Chapter 1
The Interviewer’s Questions
What is spoken of as a “clinical picture” is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his work, his relations, his friends, his joys, sorrows, hopes and fears.
Francis Weld Peabody (1881–1927)
Basic Principles
Good communication skills are the foundation of excellent medical care. Even with the exciting new technology that has appeared since 2000, communicative behavior is still paramount in the care of patients. Studies have shown that good communication improves health outcomes by resolving symptoms and reducing patients’ psychological distress and anxiety. In the United States, 85% of all malpractice law suits are based on poor communication skills. It is not that the doctor didn’t know enough; the doctor did not communicate well enough with the patient!
Technologic medicine cannot substitute for words and behavior in serving the ill. The quality of patient care depends greatly on the skills of interviewing, because the relationship that a patient has with a physician is one of the most extraordinary relationships between two human beings. Within a matter of minutes, two strangers—the patient and the healer—begin to discuss intimate details about a person’s life. Once trust is established, the patient feels at ease discussing the most personal details of the illness. Clearly, a strong bond, a therapeutic alliance, has to have been established.
The main purpose of an interview is to gather all basic information pertinent to the patient’s illness and the patient’s adaptation to illness. An assessment of the patient’s condition can then be made. An experienced interviewer considers all the aspects of the patient’s presentation and then follows the leads that appear to merit the most attention. The interviewer should also be aware of the influence of social, economic, and cultural factors in shaping the nature of the patient’s problems. Other important aspects of the interview are educating the patient about the diagnosis, negotiating a management plan, and counseling about behavioral changes.
Any patient who seeks consultation from a clinician needs to be evaluated in the broadest sense. The clinician must be keenly aware of all clues, obvious or subtle. Although body language is important, the spoken word remains the central diagnostic tool in medicine. For this reason, the art of speaking and active listening continues to be central to the doctor-patient interaction. Active listening takes practice and involves awareness of what is being said in addition to body language and other nonverbal clues. For the novice interviewer, it is very easy to think only about your next question without observing the entire picture of the patient, as described masterfully in the quote by Peabody that introduced this chapter. Once all the clues from the history have been gathered, the assimilation of those clues into an ultimate diagnosis is relatively easy.
Communication is the key to a successful interview. The interviewer must be able to ask questions of the patient freely. These questions must always be understood easily and adjusted to the medical sophistication of the patient. If necessary, slang words describing certain conditions may be used to facilitate communication and avoid misunderstanding.
The success of any interview depends on its being patient-centered and not doctor-centered. Encourage the patient to tell his or her story and follow the patient’s leads to better comprehend the problems, concerns, and requests. Do not have your own list of “standard questions” as would occur in a symptom-focused, doctor-centered interview. Patients are not standard; don’t treat them as such. Allow the patient to tell his or her story in his or her own words. In the words of Sir William Osler (1893), “Listen to your patient. He is telling you the diagnosis. . . . The good physician treats the disease; the great physician treats the patient who has the disease.” No truer words have been spoken.
Once the patient has told his or her story of the history of the present illness, it is customary for you to move from open-ended questions to direct, more focused questions. Always start by casting a wide net and then gradually close the net to develop your differential diagnosis. Start general and then get more specific to clarify the patient’s story and symptoms.
Using an Interpreter
Health care providers are increasingly treating patients across language barriers. In 2006, nearly 49.6 million Americans had a “mother tongue” other than English; an additional 22.3 million (8.4%) had limited English proficiency. Lack of English proficiency can have deleterious effects. For any patient who speaks a language other than that of the health care provider, it is important to seek the help of a trained medical interpreter. Unless fluent in the patient’s language and culture, the health care provider should always use an interpreter. The interpreter can be thought of as a bridge, spanning the ideas, mores, biases, emotions, and problems of the clinician and patient. The communication is very much influenced by the extent to which the patient, the interpreter, and the provider share the same understanding and beliefs regarding the patient’s problem. The best interpreters are those who are familiar with the patient’s culture. The interpreter’s presence, however, adds another variable in the doctor-patient relationship; for example, a family member who translates for the patient may alter the meaning of what has been said. When a family member is the interpreter, the patient may be reluctant to provide information about sensitive issues, such as sexual history or substance abuse. It is therefore advantageous to have a disinterested observer act as interpreter. On occasion, the patient may request that a family member be the interpreter. In such a case, clinicians should respect the patient’s wishes. Friends of the patient, although helpful in times of emergency, should not be relied on as translators because their skills are unknown and confidentiality is a concern. The clinician should also master a number of key words and phrases in several common languages to gain the respect and confidence of patients. When using an interpreter, clinicians should remember the following guidelines:
