Making patients the center of the medical interview

Avoiding a 'just-the-facts' approach and really talking to patients can improve your interviewing skills

From the February 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

By Christine Kuehn Kelly

Not too long ago, Heather E. Gantzer, ACP-ASIM Member, spent a lot of time counseling her newly diagnosed diabetes patients. But after attending a one-day seminar on patient-physician communication, the internist at Park Nicollet Clinic-HealthSystem Minnesota in Minneapolis decided to radically change her approach.

Now she poses just two short questions. "I simply ask early in the medical interview, 'What do you know about diabetes?' Then I follow up with, 'How do you feel about it?' " Dr. Ganzer said that the simple communication techniques she learned not only save time but make her patients happier and help improve their overall care.

That's just what the seminar's sponsor—the American Academy on Physician and Patient (AAPP)—had hoped for. The organization, along with other health plans, medical schools and a number of organizations devoted to communications issues, appear to be placing a new emphasis on the medical interview to improve patient satisfaction rates and outcomes.

Experts point out that effective medical interviews—and internists perform as many as 150,000 patient interviews during their career—improve diagnostic accuracy, get patients more involved in decision-making, increase patient compliance and reduce malpractice claims.

"Physicians should take the patient/physician dialogue as seriously as they take laboratory test results and medications," said F. Daniel Duffy, FACP, chair of the board of directors of the AAPP, senior vice president of the ABIM and a former College Regent. The organization explores how patient/physician communication can be a valid diagnostic and treatment tool.

A study supported by the Agency for Health Care Policy and Research, however, found that only half of the physicians queried asked pertinent questions about a patient's current condition, reviewed physical systems or asked about past medical history. The study also found that many physicians' preventive screening and counseling skills were deficient.

Part of the problem is that most physicians were taught to find facts and give answers. "Medical expertise consists of evaluating these facts and thinking of a good solution," explained Bill D. Clark, MD, an internist in Bath, Maine, who teaches at Harvard and Dartmouth medical schools and directs courses for the AAPP. "But when the chips are down—a patient is dying, for example—a physician who only knows how to assemble facts and give answers doesn't help with the suffering."

New skills

To teach physicians and medical students to do more than simply gather facts in the medical interview, a number of medical schools are using some cutting-edge communication techniques.

One popular technique is the Balint group, in which physicians and medical students talk to a group of their peers about a specific patient encounter and its psychological and social factors. The purpose is to make physicians more aware of how they interact with patients, and to make them more sensitive to psychological and social factors in patient care. To do that, the Balint group focuses on the physician's relationship with the patient, the patient's loved ones and other members of the health care team.

For example, a physician may present a case involving an alcoholic patient who aroused particularly strong feelings in him. The group discussion will concentrate on the physician-patient interaction and try to help the physician understand how his own underlying psychological issues, such as a history of familial alcohol abuse, affects his dealings with the patient.

Some medical schools also use the Lipkin model to help faculty teach interviewing skills to medical students. This model uses group sessions as well as role-playing, standardized patients and videotaping of interviews to help faculty develop and refine their own interviewing skills.

Medical schools are not alone. As they realize that good physician communication is good for business, a number of health plans are also getting involved.

One example is the Minnesota-based HealthSystem Minnesota (HSM). When it realized that poor communication was one of the leading causes of low patient satisfaction scores, the plan developed a series of communication courses for its 400 physicians and other medical staff. The one-day courses are offered several times a year. Further help comes through by an internal newsletter about communications and a part-time psychiatrist who counsels physicians on patient skills.

Lee Jones, MD, a psychiatrist who leads HSM's initiative to improve physician-patient relationships, finds that stepping back and looking at the big picture can help physicians focus on what's most important in a medical interview. "When doctors are having a patient communication issue, I often suggest they take a mental or even physical break," he said. Physicians often know when patients are pushing their buttons. When they feel that coming on, he advised, doctors should take a quick break and review their goals for that particular patient.

The Northwest Center for Physician/Patient Communication, a group that specializes in teaching medical interviewing skills, attempts to foster patient empathy by videotaping interviews as part of its physician courses. The idea is to help doctors focus on poor or commendable behavior that can serve as jumping off points for discussion. The courses make physicians aware of patients' feelings—and how to react appropriately.

John A. Benson, MACP, president emeritus of ABIM, who is on the board of the Northwest Center for Physician/Patient Communication, said that simply saying that you recognize what the patient is going through can often go a long way in improving medical interviews. Try to acknowledge the patient's emotions by saying something like "You must be feeling sad," he suggested. "Empathy strengthens the doctor-patient relationship," he said. "It's important to recognize and affirm your patients' feelings and nonverbal cues."

