-CHURCHILL LIVINGSTONEAnimprint of Elsevier Limited Pearson Professional Limited 1995 2002, Elsevier Limited. All rights reserved.Therights of Linda M. Merriman and Warren Turner to beidentified aseditors of this work has been asserted by them in accordance with theCopyright, Designs and Patents Act 1988Nopart of this publication may bereproduced, stored in a retrievalsystem, ortransmitted in any form or by any means, electronic,mechanical, photocopying, recording orotherwise, without either theprior permission of thepublishers ora licence permitting restrictedcopying intheUnited Kingdom issued by theCopyright LicensingAgency, 90 Tottenham Court Road, London WIT 4LP. Permissions maybesought directly from Elsevier's Health Sciences Rights Department inPhiladelphia, USA: phone: (+1) 215 238 7869, fax: (+1) 215 238 2239, e-mail: healthpermissions@elsevier.com. You may also complete yourrequest on-line viatheElsevier homepage (http://www.elsevier.com).byselecting 'Customer Support' and then 'Obtaining Permissions'.First edition 1995Second edition 2002Reprinted 2005ISBN 0 443 07112 8British Library Cataloguing in Publication DataA catalogue record for this book is available from theBritish LibraryLibrary of Congress Cataloguing inPublication DataA catalogue record for this book is available from theLibrary of CongressNoteMedical knowledge is constantly changing. As new information becomesavailable, changes in treatment, procedures, equipment and theuse ofdrugs become necessary. Theauthors and the publishers have taken careto ensure that theinformation given inthis text is accurate and up to date.However, readers arestrongly advised to confirm that theinformation,especially with regard to drug usage, complies with thelatest legislationand standards of practice.health scienceswww.elsevierhealth.comWorking together to growlibraries in developing countrieswww.elsevier.comIwww.bookaid.org Iwww.sabre.orgELSEVIER f , " ~ ~ ~ ~ ~ Sabre FoundationPrinted in ChinaThepublisherspolicy istousepapermanufacturedfrom sustainable forestsIContributorsRobert LAshfordBABEd MA MMedSci PhDDPodM MChSProfessor of Podiatry, Health and Social CareResearch Centre, Faculty of Health andCommunity Care, University of CentralEngland, UKPaul Beeson BSc(Hons) MSc DPodMSenior Lecturer,Northampton School of Podiatry,University College Northampton, UKIvan Bristow MSc(Oxon)BSc(Hons) DPodM MChSSenior Lecturer, Faculty of Applied Sciences,University College Northampton, UKC JGriffithBSc(Hons) DPodM SRChPrivate Practitioner, The Manse Health Centre,UKMary HanleyBSc(Hons) Psychology MSc PhDSenior Lecturer (Health Psychology & ResearchMethods), University College Northampton, UKLinda Merriman PhDMPhil DPodM MChS CertEdDean, School of Health and Social Sciences,Coventry University, UKJMcLeod RobertsBSc(Hons) MSc DPodMSenior Lecturer, Northampton School ofPodiatry, University College Northampton, UKPatricia NesbittDPodM MChS PGD(BioEng)Senior Lecturer, Faculty of Applied Sciences,University College Northampton, UKC PayneDipPod (NZ) MPHLecturer, Department of Podiatry, School ofHuman Biosciences, La Trobe University,Melbourne, AustraliaA PercivallSenior Lecturer, School of Podiatry, UniversityCollege Northampton, UKI Reilly DPodM BSc SRCh FCPod(S) CertMHS DMSSenior LecturerI Podiatric Surgeon, School ofPodiatry, University College Northampton, UKIan F Turbutt BSc(Hons) FChS FPodA FCPodsSpecialist in Podiatric Surgery, The ManorHospital, Bedford; Ext. Lecturer in PodiatricRadiology, University of Brighton andUniversity of Southampton, UKR Turner MB ChB MRCPConsultant Dermatologist,Churchill Hospital, Oxford, UKWarren Turner BSc(Hons)DPodMAssociate Dean, School of Podiatry, UniversityCollege Northampton, UKBen Yates MSc (Sports Injuries) BSc(Hons) FCPodHead, Podiatry Department, La TrobeUniversity, Melbourne, AustraliaPrefaceMany textbooks make reference to the assess-ment of thelowerlimbbut veryfeware dedi-cated entirely to this purpose. Those that are tendtofocus ononlyoneof thecomponents of theprocess, e.g. skin disorders oron a specific clientgroupsuchas paediatrics. Thepurposeof thisbook is to produce a textbook which encom-passes all aspects of lower limb assessment.Problems affecting the lower limb can lead to dis-comfort, pain, reductionor lossofmobility andloss of time fromwork. Effective andefficientmanagement of these problems can only bebased ona thorough assessment.Throughout the book the term 'practitioner'isusedinitsbroadest sensetodenote any personwho has an interest inthe management of lowerlimb problems. Although the podiatrist has anatural claimto specialising in caringfor thefoot, the range of practitioners with an interest inthe lower limb includes bioengineers, diabetolo-gists, general medical practitioners, nurses, occu-pational therapists, orthopaedic surgeons,orthotists, physiotherapists and rheumatologists.Thisis the second edition of this textbook and,likethe first edition, it is divided into four parts:ApproachingthePatient, SystemsExamination,Laboratory and Hospital Investigations andSpecific Client Groups.Approaching the Patient provides an introduc-tion to the assessment process and covers indetail the assessment interview, the presentingproblem andthereliability and validity ofclini-cal measurement. For thesecondeditionthesechapters have been reviewed and updated.SystemsExamination coverstheseparate com-ponents of lower limbassessment: medical andsocial history, vascular, neurological, orthopaedics,skinandappendagesandfootwear assessments.Detailsrelatingtoanatomy andphysiology havebeen discussed where relevant. Again, the chaptersinthis sectionhavebeenupdatedaspart ofthesecondedition. Thechapter ontheassessment ofskin and its appendages has been rewritten, as hasthe chapteronthe locomotorsystem, whichhasbeenrenamedorthopaedicassessment toreflectmore accurately the content of thechapter.Laboratory and Hospital Investigationsfocusesonthosetestswhich maybeperformedtoconfirm, support orclarify the clinical exami-nation: bloodanalysis, urineanalysis, microbialidentification, histopathology, radiographicimagingand methods of quantifyinggait andfoot-ground interface systems. These chaptershave been updated for the second edition.Reliance on tests without the appropriate clinicalexamination is unwise, creates higher costs, mayworrythepatientunnecessarilyandoverworkssupport departments. It is intended that this partofthebookdemonstrateswhenandhowthesetests can be used to aid the assessment process.The last part of the book, Specific ClientGroups, looksat themainareasoffoot disease:the at-risk foot,the child's foot, sport injuries andthe painful foot. Forthe secondedition two newchapters have been addedtothis section: assess-ment of theelderlyandpre- andpostoperativeassessment. The addition of these chapters reflectsthe developments within podiatry. The elderlyx PREFACEform by far the largest client group receiving foottreatment; it is, therefore, important that thespecificneedsof thisclient groupareaddressedinthis textbook. Over the last 10 years there hasbeenagrowthinthenumberofsurgicalproce-dures performed, under local analgesia, by podi-atrists. Assessing a patient for surgery underlocal analgesia requires the practitioner to beaware of the specific issues related to this type oftreatment as they do differ fromthose result-ing fromsurgery under general anaesthesia.Although Systems Examination covers the rangeof assessments and can be applied to all agegroups, the assessment of childrenand sportspeople is worthy of independent discussion. Painin the footcan arise due to a multitude of factors,affects all age groupsandhasahighlymorbidaffect on our lives; for this reason, it hasbeengivenaseparate chapter. Theearlydiagnosisofthe at-risk foot is recognised as a means of reduc-ing morbidity, mortality and minimising the costof in-hospital carefor these patients.Case histories and comments support some ofthe chapters, particularly those in SystemsExaminationandSpecific Client Groups. Thesehavebeenusedtoillustratecertainpointsandreflect real lifeexperiences. Whereappropriate,black and white photographs, figuresand tableshave also been used to support and further illus-trate points raised inthe text. A section of colourplates has been specifically used to supportChapters 6, 9 and 17. Eachchapter has been ref-erenced and some indicate Further Reading.Clearlythere is more than one approachtoundertaking an assessment. Assessment of theLower Limbhas beenwritten to support goodpractice ina wide range of outlets forallprofes-sionals withaninterest in the foot. Whateverapproach the practitioner adopts, it is hoped thatthis text will bea valuable asset.Linda Merriman, Warren Turner, 2002AcknowledgementsWeare indebtedtothosewhohavegiventheirhelpandencouragementthroughout thedevel-opment and production of this second edition: inparticular, our family and friends.A big thank you to all the contributors for theirtime and effort in updatingand/or rewritingtheir chapters. We would also like tothank AnnMarie Carr forher help with the new chapter onassessment of the elderly.This book is dedicated to Jackie McLeodRoberts in recognition of her contribution topodiatry and in particular her work in theUkraine, developing and improving footcare ser-vicesfor people withdiabetes. Jackie'spioneer-ingworkhas made a significant difference tothese people.Plate1 Anischaemicfoot.Thesuperficial tissuesareatrophied. The fifthrayhas beenexcised.Plate 2Typical ischaemiculcerationoverlyinga halluxabductovalgusina patient withchronicperipheralvasculardisease.Plate 3 'Dry'gangrene, involvingtwo toes. Thenecroticarea is surroundedby a narrowbandofinflammation. Thetoes have becomemummified, due to loss of thelocal bloodsupply.Plate 5 Atrophieblanche(whitepatches), whichoccursinassociation withchronicvenoushypertensionand venousulcers.Plate4 Telangiectasias: distortionof thesuperficialvenulessecondary to varicosity.Plate 6 Gravitational (varicose, stasis)eczemaandhaemosiderosis.Plate 8 Venousulcerationin association withgrossoedemaand haemosiderosis(from WilkinsonJ, ShawS,Fenton01993 Colour guideto dermatology. ChurchillLivingstone, Edinburgh, Figure179).Plate 7 Healedvenousulcer that had beenpresent for2 years.Plate 9 Histologysectionof normal hairy skin stained withhaematoxylinandeosin. Lightmicroscopyx 60.Plate 10 Koebner phenomenonin psoriasisdueto injury.Plate11 Subungual exostosisaffectingthesecond toe.Plate 12Extravasationwithincallusdue toprolongedhighpressure ...Plate 14 Plantarkeratoderma.Plate 13Dorsal corn.Plate 15 Bullouspemphigoid.Plate 17 Lichenplanus.Plate 18 Necrobiosis Iipoidica.Plate16 Plantarpustular psoriasis.Plate 19 Acutecontact dermatitis to adhesivesin footwear.Plate 20 Extensive plantarwartsin an immunosuppressedpatient.Plate 22 Pitted keratolysisof theheel.Plate 24 Interdigital melanoma.CHAPTER TITLE 5Plate 21 Pseudomonasinfection affecting the interdigitalarea.Plate 23 Tinea pedis affectingthe dorsum of the foot.6 PART TITLEPlate 25 Pyogenicgranuloma under thenail.Plate 27 The sampleof urine on theleft is normal; thesampleon theright is cloudyand tinged withblood,indicatinginfection.TRACE ~ MODERATE LAROE00 NOT USE AFTER: 0219400NOT EXPO$!: TO DIRECT SUNLIGHTREAD PRODUCT INSERT BEFORE USE.NONHAEMOI.YleoHAEMDLY2OlllACE TRACENEG.NEG.PRINT DATE: 02/92SPECIRC GRAVITY45secondsNITRITE60secondsBLOOD&DsecondsPRoTE1H&D secondsLUCoCYTES2minutespH60secondsTESTSANDREADINGTIMES(to be readinthectireetlon of arrow)________115'j< !Plate 26Metastaticlesion(secondaryfroma lungtumour).KfTONE40secondsPlate 28 Multistix 8SG: therange of biochemical testsavailablefromone urine sample(reproducedby kindpermissionof BayerDiagnosticsUK Ltd).GLUCOSE30secondsIi@nk,''''''NEG.CHAPTERTITLE 7Plate 30 Hyperhidrosis, particularly interdigitally, leadstoover-moist skin(macerated) whichtearseasilywhenmechanically stressed, sometimes exposingthedermisasseenhere.Complications ofhyperhidrosis includedermatophyte,yeast and bacterial infections.Plate 32 Deepneuropathic ulcer whichpenetrates to theplantartendons; thereis no cellulitisor abscessformation.Thepatientwasa noninsulin-dependent diabetic.Plate 31 A typical neuropathic foot.Plate 29Dry fissuresdevelop whentheskin is toobrittle toconformtoexternal andinternalmechanicalstresses(tension andshearparticularly).Theyare afrequentcomplicationofanhidrosisandatrophy.Plate33 Bilateral arthropathy of themidtarsal joint,withulcerationof normallynon-weightbearingsofttissues, in aninsulin-dependent diabetic withperipheral neuropathy.Plate35 Typical neuroischaemiculceration over thelateralaspect of themidfoot in a noninsulin-dependent diabetic,showingdeeperosionof softtissues, sloughybase, heavyperipheral callosityandmacerationof superficial tissues.Plate 34 A neuropathic ulcer on the plantar surface of the foot.CHAPTERCONTENTSIntroduction 3Why undertake a primary patient assessment? 