1. Choose an individual trained in medical terminology.
2. Choose a person of the same sex as the patient and of comparable age.
3. Talk with the interpreter beforehand to establish an approach.
4. When speaking to the patient, watch the patient, not the interpreter.
5. Do not expect a word-for-word translation.
6. Ask the interpreter about the patient’s fears and expectations.
7. Use clear, short, and simple questions.
9. Keep your explanations brief.
10. Avoid questions using if, would, and could, because these require nuances of language.
The U.S. Department of Health and Human Services has put together a useful mnemonic (INTERPRET) for working with interpreters in a cultural setting:
Even with a trained translator, health care workers are ultimately responsible for ensuring safe and effective communication with their patients. A recent article (Schenker et al., 2008) describes a conceptual framework of when to call for an interpreter and what to do when one is not available.
When speaking with the patient, the interviewer must determine not only the main medical problems but also the patient’s reaction to the illness. This is of great importance. How has the illness affected the patient? How has he or she reacted to it? What influence has it had on the family? On work? On social life?
The best interview is conducted by an interviewer who is cheerful, friendly, and genuinely concerned about the patient. This type of approach is clearly better than that of the interviewer who acts like an interrogator shooting questions from a standard list at the poor, defenseless patient. Bombarding patients with rapid-fire questions is a technique that should not be used.
Important Interviewing Concepts
In the beginning, the patient brings up the subjects that are easiest to discuss. More painful experiences can be elicited by tactful questioning. The novice interviewer needs to gain experience to feel comfortable asking questions about subjects that are more painful, delicate, or unpleasant. Timing of such questions is critical.
A cardinal principle of interviewing is to permit patients to express their stories in their own words. The manner in which patients tell their stories reveals much about the nature of their illnesses. Careful observation of a patient’s facial expressions, as well as body movements, may provide valuable nonverbal clues. The interviewer may also use body language such as a smile, nod, silence, hand gesture, or questioning look to encourage the patient to continue the story.
Listening without interruption is important and requires skill. If given the chance, patients often disclose their problems spontaneously. Interviewers need to hear what is being said. They must allow the patient to finish his or her answer even if there are pauses while the patient processes his or her feelings. All too often, an interview may fail to reveal all the clues because the interviewer did not listen adequately to the patient. Several studies have shown that clinicians commonly do not listen adequately to their patients. One study showed that clinicians interrupt the patient within the first 15 seconds of the interview. The interviewers are abrupt, appear uninterested in the patient’s distress, and are prone to control the interview.
As mentioned earlier, the best clinical interview focuses on the patient, not on the clinician’s agenda.
An important rule for improved interviewing is to listen more, talk less, and interrupt infrequently. Interrupting disrupts the patient’s train of thought. Allow the patient, at least in part, to control the interview.
Interviewers should be attentive to how patients use their words to conceal or reveal their thoughts and history. Interviewers should be wary of quick, very positive statements such as, “Everything’s fine,” “I’m very happy,” or “No problems.” If interviewers have reason to doubt these statements, they may respond by saying, “Is everything really as fine as it could be?”
If the history given is vague, the interviewer may use direct questioning. Asking “how,” “where,” or “when” is generally more effective than asking “why,” which tends to put patients on the defensive. Often replacing the word “Why . . .” with “What’s the reason . . .” will allow for better, less confrontational dialogue. The interviewer must be particularly careful not to disapprove of certain aspects of the patient’s story. Different cultures have different mores, and the interviewer must listen without any suggestion of prejudice.
Always treat the patient with respect. Do not contradict or impose your own moral standards on the patient. Knowledge of the patient’s social and economic background will make the interview progress more smoothly. Respect all patients regardless of their age, gender, beliefs, intelligence, educational background, legal status, practices, culture, illness, body habitus, emotional condition, or economic state.
