MAAS-MH Self

This item refers to questions about the reason for the visit to you, the physician.

Open questions, like: What can I do for you? are intended in this item. These opening questions are very general, and the answers of the patient may be very divergent.

Patients may mention some complaints; they may say that they have been sent by their family or a colleague; they may ask for a prescription or some certificate; in case of a visit to a general practitioner, they may ask for referral.

Scoring

• ‘Yes’, when you asked an open question concerning the reason for encounter.

This item is scored subjectively when you asked, by means of an open question, for a description of the complaint that formed the incentive for the patient to visit you.

The patient can have somatic and/or mental health problems.

Scoring

• ‘Yes,’ when you asked for a description of the complaints by means of an open question.

This item refers to interviewing behavior by which you explored the emotional impact of the complaint or problem on the patient.

Emotions, worries, anxiety, concerns, thoughts, etc. of the patient about the complaint are intended.

Questions, like: How do you feel about this problem? or reflections on the emotional dimension of the patient’s information may be expected. Patients are often anxious about the prognosis of their complaint or problem and they may sometimes present feelings of guilt and shame, especially in the case of mental health problems.

Scoring

• ‘Yes’, if you explored the patient’s emotions concerning his main complaint or problem.

This item asks which immediate motives have effectuated the decision to initiate the medical consultation.

The answer to this question yields information about the factors which forced the patient to seek such help.

It yields, moreover, an impression of the severity of suffering. If there has been a need for help for a long time and the patient or their important others have not asked for help, you can explore the factors which have delayed help-seeking. Feelings of guilt and anxiety may interfere with the decision to initiate a medical consultation.

Scoring

• ‘Yes’, when you explored this subject by means of an open question.

The answer yields information about causal attributions by the patient.

Questions like: What are, in your opinion, the causes of your problem? are intended.

Since patients often lack a scientific understanding of the causes of their complaints, they will construct a theory based on lay information and prior experience. The verbalization of the patient’s personal constructs provides additional insight and enables modification of the constructs towards a usually more realistic view of the complaints.

The exploration of the attributions of the patient contributes significantly to the favorable climate of the medical consultation. It enhances an atmosphere of trust and understanding.

Scoring

• ‘Yes’, when you asked, by means of an open question, about the patient’s causal attributions of the complaint.

By means of this item you examined:

• Whether the complaint and related problem is discussed with family members or other important others;
• And how they reacted, because this can be by means of reinforcement, defense, help, persuasion to initiate medical consultation, etc.

Scoring

• ‘Yes’, when both of these aspects are examined.

By means of this question, you explored what treatment has been adopted by the patient themself in order to get relief from their complaint, be it with or without success.

The answer may be for instance: self-medication, changes in life patterns. or habits.

Item 2.20 Asks about current professional consultations is related, but concerns any professional treatment.

Scoring

• ‘Yes’, when you posed this question in an open way.

This item deals with the concrete consequences of the complaint or problem for daily life.

The behavioral aspects, intended by this item, have a close relationship with the emotional aspects of Item 1.2 Explores the emotional impact of the complaint.

The emotional impact and the behavioral consequences of the complaint for daily life may give an insight into the amount of subjective suffering of the patient.

Scoring

• ‘Yes’, when you inquired about these consequences by means of an open question.

In this item, you asked the patient to talk about the problems, complaints or life-circumstances which accompany the main complaint or problem. The objective is to enquire about temporary relationships which are considered to exist between events and complaints from the patient’s point of view.

The answer to this question may be another important complaint; a stressful life-event that influences the complaint; a totally different problem which has no connection with the main complaint or problem, etc.

Scoring

• ‘Yes’, when you asked this question in an open manner.

With this item you asked about the coping mechanisms by means of which the patient has solved similar problems in the past.

Scoring

• ‘Yes’, when you asked such an open question.

Scoring

• ‘Yes’, when you explored, by means of open questions, how the patient estimates the burden they put on their primary group.

Scoring

• ‘Yes’, when you asked about acute traumatic circumstances or other heavily emotional events within the last 3 months.