3The assessment process 4Risk assessment 4Making a diagnosis 5Aetiology 7Time management 7Re-assessment 7Recording assessment information 8Confidentiality 9Summary 10AssessmentL. MerrimanINTRODUCTIONPatients present with a range of signs and symp-toms for whichtheyare seekingrelief and ifpossible a cure. However, before this can beachieved, it isessential toundertakeaprimarypatient assessment. Ineffectiveandinappropri-atetreatmentmayresult ifthepractitionerhasnot taken into account information obtainedfrom the assessment. This chapter explores whyit isnecessarytoundertakeanassessmentandconsiders specific aspects of the assessmentprocess.Whyundertake a primarypatientassessment?Information fromthe assessment helps the prac-titioner to: arrive ata differential diagnosis or definitivediagnosis identify the likely cause of the problem(aetiology), e.g. trauma, pathogenicmicroorganism identify any factors which may influence thechoice of treatment, e.g. poor blood supply,current drug regimen assess the extent of pathological changes sothat a prognosis can be made establish a baseline in order to identifywhether the condition is deteriorating orimproving assess whether a second opinion is necessary.34 APPROACHING THE PATIENTAll the above informationis essential if thepractitioner is to provide effective treatment andcare for the patient.THE ASSESSMENT PROCESSTable 1.1 Components of anassessmentAssessment comprises three elements; theinterview, observation and tests (Table 1.1).Information fromthe interview andobservationis used to formulate ideas as to the likely diagno-sis and cause. Further information may be soughtvia the ihterview and the use of clinical and lab-oratory tests. The practitioner uses the datagained from the assessment to formulate ahypothesis(es) fromwhicha diagnosis will bereached. This diagnosis will beusedtoinformthe management plan(Fig. 1.1). Where possible,thecause(aetiology) of theproblemshouldbeidentified, as part of the management planwould be to eradicate or reduce the effects of thecause.What has been outlinedaboveistheideal. Inreality, patients often present with ill-definedproblems andit is not possible toreach adefin-itive diagnosis. In these instances the practitionerexplores a range of likely possibilities and devel-ops the management planinrelation to theseComponentAssessment interviewObservationand clinicalexaminationLaboratory andhospital testsPresentingproblemPersonal detailsMedical historyFamily historySocial historyCurrent healthstatusVascularNeurologicalLocomotorSkinandnailsFootwearUrinalysisMicrobiologyBlood testsHistoryGait analysisX-rayOther imaging techniquesECGNerve conductionFigure1.1 The stages of assessment summarised.possibilities.This approach focuses on symptomreduction and palliation.Agood assessment requires that the practi-tioner demonstrates good interviewing (commu-nication)andobservational skills. It isessentialthat the practitioner has effective listening skillsand knows when and which questions to ask thepatient (see Ch. 2). Research has shown thatmost diagnoses are basedonobservationandinformation volunteered by the patient (Sandler1979).Clinical, laboratoryand hospital based testsprovide additional data. Clinical tests involvephysicalexaminationof thepatient (e.g. assess-ing ranges of motion at joints, taking a pulse)aswell as near-patient tests such as assessing bloodglucoselevels witha glucometer. Most clinicaltests are relatively quick and inexpensive to carryout and in most instances give fairly reliable andvalidresults. Technologicaladvancesmeanthatthere are an increasing number of available clini-cal tests. Testsinlaboratoriesandhospitalsaremore expensive and can be time-consuming.Such tests should only be used when it is neces-sary to confirm a suspected diagnosis, in cases ofdifferential diagnosis or when the outcome of thetest will have a positive influence on treatment.Risk assessmentRisk assessment can serve two purposes:ASSESSMENT 5Problem FeaturesTable1.2 Presentingproblemswhichshould be givenhighprioritywhole area before suchmeasures canbe usedwith confidence.Making a diagnosisArriving at a diagnosis is a complex activity.Studies of clinical reasoningshowthat practi-tioners use one or more of the followingapproaches (Higgs &Jones 2000): hypothetico-deductive reasoning pattern recognition interpretative model.Hypothetico-deductivereasoningisbasedongeneratinghypotheses usingclinical data andknowledge. These hypotheses aretested throughfurther inquiry duringtheassessment. Theevi-dence gainedis evaluatedinrelation toexistingknowledge and a conclusion reached on the basisof probability (Gale 1982).Pattern recognition isa process of recognisingthesimilarity betweenasetofsigns andsymp-toms. Theimportant aspect of theuse of cate-gorisation in clinical reasoning is the linkpractitioners make between the pattern they arecurrently observing and previous cases showingthe same orsimilar patterns.The interpretative model is very differentfromthe other twomodels. This approachisbased on the practitioner gaining a deep under-standingof the patient's perspective and theinfluenceof contextual factors. Protagonistsofthis approach believe that the meaning patientsgiveto their problems, includingtheir under-standing of and their feelings about theirproblem, can significantly influence their levelsof pain tolerance, disabilityand the eventualoutcome (Ferurestein & Beattie 1995).Studies have shown that with all theseapproaches there is an association between clinicalreasoning andknowledge(Higgs&Jones2000).There is a symbiotic relationship between theknowledge base of practitioners and their clinicalreasoning ability. It is not possible to developproblem-solving skillsinthe absence of cognitiveknowledge related to the specific problem.There are three partners in the assessmentprocess; the practitioner, the patient and theDistinct colour changeDischargemay be malodorousItchingBleedingAbnormal skin changesAcute swellingUlcerationPain Constant, weightbearingandnon-weightbearingAffects patient'snormal dailyactivitiesRaised temperature(pyrexia)Sign of acuteinflammationSigns of spreadingcellulitisLymphangitis, lymphadenitisLoss of skinMayor may not be painfulMay exposeunderlyingtissuesUnrelievedpainVery noticeableswellingMay have associatedsignsofinflammationInfection identify patients who need immediateattention serve as a predictor forthose 'at risk'.On account of the demands on time it isoftennecessary for the practitioner to differentiatebetween those patients who need immediateattentionandthosewhodonot. Table1.2 sum-marises thepresentingproblems whichshouldbegiven high priority.Inclinics where there arelengthywaitinglists patients maybe screenedinitially to assess whether they have one or moreproblems which appear inTable 1.2 and arethengiven immediate treatment.The term 'at risk' usually denotes thosepatients at risk of developing ulceration andinfection. Identifyingthoseat riskisacomplextask. Currently, research intorisk factorsrelatedtolowerlimbproblemsissparseandthusit isdifficult to produce risk assessment methods thatarerobust andvalid. Considerableresearchhasbeen undertaken into the risk assessment of pres-sure ulcers (Lothian 1987). In relation to thelower limb some work has been undertaken intodevelopingmethodsofrisk assessment toiden-tify diabetics at risk of developing diabetic ulcers(Zahra 1998). Further work is needed in thisTable1.3 Factors whichshouldbe takenintoconsideration whenmakinga differential diagnosisdroses), whereas other conditionshavespecificpresentingfeatures(e.g. the sudden, acute, noc-turnal pain associated with gout).Thepatient is thekeypartner in the assess-ment process. Some patients want to playagreater role indecision making andtheir healthcare management. Additionally, patients areincreasinglybeingseenas consumers of healthcare. Assuch, they have expectations of the typeand quality of the health services they receive.Patients' perceptions, beliefs andexpectationsrelated to their lower limb problems can beinfluenced by the following factors: home environment work environment culture socioeconomic status language skills general state of health.The above factors canaffect patients' needs,communication skills and, ultimately, the choicesthey make.The wider health environment and contextcannot be ignored in the assessment process.6 APPROACHING THEPATIENTwiderenvironment. Theability ofapractitionerto undertake an effective assessment and make adiagnosis is influenced by a range of factors: personal values, beliefs and perceptions knowledge base related tothe problem(s) reasoning skills (cognition and metacognition) previous clinical experience familiarity with similar cases.There canbe enormous differences betweenpractitioners, bothin their assessment findingsand their diagnoses. For example, Comroe &Botelho (1947) described a studyin which 22doctorswereaskedtoexamine20patientsandnotewhethercyanosiswaspresent. Undercon-trolled conditions these patient were assessed forcyanosis byoximeter. Whenthe results of theclinical assessment were compared with theoximeterresults, it wasfoundthat only53%ofthedoctorsdiagnosedcyanosisinsubjects withextremely low oxygen content: 26% said cyanosiswas present in subjects with normal oxygencontent. Curran & Jagger (1997) found pooragreement between podiatrists when diagnosingcommon conditions of the leg and foot.Agreement improved when a patient expertsystemwas used. Expert patient systems areincreasingly being used, in particular in medicine(Adams et al 1986). These computer-basedsystems