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The good physician treats the disease; the great physician treats the patient who
has the disease.
Sir William Osler, circa 1900
The Medical Interview
The position of clinician is one of privilege. Patients entrust clinicians with
the most intimate details of their lives, and society rewards them with pres-
tige, job stability, and a decent standard of living. With this privilege comes re-
sponsibility. Patients expect support, understanding, explanation, relief from
their symptoms and/or cure of their ailments, and society expects clinicians to
act in the best interest of their patients, subordinating their own self-interest.
1
Modern medicine was built on the foundations of the biological sciences to
improve the diagnosis and treatment of human suffering. The resulting bio-
medical model focused narrowly on the pathophysiology of disease caused by
anatomic, biochemical, and/or neurophysiologic deviations from the norm.
Within this framework the clinicians task was to focus on identifying, de-
scribing, and determining the cause of diseases and then preventing, manag-
ing, and/or curing them. This focus led to the discovery and management of
many genetic, infectious, and other medical diseases. However, scholarship
over the past three decades has underscored some critical limitations of the
biomedical model. For example, the model did not address symptoms that are
caused by factors other than disease or abnormalities in anatomical, biologi-
cal, and/or neurophysiologic states. The model also largely ignored the social,
psychological, and behavioral dimensions of illness.
2,3
Indeed, some medi-
cal professionals believed that mental illness is a myth, and some argued
that it was not appropriate for medical professionals to attend to psychoso-
cial issuesa stance that perpetuated the suffering of many patients and the
healthcare professionals whom they sought for help.
4
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2 SMI TH S PAT I ENT- CENTERED I NTERVI EWI NG
By the latter part of the twentieth century, it had become clear that the
biomedical model was no longer adequate for the scientific tasks and so-
cial responsibilities of medicine.
4
The human condition was noted to be too
complex to be fully described and explained by the biomedical model alone.
Engel proposed a biopsychosocial model to better explain how the symptoms
and course of one patient with a particular disease can be completely different
from those of another individual with the same disease.
4,5
The biopsychoso-
cial model explicitly acknowledges the interdependence of patients biological
(disease), psychological, and social characteristics, making it consistent with
general system theory (Fig. 1-1).
According to general system theory, disturbances in a system at one level
have implications for other levels in the hierarchy of natural systems. A person
is part of a hierarchy of systems that ranges from the smallest organelle to the
largest community and culture and can be profoundly affected by changes in
any of these systems. Unlike the biomedical model, the biopsychosocial model
makes clear that the patients relationships (including the clinicianpatient
relationship) can be as important to the illness experience as the patients dis-
ease. It also explains why a person with no discernible pathology or significant
aberration in physiology can experience debilitating symptoms and physical
illness in the absence of disease.
Disease implies a disruption in normal biologic function. Disease is objec-
tive: you can see disease processes under a microscope and in abnormal labora-
tory or imaging tests. Illness is subjective: people feel a sense of dis-ease; they
identify themselves as sick; they behave in accordance with the way they feel,
which is different from how they act when they feel healthy. In many cases, they
Hierarchy of Natural Systems
Culture
Community
SOCIAL
PSYCHO
BIO
Nervous System
2-Person; Family; Clinician
PERSON
(Experience and behavior)
Tissues
Cells
Organelles
FIGURE 1-1. The hierarchy of natural systems.
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Chapt er 1 T HE MEDI CAL I NTERVI EW 3
seek medical care. A patient can have disease without illness, as in an individual
with hypertension who does not experience any symptoms; and illness without
disease, as in an individual with hypochondria who is convinced that the slight
and transient discomfort in her or his abdomen is due to cancer, not peristalsis.
Most patients who seek medical care have both disease and illness, in vary-
ing degrees. Some stoic patients can have serious disease but exhibit little
illness behavior, while other more demonstrative patients may have little bio-
logic disease yet be incapacitated. These are important distinctions relevant to
daily clinical work, since patients come to clinicians with their illness experi-
ences seeking relief of symptoms, and clinicians were traditionally taught to
find and treat diseases. The distinctions between curing and healing now be-
come clearer: we cure diseases with medications, surgery, and biotechnology;
we heal illnesses mainly through our words and the therapeutic relationships
we establish with our patients. To be most effective as clinicians we must be
able to combine both curing and healing to benefit our patients.