Clinicians must be compassionate and interested in the patient’s story. They must create an atmosphere of openness in which the patient feels comfortable and is encouraged to describe the problem. These guidelines set the foundation for effective interviewing.
The interviewer’s appearance can influence the success of the interview. Patients have an image of clinicians. Neatness counts; a slovenly interviewer might be considered immature or careless, and his or her competence may be questioned from the start. Surveys of patients indicate that patients prefer medical personnel to dress in white coats and to wear shoes instead of sneakers.
As a rule, patients like to respond to questions in a way that satisfies the clinician to gain his or her approval. This may represent fear on the part of patients. The clinician should be aware of this phenomenon.
The interviewer must be able to question patients about subjects that may be distressing or embarrassing to the interviewer, the patient, or both. Answers to many routine questions may cause embarrassment to interviewers and leave them speechless. Therefore there is a tendency to avoid such questions. The interviewer’s ability to be open and frank about such topics promotes the likelihood of discussion in those areas.
Very often, patients feel comfortable discussing what an interviewer might consider antisocial behavior. This may include drug addiction, unlawful actions, or sexual behavior that does not conform to societal norms. Interviewers must be careful not to pass judgment on such behavior. Should an interviewer pass judgment, the patient may reject him or her as an unsuitable listener. Acceptance, however, indicates to the patient that the interviewer is sensitive. It is important not to imply approval of behavior; this may reinforce behavior that is actually destructive.
Follow the “rule of five vowels” when conducting an interview. According to this rule, a good interview contains the elements of audition, evaluation, inquiry, observation, and understanding. Audition reminds the interviewer to listen carefully to the patient’s story. Evaluation refers to sorting out relevant from irrelevant data and to the importance of the data. Inquiry leads the interviewer to probe into significant areas in which more clarification is required. Observation refers to the importance of nonverbal communication, regardless of what is said. Understanding the patient’s concerns and apprehensions enables the interviewer to play a more empathetic role.
Speech Patterns
Speech patterns, referred to as paralanguage components, are relevant to the interview. By manipulating the intonation, rate, emphasis, and volume of speech, both the interviewer and the patient can convey significant emotional meaning through their dialogue. By controlling intonation, the interviewer or patient can change the entire meaning of words. Because many of these features are not under conscious control, they may provide an important statement about the patient’s personal attributes. These audible parameters are useful in detecting a patient’s anxiety or depression, as well as other affective and emotional states. The interviewer’s use of a warm, soft tone is soothing to the patient and enhances the communication.
Body Language
A broad interest in body language has evolved. Body language, technically known as kinesics, is a significant aspect of modern communications and relationships. This type of nonverbal communication, in association with spoken language, can provide a more comprehensive picture of the patient’s behavior. Your own body language reveals your feelings and meanings to others. Your patient’s body language reveals his or her feelings and meanings to you. The sending and receiving of body language signals happens on conscious and unconscious levels.
It is well known that the interviewer may learn more about the patient from the way the patient tells the story than from the story itself. A patient who moves about in a chair and looks embarrassed is uncomfortable. A frown indicates annoyance or disapproval. Lack of comprehension is indicated by knitted brows. Body language experts generally agree that hands send more signals than any part of the body except for the face. A patient who strikes a fist on a table while talking is dramatically emphasizing what he or she is saying. A patient who slips a wedding band on and off may be ambivalent about his or her marriage. A palm placed over the heart asserts sincerity or credibility. Many people rub or cover their eyes when they refuse to accept something that is pointed out. When patients disapprove of a statement made by the interviewer but restrain themselves from speaking, they may start to remove dust or lint from their clothing.
Six universal emotional facial expressions are recognized around the world. The use and recognition of these expressions is genetically inherited rather than socially conditioned or learned. Although minor variations and differences are found among isolated people, the following basic human emotions are generally used, recognized, and part of humankind’s genetic character:
Of interest, Charles Darwin was first to make these claims in his book The Expressions of the Emotions in Man and Animals, published in 1872.
