beforehand about the importance of entering information and reinforcing confidentiality. Adolescents are often concerned about confidentiality. Some may be quite guarded if they have experienced providers sharing information with their parents.

In this vignette:

  • The medical provider greets the patient warmly and informs him about confidentiality. When the patient expresses skepticism about confidentiality, the provider reassures him.
  • The provider asks the patient general questions about his life in an effort to put him at ease.
  • After the patient says he is tired, the provider begins to enter information on the computer. When the patient questions this, the provider identifies what he is doing and then stops to give his full attention to the patient.
  • When the patient talks about staying up late and feeling tired, the provider lectures him about sleep hygiene. This intervention distances the patient and also causes the provider to miss this possible symptom of depression, anxiety, or other concerns. The patient feels disconnected, as shown by his facial expression and lack of eye contact. The provider catches his awkward interaction and attempts to re–establish connection. However, he does not ask about depression.
  • After the provider re–establishes connection, the patient begins to make eye contact and relaxes.
  • The provider asks necessary but out–of–context questions about seat belts and bicycle helmets. The patient is cooperative but does not appear engaged.
  • The provider then asks about drug and alcohol use, renewing concern about confidentiality. As the provider explains again about confidentiality, the patient feels reassured and they continue a comfortable conversation.

The positive elements of this interview are:

  • The provider is warm and friendly. He shakes the patient’s hand and makes eye contact.
  • The provider reassures the patient about confidentiality. He accepts that the patient is concerned about confidentiality and repeats his reassurance as often as is necessary for the patient to feel comfortable.
  • The provider expresses interest in the patient’s life, not just his medical concerns.
  • The provider catches his mistake in lecturing the patient. He is forthright in acknowledging this error, yet confident in his demeanor. The provider begins to enter information on the computer. When the patient questions this, the provider identifies what he is doing and stops to give his full attention to the patient.

The negative elements of the interview are:

  • The provider types on the computer without telling the patient he is going to do this, causing the patient to feel concerned.
  • The provider misses the possibility that the patient’s tiredness could be an indication of depression, anxiety, or a school or drug problem.
  • The provider “lectures” the patient, causing the patient to withdraw.
  • The provider asks questions about seat belts and bicycle safety out of context.
  • The provider doesn’t start the questions with strengths and doesn’t mention that he is going to ask many routine questions that he asks of all his patients.
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