This item deals with the kind of help the patient wishes to receive.

Although these wishes may have unrealistic aspects, because too much regarding the solution of the problems is expected from the physician, the physician must have an insight into these wishes. The physician has to meet the wishes of the patient as much as possible during the management plan they offer the patient.

In this respect, the difference between wishes and expectations concerning help is of importance. The patient may, for instance, wish for a management plan A, but is expecting, on the ground of previous experience with the physician, that not management plan A, but management plan B will be offered.

Scoring

• ‘Yes’, when you explicitly asked for the wishes of the patient with regard to the help that is desired.

You asked for a subjective description of the intensity of the complaint which provided the motive for the consultation.

The intensity is an important aspect of the complaint and provides an estimate of the degree of suffering of the patient. Intensity often becomes evident from the impact of the complaint on the patient’s behavior.

For instance,

• A stabbing headache may hinder physical exertion;
• A depression may vary from a low mood after disappointment with few implications for daily life to a psychotic depression which profoundly influences the emotional and thought processes.

Scoring

• ‘Yes’, when you asked about the intensity of the complaint.

Scoring

• ‘Yes’, when you inquired about the ‘time-intensity graphic’ during the time cycle of the day.

By this item is meant the gathering of information about:

• The start of the complaint;
• Any fluctuations;
• Any complaint-free intervals;
• Any change in character and intensity of the complaint during lifetime.

Scoring

• ‘Yes’, when you asked about one or more of these four aspects of the history of the complaint.

This item scores your questioning behavior in the search for internal or external factor(s) which elicited the complaint.

Provoking factors from history and present time may be revealed. These questions form the ‘interviewing correlate’ of your clinical problem-solving process as a physician.

Scoring

• ‘Yes’, when you searched for provoking and triggering factors in past and present.

NB: The quality of the clinical problem-solving process and hypotheses is not judged; only the presence of the ‘search behavior’ is judged.

You, while using open or closed – directive – questions, asked about factors that increase already existing complaints/problems.

Open questions will be asked when you have no clear hypotheses; closed or directive questions will be asked to test hypotheses.

Scoring

• ‘Yes’, when you put open or closed – directive – questions in order to analyze factors that increase the problems/complaints.

See the comment at Item 2.4.

Scoring

• ‘Yes’, when you asked for complaint-maintaining factors by means of open or closed – directive – questions.

See the comment at Item 2.4.

Scoring

• ‘Yes’, when you, by means of open or closed – directive – questions, asked about factors that decrease or eliminate complaints.

See the comment at Item 2.4.

This question measures whether any other symptoms accompany the main complaint.

These symptoms were experienced by the patient as less salient or les disturbing, went un-noticed, and were therefore not yet mentioned by the patient.

This question can be asked in two ways:

• Through an open-ended question intended to explore the presence of other symptoms;
• Through a closed-ended question when you have any specific symptoms in mind. In this last case, you are likely to enter the Review of Systems in order to examine risks and disorders of the system pertaining to the main complaint.

Scoring

• ‘Yes’, when you asked, through an open or closed-ended question, whether other symptoms accompany the complaint.

You asked for a ‘historical picture’ of illnesses and (mental) health problems.

A relationship with the present complaint/illness is not necessary.

Scoring

• ‘Yes’, when you asked about illnesses and mental health problems in the past.

This item asks about the way the patient has presented their complaints to other professionals in the past and the effects of their treatment.

This item contrasts to self-care, which is asked about in Item 1.7 I asked how the patient has tried to solve the problem by themself.

Scoring

• ‘Yes’, when you payed attention to both the kind of treatment and the effects of treatment.

This item refers to the exploration of consultations, diagnostic investigations, and treatment that are being carried out currently, but that are (not) related to the main problem or complaints.

By ‘professional’ is meant (para)medical disciplines as well as professional ‘alternative healers’. Overlap with Item 1.7 I asked how the patient has tried to solve the problem by themself pertaining to self-help may arise when the patient applies prescriptions or advice that has been given in the past to the current complaint on his own initiative.