Smiling is an important part of body language. As a general rule, a genuine smile is symmetrical and produces creases around the eyes and mouth, whereas a fake smile tends to be a mouth-only gesture.
Arms act as defensive barriers when across the body, and conversely indicate feelings of openness and security when in open positions, especially combined with open palms. Arms are quite reliable indicators of mood and feeling, especially when interpreted with other body language. For example:
• Crossed arms may indicate defensiveness.
• Crossed arms and crossed legs probably indicate defensiveness.
Full interpretation of body language can be made only in the context of the patient’s cultural and ethnic background because different cultures have different standards for nonverbal behavior. Middle Eastern and Asian patients often speak with dropped eyelids. This type of body language indicates depression or lack of attentiveness in a patient from the United States. The interviewer may use facial expressions to facilitate the interview. An appearance of attention demonstrates an interest in what the patient is describing. Attentiveness on the part of the interviewer is also indicated by leaning slightly forward toward the patient.
Body language in a certain situation might not mean the same in another. Occasionally, body language isn’t what it seems. For example:
• Someone rubbing his or her eye might have an irritation, rather than being disbelieving or upset.
• Someone with crossed arms might be keeping warm, rather than being defensive.
• Someone scratching his or her nose might actually have an itch, rather than concealing a lie.
A single body language signal isn’t as reliable as several signals. As with any system of evidence, groups of body language signals provide much more reliable indication of meaning than one or two signals in isolation. Avoid interpreting only single signals. Look for combinations of signals that support an overall conclusion, especially for signals that can mean two or more quite different things. It is important to recognize that body language is not an exact science.
Touch
Touching the patient can also be very useful. Touch can communicate warmth, affection, caring, and understanding. Many factors, including gender and cultural background, as well as the location of the touch, influence the response to the touch. Although there are wide variations within each cultural group, Latinos and people of Mediterranean descent tend to use a great deal of contact, whereas British and Asians tend not to use contact. Scandinavians and Anglo-Saxon Americans are in the middle of this range. Be aware, however, that certain religious groups prohibit touching a person of the opposite sex. In general, the older the patient, the more important touch is. Appropriate placement of a hand on a patient’s shoulder suggests support. Never place a hand on a patient’s leg or thigh, because this is a threatening touch. An interviewer who walks with good posture to a patient’s bedside can hope to gain the patient’s respect and confidence. An interviewer who maintains eye contact with the patient conveys interest in the patient.
Depersonalization of the Doctor-Patient Relationship
In this age of biomedical advancements, a new problem has arisen: a depersonalization of the doctor-patient relationship. Clinicians may order computed tomography scans or sonograms without taking the appropriate time to speak with the patient about the tests. Both doctor and patient may feel increasingly neglected, rejected, or abused. Patients may feel dehumanized on admission to the hospital. Many find themselves in a strange environment, lying naked while clothed people march in and out of the room and touch them, tell them what to do, and so forth. They may be apprehensive because they have a problem that their health care provider considers too serious to be treated on an outpatient basis. Their future is filled with uncertainty. A patient admitted to the hospital is stripped of clothing and often of dentures, glasses, hearing aids, and other personal belongings. A name tag is placed on the patient’s wrist, and he or she becomes “the patient in 9W-310.” This lowers the morale of the patient even more. At the same time, clinicians may be pressed for time, overworked, and sometimes unable to cope with everyday pressures. They may be irritable and pay inadequate attention to the patient’s story. They may eventually come to rely on the technical results and reports. This failure to communicate weakens the doctor-patient relationship.
Inexperienced interviewers not only must learn about the patient’s problems but also must gain insight into their own feelings, attitudes, and vulnerabilities. Such introspection enhances the self-image of the interviewer and results in the interviewer’s being perceived by the patient as a more careful and compassionate human being to whom the patient can turn in a time of crisis.
A good interviewing session determines what the patients comprehend about their own health problems. What do the patients think is wrong with them? Do not accept merely the diagnosis. Inquire specifically as to what the patient thinks is happening. What kind of effect does the illness have on the patient’s work, family, or financial situation? Is there a feeling of loss of control? Does the patient feel guilt about the illness? Does the patient think that he or she will die? By pondering these questions, you can learn much about patients, and patients will realize that you are interested in them as whole persons, not merely as statistics among the hospital admissions.