Medical interviewing is the process of gathering and sharing information
in the context of a trustworthy relationship that takes into account both dis-
ease, if present, and illness. Even in this age of medical advances, the medi-
cal interview remains the single most effective diagnostic tool, contributing
to the correct diagnosis more often than physical examination or laboratory
tests. Doctors and other healthcare professionals conduct over 100,000 inter-
views during their careers making the interview, by far, the most frequently
performed medical procedure. Even a small improvement in your skills will
have significant long-term benefits for you and your patients. The medical in-
terview is what makes the clinician. Through your interviewing skill you will
establish relationships with your patients that are meaningful, intimate, and
caring. Your patients will tell you secrets they share with no one else. You will
have a window on the world of human suffering and resilience and will de-
velop respect for your patients courage and humanity. You will feel honored
and privileged to be a healing presence in your patients lives.
This book describes an 11-step, evidence-based interviewing method used
to obtain a complete biopsychosocial story that describes the persons illness
experience as well as her or his disease state and will guide you in ways to
educate the patient and help change health-related behaviors. The patients
story can include pertinent personal features of the patient, the effectiveness
of the clinicianpatient relationship, the family, the community, and the pa-
tients spirituality or lack thereof (Table 1-1).
4,5
J THE HISTORY OF PATIENT-CENTERED INTERVIEWING
Clinicians who were trained in the last century under the biomedical model
were taught to interview patients using only clinician-centered interviewing
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4 SMI TH S PAT I ENT- CENTERED I NTERVI EWI NG
skills to elicit symptoms of disease. Clinician-centered interviewing means
the clinician takes charge of the entire interaction to acquire the details of
the patients symptoms and other data that will help her or him to iden-
tify a disease. This usually meant that the patients concerns and what the
interviewer perceived as nonmedical data were largely ignored or even
discouraged in the clinicians quest for a biomedical diagnosis. In a typical
Step 1 Set the stage for the interview
1. Welcome the patient
2. Use the patients name
3. Introduce self and identify specific role (student
nurse/student doctor/resident/fellow)
4. Ensure patient readiness and privacy
5. Remove barriers to communication
6. Ensure comfort and put the patient at ease
Step 2 Elicit chief concern and set agenda
7. Indicate time available
8. Forecast what you would like to have happen
during the interview
9. Obtain list of all issues patient wants to discuss;
specific symptoms, requests, expectations,
understanding
10. Summarize and finalize the agenda; negotiate
specifics if too many agenda items
Step 3 Begin the interview with nonfocusing skills
that help the patient to express her/himself
11. Start with open-ended request/question
12. Use nonfocusing open-ended skills
13. Obtain additional data from nonverbal sources:
nonverbal cues, physical characteristics, accou-
trements, environment, self
Step 4 Use focusing skills to elicit three things:
symptom story, personal context and emotional
context
14. Elicit symptom story
Description of symptoms, using focusing open-
ended skills
15. Elicit personal context
Broader personal/psychosocial context of
symptoms, patient beliefs/attributions, again
using focusing open-ended skills
16. Elicit emotional context
Use emotion-seeking skills
Direct
Indirect
Impact
Belief
Triggers
Self-disclosure
17. Respond to Feelings/Emotions
Use empathy skills to address the feelings and
emotions (naming, understanding, respecting,
and supporting [NURS])
18. Expand the story
Continue eliciting further personal and emo-
tional context; address feelings and emotions
(NURS)
Step 5 Transition to middle of the interview
19. Brief summary
20. Check accuracy
21. Indicate that both content and style of inquiry will
change if the patient is ready
Continue with middle of the interview
Step 6 Obtain a chronological description of
HPI/OAP
Step 7 Past medical history
Step 8 Social history
Step 9 Family history
Step 10 Review of systems
(Physical examination)
Step 11 End of the interview
J TABLE 1-1. Evidence-Based Interviewing Method
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Chapt er 1 T HE MEDI CAL I NTERVI EW 5
clinician-centered interview, the clinician controlled the flow of information,
kept the focus away from the patients experience of illness and prevented
most personal information, feelings, and emotions from emerging, limiting
the clinicians ability to form an adequate relationship with the patient or
develop a biopsychosocial description of the patients problem.
2,3
As noted in
Appendix B, this leads to poor patient satisfaction, physician frustration, and
worse health outcomes.
Recognizing these limitations, patient-centered interviewing was devel-
oped
610
as part of the relationship-centered care approach.