providepractitionerswithawealthofinformationand are used to guide and directclinical decision making.Unfortunately, making a diagnosis is not aprecise science: errors can and do occur.Practitionersshouldalwayskeep an open mindwhen making adiagnosis, reflect on theprocessthey have used, keep up to date with current lit-erature and technology and request a secondopinion when unsure.Sometimes the practitioner mayhave gener-atedmorethanonepossiblediagnosis; intheseinstances the practitioner has to undertake a dif-ferentialdiagnosis, i.e. decide which isthe mostlikely from a number of possibilities. When arriv-ing at a differential diagnosis the practitionershould take into account the factors listed inTable1.3.Forexample, anumberof conditionsaffect specific age groups (e.g, the osteochon-Social historyMedical historySymptomsSignsSpecifictestsAgeGenderRaceSocial habitsOccupationLeisurepursuitsFamily historyMedicationOnsetType of painAggravatedby/relievedbySeasonal variationSiteAppearanceSymmetryImaging techniquesUrinalysisMicrobiologyBlood analysisBiopsyFoot pressureanalysisElectrical conductivestudiesHealthcare isapoliticalissueandgovernmentpolicy changes canradically affect available ser-vices. Finance is another major influencing factorthat maylimit therangeofclinical andlabora-tory teststhat may beused.Conversely, techno-logical advances haveledtoimprovedclinicaland laboratory test equipment. Employingorganisations can affect the assessment process ina variety of ways, e.g. use of specific frameworksof operation. Profession-specific frameworks andthe status of knowledge withinthe professioncan also be influencing factors.AetiologyInformation fromtheassessment canenablethepractitioner to identify the cause of the problem.A variety of aetiological factors can result indis-ordersofthelowerlimb. Thesecanbedividedinto hereditary, congenital (present at birth) oracquired.Hereditary conditions may manifest immedi-atelyafter birth, e.g. epidermolysis bullosa, ormay not appear until some years after, e.g.Huntington's chorea.Congenital conditions include chromosomalabnormalities, e.g. Down'ssyndrome, develop-mental defects, e.g. spina bifida, or birth injuriessuch as cerebral palsy.Acquired conditions are those which ariseafter birth. Infectionbyapathogenicorganismresultinginsepsisisacommonexampleof anacquired condition affecting thelower limb.Many conditions occur as a result of more thanone factor, i.e. they are multifactorial. Athero-sclerosis is thought to be due to the interplay of anumber of factors, including dietary intake,familial highcholesterollevel, highbloodpres-sure, sedentary lifestyle and stress. In many casespredisposing factors present inconjunction withanexciting factor before the condition manifests.Anexample is a septic toe, where there hasto bea portal of entry inorder forthebacteria togainentry into the skin and multiply.If thecause can be identified (e.g. lack of shockabsorption, contaminationby a pathogen) thentreatment can be aimed at eradicating or reducingitseffects. Knowingwhat has causedaproblemASSESSMENT 7can assist in identifying the most appropriatetreatment andhelp toproduce anaccurate prog-nosis. For example, if thecause of pain in the footis chronic ischaemiadueto atherosclerosis, theprognosis maybe poor unless radical (bypass)surgery is performed. Conversely if thefoot painisduetoacuteischaemiathathas occurredasaresult of hosiery constricting theperipheral circu-lation, the prognosis is good and advice may be allthat is required. Unfortunately, it isnot alwayspossibletoisolatethe cause; inthese cases theterm idiopathic (unknown cause) is used.TIME MANAGEMENTThe assessment process is fundamental to a satis-factory outcome for both patient and practitioner.However, practitioners often find themselvesworkingwithinstrict timeconstraintsandmayfeel they have"insufficient time in which toundertake a full primary patient assessment. It isimportant that the practitioner does not compro-mise the assessment process in order to savetime. Such action, although it may deliver ashort-termtimesaving, mayresult inunfortu-nate long-term effects. Thepractitioner who hasnot obtainedimportant information or failedtorecognisesalient clinicalfindingsmayreachanincorrect diagnosis and/ or implement treatment,that putsthepatient at considerable risk. Inthelong term this willlead toavoidable patient suf-fering and extra time being spent in dealing withthe complications arising from treatment.In order to use time effectively it is important toplan and prioritise activities. The time allotted to aprimary assessment may be as littleas 5 minutesor maystretchto30minutes plus. On averagepractitioners should be able to undertake a routineassessment in 10minutes; further time mayberequired if theproblem is complex, if a definitivediagnosis cannot be reachedor iflaboratoryorhospital testsare required. Table 1.4 identifies theessential components of any assessment.RE-ASSESSMENTAssessment should not be something that is onlyundertaken on the patient's first visit.Every time8 APPROACHING THEPATIENT----------_._---------------------Figure 1.2 The assessment loop.Table1.4 The essential components of anassessment.These shouldbe carried out withall patients. Further testsandexamination shouldbeused if indicated fromtheinformation obtained fromthe essential assessmentthepatientattendstheclinicamini-assessmentshould be undertaken in order that the followingcan be noted: changes to the patient's general health status changes to the status of the lower limb patient's perception of previous treatment effects of previous treatment information about treatment from otherpractitioners.The process of assessment, diagnosis and treat-ment should be an uninterruptedloop:ateverysubsequent consultation, the patient shouldbere-assessed and evaluated (Fig. 1.2).ObservationInterviewObservationTestsGait as thepatient walks into theroominorder to detect abnormal functionFacialfeatures for signs of currenthealthstatusPresentingproblemPersonal detailsMedical historyFamily historySocial historyCurrent health statusSkinandnails to detect trophic changesand abnormal lesionsPositionof lower limb tonote deformity,mal alignmentFootwearPulses,capillary fillingtimeRECORDING ASSESSMENTINFORMATIONInformation gained from the assessment shouldbeaccurately andclearly notedinthepatient'srecord. Thisrecordisthestorehouseof knowl-edge concerning the patient and his/hermedical history. It should contain a summary ofthe main points from the assessment andsufficient datatojustifythediagnosis. Ideally,whether ina hospital or primarycaresetting,healthcare practitioners shoulduse the samepatient record. This ensures that all practitionersinvolved with thecare of the patientare awareof eachother'sassessmentsandinterventions.Althoughthisis goodpractice, thekeepingofseparate records by each health care profes-sional, e.g. general practitioner, district (home)nurses, podiatrists, isstillprevalent. Thisprac-tice does not facilitate teamworking.Two methods may be used to record theassessment information. The first involves usinga blank piece of paper on which the practitionerwrites, in a logical sequence, assessment anddiagnostic details. The other involves the use ofapro-forma; thismayvaryfromaformwithafewheadings to a very detailed format withboxes in which to write specific details. Such pro-formas canbeself-designedorpurchasedfromspecialised suppliers.Whatever the method used, it is important thatall detailsare written in such a way that practi-tioners not involved with the assessment canfamiliarise themselves with the salient detailsand any previous treatment. Records may behandwritten ortyped; typedrecordsareprefer-ableastheyaremorelegiblebuttheydohaveresource implications. If handwritten,the hand-writing must be legible and in ink (blue or black).The use of computers is already having animpact: it is likely that computers will eventuallybe the prime means of recording patient data.The record should be madeat the timeof theassessment: anyblankspacesshouldbescoredthrough. The original record should not bealtered or disguised. If it proves necessarytoamend the record, the nature of the amendmentshouldbeclearandtheamendment shouldbesigned and dated bythe practitioner making thealteration.Itisrecommendedthat abbreviationsshouldbeavoided (Bradshaw & Braid 1999). Theuse ofprofession-specific abbreviationscan beparticu-larly problematic in multi-authored patientrecords, which arecompleted by morethanonehealth care profession. However, the use ofabbreviations in patient records is common.Curran (1994) noted that 97%of respondentsused clinical abbreviations in their podiatrictreatment records.All entries should be dated and signed. In par-ticular, details regarding the patient's medicationshouldalways bedated,asthemedication mayhave been changed by the time the patientattendsfor thenext appointment. The patient'snameor the patient identifier should appear onevery page. Records should always be written insuch a way as not to beoffensive orcontain sub-jective opinions.Most professional bodies provide guidance onrecording information in patient records. Forexample, the Society of Chiropodists andPodiatrists (2000) produce Guidelines on theMinimumStandardsinClinical Practice, whichcontainspecificinformationonrecordkeeping.Bradshaw &Braid (1999) identified the followingfour reasons forpoor record keeping: illegible handwriting incomplete information inaccurate information ambiguous abbreviations.It is suggested that practitioners as part of theircontinuing professional development receiveperiodic reminders and refresher sessions relatedto record keeping (Bradshaw &Braid 1999). It hasbeen foundthat regular audit of medical recordsimproves record keeping (Donnelly 1995).The information recorded from the assessmentmay be used for: ensuring contraindicated treatments are notused clinical and epidemiological research audit planning legal purposes.ASSESSMENT 9Retrospective and prospective analysis ofpatient records is commonlyusedfor clinicalandepidemiological research, audit andplan-ning. Ifwell documented, theycanprovideawealth of information. However, one of theproblems with patient records is that there is nostandardisedmanner in whichinformationiscollected.For example, the use of clinical termscan beambiguous.The International Statistical ClassificationofDiseases, Injuries and Causes of Death was estab-lishedbythe WorldHealthOrganizationas auniversal system forcollecting data. Thesystemwas originallydesignedfor mortalitystatisticsbut hasevolvedtocoverabroadrangeof dis-eases. It is updated every 10 years to keep abreastof the constantly changing information base. Thissystemcanbe usedto recorddiseases for thepurpose of clinical and epidemiological researchand audit.In an increasingly litigious society it is impor-tant that high standards of record keepingare maintained. The St Paul InternationalInsuranceCompanyLimited (1991)states that35-40%of all malpracticeclaimsintheUnitedStates cannot be defended because of 'documen-tation problems'. The Society of Chiropodistsand Podiatrists (1998) found that inadequatepatient records were the main reason whylegal claims against state-registered chiropodistssucceeded.CONFIDENTIALITYThe