Medical Malpractice and Communication Skills
The literature indicates that malpractice suits have increased at an alarming rate. A good doctor-patient relationship is probably the most important factor in avoiding malpractice claims. As mentioned previously, most malpractice litigation is the result of a deterioration in communication and of patient dissatisfaction rather than of true medical negligence. The patient who is likely to sue has become dissatisfied with the clinician and may have lost respect for him or her. From the patient’s point of view, the most serious barriers to a good relationship are the clinician’s lack of time; seeming lack of concern for the patient’s problem; inability to be reached; attitude of superiority, arrogance, or indifference; and failure to inform the patient adequately about his or her illness. Failure to discuss the patient’s illness and treatment in understandable terms is viewed as a rejection by the patient. In addition, the congeniality and competence of a physician’s office staff can go a long way toward avoiding malpractice suits. Physicians who have never been sued orient their patients to the process of the visit, use facilitative comments, ask the patient for opinions, use active learning, use humor and laughter, and have longer visits. A doctor-patient relationship based on honesty and understanding is thus recognized as essential for good medical practice and the well-being of the patient.
It is sometimes difficult for a novice interviewer to remember that there is no need to try to make a diagnosis out of every bit of information obtained from the interview. Accept all the clues and then work with them later when trying to establish a diagnosis.
If during the interview you cannot answer a question, do not. You can always act as the patient’s advocate; listen to the question and then find someone who can provide an appropriate answer.
Doctor-Patient Engagement
A very important task of communication is to engage the patient. A helpful way of building rapport with a patient is to be curious about the person as a whole. Ask, “Before we begin, tell me something about yourself.” When the patient returns, mention something personal that you learned from a previous visit, for instance, “How was your trip to Seattle to see your son?” Another part of engagement is to determine the patient’s expectations from the visit; for instance, ask, “What are you hoping to accomplish today?” At the conclusion of the visit, ask, “Is there anything else you are concerned about?” If the patient has several problems, it is acceptable to say, “We might need to discuss that problem at another visit. I want to be certain that we completely evaluate your main concern today.”
Privacy Standards
On April 14, 2003, the first federal privacy standards were put in place to protect the medical records and other health information of patients. The U.S. Congress asked the Department of Health and Human Services to issue privacy protection as part of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA regulations include provisions designed to encourage electronic transactions and to safeguard the security and confidentiality of health information. The final regulations cover health plans, health care clearinghouses, and health care providers who conduct financial and administrative transactions electronically. In short, these regulations regarding patient confidentiality limit the ways in which health care providers, health plans, pharmacies, hospitals, clinics, and other entities can use patients’ personal medical information. These regulations ensure that medical records and other identifiable health information, whether on paper, in computers, or orally communicated, are protected.
In summary, the medical interview is a blend of the cognitive and technical skills of the interviewer and the feelings and personalities of both the patient and the interviewer. The interview should be flexible and spontaneous and not interrogative. When used correctly, it is a powerful diagnostic tool.
Symptoms and Signs
The clinician must be able to elicit descriptions of, and recognize, a wide variety of symptoms and signs. Symptom refers to what the patient feels. Symptoms are described by the patient to clarify the nature of the illness. Shortness of breath, chest pain, nausea, diarrhea, and double vision are all symptoms. These labels help the patient describe the discomfort or distress that he or she is experiencing. Symptoms are not absolute; they are influenced by culture, intelligence, and socioeconomic background. As an example, consider the symptom of pain. Patients have different thresholds of pain. This is discussed further in Chapter 27, Caring for Patients in a Culturally Diverse Society, which can be accessed on the internet version of this textbook.
Constitutional symptoms are symptoms that commonly occur with problems in any of the body systems, such as fever, chills, weight loss, or excessive sweating.
A sign is what the examiner finds. Signs can be observed and quantified. Certain signs are also symptoms. For example, a patient may describe episodes of wheezing; this is a symptom. In addition, an examiner may hear wheezing during a patient’s physical examination; this is a sign.