Scoring

• ‘Yes’, when you asked about current professional consultations (not) related to the main complaints.

Medication and substances are:

• Self-medication;
• Professionally-prescribed medication;
• Drugs, e.g. smoking, alcohol;
• Soft- and harddrugs.

You should explore the following 4 aspects:

• What medication is used?
• What drugs are used?
• The quantity of use?
• The degree of dependence.

Scoring

• ‘Yes’, when you explored these 4 aspects.
• ‘No’, when medication and substance use are not or insufficiently explored

You checked whether the complaints have a function in the illness behavior of the patient in the sense of secondary gains of the illness.

This is done in two steps:

• Firstly, you asked how important others have reacted to the patient’s illness/complaints. This issue is scored in Item 1.6 Asks how the complaint is discussed with the family;
• Secondly, you explored the function that this reaction can have for the patient. A possibility is:
  • An excuse function;
  • Diminished responsibility;
  • Diverting attention from other problems;
  • Control of communication patterns within the patient’s system (rigidity).

Scoring

• ‘Yes’, when you explored the function that the reaction of important others has to the patient.

Scoring

• ‘Yes’, when you asked this question.

Scoring

• ‘Yes’, when you asked about such feelings originating from the patient.

Scoring

• ‘Yes’, when you asked such question(s).

This item pertains to life cycle problems.

Scoring

• ‘Yes’, when you asked, through open questions, on perspective, aspirations and their fulfillment.

Caregiving may be accompanied by satisfaction as well as by too heavy a physical or emotional burden.

Scoring

• ‘Yes’, when you asked a question about caregiving with the accompanying effects.

Scoring

• ‘Yes’, when you posed open questions on this subject.

Scoring

• ‘Yes’, when you raised this topic by means of an open question.

The patient is asked to describe their character.

You asked about personality traits which cause vulnerability to mental health problems, such as dependent, paranoid, compulsive, histrionic, schizoid, anti-social, borderline, passive-aggressive, avoidant traits.

Scoring

• ‘Yes’, when you asked the patient for a character self-description and/or two or more questions about the above-mentioned personality traits.

As features of these relationships, the following aspects may be considered:

• Flexibility in the case of changing situations;
• Flexibility of roles and positions;
• Differentiation of roles and tasks;
• Possibilities of emotional and social support;
• Flexibility and tolerance in norms and values.

Scoring

• ‘Yes’, when you explored two or more of these features.

This item pertains to the social support system of patients.

Scoring

• ‘Yes’, when you asked whether, in the patient’s social orbit, there are persons who support them emotionally or materially.

Confrontation with habits, values, and norms of different (sub)cultures may entail adaptation problems.

Scoring

• ‘Yes’, when you asked such a question.

By ‘professional functioning’ is meant any functioning in profession, household or study.

Scoring

• ‘Yes’, when you asked for the experienced quality of one of these three aspects.

Scoring

• ‘Yes’, when you explored satisfaction in functioning during leisure time.

Scoring

• ‘Yes’, when you explored the quality of sleep and – in case of insomnia – the nature of it.

In this item, you explored:

• The eating habits of your patient (appetite, dietary habits);
• Possible disturbances, such as fear of becoming obese, extreme weight loss, periods of bulimia, disgust.

Scoring

• ‘Yes’, when:
  • You asked about appetite and eating habits;
  • And, in the case of disturbances, explored their nature.

You explored:

• The kind and amount of daily exercise;
• The involvement in sport, currently and in the past;
• Any concerns your patient has about insufficient or lack of daily exercise and health issues, such as weight, lack of breath, hypertension, diabetes mellitus, medication, etc.

Scoring

• ‘Yes’, when you explored at least two of these three issues.

In this item, you explored the risk and plans for a suicide attempt in order to reduce the risk and provide a treatment plan.

Item 3.1-4 Suicidal Ideation is related, but asks for suicidal ideation as a symptom of depressive disorder.

Scoring

• ‘Yes’, when you asked a comprehensive set of questions regarding suicidal ideation and plans.