11,12
In a general
sense, every action with the patient is patient centered; everything is done in
the patients interest. As a technical term, patient-centered interviewing skills
encourage patients to express what is most important to them. In addition to
symptoms, the patient-centered approach also recognizes the importance of
patients expressions of personal concerns, feelings, and emotions. With these
personal data, the interviewer can synthesize a biopsychosocial description of
the patient. Not only does the clinician avoid an isolated focus on symptoms,
but she or he also allows the patient to lead and direct portions of the con-
versation.
13
This means the patients ideas and concerns, rather than the clini-
cians, are drawn out. The clinical benefits of this theoretical improvement
have been substantiated by significant research (see Appendix B).
Patient-centered interviewing skills were developed to complement cli-
nician-centered interviewing skills. Like clinician-centered interviewing,
patient-centered interviewing should not be used in isolation. The method
described in this book integrates the patient-centered and clinician- centered
interviewing skills you will need to elicit symptom, personal, and emotional
information. You must then interpret and synthesize these data, using your
knowledge of medicine, along with available data from physical examination
and laboratory and imaging tests, to produce a biopsychosocial description
the patients story.
J THE PATIENT-CENTERED APPROACH
The patient-centered approach is built on several premises:
Patients often do not seek healthcare only because of a symptom
Clinicians trained in the era of biomedicine assumed that their role
was solely to diagnose a patients symptom and treat the disease. They
did not recognize that often there were more complex reasons behind
the patients decision to seek healthcarethe personal context of a
symptom story often drives healthcare seeking behavior, rather than
the symptom per se. For example, a 19-year-old man develops low
back pain that, if he worked at a desk job, would not cause him to see
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6 SMI TH S PAT I ENT- CENTERED I NTERVI EWI NG
his clinician. However, because he works on a loading dock, the pain is
interfering with his job and he makes an appointment to be seen.
The emotional context of a symptom is another common factor lead-
ing patients to see their clinicians. This same young man recently bought a
home for his new family. He is worried that if he cannot perform his work
duties he will be fired and will not be able to keep up with his mortgage
payments. Clinicians increase their effectiveness and their patients satis-
faction when they seek to understand the personal and emotional context
of patients symptom stories.
Patients usually bring more than one concern to their clinician
Research shows that patients in outpatient primary care settings average
three or more concerns per visit.
1416
Indeed the first concern mentioned
may not be the most important one to the patient (or to the clinician)
and sometimes the last concern raised is the most important one, but was
saved for last because it is frightening or shameful. Clinicians who assume
the first concern is the patients only one will likely hear the additional
concern(s) voiced at the very end of the visit, which is frustrating and inef-
ficient. It also results in low patient satisfaction.
Allowing the patient to tell her or his symptom story is diagnostically use-
ful
Clinicians who encourage patients to tell the story of their symptom arrive
at the correct diagnosis more often and more quickly than clinicians who
learn about the symptom only through the use clinician-centered inter-
viewing skills. The way the patient describes the symptom is as important
as the facts that are stated. This observation is not newthe physician Sir
William Osler urged his students in 1910, Listen to the patient, he is telling
you the diagnosis.
Allowing the patient to tell her or his symptom story is therapeutic
When patients are allowed to tell their illness narrative rather than only
respond to multiple clinician- centered questions, they experience a ca-
tharsissimply getting the story off ones chest can result in feeling better.
Most of us have experienced feeling unburdened and less alone after shar-
ing a story of difficulty with a good listener.
Patients do not want us to try to fix everything they tell us about
Many clinicians have a strong curative need, wanting to fix things and
make them right. This need can cause them anxiety when a patient men-
tions something (such as being unable to do work duties and feeling wor-
ried about losing the job) that is not fixable. Patient-centered clinicians
understand that patients do not expect them to fix everything, but that
simply being able to share their struggle and have it responded to is often
enough.
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Chapt er 1 T HE MEDI CAL I NTERVI EW 7
Patients may not experience our caring and compassion unless we give
voice to them
Because patients are often in pain or have significant feelings such as fear,
worry and frustration, they may not be attuned to clinicians innate caring.
The many hours of study, the sacrifices made to become a clinician and the
daily hard work of medicine may not be interpreted as compassion and
caring. Patient-centered clinicians know that empathic communication
cuts through patients pain and fear and allows patients to experience their
clinicians compassionate presence.
In clinical medicine the patients needs always take precedence.