The major task of the interviewer is to sort out the symptoms and signs associated with a specific illness. A major advantage that the seasoned interviewer has over the novice is a better understanding of the pathophysiologic processes of disease states. The novice operates under the limitation of not knowing all the signs and symptoms of the associated diseases. With experience and education, the novice will recognize the combination of symptoms and signs as they relate to the underlying illness. For any given disease, certain symptoms and signs tend to occur together. When there is only an isolated symptom, the interviewer must be careful in making a definitive assessment.
Conducting an Interview
Getting Started and Introduction
The diagnostic process begins at the first moment of meeting. You should be dressed appropriately, wearing a white coat with your name badge identifying you as a member of the health care team. Patients expect this standard of professional attire. Casual attire may signify condescension.
Introduce yourself, greet the patient by last name, make eye contact, shake hands firmly, and smile. You may wish to say something like
Alternatively, you may say,
or
The term student doctor should generally be avoided because patients may not actually understand this term; they may hear only the word doctor. The introduction also includes a statement of the purpose of the visit. The welcoming handshake can serve to relax the patient.
It is appropriate to address patients by their correct titles—“Mr.,” “Mrs.,” “Miss,” “Dr.,” “Ms.”—unless they are adolescents or younger. A formal address clarifies the professional nature of the interview. For a woman, the default always is “Ms.” unless you know positively that a woman wishes to be addressed as “Miss” or “Mrs.” Name substitutes such as “dear,” “honey,” or “grandpa” are not to be used. Also, avoid using “Sir” or “Ma’am.” “Ma’am” is mostly obsolete, with a few exceptions. It is commonly used to address any woman in the southern or southwestern areas of the United States. Use the patient’s name. If you are not sure about the pronunciation, ask the patient how to say his or her name correctly.
The patient may address an interviewer as Ms. Jones, for example, or might elect to use the interviewer’s first name. It is not correct for an interviewer to address the patient by his or her first name, because this changes the professional nature of this first meeting.
If the patient is having a meal, ask whether you can return when he or she has finished eating. If the patient is using a urinal or bedpan, allow privacy. Do not begin an interview in this setting. If the patient has a visitor, you may inquire whether the patient wishes the visitor to stay. Do not assume that the visitor is a family member. Allow the patient to introduce the person to you.
The interview can be helped or hindered by the physical setting in which the interview is conducted. If possible, the interview should take place in a quiet, well-lit room. Unfortunately, most hospital rooms do not afford such luxury. The teaching hospital with four patients in a room is rarely conducive to good human interactions. Therefore make the best of the existing environment. The curtains should be drawn around the patient’s bed to create privacy and minimize distractions. You may request that the volume of neighboring patients’ radios or televisions be turned down. Lights and window shades can be adjusted to eliminate excessive glare or shade. Arrange the patient’s bed light so that the patient does not feel as if he or she is under interrogation.
You should make the patient as comfortable as possible. If the patient’s eyeglasses, hearing aids, or dentures were removed, ask whether the patient would like to use them. It may be useful to use your stethoscope as a hearing aid for hearing-impaired patients. The ear tips are placed in the ears of the patient, and the diaphragm serves as a microphone. The patient may be in a chair or lying in bed. Allow the patient the choice of position. This makes the patient feel that you are interested and concerned, and it allows the patient some control over the interview. If the patient is in bed, it is a nice gesture to ask whether the pillows should be arranged to make him or her more comfortable before the interview begins.
To Stand or to Sit?
Normally, the interviewer and patient should be seated comfortably at the same level. Sometimes it is useful to have the patient sitting even higher than the interviewer to give the patient the visual advantage. In this position, the patient may find it easier to open up to questions. The interviewer should sit in a chair directly facing the patient to make good eye contact. Sitting on the bed is too familiar and not appropriate. It is generally preferred that the interviewer sit at a distance of about 3 to 4 feet from the patient. Distances greater than 5 feet are impersonal, and distances closer than 3 feet interfere with the patient’s “private space.” The interviewer should sit in a relaxed position without crossing arms across the chest. The crossed-arms position is not appropriate because this body language projects an attitude of superiority and may interfere with the progress of the interview.
