The initial psychiatric interview of a patient is often a crucial part of the developing relationship between patient and physician. Establishing rapport, reaching a diagnosis, discussing treatment options, and formulating a plan, are the main frameworks of the interview. There remain, however, increasing pressures to reach the final diagnosis, often from patients and caregivers on initial meetings with providers that can lead to rushed or overlooked symptoms. Where, then, does the standard interview model leave time for educating the patient on reaching a proposed diagnosis?
Learning styles can help in both understanding the patient and assessing their personal understanding of information. Learning styles are often categorized as visual (understanding by seeing visual forms of information), auditory (understanding by hearing and repeating back information), reading/writing (understanding by writing down), and kinesthetic (understanding info by touching and active participation).
Further questioning can assist the clinician’s understanding but also act as a learning tool to counsel and educate the patient while assessing for key symptoms for diagnoses. For instance, assessing learning styles could occur with an understanding abstract statements (part of cognition in MSE), exploring key triggers and choices in life (assessing judgment skills), accomplishments while or previously in school, or while asking open-ended questions such as the nature of their visit or current events. How the patient responds to these questions and the attitudes elicited as the clinician transitions to the next topic can act as an informed gathering to tailor education strategies while contributing to health literacy.
Cognitive flexibility is another tool that can help in ascertaining patients’ preferences and encourage participation in their education and decision making. Cognitive flexibility is an essential function people use daily to interact with others and the environment. It’s the ability to hold multiple views and change or reframe a thought, situation, or perspective. This term may be unfamiliar to the budding resident, but it becomes an inherent detection tool that develops throughout the years. Features of cognitive inflexibility become obvious on the exam and are often found in neuropsychiatric disorders such as attention-deficit hyperactivity disorder, obsessive-compulsive disorder, schizophrenia, and autism that showcase specific symptoms and thought-processing patterns.
Marked changes in cognitive flexibility are especially notable in certain demographics that will play a role in learning and assessment during interviews. It declines with age and often results in an inability to adapt to new situations and environments. The Wisconsin Card Sorting task for example, which requires individuals to adapt to new rules, shows that normal aging decreases cognitive flexibility. On the other hand, cognitive flexibility develops rapidly in preschool and continuously increases well into adolescence, mirroring the growth of neural networks involving the prefrontal cortex. The natural ebb and flow of the interview can clue the clinician into the adaptability of a patient and the considerations needed for assessment for both diagnosis and education.
Shared decision-making promotes understanding between clinician and patient and is an important process for both parties to collaborate and align goals, preferences, and values. In specific populations, however, involvement in decision-making may differ. For example, those with less education, who often present with a worse prognosis or a higher level of anxiety, could be less likely to prefer involvement. This may be noted early on the exam while obtaining social and past psychiatric history and could be offsetting the shared decision-making model. The intent to foster both quality of care and effective patient participation in the future remains.
Psychiatry is one of the unique fields in which rapport with patients and longevity of care are building blocks to effective communication. Time constraints can still hamper effective communication, but by integrating assessments for cognitive flexibility, understanding patients’ learning styles, and encouraging shared decision-making between physicians and patients, individuals can foster an environment of collaboration and education.
Laura Faluade is a psychiatry resident.