In cases of dissatisfaction:

• Objective data should be collected about the housing situation;
• And assessed what changes the patient has in mind.

Scoring

• ‘Yes’, when you asked your patient about their satisfaction with their housing situation and, in case of dissatisfaction, for objective data concerning housing and the desire for change.

In cases of dissatisfaction:

• Objective data should be collected about the financial situation;
• And what changes the patient has in mind should be assessed.

Scoring

• ‘Yes’, when you asked your patient about their satisfaction with their financial situation;
• And, in case of dissatisfaction, for objective data concerning the financial situation and the desire for change.

You will mentions a – probable – diagnosis or any other definition of the problem, sometimes an important ‘rule-out’.

The information is mainly on a descriptive level. For instance: The symptoms are indicative for measles. Etiology is not considered here but in the next item (e.g. Measles are a contagious infection caused by a virus). Nevertheless, there may be some overlap with the next item.

If you don’t have any – probable – diagnosis, but made some important ‘rules-out’ (e.g. The chest pain probably does not mean a heart disease), these statements are also valid in this item.

It is important that you should not use any jargon or terms which do not match the intellectual or/and socio-cultural level of the patient.

Scoring

• ‘Yes’, when you gave descriptive information about what is wrong (or not wrong) in terms understandable to the patient.

This item means an explanation of the complaint in terms of pathophysiological mechanisms. As in the former item, the patient must be able to understand the explanation.

Scoring

• ‘Yes’, if etiological explanation and understandability are present in the given information.

The prognosis of a disease may be strongly influenced by medical treatment. You should include minimally some information about the severity of the illness consisting of a description of the natural course of the disease.

In addition, information about the disease after treatment should be given.

Scoring

• ‘Yes’, when information concerning the prognosis of the disorder/problem is conveyed, in treated as well as untreated conditions.

Expectations always have a factual and emotional aspect.

We draw attention to the difference between wish and expectation as explained in Item 1.6 I asked the patient to state what help they desire. In short, wishes tend to reflect unrealistic hopes, whereas expectations are hopes which have been moulded by reality.

For example: the patient wishes to obtain a thorough explanation from you, their physician, but they expect to receive only a prescription which does not resolve all their worries or fears. This item must be distinguished from Item 1.6 although some overlap may be inevitable.

Scoring

• ‘Yes’, when both factual and emotional aspects of the expectation concerning help and solutions for the problems were explored.

Scoring

• ‘Yes’, when you explored how much responsibility the patient is prepared to take for the method of treatment (rules, obligations, efforts, time investment, etc.) and for the determination of the objectives of treatment.

This proposal may consist of:

• Further history-taking,
• Further investigations (with or without referral),
• Treatment,
• Preventive advice.

You may offer possible alternatives, of which one is always no further professional help.

This gives the patient the opportunity to make a choice for which they take responsibility.

Scoring

• ‘Yes’, if you introduced a proposal for help with one or more alternatives.

Scoring

• ‘Yes’, if you offered this explanation (related to the problem stated in Item 3.1) in an understandable way.

Information about pros and cons is intended to support the patient by choosing the most suitable solution to his problem.

The pros and cons must be weighed against the patient’s situation in order to result in a feasible plan.

Pros and cons may be:

• Adverse and beneficial effects (e.g. medication);
• Estimated probability of success or failure;
• Impact on daily life;
• Social restrictions;
• Cost, waiting list, etc.

Scoring

• ‘Yes’, when you discussed at least one pro and con of the proposed help with the patient.

Scoring

• ‘Yes’, when you explored the patient’s attitudes towards the proposed solution.

There may be a mutual influence on each other of ‘proposed help’ and ‘the important others’ of the patient.

For example:

• The ‘proposed help’ implicates involvement of ‘important others’ in the treatment;
• The ‘proposed help’ may be unacceptable for ‘important others’;
• Considerable support may be asked for in the compliance of the ‘proposed help’; etc.

Scoring

• ‘Yes, when you explored the mutual influence on each other of the ‘proposed help’ and ‘important others’.