If the patient is bedridden, raise the head of the bed, or ask the patient to sit so that your eyes and the patient’s eyes are at the same level. Avoid standing over the patient. Try to lower the bed rail so that it does not act as a barrier to communication, and remember to put it back up at the conclusion of the session.
Regardless of whether the patient is sitting in a chair or lying in bed, make sure that he or she is appropriately draped with a sheet or robe.
The Opening Statement
Once the introduction has been made, the interview may begin with a general, open-ended question, such as “What medical problem has brought you to the hospital?” or “I understand you are having. . . . Tell me more about the problem.” This type of opening remark allows the patient to speak first. The interviewer can then determine the patient’s chief complaint: the problem that is regarded as paramount. If the patient says, “Haven’t you read my records?” it is correct to say, “No, I’ve been asked to interview you without any prior information.” Alternatively, the interviewer could say, “I would like to hear your story in your own words.”
Patients can determine very quickly if you are friendly and personally interested in them. You may want to establish rapport by asking them something about themselves before you begin diagnostic questioning. Take a few minutes to get to know the patient. If the patient is not acutely ill, you may want to say, “Before I find out about your headache, tell me a little about yourself.” This technique puts the patient at ease and encourages him or her to start talking. The patient usually talks about happy things in his or her life rather than the medical problems. It also conveys your interest in the patient as a person, not just as a vehicle of disease.
The Narrative
Novice interviewers are often worried about remembering the patient’s history. However, it is poor form to write extensive notes during the interview. Attention should be focused more on what the person is saying and less on the written word. In addition, by taking notes, the interviewer cannot observe the facial expressions and body language that are so important to the patient’s story. A pad of paper may be used to jot down important dates or names during the session.
After the introductory question, the interviewer should proceed to questions related to the chief complaint. These should naturally evolve into questions related to the other formal parts of the medical history, such as the present illness, past illnesses, social and family history, and review of body systems. Patients should largely be allowed to conduct the narrative in their own way. The interviewer must select certain aspects that require further details and guide the patient toward them. Overdirection is to be avoided because this stifles the interview and prevents important points from being clarified.
Small talk is a useful method of enhancing the narrative. Small talk, also known as “chit-chat,” is neither random nor pointless, and studies in conversation analysis indicate that it is actually useful in communication. It has been shown that during conversations, the individual who tells a humorous anecdote is the one who is in control. For example, if an interviewer interjects a humorous remark during an interview and the patient laughs, the interviewer is in control of the conversation. If the patient does not laugh, the patient may take control.
Be alert when a patient says, “Let me ask you a hypothetical question” or “I have a friend with . . . ; what do you think about . . . ?” In each case, the question is probably related to the patient’s own concerns.
A patient often uses utterances such as “uh,” “ah,” and “well” to avoid unpleasant topics. It is natural for a patient to delay talking about an unpleasant situation or condition. Pauses between words, as well as the use of these words, provide a means for the patient to put off discussing a painful subject.
When patients use vague terms such as “often,” “somewhat,” “a little,” “fair,” “reasonably well,” “sometimes,” “rarely,” or “average,” the interviewer must always ask for clarification: “What does sometimes mean?” “How often is often?” Even terms such as “dizzy,” “weak,” “diarrhea,” and “tired” necessitate explanation. Precise communication is always desirable, and these terms, among others, have significant variations in meaning.
The interviewer should be alert for subtle clues from the patient to guide the interview further. There are a variety of techniques to encourage and sustain the narrative. These guidelines consist of verbal and nonverbal facilitation, reflection, confrontation, interpretation, and directed questioning. These techniques are discussed later in this chapter.
The Closing
It is important that the interviewer pace the interview so that adequate time is left for the patient to ask questions and for the physical examination. About 5 minutes before the end of the interview, the interviewer should begin to summarize the important issues that were discussed.
If the patient asks for an opinion, it is prudent for the novice interviewer to answer, “I am a medical student. I think it would be best to ask your doctor that question.” You have not provided the patient with the answer that he or she was seeking; however, you have not jeopardized the existing doctor-patient relationship by possibly giving the wrong information or a different opinion.