information volunteered by the patient andrecorded in the patient's notes should be treatedas confidential andnot divulgedtoanyotherparty without the consent of the patient.However, theinformationcanbe madeavail-abletoall thoseinvolvedwiththecareofthatpatient.Patient records, whether in manual or elec-tronicformat, aresubjecttotheDataProtectionAct 1998, whichbecame effective fromMarch2000. Thismeansthatpatientshavetherightofaccess, for a pre-set fee, to informationstoredabout them. The act gives rights to individuals in10 APPROACHING THE PATIENTrespect of personal data held about thembyothers. Where information about a patient isstored electronically it is a legal requirement thatpractitioners (or their employingorganisation)comply with the notification requirements of theData Protection Act (1998). If information issolelystoredmanuallythenthereisnorequire-ment to notify.REFERENCESAdams I D, Chan M, Clifford P 1986 Computer aideddiagnosis of abdominal pain: a multi centre study. BritishMedical Journal 293: 80-84Bradshaw T, Braid S 1999 Thepractice of recording clinicaltreatment and audit of practice - anoverview forpodiatrists. British Journal of Podiatry 2(1): 8-12Comroe J H, Botelho S 1947 Theunreliability of cyanosis intherecognition of arterial anoxemia. American Journal oftheMedical Sciences214: 1-6Curran M 1994 Use of abbreviations in chiropody/podiatry.Journal of British Podiatric Medicine 49(5): 71-72Curran M, Jagger C 1997 Interobserver variability in thediagnosis of footand legdisorders using a computerexpert system. TheFoot 7: 7-10Data Protection Act 1998 EC Data Protection Directive(95/46/EC)Donnelly A 1995 Improve your nurses'record collection.Nursing Management 2(3): 18-19Ferurestein M, Beattie P 1995 Biobehavioural factorsaffectingpain and disability in low backpain:mechanisms andassessment. Physical Therapy 75: 267-280SUMMARYThis chapter has statedthe purposeof assess-ment and outlined the assessment process. Ifundertakenwell, it leadstothe drawingupofappropriateandeffectivetreatment plans. It istherefore an activity that should be seen aspivotal to good patient-practitioner interaction.Gale J 1982 Some cognitive components of thediagnosticthinking process. British Journal of EducationalPsychology 52: 64-72Higgs J, Jones M 2000 Clinical reasoning in thehealthprofessions, 2nd edn. Butterworth-Heinemann, LondonLothian P 1987 Thepractical assessment of pressure sorerisk. CARE Science and Practice 5(4): 3-7Sandler G 1979 Costs of unnecessary tests. British MedicalJournal 1: 1686-1688Society of Chiropodists and Podiatrists 1998 Defensivepractice (editorial). Podiatry Now 1(1): 1Society of Chiropodists and Podiatrists 2000 Guidelines onminimum standards of clinical practice, DecemberSt Paul International Insurance Company Limited 1991Defensible documentation. St Paul House, 61-63LondonRd, Redhill, Surrey RHIINA (information leafletforhealth careprofessionals)Zahra J 1998 Can podiatrists predict diabetic footulcersusing a riskassessment card? British Journal of Podiatry1(3): 79-88CHAPTERCONTENTSIntroduction 11Is an interviewdifferent from a normalconversation? 11Aims of the assessment interview 12Communicating effectively 12Questioningskills 13Listeningskills 15Non-verbal communication skills 16Stereotyping 21Documenting the assessment interview 21Structuring the asseSSment interview 22Preparation 22The interview 23,Closure 24Confidentiality 25What makes a good assessment interview? 25Summary 26The assessmentinterviewM. HanleyINTRODUCTIONResearch has shown that the interview, asopposed to any other method of assessment suchas clinical tests andexaminations, is the mostefficient methodinreaching aninitial diagnosis(Sandler 1979). This chapter examines thepurposeof the interview, the skills requiredtocommunicate effectively, howthe interviewshould bestructured and thepitfalls toavoid.Itconcludesbyexaminingthe features ofagoodassessment interview.Is an interview different from anormal conversation?An interviewis based upon a conversationbetween two ormore people. As individuals weconverse with a broad range of people.Conversation serves a multitude of purposes.Theconversation inaninterview differs fromanordinary conversation in a number of ways: It is anopportunity for anexchange ofinformation. It hasa specificpurpose; e.g. to solve aproblem. It has anoutcome, e.g. a course of treatment. It hasless flexibility than anordinaryconversation. The interviewer has a perceived position ofauthority/power over the interviewee. It is important that this power is not abused.Every effort should be made to put theinterviewee (thepatient) at ease.1112 APPROACHING THEPATIENT A written record of the interview is usuallykept.Practitioners may be involved with other typesof conversation with patients, which requireadditional skills such as counselling, teachingand advising. These arediscussed inthe accom-panying text to this book: Clinical skills in treatingthe foot.Aims of the assessment interviewThe assessment interview isa conversation witha purpose, which takes place between the practi-tioner and the patient. Patients present withproblems, which may have physical, psychologi-cal andsocial dimensions. Patients oftenhavetheir own ideas and concerns about the problemstheypresent with, andabout the medical carethat they mayor may not receive. Likewise, prac-titioners approach the interviewwith percep-tions of their role. These will have beeninfluenced by training, past experiences, atti-tudes andbeliefs. The availabilityof resourcesand facilitieswill contribute to the practitioner'sresponse to the patient. It is essential that thepractitioner and the patient develop commongroundduringtheinterviewandthatbothareaware of each other's perspectives. If this cannotbeachieved the interview may bean unsatisfac-tory experience for both of them.Theprime purposeofthe interview isfor thecauseof thepatient's concernstobe identifiedand appropriate action taken. This is bestachieved by the patient and the practitionerworking in partnership to reduce or resolve theseconcerns.It is essential that the practitioner providesample opportunity for thepatienttoconvey hisconcerns andworries. Inother words, the inter-viewshould be patient-centred. Research hasshownthat this is not always the case. Afewyears after qualification most practitioners areconfidentthat theyare goodat takinghistoriesand explaining things to patients. Is thisconfidencejustified?Adetailedanalysis of therecordings of over 2500 doctor/patient inter-views showedthat 77%of themwere doctor-centred, comparedwith21% classedaspatient-centred (Byrne &Long 1976).Information gathered collectively from theinterviewandexaminationshouldfacilitatetheidentification of the patient's health problemand, where appropriate, a diagnosis can bemade. However, aswell as aiding the diagnosticprocess, the interviewserves other importantpurposes: The information gained may be of help whendrawing up a treatment plan. For example, theinterview can provide a picture of thepatient'ssocialcircumstances, which may affect themanner of, or the actual advice given. It provides an opportunity to gain thepatient's trust and confidence in you asapractitioner. It facilitates the development of a therapeuticrelationship between the health carepractitioner and the patient.However, not all health care students areaware of how to communicate effectively and, asa result, communication skills training is becom-ingacommonpart of thecurriculuminhealthcarecourses (Hargie et a11998, Sleight 1995).COMMUNICATINGEFFECTIVELYSince the interview plays a particularlysignificant role in the assessment of the patient, itis important toensurethat themeetingis suc-cessful. In other words, good communicationskills areessential if you aretoachieve an effec-tive assessment interview. What is meant bycommunication?In its simplest formit canbeseen as the transmission of information from oneperson and the receiving of information byanother. Unfortunately, the communicationprocess is not that simple; if it were there wouldnot be communication breakdowns or misunder-standingbetweenpeople as to what has beensaid.Communicationcanbeinfluenced bycharac-teristics of the sender (e.g. ability to express ideasclearly, verbal skills, attitude toward the patient),the receiver (e.g. the extent to which thereceiveris payingattention, abilityto hear andunder-stand the conversation, prior beliefs and expecta-tions) or characteristics of the social environmentinwhichtheinterviewisbeingconducted(e.g.disruptiondue to background noise). With somanyopportunitiesfor theseforms of interfer-ence, it isnotsurprisingthat manyattemptstocommunicate effectively fail. Consequently,health care professionals should develop theircommunicationskillsinordertomakethebestuse of the interview.A common question asked is: 'Are good com-municators bornor isit askill youcanlearn?'.The answer has to be, it's a bit of both. We can allthink of people we consider to begood commu-nicators; these people appear to have an inherentskill. Forothers, communicationmaynotcomesoeasily. Itisparticularlyimportantfor healthpractitionerstobe awareofanddevelopeffec-tive communication skills because so much clin-ical information is gathered through theassessment interview. Researchhasshownthatwith assistance and motivation, good communi-cation skills can be developed (Ryden et aI1991).A myriad of books areavailable on the subjectof communication skills. However, just reading abook does not automatically mean you become agood communicator. Observing others, notinggoodandbadpoints, receivingfeedbackfromothers, role-play exercises, video- andaudiotap-ing of interactions, practising infront of a mirroror withfriends are all helpful ways in whichskillscan bedeveloped. Being an effective com-municator is a skill - and likeany clinical skill itshould be regularly practised and reviewed.Constructive criticismis an essential part oflearning but not always an easy method toaccept!While you may not be able to change the com-municationcharacteristics of thepatient or thesocial environment, you canensure that yourcontributionto theinterviewis as effective aspossible. Youcandothisbysendingclearandappropriate messages to the patient and byensuring that you understand fully what thepatient is trying to communicate to you. In orderto achieve this, you need to pay careful attentiontothreekeycomponentsofthecommunicationprocess:THEASSESSMENT INTERVIEW 13 questioning skills listening skills non-verbal communication skills.Each of these skills will be considered in turn.Questioning skillsThe prime purpose of the assessment interview isto gain as much information as possible from thepatient inorderthat adiagnosisandtreatmentplan can bearrivedat. To achievethisobjectivethe practitioner uses a range of questioning skills.There arethree categories of question: open closed leading.Open questions. Open questions invite thepatient togive farmore than one-word answers.Thepatientisinamuch betterpositiontocon-structtheresponsehewishestogive. Examplesof open questions are: What happened when you went intohospital? What do you look forwhen buying a pair ofshoes? What do you think is causing theproblem?This sort of question can elicit informationfrom the patient that you had not expected. Openquestions areoften preferable to closed questionssuch as'When you were in hospital did they testyour bloodsugar or give youan X-ray?'