While giving information, it may become clear that the patient does understand you, but holds a different opinion on some part. You should then check this difference in point of view explicitly.

You should discuss the possible difference in viewpoint and clarify the exact point of difference.

By ‘discussing’, we do not mean arguing with the patient about his point of view. This item refers only to a discussion of different points of view. When arguing takes place and you obliges the patient to adopt his opinion, this item will be scored ‘no’.

Scoring

• ‘Yes’, when you explored the presence of a different point of view on problem-definition or treatment plan and when possible differences in points of view are clarified.
• ‘No’, when you didn’t check any possible differences in points of view or when you tried to persuade the patient to change their opinion.

After proposing alternatives for help, after discussing their feasibility, and after exploration of the patient’s opinion, the physician asks the patient to make a choice between the alternatives.

Scoring

• ‘Yes’, when you asked the patient to make a selection from alternatives of help (of which one is – of course – no help!).

After reaching a decision about the advice, you should explain how this advice has to be followed.

If the explanation is of good quality, it will increase the patient’s compliance and therapeutic results. Good advice must always be given in terms of concrete behavior so that it enables the patient to carry out the advice.

For example: when rest is advised it should be clear whether the patient should sleep longer, should seek situations of relaxation, should avoid conflicts, or should stay in bed day and night with someone to look after him.

Scoring

• ‘Yes’, when, according to your opinion, the advice given is formulated concretely enough for the patient to follow adequately.

After having made clear in terms of concrete behavior how the patient should follow the advice, you should check whether the patient has understood the advice.

There are several ways to do this:

• You can ask the patient if they have understood the advice;
• You can ask the patient to repeat the advice.

Scoring

• ‘Yes’, when you made sure that the advice given is understood by the patient.

The following subjects can be arranged:

• What is going to happen;
• Who is doing what;
• Who takes initiatives;
• At what time.

Scoring

• ‘Yes’, when all four subjects are treated concretely;
• ‘No’, when otherwise.

This item relates to two subjects, namely, the introduction and the clarification of the relationship.

Since the MAAS is used in a variety of situations, it can be the case that one or either subject may not be applicable, because they are already known to the patient, e.g. in the practice of a general practitioner.

Clarifying the functional relationship is not only important for physicians and students in training situations, but also for physicians communicating with patients via different functional connections, such as physicians in examining advising relationships; physicians standing in temporarily; or physicians cooperating in different situations all of whom have to explain their functional relationship with the patient.

Scoring

• ‘Yes’, only if both introduction and clarification actually took place.

Having clarified the reason for the encounter, you framed a plan in which you explained how you wished to handle this request for help from the patient. This design for the rest of the interview includes:

• The subjects you wished to bring under discussion,
• The physical exam you wished to perform,
• And the intended sequence.

Scoring

• ‘Yes’, only if such a plan is offered to the patient.

This item checks whether the reason for encounter is well understood by you, the interviewer, and is done by means of a summary.

We wish to emphasize that a summary always has a testing character. You invite the patient to react to the summary by means of the content of the summarized information and the interval afterwards. If the reason for encounter is understood sufficiently, you will continue by asking more directive questions stemming from History-taking, Psychiatric Examination and Socio-emotional Exploration.

Theoretically, the following possibilities can occur with regard to this item:

• The request for help is implicit (the patient comes for the results of investigations done before) or the request is being verbalized by the patient spontaneously. In both cases, a summary has still to be made in order to test whether you have understood the request well. In the first case, a (closed-ended) question like Did you come for the results? will suffice.
• The request for help has not (yet) been verbalized properly by the patient which means that the summary comes too quickly and is, by definition, incomplete. This becomes obvious, because the patient adds further information to the summary.

When the request for help has not been explored sufficiently, the exploration has to be continued and has to be concluded with a summary again.

This item measures the concluding function of the summary. The quality of the summary is assessed by Item C.3 I made proper summaries.

Scoring

• ‘Yes’, if a summary is made at the end of Exploring Reasons for Encounter or if the summary is perfected after another try.