At the conclusion, it is polite to encourage the patient to discuss any additional problems or to ask any questions: “Is there anything else you would like to tell me that I have not already asked?” “Are there any questions you might like to ask?” Usually, all possible avenues of discussion have been exhausted, but these remarks allow the patient the “final say.”
Thus a good closure should consist of the following four parts:
Basic Interviewing Techniques
The successful interview is smooth and spontaneous. The interviewer must be aware of subtleties and be able to pick up on these clues. The successful interviewer sustains the interview. Several techniques can be used to encourage someone to continue speaking, and this section discusses those interviewing techniques. Each technique has its limitations, and not all of them are used in every interview.
Questioning
The secret of effective interviewing lies in the art of questioning. The wording of the question is often less important than the tone of voice used to ask it. In general, questions that stimulate the patient to talk freely are preferred.
Open-Ended Questions
Open-ended questions are used to ask the patient for general information. This type of question is most useful in beginning the interview or for changing the topic to be discussed. An open-ended question allows the patient to tell his or her story spontaneously and does not presuppose a specific answer. It can be useful to allow the patient to “ramble on.” An open-ended question is a question that cannot be answered by saying “Yes” or “No.” Examples of open-ended questions are the following:
“What kind of medical problem are you having?”
“Are you having stomach pain? Tell me about it.”
“Tell me about your headache.”
“How was your health before your heart attack?”
Too much rambling, however, must be controlled by the interviewer in a sensitive but firm manner. This freedom of speech should obviously be avoided with overtalkative patients, whereas it should be used often with silent patients.
Direct Questions
After a period of open-ended questioning, the interviewer should direct the attention to specific facts learned during the open-ended questioning period. These direct questions serve to clarify and add detail to the story. This type of question gives the patient little room for explanation or qualification. A direct question can usually be answered in one word or a brief sentence; for example:
Care must be taken to avoid asking direct questions in a manner that might bias the response.
Symptoms are classically characterized according to several dimensions or elements, including bodily location, onset (and chronology), precipitating (and palliating) factors, quality, radiation, severity, temporal, and associated manifestations. These elements may be used as a framework to clarify the illness. Examples of appropriate questions follow.
Onset (and Chronology)
Precipitating Factors
Palliating Factors
Radiation
Severity (or Quantity)
“On a scale from 1 to 10, with 10 the worst pain you can imagine, how would you rate this pain?”
“How has the pain affected your lifestyle?”1
“What do you mean by ‘a lot’?”
“How many sanitary napkins do you use?”
“How many times did you vomit?”
“What kind of effect does the pain have on your work?”
“How does the pain compare with the time you broke your leg?”
Temporal
Associated Manifestations
“Do you have any other symptoms?”
“Do you ever have nausea with the pain?”
“Have you noticed other changes that happen when you start to sweat?”
“Before you get the headache, do you ever experience a strange taste or smell?”
The mnemonic O-P-Q-R-S-T, which stands for onset (chronology), precipitating (or palliative), quality, radiation, severity, and temporal, is useful in helping the interviewer remember these important dimensions of a symptom. The setting is also important to determine. Did the symptom occur when exposed to certain environmental conditions, during specific activities, during emotional periods, or under other circumstances?
Question Types to Avoid
There are several types of questions that should be avoided. One is the suggestive question, which provides the answer to the question. For example:
A better way to ask the same question would be as follows:
The why question carries tones of accusation. This type of question almost always asks a patient to account for his or her behavior and tends to put the patient on the defensive; for example:
The answers to such questions, however, are important. As mentioned previously, try rephrasing as “What is the reason . . . ?” The “why” question is useful in daily life with friends and family, with whom you have a relationship different from that with your patients; do not use it with patients.
The multiple or rapid-fire question should also be avoided. In this type of question, there is more than one point of inquiry. Don’t barrage the patient with a list of questions. The patient can easily get confused and respond incorrectly, answering no part of the question adequately. The patient may answer only the last inquiry heard; for example:
The other problem with multiple questions is that you may think you have asked the question, but the patient has answered only part of it. For example, in the first inquiry just mentioned, the patient may answer “No” to indicate “no chills,” but if you ask about the symptoms separately, you might find out that the patient does have a history of night sweats.
Questions should be concise and easily understandable. The context should be free of medical jargon.