. Thepatient may legitimately answer 'no' to thesedirect questions and fail to tell youthat theyundertook a test you have not mentioned.Closedquestions. Closedquestions limit theresponses a patient may give. They usuallyrequirea onewordresponse. Closedquestionsmay: require a yes/no response, e.g. Do you sufferfrom rheumatoid arthritis? require the patient to select, e.g. Is the painworse in the morning orthe afternoon? require the patient to provide factualinformation, e.g. How long have you been adiabetic?14 APPROACHING THE PATIENTClosed questions serve useful purposes duringtheassessment interview. Theyprovideaquickmeans of gaining and verifying information.Patients often find them easier to answer than themore open type of question. They can be used tofocus the assessment interviewin a particulardirection. Ontheotherhand, ifusedtoomuchthey limit what the patient can say. As a result thepatient may not volunteer important informa-tion.Leadingquestions. Leadingquestionsshouldbeavoided where possible.Ingeneral, they giveresponses that the professional expects to receive.Examples of leading questions are: You don't smoke, do you? That doesn't hurt, does it? You said you get the pain a lot; that mustmean you get it every day?Whileyoumayget theanswer youwant orexpect tohear, it does not necessarily mean itistrue!Inadditiontoaspecificstyleofquestion, thepractitioner mayalso use a range of interviewtechniques to elaborate further on the issuesraised. These techniquesareoften referredtoasprobes. Probing questions are a very usefuladjunct to bothopenandclosedquestions. Ingeneral theyaimat findingout morefromthepatient. Inparticular, theyareusefulingainingin-depth rather than superficial information.Examples include: Could you describe the type of pain it is? What makes you think it might be linked toyour circulation?You might also use silence as a probe toencourage the patient to expand on a givenanswer, or say 'yes', 'uh-hm' or simply nod,techniques that are particularly useful whenyou feel the patients may have more to sayand are thinking about expanding theiranswer.General pointers when questioning patientsThefollowingpointsshouldbe borneinmindwhen interviewing patients: Show empathy. Authier (1986) definedempathy as: '[being] attuned to the way anotherperson is feeling and conveying thatunderstanding in a language he/sheunderstands' . Use language that is simple, direct andunderstandable. Avoid medical and technicalterms. The'fogindex' can beusedtoassessthecomplexityof apieceofcommunication(Table 2.1). It is primarilyused in writtencommunication but has also been used,although less frequently, to analyse thecomplexity of the spoken word. It involves amathematical equation that produces a score.For example,tabloidnewspapershaveafogindex score between 3 and 6, whereasgovernment policy documentscanachieveascore of 20+. Applying the fog index tospoken communication or a foot healtheducation leaflet will give an indication of thecomplexity of that particular communication.If it receives a high fog index score, theaveragepatient mayfindit verydifficult tounderstand. Avoidpresentingthepatient withalonglistof conditions. This is especially importantduringmedical historytaking. It is unlikelythat a patient has experienced more thanone or twoofthe problems on a list. Patientsmay fall into the habit of replying 'no' toall the items onthe list andfail torespondin the affirmative to ones they do sufferfrom. Strategies that can be used to avoid thissituation include a pre-assessment ques-tionnaire (see Ch. 5) or breaking up thelist of closed questions with some openquestions.Table2.1 Thefog indexTake a passageof about 100 words, endingin a full stop.Workout theaveragesentencelength. Thisis achievedbydividingthenumberof sentencesinto100. Then workoutthenumberof wordsof threeormore syllables. Ignore two-syllablewordsthat have becomethreesyllableswithpluralor endingslike-ed or -ing, technical wordsand propernouns. Add theaveragesentencelength to the numberofdifficult wordsand multiplyby 0.4. Theresult will give youthereadingscore(fog index) Don't ask the patient more than one questionat a time. For example, if asking a closed-typequestion do not say, 'Could you tellmewhenyou first noticed the condition, when the painisworseandwhat makes it better?'. Bytheend of the question the patient will haveforgotten the first part. Attempt to get the patient to give youan honest answer using his or her ownwords. Avoid putting words into the patient'smouth. Clarify inconsistencies in what the patient tellsyou. Get thepatienttoexplain whathemeansbyusingcertainterms,e.g. 'naggingpain'.Yourinterpretation of this term may differ from thepatient's. Pauses are an integral part of any com-munication. Theyallowtimefor participantsto take in and analyse what has beencommunicated and provide time for aresponsetobeformulated. Allowthepatienttimetothink howhewishestoansweryourquestion. Avoid appearing as if you areundertaking aninterrogation. Intheearly stages ofthe interview itisoftenbetter to use the term'concern' rather than'problem'. Asking patients what concernsthem may elicit a very different response fromasking themwhat the problemis. Somepatients may feelthey do not have a problemas such but areworried about some symptomorsign they havenoticed. Asking them whatconcerns themmayget themto reveal thisrather than a denial that they have anyproblems. Askingpersonalandintimatequestionscanbe verydifficult. Donot start theinterviewwith thistypeofquestion; wait until furtherinto the interview when hopefully the patientis more at ease with you. Try to avoidshowing any embarrassment when asking anintimate questionasthismay well makethepatient feel uncomfortable. It is important that the patient understandswhy you are asking certain questions.Rememberthattheassessment interview isatwo-way process: besides gathering infor-THEASSESSMENT INTERVIEW 15mationfromthe patient it can be usedforgiving information to him. Some patients, on account of a range ofcircumstances such as deafness, speech deficitor language difference, maynot be able tocommunicate withthe practitioner. In theseinstancesit isimportantthatthe practitionerinvolves someone known to the patient tocommunicate on his behalf, e.g. relative,friend or carer. Thepatient may have difficulty listening andinterpreting what you are saying through fear,anxiety, physical discomfort or mentalconfusion.Be aware of non-verbal and verbalmessagesthat cangive clues tothe patient'semotional state.ListeningskillsListening isanactivenot apassiveskill. Manypeople ask questions but do not listento theresponse. Acommon example is the generalintroductory question: 'Howare you?'. Mostresponses tendtobe in theaffirmative: 'Fine','OK'. Occasionally, someone responds bysayingthey have not been too well, only to get theresponse fromthe supposed listener: 'Great;pleasedtohear everything isfine'. Similarly, donot limit your attention tothat which you wantto hear or expect to hear. Listen to all that is beingsaidandwatchthe patient'snon-verbal behav-iour. The average rate of speech is 100-200 wordsa minute; however, we can assimilate the spokenword at around 400 words per minute. As aresult the listener has'extra time' to understandandinterpret what is beingsaid. If youhaveaskedaquestionyoushouldlistentoall oftheanswer. Oftenwhentryingto understand theclinical natureofapatient'sproblem, thereisagreat temptationtolistentothefirst partofananswerandthentoimmediately usethis infor-mationtotryandmakeadiagnosis. This maymean that you are not paying careful attention toimportant clinical information, which the patientmaygive, at theendoftheirreply. Finally,itisimportant that you don'tletyour mindwanderontounrelatedthoughtssuchaswhat youaregoing to doafter the interview. Before you know16 APPROACHING THE PATIENTit youhavemissedagoodchunkof what thepatient has been telling you and have most prob-ably missed important and relevant information.Inorder tobeagoodlistener you needtosetasideyourownpersonal problemsandworriesandgive your full attention tothe other person.It is inevitable that, attimes, one's attention doeswander. Thismaybe duetolackof concentra-tion, tiredness or becausethepatient hasbeenallowed to wander off the point. In the case of theformer donot be afraid to sayto the patient,'Sorry, could I ask you togo over that again?'. Inthe latter case, politely interrupt the patient anduse your questioning skills to bring the conversa-tion back tothe subject inhand.Duringtheinterviewthetechniquesof para-phrasing, reflection and summarising can beused to aid listening and ensure you understandwhat the patient is trying toconvey.Paraphrasing. This technique is used to clarifywhat a person has just said to you in order to gethim toconfirm itsaccuracy ortoencourage himto enlarge. It involves re-stating, using your ownand the patient's words, what the patient hassaid.Reflection. This technique is similar topromptingin that it is used to encourage thepatient to continue talking about a particularissue that mayinvolvefeelings or concerns. Itmaybe used whenthe patient appears to bereluctant to continue or is 'drying up'. It involvesthe practitioner repeatingin thepatient's ownwords what the patient has just said.Summarising. Thistechniqueisusedtoiden-tifywhat youconsidertobethemainpointsofwhat the patient istrying totell you. It can alsobe auseful means of controllingthe interviewwhen a patient continues totalk at length aboutanissue. Tosummarise, thepractitioner drawstogether thesalient pointsfromthewholecon-versation. Atthe end of the summary the patientmayagreewith, addtoor makecorrectionstowhat the practitioner has said. Summarisingserves a useful purpose inchecking the validity,clarity andunderstandingofoldinformation;itdoes not aim to develop new information.Thebasic skills of a goodlistener are high-lighted in Table 2.2.Table2.2 Skills ofa good listener Look at the patient when he/she startstotalk Use body language suchas nodding, leaning forward todemonstrate tothe speaker that you are interestedinwhat is being said Do not keep looking at thetime Adopt a relaxed posture Use paraphrasing, reflecting andsummarising toshow thepatient that you are listening to and understanding whathe/sheis/are sayingNon-verbal communication skillsThisinvolvesall formsofcommunication apartfromthepurelyspoken(verbal) message. It isthrough this medium that we create firstimpres-sions of people and, similarly, people make initialjudgementsabout us. Oncemade, first impres-sionsare oftendifficult tochange, yet researchhas shown they are not always reliable.Therefore, it is particularlyimportant that weconsider non-verbal communication here since itaffectsnot only how we areperceived when wecommunicate but also how wemake judgementsabout the patient.Non-verbal behaviour includes behaviourssuch asposture, touch, personal space, physicalappearance, facial expressions, gestures andparalanguage (i.e. the vocalisations associatedwith verbal messages, such as tone, pitch,volume, speedof