610
At
the same time, we recognize that a patient can have many different needs,
as detailed in Table 1-2. Before beginning the interview and during its
opening moments, observe the patient for obvious symptoms of an ur-
gent disease problem that requires immediate clinician-directed input;
for example, unconscious, acute chest pain, profound shortness of breath,
overtly disruptive, extremely anxious, or actively psychotic. If these signs
are present, you must act immediately to address the problem. In these
unusual and almost always very obvious circumstances, the patient needs
you to direct the interview.
Most patients in outpatient and inpatient settings do not have such critical
problems. They are able to communicate; are not prohibitively anxious; and
1. Very common: Needs to express symptoms, personal context of illness, feelings
and emotions, interests, desire for information, and other ideas; eg, worry about
cancer; sore throat; cant work with this back pain; feeling down; want to lose
weight; fever; refill medications
a
2. Common: Special communication needs
b
; eg, non-English speaker, deaf, blind,
cognitively impaired
3. Uncommon: Urgent, sometimes life-threatening needs requiring immediate
attention
c
a. Biomedical; eg, unconscious, hematemesis, symptoms of acute myocardial
infarction, recent history of syncope, severe pain, severe nausea and
vomiting, marked shortness of breath, multiple trauma
b. Psychosocial; eg, suicidal, homicidal, very disruptive, overtly psychotic,
severe organic brain syndrome, very agitated or very anxious
a
Addressed in Chapters 15.
b
Addressed in Chapter 7.
c
Not addressed in this book.
J TABLE 1-2. Needs Communicated by Patients
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8 SMI TH S PAT I ENT- CENTERED I NTERVI EWI NG
want to talk about their symptoms, interests, fears, and concerns. In these
more common situations, you will meet these needs, not by controlling, but
by allowing the patient to lead the conversation and to discuss the symptoms
or personal issues s/he prefers. Ideas in the initial dialogue originate in the
patients mind rather than in the clinicians; later, the clinician will insert her
or his ideas into the exchange.
We will next introduce the process (timeline) and content (components)
of the basic medical interview. In Chapters 26, we will discuss how to con-
duct the interview, and will consider how to handle communication problems
in Chapter 7; you will learn the approach to emergency medical and psycho-
logical conditions elsewhere in your clinical training.
J INTEGRATED INTERVIEWING
Figure 1-2 shows a timeline of the medical interview. In the beginning
of the interview, patient-centered skills are used (covered in Chapters 2
and 3); in the middle of the interview clinician-centered skills predomi-
nate (detailed in Chapters 4 and 5); ending the interview involves a return
to patient-centered skills (discussed in Chapter 6). The amount of time
Integrated Medical Interviewing
BIOPSYCHOSOCIAL STORY
Patient-
centered
Patient-
centered
Patient-
centered
Patient-
centered
Physical
Exam
11 10, 9, 8, 7, 6, 3, 4, 5 2 Steps: 1
Components: [CC, HPI ---- -- HPI/OAP, PMH, SH, FH, ROS]
Beginning: Patient-Centered =
Psychosocial and
Symptom Data
Middle: Clinician-Centered =
Symptom and
Psychosocial Data
Clinician
Synthesizes
Set
the
Stage
Set
the
Agenda
(Patient-
Centered
Skills)
(Clinician-Centered
Skills)
Middle
End
B e g i n n i n g
FIGURE 1-2. The integrated medical interview.
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Chapt er 1 T HE MEDI CAL I NTERVI EW 9
spent in each varies with the circumstances but, generally, the middle of
the interview takes much longer. We discourage you from starting the in-
terview with the clinician-centered skills except in the rare emergency
situations noted earlier. Even if you were to later attempt to use patient-
centered interview skills to hear the patients concerns, your having started
with clinician-centered skills would suggest that your agenda was more
important than the patients. Additionally, there is evidence that patients
have difficulty providing information in a narrative fashion after they have
been interrogated by clinician-centered questions; this has been called the
question-answer trap.
17
Because Fig. 1-2 depicts a first time interview with a new patient, all compo-
nents of the history are included: chief concern (CC), history of present illness
(HPI), other active problems (OAP), past medical history (PMH), social history
(SH), family history (FH), and review of systems (ROS). You will learn more
about these in the chapters that follow. In patients whom you have previously
evaluated, you will usually need only the CC and HPI because other data are
already known, although sometimes a brief updating of the other components
is necessary.
The CC is the patients most bothersome concern. The HPI usually is
the most helpful historical component and is where the patient gives both
symptoms of possible disease and the personal and emotional context in
which they occur. When patients have more than one current medical con-
cern, you will obtain these in OAP. The PMH is where the patient gives
important past medical information that does not pertain to the HPI or
OAP. In the SH, you will ask the patient about health-promoting behaviors,
health hazards, routine personal data, relevant ethicalsocialspiritual is-
sues, and functional capacity. The FH does the same with routine family
medical information. The ROS screens for any symptoms or other problems
not already discussed.