You mention the main problems which have come up during Exploring Reasons for Encounter, History-taking, Psychiatric Examination and Socio-emotional Exploration.

This summary originates from your frame of reference and differs in this respect from a summary which originates from the patient’s frame of reference.

With the ordering, you close the first phases of the initial interview.

Scoring

• ‘Yes’, when the information is ordered after Exploring Reasons for Encounter and the open or more-directive questions pertaining to the History-taking, Psychiatric Examination and Socio-emotional Exploration.

In the medical interview, physicians frequently switch between different sections which appears to have confounding effects on the patient. Ideally, the section with History-taking, Psychiatric Examination and Socio-emotional Exploration questions is preceded by the Exploration of the Request for Help.

Scoring

• ‘Yes’, if, according to your opinion, the Request for Help has been explored sufficiently before you continued with History-taking, Psychiatric Examination and Socio-emotional Exploration.

Scoring

• ‘Yes’, if Exploring Reasons for Encounter, History-taking, Psychiatric Examination and Socio-emotional Exploration have been sufficiently completed before solutions are presented;
• ‘No’, if one of the following cases is present:
  • You went back to items from former phases when parts of Presenting Solutions have already been under discussion;
  • The phases of Exploring Reasons for Encounter, History-taking, Psychiatric Examination and Socio-emotional Exploration were not  elaborated extensively enough in your opinion.

Scoring

• ‘Yes’, when you introduced Presenting Solutions with information about a probable diagnosis, a problem definition or an important rule-out of the problem/complaint;
• ‘No’, if this does not happen.

Scoring

• ‘Yes’, when you asked this question.

This item requires you to give a global judgment of the quality of your facilitating behavior during the interview.

Facilitating is necessary to stimulate the patient to speak from their own frame of reference and experience, and to express emotions and concerns. Also is it important to ask questions about factual information in a facilitative way.

Facilitation is given concrete form in the following ways:

• Well-indicated open questions, especially during Exploring Reasons for Encounter, and the exploration of emotions, concerns and ambivalence during Presenting Solutions;
• Stimulating questioning behavior within the patient’s frame of reference;
• Reflections and remarks stimulating to openness, such as Tell me… or What else …?;
• A listening attitude which becomes apparent by means of well-timed, short periods of silence;
• Physician’s self-disclosure.

Scoring

• ‘Yes’, when at least 4 aspects are shown during the interview;
• ‘Indifferent’, when 2 or 3 different aspects are shown;
• ‘No’, when 1 or fewer aspects are shown.

This item covers reflections about verbally or non-verbally expressed emotions by the patient. Reflections form the most important interview behavior for you to react to the patient’s emotions.

Reflections on emotions are used in the proper way, when:

• Reflections are timed adequately, meaning at or directly after the moment that the emotions are expressed. The relation between the patient’s emotion and the reflection has to be clear;
• Non-verbally expressed emotions are recognized and reflected upon;
• The right content of the emotion is reflected, which means congruence between emotion and reflection.

Scoring

• ‘Yes’, when 80% of reflections on emotions are used according to the criteria;
• ‘No’, when less than 80% of the reflections of emotions are used according to the criteria, or when you did not react to clearly expressed emotions;
• ‘Indifferent, when no reflections on emotions are used, and when they are also not necessary.

This item refers to your reactions to emotional expressions of the patient directed against you, the physician. When the patient expresses sadness, disappointment, anxiety, anger, blame or cynicism against you, you have to try to keep the communication ongoing.

The communication can be disturbed when you did not handle these emotions well by presenting different defense mechanisms against the emotions, e.g.:

• Denial, negotiation, minimizing, rationalization, shifting, reacting by the counterpart;
• Antagonistic behavior, e.g. discussion, quarreling.

Scoring

• ‘Yes’, when you handled emotions, which are directed towards you, in the appropriate way, with the result that the communication keeps going;
• ‘No’, when you used defense mechanisms or antagonistic behavior;
• ‘Indifferent’, when the patient does not express emotions which are directed towards you.