speech). It issaidthat wepri-marily communicate non-verbally. Rememberthe old adage 'apicture says a thousand words'.Your body language and paralanguage will sendan array of messages to your patient prior to yousaying anything. Non-verbal communicationserves many useful purposes. It can be used to: replace, support or complement speech regulate the flowof verbal communication provide feedback to the person who istransmitting the message, e.g. lookinginterested communicate attitudes and emotions (Argyle1972, Hargie et aI1994).Theaveragepersononly speaksfor atotal of10-11 minutes daily, with the average spoken sen-tence lasting only around 2.5 seconds(Birdwhistell 1970). Therefore, non-verbal com-municationisthemainmodeof conveyingouremotional state inmosttypesofhuman interac-tions. Infact, inatypical conversation only one-third of the social meaning will be conveyedverbally - a full two-thirds is communicatedthrough non-verbal channels! (Birdwhistell1970).Due to the broad literature inthis area the fol-lowingsection will focuson selectedaspectsofnon-verbal behaviour and how they mayinfluence the success of the assessment inter-view. For theinterestedreader, thereisawiderange of books available which look at the topicof non-verbal communication, manyspecialis-ingintheclinicalinteraction: seeDavis(1994),Dickson et al(1997), Hargie (1997), orthe winter1995 editionofthe Journalof Nonverbal Behaviorforfurther information on this topic.Eyecontact. Eye-to-eye contact is frequentlythe firststage of interpersonal communication. Itis the way we attract the other person's attention.Direct eye-to-eyecontact creates trust betweentwo people; hence, the innate distrust felt ofsomeonewhoavoidseyecontact. However, wedonot keep constant eye-to-eye contact through-out a conversation. The receiver looks at thespeaker for approximately25-50%of thetime,whereas the speaker looks at the other person forapproximatelyhalfas long. Soinotherwords,people tend to lookmore at the other personwhentheyare listeningcomparedwithwhenthey arespeaking.Too much eyecontact is interpreted asstaringand is seen as a hostile gesture. Too little is inter-preted as a lack of interest, attention or trustwor-thiness. Interviewers cannot afford to lookinattentive because the patient may interpret thisas meaningthat he has saidenoughandas aresult maystoptalking. Conversely, withdraw-ing eyecontact may beused asa legitimate wayof getting the patient to stop talking.Healthcarepractitioners shouldbe awareofthefrequencyanddurationof eye contact theyhave with their patients. The use of eye contact isimportant forassessing arangeof patient needsand providing feedback and support, and its useduring the interview should be based on the pro-THE ASSESSMENT INTERVIEW 17fessional judgement of the practitioner(Davidhizar 1992). Certainly eye-to-eye contact isrecommendedat the beginning of the interview,togainrapport andtrust, andat theendof theinterviewby way of closing the interview.However, you should always beaware of poten-tial cultural and gender differences in appropriatelevel of eyecontact. Forexample, Hall (1984) hasreportedthat onaveragewomentendtomakemoreeye-to-eye contact comparedwithmen,soadjust your non-verbal behaviour accordingly.Facial expression. Facial expressionis argu-ablythemost important formof humancom-municationnext to speechitself (Hargieet al1994). It is via our facial expression wecommu-nicatemost aboutouremotionalstate, andthemeaningof awiderangeof facial expressions(e.g. happyor sad) arerecogniseduniversally(Ekman&Fresen 1975). Smiling, togetherwithjudicious eye-to-eye contact, signifies a recep-tive and friendly persona and inspires a feelingof confidence and friendliness. Facial expres-sionsoftencarryevenmoreweight inasocialinteraction than the spoken word. Forexample,if apractitioner isgiving avery positive verbalmessage to the patient but, at the same time, thepractitioner's facial expression communicatesanxiety and doubt, then it is likely that thepatient will pay more attention to the facialmessage. This is because verbal behaviour ismuch easier to control than non-verbal and, as aresult, non-verbal communication is likely to bemore honest! Therefore, it is important thatpractitionersarealwaysawareof themessagethey are communicating using their facialexpressions.Postureandgestures. The manner in whichwe hold ourselves and the way in whichwemove says a lot about us as individuals. This areaof non-verbal behaviour is oftenreferredtoaskinesics and includes allthose movements of thebodywhichcomplementthespokenword(e.g.gestures, limb movements, head nods,etc.), Oneparticularly important aspect is posture. Fourtypes of posture have been identified: approaching posture, which conveys interest,curiosity and attention, e.g. sitting upright18 APPROACHING THEPATIENTand slightly forward in a chair facing towardsthe person you arecommunicating with withdrawal posture, which conveys negation,refusal and disgust, e.g. distance between thereceiver and the communicator, shuffling,gestures indicating agitation expansion, which conveys a sense of pride,conceit, mastery, self-esteem, e.g. expandedchest, hands behind head with shoulders inair, erect head and trunk contraction, which conveys depression,dejection, e.g. sitting in a chair with headdrooped, arms and legs crossed or head heldin hands, avoiding eyecontact.Clearly, the posture adopted bythe health carepractitioner is important in developing a rapportand a working therapeutic relationship with thepatient.When we speak we alsotend touse our armsand hands to reinforce and complement theverbal message. In fact, whenpeople are con-strainedfromusingtheirarmsandhands, theyexperience greater difficultyin communicating(Riseborough1981). Self-directedgesturessuchas ring twisting, self-stroking and nail biting mayindicate anxiety. Be aware of self-participation inthese types of activities as youmayconveyanon-verbal message of anxietyto your patientwhile verbally you are trying to convey aconfident approach. The healthcareprofessionshouldbe sensitive to the non-verbal gesturesusedby the patient as thesemayreveal moreabout the patient's thoughts andfeelings thanthey areableto communicate verbally (Harrigan&Taing1997).Touch. The extent towhichtouchingisper-missible or encouraged is related to culture(McDaniel & Andersen 1998). In general, theBritish people are not known as a nation ofTable 2.3 Four zonesof personal space(Hall 1969)'touchers'. During the assessment it may be nec-essary to touch the patient in order to examine apartofhis body. This typeoftouching, knownas functional touching, is generallyacceptabletomost patients as part of the roleof the practi-tioner andassuch does notcarry any connota-tionof a social relationship. However, peoplefromcertain cultures mayfind it difficult toaccept, eveninmedical settings. Priortofunc-tional touching ofa patient, itis important thatyouinformthepatient what youintendtodoand the reasons fordoing it.During the interviewyou may wish to usetouchas a means of reassuringthe patient, toindicatewarmth, showempathyor asasignofcareandconcern (McCann &McKenna1993). Ahand lightly placed upon a shoulder or holding apatient's hand are means of showing concern andgiving reassurance. It is difficult to produceguidelines for when thistype of touching shouldor should not be used. Practitioners must feelconfident and happy in its use, and must also takeintoaccount a multitude of communication cuesfrom the patient before deciding whether it is or isnot appropriate (Davidhizar & Newman 1997).Proxemics. All ofus havea sense of our ownpersonal territory. Whensomeoneinvades thatterritory, depending uponthesituation, wecanbe fearful, disturbedor pleasedandhappy. Aswith touch, our sense of personal space isaffected by culture. Insome cultures individualshavealargepersonal space, whereasinothersthey have a very small personal space.Encroachingonsomeoneelse's personal spacecan beperceived as intimidation and, in the caseof the assessment interview, may put patients ontheir guard. Asaresult the patient may becomereluctant to discloserelevant information. Hall(1969) definedthefour zonesofpersonalspace(Table 2.3).ZoneIntimatePersonalSocial/consultativePublicDistance0-0.5metres0.5-1 .2 metres1.2-3metres3 metres+ActivitiesIntimaterelationships/close friendsWhatis usuallytermed'personal space'Distanceof day-to-day interactionsDistancefromsignificant publicfiguresThe zonein whichpeople interact is highlyinfluenced by social status and people who havean equal status tend to interact at closer distances(Zahn1991). Theassessment interviewusuallytakes place in the social/consultative and thepersonal zone. Duringtheinterviewit maybenecessary to enter the intimate zone. Prior todoingthis, notifythepatientinordertojustifyany actions requiring closer contact.Social interactionsare not onlyinfluencedbydistance, but also by bodily orientation. The angleACTHE ASSESSMENT INTERVIEW 19at whichyouconducttheassessment interviewmay have a significant effect onthesuccess of theinteraction. Thereare four mainwaysinwhichyou can position yourself in order to interactwith the patient (Fig. 2.1): (i) conversation;(ii) cooperation; (iii)competition; and(iv)coac-tion. Research indicates that the conversationpositionis most appropriatefor an assessmentinterview. In fact, research has shown thatwhen CPs sat at a 90Qangle to their patientsduring a clinical interview, the amount ofBoFigure2.1 Body orientationmay influence the success of the interview. The figures show four positions commonlyencountered when two peopleinteract. Which of the following orientations do you think wouldbe most appropriate for theassessment interview? A. Conversation B. Cooperation C. Competition D. Coaction.20 APPROACHING THE PATIENTclinician-patient informationexchanged increa-sed by up to six times compared with when theyinteracted face-to-face (Pietroni 1976).Clearly, thehealthcareprofessional needstobe aware of the physical position they adoptwhen assessing a patient as this will have asignificant impact on the kind of relationshipthey arehoping toachieve (Worchel1986).Physicalappearance. We use our clothing andaccessoriestomakestatementsaboutourselvestoothers. Clothing can beseen as an expressionof conformity or self-expression, comfort,economy or status. Uniformsare usedasinten-tional means of communicating a message toothers; oftenthemessageis todowithstatus.Uniforms are also used in the health care profes-sions for cover and protection. Whether onewearsauniform(whitecoat, colouredtopandtrousers) for theassessment interviewis openfor debate, but one should pay attention toissues of cleanliness andappearance of dress,hair, hands, footwear and accessories suchasjewellery - they all send messages to the patient.In addition to physical factors, which canbealtered, you shouldalsobeawareofhow'non-changeable' physicalcharacteristicsmay playarole in your interaction with the patient. Forexample, physically attractive and/or tallerpeopleare typically judgedmorefavourablyingeneral social interactions (Hensley&Cooper1987, Melamed & Bozionelos 1992). Research hasshownthat withina healthcareenvironment,children make judgements about healthcare professionals on the basis of