Open-ended questions

Another simple way to improve your medical interviewing skills is to use open-ended questions. Open-ended questions—tell me more, how did that work for you—give patients a chance to expand on how they're feeling. Closed questions—when did it happen, how many times—limit patient responses.

Experts say that open-ended questions help shift physicians' focus from diagnosing disease to interacting more broadly with patients. "The biomedical culture encourages physicians to think principally of the disease paradigm, to the exclusion of a patient's experience of symptoms and illness," pointed out Beth A. Lown, MD, an internist at Mt. Auburn Hospital in Cambridge, Mass., who is also an instructor at Harvard Medical School. "But if you ask questions about the patient's experience, you will be more efficient, more patient-centered and inherently more empathetic. You end up widening the list of diagnostic and therapeutic possibilities."

Dr. Lown said that she tries to understand how patients' symptoms affect their lives, particularly when they have chronic illnesses. "I ask patients how their symptoms are impacting their daily living, what adaptations they have to make, who helps them, what they can't do now that they were able to do before the illness," she said.

"It may sound like these questions extend the interview, but you really save time by avoiding the wrong track," she said, adding that phrases like "Can you tell me what it feels like?" can help flesh out the diagnostic picture. Dr. Lown also discourages the use of medical terminology by patients. "My headache may not be their headache," she said. "You need to find out what the patients are feeling in their own words."

Once you've asked an open-ended question, however, you risk getting too much feedback. "You want to turn off the conversation, not the patient," said Dr. Benson from the Northwest Center for Physician/Patient Communication. "Simply return to the original topic of conversation: 'Let's get back to the pain in your arm.' "

Problem patients

Experts point out that these communication techniques can also help physicians cope with problem patients.

Maine internist Dr. Clark said that when a patient is angry or demanding, you shouldn't defend yourself or blame someone else for the problem. "Instead, make a relationship-building statement that shows your interest in the patient as a person," he said. "You might say, 'I can see how upset you are about this.' This can help build a trusting alliance, the foundation for all your clinical work."

After taking an AAPP workshop that helped him focus on this kind of relationship building, Mark S. Perlmutter, ACP-ASIM Member, an internist in Rockport, Maine, now asks questions such as: "You are looking exhausted—is everything OK?"

At courses run by the Bayer Institute for Health Care Communication, another organization that focuses on medical interviewing skills, workshop participants are taught a "confidence and conviction" model to help analyze why patients aren't changing risky behavior. The model involves determining how important a change in behavior is to patients, and how confident they are they can make the change.

Geoffrey H. Gordon, FACP, assistant director of clinical education and research at the Bayer Institute, suggested quantifying a patient's attitude toward change on a scale of one to 10 and then making notes in the margins of the patient's record explaining how the patient has—or has not—changed his behavior. "There's no sense giving a nicotine substitute to a person with a low conviction/confidence level about quitting smoking," he said. "Instead, find out what the patient already knows about the risk of smoking and what other problems he solved in the past. Then build a plan that provides personalized information and small, doable steps to change."

And if patients have trouble following your recommendations, Dr. Gordon said, take the time to talk about their behavior. Instead of telling them why they should be changing their behavior, he said, ask if they have heard of other treatments or are confused, upset or distressed about your suggestions. Ask about their expectations and allow them to reflect and be part of the answer.

Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.

Resources to improve your interviewing skills

Here are some organizations and publications that can help you improve your medical interviewing skills.

Organizations

• The American Academy on Physician and Patient (703-556-9222) offers one-day, weekend and five-day courses that use real and simulated patients.
• ACP-ASIM (800-523-1546) offers a number of Annual Session workshops and courses focusing on doctor- patient communication. The College is also developing communication courses for its chapters. The first of these courses is expected to focus on end-of-life care. For more information, contact Linda Casey, MPH, in the Department of Research, Development and Evaluation.
• The Northwest Center for Physician/Patient Communication (503-636-2234) offers one hour, half- and full-day courses. A number of organizations in the Pacific Northwest, including Kaiser Permanente-Group Health Cooperative of Puget Sound, Physicians Mutual Liability Insurance Company and Regence Blue Cross/Blue Shield in Oregon and Washington, also provide communication skills courses for their physicians through the Northwest Center.
• The Bayer Institute for Health Care Communication (800-800-5907) offers half-day, full-day and multiple-day courses. The Institute also offers individual counseling.

Publications

• Lipkin M. Jr., Samuel M. Putnam, Aaron, Lazare. Eds.: "The Medical Interview. Clinical Care, Education and Research." Springer-Verlag, 1995.
• Dialogue: The Core Clinical Skills. Annals of Internal Medicine. 1998; Vol. 128, No. 2: 139-141.

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