This item refers to your questions about the feeling the patient has during the interview.

The questions are most likely to occur during Presenting Solutions. The questions have the characteristics of open-ended questions, and pertain to the momentary feelings and emotions of the patient.

Open-ended questions are asked in a proper way when:

• You asked questions within the patient’s frame of reference;
• The question does not rule-out any categories for answering;
• Each question deals with one subject.

Scoring

• ‘Yes’, when these questions were asked in the appropriate way in 80% or more of the cases;
• ‘No’, when these questions were asked in the appropriate way in only 50% or less of the cases;
• ‘Indifferent, when you did not show or not handled this interview behavior appropriate in only 50-80% of the cases.

You make meta-communicative comments to stimulate an inhibited communication.

Inhibition of communication may have several causes, but results mostly from inadequate and not corrected interview behavior earlier in the interview.

Examples:

• Neglecting or minimizing strong emotions;
• Inadequate reassurance;
• Asking questions which have nothing to do with the case.

Inhibited communication is expressed and can be detected by several characteristics of the physician-patient communication:

• Defensive behavior of the patient, e.g. negativism, denial, refusal;
• Obstinate discussion;
• Frequent misunderstanding;
• Long periods of silence;
• Repetition.

The result is that communication is hampered over the course of several phases of the medical interview. Inhibited communication can be addressed by meta-communicative comments, like: It seems that we are going around in circles here, or How can it be that we frequently misunderstand each other?

Scoring

• ‘Yes’, when inhibited communication is stimulated by meta-communicative comments;
• ‘No’, when in the case of inhibited communication, you did not make meta-communicative comments, or when you made unnecessary meta-communicative comments which have a further inhibiting influence on the communication;
• ‘Indifferent’, when meta-communication is not shown and not necessary.

You should briefly explain why you want to ask a number of directive questions, and these questions should not take too much time and attention.

Directive medical questions during History-taking, Psychiatric Examination and Socio-emotional Exploration should not lead to endless rows of questions, as they can stimulate feelings of uncertainty and anxiety, and are likely to be misunderstood.

Scoring

• ‘Yes’, when you briefly explained why you want to ask a number of directive questions, and when these questions do not take too much time and attention in your opinion;
• ‘No’, when directive medical questioning does not fulfill both criteria;
• ‘Indifferent’, when there is no history-taking.

This item refers to specific and explicit behavior which is aimed at putting the patient at ease.

It can be necessary to put the patient at ease:

• To make acquaintance with you, the physician;
• During physical examination;
• After the expression of strong emotions during Exploring Reasons for Encounter or Presenting Solutions.

Scoring

• ‘Yes’, when you showed explicit behavior which is meant to put the patient at ease;
• ‘No’, when this behavior is necessary, but you failed to perform it in the observer’s opinion;
• ‘Indifferent’, when such behavior is not necessary and is not shown.

The pace of an interview is strongly related to facilitative behavior and to ‘directivity’, the patient’s feeling that you would like to take over interview and treatment plan. The proper pace is considered as such an important quality of an interview.

Scoring

• ‘Yes’, when you regulated the pace of the interview smoothly;
• ‘No’, when:
  • Periods of silence disturb the pace of the interview;
  • You jump too quickly from one subject to another;
  • You interrupted the patient;
  • You allowed the patient too much discussion of subjects which are not of evident importance for the present complaint/problem;
• ‘Indifferent’, when there is a mixture of ‘proper’ and ‘improper’ pace.

This item is best scored by first judging your non-verbal behavior, and then comparing the nature of the verbal behavior with that of the non-verbal behavior. Afterwards, you can judge whether or not they agree.

Cues for non-verbal behavior are:

• Look/eye-contact;
• Tone of voice;
• Expression;
• Body expression;
• Gestures.

Scoring

• ‘Yes’, when the non-verbal behavior agrees with the verbal behavior;
• ‘No’, when incongruent behavior is present in the interview;
• ‘Indifferent’, when you find it impossible to decide either ‘Yes’ or ‘No’.