height. Ingeneral, tallerhealth professionalswerejudgedto be stronger andmore dominant thantheirsmaller colleagues, but they were not consideredto be more intelligent nor more empathetic(Montepare 1995).Finally, health care practitioners should also beawareoftheimpactoftheir appearance on anyhealth promotion message that they hope tocommunicate. For example, the patient will oftenpay attention to the footwear worn by the practi-tioner. Avoidgivingconflictingverbal andnon-verbal messages, e.g. by wearing high-heeledslip-onshoes whileadvisingpatients that theyshould not wear this type of shoe.Paralanguage. This involves the manner inwhich we speak. It includes everything from thespeedat which wespeaktothedialectweuse.Paralanguage is the bold, underlining, italics andpunctuationmarksinoureverydayspeech!Anindividual who speaks fast is often considered bythereceiver tobeintelligent andquick, whereasa slowdrawl maybe associatedwitha lowerlevel of intelligence. When talking to patients weshould be careful not to speak tooquickly as theywill not understand what wesay. Conversely, ifspeech is too slow, the patient may not haveconfidence inthe practitioner.When we speak weusepitch, intonation andvolume to affect the message we transmit.Individuals who speak ata constant volume anddonot use intonationand/or alter their pitchoften come across as monotonous, dull andboring. Such speech is often difficult tolisten to.Intonation and pitch should be used to highlightthe important parts of your question and canbeused to change the point you aretrying to make.For example, inthefollowingsentence youcansee how changing the point of emphasis changesthe message you aretrying toget across. You must use the cream on your foot daily,i.e. treatment is the responsibility of the patient. You must use the cream on your foot daily,i.e. it is essential that the treatment is carried out. You must use the cream on your foot daily,i.e. it is important that the cream is usedand notsome othersubstance. You must use the cream on your foot daily,i.e. the cream should beusedon thefoot and notsome other part of the body. You must use the cream on your foot daily,i.e. treatment needs to beon a regular basis.Thefluency with which wespeak alsotends toconveymessages about mental andintellectualabilities. Repeatedhesitations, repetitions, inter-jections of 'youknow' or 'urn' andfalse startsdo not inspire confidence in the receiver(Christenfeld1995). Weall experienceoccasionswhen we are not as fluent as at other times. Theseoccasions tend to occur whenwe are tired orunder great stress. If possible, these times shouldbe keep to a minimum during clinical assessment.Dialect conveys which part ofthecountry weoriginate from. It may also cause us to use vocab-ularya person from another part of the country isnotfamiliarwith. Avoidusingcolloquialterms.Dialect, on the other hand, is not so easy toalter.The onlytimeit shouldbe considerediswhenpatients cannot understand what the practitioneris saying. Finally, volume should not be changedtooregularly. Shoutingat thepatientshouldbeavoided. In the clinical setting, as in life ingeneral, it certainly doesnotguarantee thattheother person will listen more to what you say!From this section it should beclear that healthcare professionals need to be sensitive to the kindof atmosphere theyare creatingthroughtheirnon-verbal communication, and the role this mayhave in the subsequent interaction with thepatient. The extent to which you establish a satis-factory rapport will depend heavily on your non-verbal skills and how you develop them in yourclinical work (Grahe &Bernieri 1999).StereotypingHealth care practitioners should be aware of theirown underlying psychological characteristics,which may have a profound effect on the interac-tion -i.e. stereotypes. A stereotype is a belief thatall members of a particular social groupsharecertaintraits or characteristics (Baron& Byrne2000). For example, youmight holdparticularideas about the characteristics of a patient who isanalcoholic, elderly, froman uppersocial classgroup, from a minority ethnic group or female. Infact, you probably already hold a range of stereo-types about a wide group of patients whom youhave never actually treated! While stereotypesare not always negative, they do share a commoncharacteristic in that they reduce the ability of thehealthcare worker toseethepatient asanindi-vidual. Consequently, anyinformationgatheredfrom the patient during the assessment interviewis likelyto be interpretedin the light of suchstereotypes (Price 1987). Ganong et al (1987) con-ducteda reviewof 38researchstudies, whichexamined stereotypingbynurses and nursingstudents. Results indicated that nurses heldstereotypesabout patientsonthebasis of age,THE ASSESSMENT INTERVIEW 21gender, diagnosis, social class, personalityandfamilystructure. However, the impact onactualpatient care was harder to classify. What doesseemto be the case is that patients were lesslikely to be seen as having unique concerns,health problems and social circumstances.Consequently, in addition to practising inter-viewing skills, it is important for health carepractitioners to reflect on any belief systems theymayhold regarding particular patient groups,andconsider howsuchviews mayimpair theoverall success of the assessment interview.Documenting the assessmentinterviewItisessentialeitherduringor at theendoftheassessment tomakeapermanent recordof thefindings of the interview. Thisrecord is essentialas anaide-memoire for future reference whenmonitoringand evaluating the treatment planand asa means of communicating your findingstoanother practitionerwhomaycollaborateintreating the patient.Despite recent discussions within the fieldofpodiatryregardingchangingtoelectronicdatamanagement systems, the majority of patientrecordsarestill storedonpaper. However, theuseofcomputerisedrecordsisontheincrease,particularly in private practice. It may well be inthe future that paper records arediscarded com-pletely, and replaced by computerised tech-niques. Whatever the future may hold, theneed forclear, accurate recording of informationwill still be thesame. Therecordingof assess-ment findings, together withthe recordingoftreatment provided, forms a legal document.Patient records would certainly be used if actionwas taken by a patient against a practitioner, orif certain agencies required detailed evidenceof management and progress in the case ofdisability awards.Patient records may take a variety of forms: atthe simplest level aplain piece of paper may beused. If using plain paper it is essential to adoptanordertothe presentation ofyourassessmentfindings: e.g. name, address, doctor, age, sex,weight, height, main complaint, medical history,22 APPROACHING THE PATIENTetc. This is consideredfurther inChapter 5. Avarietyofpatientrecordcardsexistinthe NHSand private practice. Many practitioners andhealth authorities produce their own tailor-maderecordcard. The Association of Chief ChiropodyOfficersproducedastandardrecordin1986 forcharting foot conditions, diagnoses and treat-ment progress.Handwritten recording of information requiresthe following: The writing is legible and inpermanent ink,not pencil. If another practitioner cannot readyour writing the information is of nouse. The information is set ina clear and logicalorder. It is essential to use an acceptedmethod. Accurate recording of location and size oflesions ordeformities. The use of preparedoutlines of the feet arevery good forindicating anatomical sites and saveadditional writing. Abbreviations are avoided where possible.What is obvious to you may not besoobvious to another practitioner. Entries aredated. Recording the medication apatient is taking is useless unless it is dated.Once dated the information can be updatedas and when there is a change. Each entry should besigned and dated by thepractitioner.STRUCTURING THEASSESSMENTINTERVIEWPreparationInorder toachieve a goodassessment interviewitisessential you prepare yourself for theinter-view. The following should betaken into consid-eration.Purpose. It isessential that thepractitionerisclear as to the purpose of interview. In someinstancesthe assessment interview may beusedas a screening mechanism to identify patients forfurther assessment. It may beused to gain infor-mationfrompatients in order that their needscan beprioritised and those judged tobeurgentcan beseen first. On theother hand, theassess-mentinterviewmaybeaimedat undertakingafull assessment of the patient, with treatmentprovided at the end of the interview.Letterofapplication. Wasthepatient referredor self-referred?If the patient was referredbyanotherhealthcare practitionerthereshouldbean accompanying letter of referral. Read thiscarefully so you are fully informed of the reasonsforreferral. Thisinformation should be used as astarting point for the assessment. If patients havereferredthemselves directly(self-referred) theyshould complete any appropriate documentationprior to the interview. Information on applicationforms can be used to prioritise patients andensure the most suitable practitioner sees them. Ifnoapplication formor letterofreferralisavail-ablethepractitioner hasverylittleinformationprior to the interview, possibly only the patient'sname.You may wish to give the patient a short healthquestionnaire to complete prior to the assess-ment (pp. 77-78). Thisquestionnaire may be sentto the patient prior to the interview or the patientmay beaskedtofill itinonarrival. These ques-tionnaires providethepractitionerwithimpor-tant information before the start of the interview.Thepatient should beallowedtime tocompletethe questionnaire in order that he can think abouthisresponses. The advantage of such a question-naire is that the practitioner does not have to askthepatient aseriesof routinequestionsduringtheinterview. However, somepatients maybereluctant tofill in a form without having met thepractitioneror reluctant todiscloseinformationinwriting.Prior tothe interview try toread all the infor-mation you have about the patient. You can thencome across tothe patient aswell informed andas someone who has taken an interest in him.Patient expectations. Does the patient knowwhat toexpect fromtheassessment interview?Some newpatients, prior to attending theirassessment appointment, are sent an informationsheet or booklet explainingthepurposeof theassessment interviewand what will happenduring it. Such an initiative is helpful. Thecauseof a poor interviewmaybe that the patient'sexpectations of what will happen are very differ-ent from what actually happens. For example,apatient whoexpectedimmediatetreatmentandhadnot envisagedanyneedfor historytakingmay wellsay, 'Why areyou asking meall thesequestions?'