Ordinarily the CC/HPI/OAP takes approximately half the total time avail-
able. The CC and initial portions of HPI/OAP are developed in the begin-
ning of the interview using patient-centered interviewing skills while in the
middle of the interview the latter portions of the HPI/OAP and the remain-
der of the sections are elicited using clinician-centered skills. The PMH, FH,
SH, and ROS are elicited largely by using clinician-centered skills, but as the
islands of patient-centeredness in Fig. 1-2 show, you will not remain entirely
clinician centered during this time, but will periodically return to patient-
centered skills as needed. For example, while obtaining the FH, if you ask the
patient for his fathers age and he begins to cry, saying that his father died
last month, your next question is not How old is your mother?! Rather,
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10 SMI TH S PAT I ENT- CENTERED I NTERVI EWI NG
you use patient-centered interviewing skills to empathize with the patient
and try to further understand his sadness before going on with additional
clinician-centered questions, such as the mothers age. If the beginning of the
interview has been conducted effectively, most emotionally-charged issues
will already have arisen and use of patient-centered interviewing skills will
tend to be brief.
The patient-centered skills used in the beginning of the interview allow you
to gather the patients unique perspective on her symptoms and important
psychosocial information. In contrast, the clinician-centered interviewing
skills used in the middle of the interview produce mostly symptom informa-
tion and, to a lesser extent, psychosocial data (which also are of a more rou-
tine type than psychosocial data obtained in the beginning of the interview).
Using your knowledge of medicine, you then synthesize these data into a bio-
psychosocial description of the patient.
Integrated interviewing is used for most medical interactionsnew or return
patients, hospital settings or clinics, surgical or medical services, tertiary care or
primary care, and emergency room or consultation visits.
Having introduced the process and content of the medical interview, it is
logical to ask about its intended functions. There are three distinct functions
of the interview: (a) creating a safe atmosphere and establishing a trust-
worthy relationship with the patient; (b) gathering information; and (c)
informing and motivating the patient (patient education).
1820
Most clinical
encounters will contain all three. In Chapters 25, you will learn skills that
help you to establish a safe and trustworthy relationship with your patient,
and to gather diagnostically important data. The third function, patient
education, is covered in Chapter 6. Chapters 7 and 8 will address advanced
interviewing issues and Chapter 9 will discuss how to summarize and pres-
ent the patients story.
Throughout the book we will refer you to modules in doc.com, a web-
based curriculum resource where you can get more in-depth information
on over 40 important medical interview topics. Many schools provide
access to doc.com for their students; individual licenses can also be pur-
chased. The website is http://webcampus.drexelmed.edu/doc.com/user/.
Module 1 of doc.com provides a good overview of doc.com
21
and Module
5 discusses the integrated patient-centered interviewing module presented
in this book.
22
We have identified the general interviewing process, its content, and func-
tions, but we still are left with an unanswered question: What actually goes on
at the bedside or in the clinic? What do we say and how do we say it? We are
now ready to begin.
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Chapt er 1 T HE MEDI CAL I NTERVI EW 11
KNOWLEDGE EXERCISES
1. Define medical interviewing.
2. Define the biopsychosocial model,
patient-centered interviewing, and clini-
cian-centered interviewing. How are they
related?
3. Give examples of some patient needs
that can be overlooked with isolated
clinician- centered interviewing.
4. Under what circumstances would you not
begin an interaction with a patient-centered
approach?
5. Describe three problems encountered
with isolated clinician-centered interview-
ing.
6. List the benefits from integrating patient-
centered and clinician-centered interview-
ing that make this more scientific and
more humanistic, as compared to iso-
lated clinician-centered interviewing. See
Appendix B.
7. Draw the full diagram of the interview and
label the following: beginning, middle,
physical examination, and end; CC and
HPI/OAP, PMH, SH, FH, ROS.
8. What do each of the components of the
interview listed in question #7 contribute?
9. Where does important disease informa-
tion first arise in the interview? Would you
expect personal and psychosocial infor-
mation to arise in the clinician-centered
process?
10. How do you think the interviewer might
feel in an isolated clinician-centered inter-
view compared to an interview integrating
patient-centered with clinician-centered
processes? Why is that the case?
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