Scoring

• ‘Yes’, when normal eye-contact is maintained;
• ‘No’, when you avoided eye-contact, or continued to gaze at your file or at some other object;
• ‘Indifferent’, when no judgement is possible (for instance in case of an unsuitable camera position in taped consultations).

You ask closed-ended questions in a proper way when:

• The question does not contain a suggestion for an answer;
• The question deals with one subject only;
• This type of question is used on the proper indication.

Closed-ended questions are indicated when:

• You searches for factual information;
• The patient deviates from the subject;
• The patient resists the discussion of a subject.

Closed-ended questions are not indicated when:

• There is a chance that you will miss the relevant answer by limiting the answer categories;
• They are used instead of open questions, e.g. during Exploring Reasons for Encounter, or the exploration of emotions and concerns in general.

Scoring

• ‘Yes’, when 80% of all closed-ended questions are used in the proper way;
• ‘No’, when less than 60% of all closed-ended questions are used in the proper way;
• ‘Indifferent’, when 60-80 % of all closed-ended questions are used in the proper way.

N.B. While scoring the item, it can be helpful to use the scoring stave on the scoring list. Each closed-ended question can be scored right or wrong. At the end of the interview, the item can then be scored.

You invite the patient to express themself in a more clear, personal and specific way.

Concretization is necessary when the patient speaks in a vague, impersonal, general or unclear way about subjects related to the complaint.  If one of these aspects is evident, then the intervention is done in an appropriate manner.

Scoring

• ‘Yes’, when you concretized in the proper manner and in an appropriate situation;
• ‘No’, when you didn’t concretize when it is necessary, or when you didn’t concretize in the proper manner, or when you concretized too much;
• ‘Indifferent’, when it is not necessary to concretize and it is not done.

A summary is a restatement of important information given by the patient, but verbalized in your own words.

A summary is close to the patient’s frame of reference, in contrast with ordering, which stems from your, the physician’s, frame of reference. In this item, you make a judgement on the proper content of the summary.

Scoring

• ‘Yes’, when 80% or more of the summaries are an appropriate restating of the content of the patient’s utterances;
• ‘No’, when 60% or less of the summaries restate the content of the patient’s utterances appropriately;
• ‘Indifferent’, when this interview behavior is not shown or when 60-80% of the summaries are appropriate.

Recall of information can be stimulated by providing information in small amounts.

During the presentation of solutions, you provide the patient with information which has to be understood and remembered. Small amounts are considered to be two or three sentences.

Scoring

• ‘Yes’, when 80% or more of information is provided in small amounts;
• ‘No’, when less than 80% of the information is provided in small amounts;
• ‘Indifferent’, when no information is provided.

After providing information about diagnosis, causes, prognosis and treatment plan, you have to check whether the patient has understood the information.

Scoring

• ‘Yes’, when you checked whether the patient has understood the information 3 or more times;
• ‘No’, when you didn’t check;
• ‘Indifferent’, when you checked whether the patient has understood the information once or twice. 

Your ability to make proper confrontations is measured in this item. Proper refers to situations in which confrontations are necessary because communication is inhibited by contradictions.

This situation occurs when:

• There are contradictions in the patient’s words;
• There are contradictions between the patient’s words and their nonverbal behavior;
• There are contradictions between the past and present behavior of the patient.

Scoring

• ‘Yes’, when you made proper confrontations which stimulate the communication;
• ‘No’, when you failed to make proper confrontations and the communication remains hampered or when you made unnecessary confrontations which inhibit the communication;
• ‘Indifferent’, when the behavior is not shown and is not necessary.

Language-use that can be understood by the patient is of pivotal importance for patient-centered communication and a shared understanding of complaints, disease and treatment plan.

Scoring

• ‘Yes’, when comprehensible language is used during the interview;
• ‘No’, when, according to your opinion, several difficult words, such as medical jargon or words from a different social class, are used, or when problems arise from using out-of-place dialect;
• ‘Indifferent,’ when this category is not applicable in this item.