. Table2.4 highlights what should becontained ina patient information booklet.Waitingroom. Patients can spend a lot of timeinthe waiting room, especially if they arrive tooearly orarekept waiting due to unavoidable cir-cumstances. Trysittingin thewaitingroominyour clinic.Look around you: how welcoming isit? The waiting room sets the scene forthe rest oftheinterview. Where possible, ensure that it is ingooddecorative order,clean, with magazines toread and informative, eye-catching posters orpictures on the wall. Make the most of a captiveaudience to put over important health educationinformation. TVmonitors showinghealthpro-motion videos may beused.The name of the practitioner displayed outsidethe clinic may be useful. Some clinics, like anumberofhighstreetbanks, haveadisplayofphotographswiththenamesandtitlesofthosewithin the department orcentre.Interview room. The assessment interview maybe carried out in an office or in a clinic. Both haveadvantagesanddisadvantages. Usinganofficepreventsthepatient being putoff bysurround-ing clinical equipment. It facilitates eye-to-eyecontact by sitting inchairs, and providesanon-clinicalenvironment. This isespeciallyuseful ifTable2.4 Informationbooklet for patientsto read prior tothe interviewThe booklet shouldcontainthe followinginformation:The purposeof the assessment interviewHow long theinterviewshould takeWhat willhappen during theinterviewSpecificinformationthepatientmay be asked to provide,e.g. list of current medicationSpecificitems the patient may be asked to bring, e.g.footwear Examples of questionshe/sheis likely to be asked The possibleoutcomesof the assessment interview, e.g.whetherthepatientwillreceive treatment at the end of it.The booklet may also containa health questionnaire for thepatient to completeand bring to the assessment interview.THE ASSESSMENT INTERVIEW 23treatment is not normally provided at the end ofthe assessment. On the other hand, using a clinicensures that clinical equipment is readily to handand the patient can be moved into different posi-tions if there arecontrols on the couch.Duringtheinterviewyoushouldensurethatyou arenotdisturbed. If there isa phone intheroom, redirect calls. Ensure the receptionist doesnot interrupt. Whilethepatient is inthe roomyou should begiving him your undivided atten-tion. Constant disturbancesnot onlymakestheassessment interviewaprotractedoccasion butalsocan prompt thepatient into feelingthat hisproblem is not worthy of your attention.TheinterviewWhen the patient enters the room,welcome himtotheclinic, preferablybyname. This person-alises the occasion for the patient and at the sametime ensures that you have the correct patient. Ifyou have difficulty with thepatient'sname, askpolitely how to pronounce it rather than doing soincorrectly. Introduce yourself. As part of thePatient's Charter you should bewearing a namebadge but a personal introduction is usuallypreferable, especiallyifthepatient'seyesight ispoor. It is useful to shake the patient by the handsince touch is an important aspect of non-verbalbehaviour (as discussed earlier), although thismay be influenced by personal preference.At this stage you may findithelpful tomakeoneor twogeneral conversationpoints aboutthe weather, the time of year or some news item.This enables patients to see you as a fellowhuman. Remember that during the interviewthey aregoing to give a lot of themselves to you.It is important that patients feel you aresomeonetheywishtodiscloseinformationto.Use the introduction as an opportunity toexplainthepurposeof theinterview andwhatwill happen.The positioning of patient and practitioner caninfluence the success of the assessment interview.Ideally, you and the patient should be at the samelevel in order to facilitate eye-to-eye contact.Barriers such asdesks are often used inmedicalinterviews. Theycan beconsideredasmeans of24 APPROACHING THE PATIENTmakingthe interviewformal. Standingover apatient who is sitting down orlying onacouchmay be intimidating.Datagathering. Itis essential that the practi-tioner is clear as to what areas should be coveredin the interview. A logical and ordered approachshouldbe adopted. However, it is not alwayspossible or desirable to stick to an orderedapproach. Patients tendtotalk aroundissuesorelect togiveinformationabout aquestionthatyou asked earlier at the end of the interview. Youmust make allowances forthis.Effective and efficient use of time is para-mount. Experiencedpractitioners combinetheinterview with the examination. This isachieved by, for example, feeling pulses andskintemperaturewhilesimultaneouslyaskingquestions about medical history. This techniqueisamatter of preference; someprefertocom-plete the interviewbefore commencing theexamination.After eachassessment interviewreflect uponit. Ask yourself howyoucouldimproveyourperformance and how you could make better useof the time. Thiswill helpyou tomake the bestuse of the data-gathering stage of the interview.Peer appraisal is another mechanismthat youmay findhelpful inaiding you todevelopgooddata-gathering skills.ClosureBringing theassessment interview toa close is adifficult task. When do you knowyou haveenough information? Thisisadifficultquestiontoanswer. Somepresentingproblems, togetherwith information fromthe patient, can beeasilydiagnosed. Other problems are not so easytoresolve and may require further questioning andinvestigations.General medical practitioners have beenshown to give their patients, on average, 6minutesoftheirtime. Psychotherapists, ontheother hand, spend 1 hour or more on eachassessment. Unfortunately the demands onpractitioners' time means they areoften not in aposition to give the patient as much time as theywould like.As a general rule of thumb the interview shouldbebrought toaclosewhen thepractitioner feelsthepatient hasbeen given anopportunity to talkabout theproblem. Body language can be used toconvey theclosing of theinterview. Standing upfroma sitting position, shuffling of papers, with-drawing eye-to-eye contact are all ways by whichtheendoftheinterview canbeconveyedtothepatient, together with a verbal message.The patient should not leave the interviewwithoutfullyunderstandingwhatistohappennext andwithout an opportunitytoaskques-tions. A rangeofoutcomesmayresultfromtheassessment interview (Table 2.5). Patients shouldknowwhich outcome applies to them. Theyshould always begiven theopportunity toraiseany queriesorconcernsthey may havepriortoleavingtheassessment. This isoneofthe mostimportant parts of the assessment and should notbe hurried. The patient must leavethe assess-ment fully understanding the findings of theassessment interview andwhataction,if any, istobe taken, andit is the responsibilityof thehealth careprofessional to ensure that they havecommunicated such information clearly (Calkinset al 1997).It is helpful to provide written instructions as afollow-uptotheinterview. For example, if thepatient is to be offered a course of treatment whatwill the treatment involve, when will it be given,who will give it, what problems may the patientexperience?Table2.5 Outcomesfrom the assessment interview Treatment is not required; the patientrequires adviceandreassurance Thepatient can look after the problem once appropriateself-helpadvicehas been given A courseof treatment is required; thepatient should beinformedas to whethertreatmentwill commencestraightafter the assessment interview or at a later date Thepatientneeds to be referred to anotherpractitionerfortreatment Further examinationandinvestigationsare requiredbeforea definitivediagnosiscan be made A secondopinionis required Theurgency for treatment should be prioritisedConfidentialityTheinformation the patient divulges during theinterviewis confidential. It shouldnot be dis-closed to other people unless the patient hasgiven consent. The Data Protection Act 1998requires that all personal data held on computersshould be'secure from lossorunauthorised dis-closure'. The General Medical Council (1991) andthe National Health Service (1990) have laiddown guidelines on confidentiality.WHATMAKES A GOODASSESSMENT INTERVIEW?The prime purpose of the assessment interview istodrawout information, experiences andopin-ions fromthepatient. It isthe duty of the inter-viewer toguideandkeeptheinterviewtothesubjectinhand. At thesametime, it isequallyimportant to encourage thepatient to talk and toclear up any misunderstandings as you go along.Keeping the balance between these two compet-ing aims is not an easy task. One way of checkingon this is to ask yourself who is doing most of thetalking. Isit youor the patient?Ifyouare toachievetheaimsoftheassessment interviewitshould bethe patient.It is not essential that you likethe patient youareinterviewing. Whatisimportant isthatyouadopt a professional approach, demonstrateempathyanddealwiththepatient inacompe-tent andcourteous manner. It is essential thatyou do not make value judgements based onyour own biases and prejudices. Respect thepatient; avoid stereotyping. Donot jump tocon-clusions before reaching the end of the interview.As highlighted earlier, the assessment inter-view should be patient-centred; its primepurpose is togain information fromthepatient.However, onesometimescomesacrosspatientswho appear unable to stop talking. What can thepractitioner doin these instances?Thefirst questiontoask is why the patient istalkingsomuch. Isit becauseheislonelyandwelcomes the opportunity to talk, is he very self-centred, is heavoiding telling you what the realconcernis by talkingabout minor issues? TheTHEASSESSMENT INTERVIEW 25reason will influencethe action you take. If youfeel the patient wants to tell you something but isfindingit difficult, tryreflectingor summarisewhat you think has been said. Ask if there is any-thing else the patient would like to discuss.Encourage patients by telling them that you wantto beabletohelpas much asyou can;themorethey tellyou about their concernsthemore youcan help them.Ontheother hand, ifyoufeel youneedtocontrol atalkativepatient you may findthefol-lowing techniques helpful: use eye contact and your body language toinform the patient that you are bringing aparticular section of theinterview to a close politely interrupt thepatient, summarisewhat he has said and say what is to happennext ask questions that bring thepatient back tothe topic under discussion.The converse of talkative patients are thosewhoarereluctanttodiscloseinformation aboutthemselves. Thismay be because they donot seethe purpose of the questions you are asking, theyare shy, they cannot articulate their concerns,they arefearful of what theoutcomes may be orthey are too embarrassed to disclose certaininformation. Your responsewill dependonthecause of the reticence.Explaining why you need to knowcertaininformation will behelpful if thepatient is hesi-tant. For example, apatient maywonder whyyou need to know what medication heis takingwhen all he wants is to have a corn treated. If youfeel the patient cannot articulate what hewantstosay, youmayfind that closedquestionscanhelp. This typeof questioninglimitsresponsesbut can be helpful for a patient who has difficultyputting concerns andproblems intowords. Youneed to use a range of closed questions and avoidleading questions if you areto ensure you reachanaccurate diagnosis.Theshy orembarrassed person may findself-disclosure verydifficult. Ithasbeen shown thatpeople tend to disclose more about themselves asthey get older. Ingeneral, femalesdisclose morethanmales. Whenprivacyis ensuredandthe26 APPROACHING THE PATIENTinterviewer shows empathy, friendliness andacceptance, patients have been shown to disclosemore information. Reciprocal disclosure can alsobehelpful.Feedback. Inorder todevelop your int