Modules

The core interviews

Overview

  • You will use the Observation Guide as you proceed to the core interviews.
  • The majority of the core interviews illustrate two versions of an initial interview with a patient.
  • You will see the contrast between physician-centred and patient-centred communication.
  • Each core interview will be examined in detail.
  • Each version of each core interview will take time to watch, dissect and process.

Objectives

By the end of this portion of the Communication skills module you will:

  • Have a clear understanding of the features of physician-centred and patient-centred behaviours
  • Have become familiar with using the Observation Guide

Core interview procedures

The core interviews illustrate complete initial interviews. They are as follows:

 

Here are the steps to follow for each of the core interviews:

  • Print the Observation Guide to use as your working copy to note the techniques, styles and attitudes the physician employs. If there are terms you do not understand, you can consult the Observation Guide: Selected glossary.
  • Watch the core interviews and fill in your answers on the Observation Guide.
  • Transfer your answers to the online Observation Guide.
  • Submit your answers online.
  • View the “Application commentary.”
  • Watch the interview again.
  • Read the “Interpretive commentary.”

How to use the Observation Guide with the core interviews

  • Check items on the Observation Guide based on your observation of the physician’s verbal and non-verbal behaviours.
  • Observe the direction in which each question, statement or response takes the interview.
  • Note the patient’s verbal and non-verbal responses.
  • Not all items in the Guide are found in any particular interview. Only check the items that you either saw or heard. The appropriateness or effectiveness of behaviours will be discussed in the commentaries.
  • Note that you may prefer to complete the “attitudes” items in the Guide only after watching the entire interview.
  • Complete and submit the Observation Guide for each core interview.

After submitting your observation guide for each core interview, you can review the commentaries on each of them. First, you can compare your observation guide to the one provided at the beginning. Even if the two guides are in agreement, the reasons might be different. An action that occurred may be appropriate or not, effective or ineffective. Remember, this is not about whether the physician is good or bad, right or wrong. Rather, we are looking at the effect that a physician’s words and behaviour have on the process of the interview and how this affects the relationship with the patient.

 

The rest of the commentary is divided into two parts:

First, the application, a specific, detailed analysis of each of the core interviews. In this initial section, we will try to describe without assumptions, judgment or interpretation just what can be seen or heard at certain points in the interview. Compare this to your own observation guide. There are questions in this section but no answers to submit; they are intended to provoke thought about the situations. After considering the questions, would you change anything in the guide you completed?

Second, an interpretive commentary on each of the core interviews which interprets the interview from the patient-centred point of view. This analysis might appear to judge the physician’s behaviour harshly. Remember, the intent is not to show a bad interview, but to illustrate the effect that our interviewing behaviours can have on the care of patients. Note where you agree or disagree.

Watch each interview again. You might now see even more instances of certain techniques, styles or attitudes which take the interview in a certain direction.

Complex clinical problem/multiple morbidities

MCC role objectives

Communicator

  • Elicit patient information through active listening and the appropriate use of open and closed questions, as well as using clear language appropriate to the patient’s understanding (2.1)
  • Appropriately use interviewing skills such as clarifying, bridging, and summarizing (2.2)
  • Receive relevant information from other sources such as the patient’s family, caregivers, and other professionals and, with the patient’s permission, seek out additional information (2.4)
  • Identify the personal and cultural context of the patient, and the manner in which it may influence the patient’s choices (3.2)
  • Physician: Hello.

    Patient: Hi.

    Physician: Hi there, you’re Victoria Sharp?

    Patient: Yes I am.

    Physician: Hi there. I see you’re new to our clinic.

    Patient: Ah yes, we just moved to this community.

    Physician: Oh great, well nice to have you here. How old are you?

    Patient: I’m 60.

    Physician: Okay. And are you married?

    Patient: Yes.

    Physician: Okay well Mrs. Sharp tell me why you’ve come in.

    Patient: Well I’m just not quite right.

    Physician: Mhmm.

    Patient: And I’m feeling very tired.

    Physician: Yeah.

    Patient: And short of breath …

    Physician: Okay and how long has that been going on?

    Patient: When I exercise.

    Patient: Well I’ve very good at checking on my body and lately I found about a month ago …

    Physician: About a month …

    Patient: I started feeling like this.

    Physician: Okay, been getting worse or?

    Patient: No.

    Physician: No?

    Patient: No, it’s just I’m so tired.

    Physician: Yeah okay. And the shortness of breath … Um, when you have that, are you wheezing? Or do you have pain in your chest, or down your arm? Anything like that?

    Patient: No.

    Physician: No. Okay good. How about dizziness? Have you been dizzy?

    Patient: No.

    Physician: No, okay good. Well that’s good to know. Okay. How about you, have you got any idea what’s behind this? What’s causing this?

    Patient: Well, first I thought it was because I gained eight pounds.

    Physician: Mhmm, you gained eight pounds.

    Patient: So about two weeks ago I started cutting down on my calories and I managed to lose three pounds, but I’m still feeling …

    Physician: Okay.

    Patient: … the same, sluggish.

    Physician: So you haven’t lost it all okay. So eight pounds.

    Physician: Have you ever had your thyroid checked out?

    Patient: No. That would be one more thing to add to my long list of things going on.

    Physician: Yeah thyroid can sometimes you know be a factor with gaining weight. So we should probably have a look at that, see what’s going on, okay.

    Physician: Anybody in your family have thyroid problems?

    Patient: Not that I know of.

    Physician: No. Okay. Great. Um, okay now the other thing I’m thinking about the tiredness, we should check out diabetes. Have you or anybody in your family had diabetes or been diagnosed?

    Patient: Me.

    Physician: You have it?

    Patient: Yes.

    Physician: Oh okay. And how long have you been dealing with that?

    Patient: Oh, for seven years now.

    Physician: Seven years, okay. And what kind of medications are you on?

    Patient: They put me on Glyburide.

    Physician: Mhmm. And how’s that going?

    Patient: Well I haven’t taken it for four years now.

    Physician: Oh why’s that?

    Patient: Because they put me on a very good diet, and I started exercising and I managed to lose some weight.

    Physician: Oh good. Oh well that’s neat. Well we might have to have a look at that though. Just I mean, if you’re feeling tired, maybe something’s going on there again so we should check that out, okay.

    Just while we’re on that topic too, have you had any trouble with your vision?

    Patient: No.

    Physician: No. How about, have you been peeing more, or thirsty more than usual?

    Patient: No.

    Physician: No. How about ulcers on your feet, anything like that?

    Patient: No.

    Physician: Okay. And um … so you’re not on the Glyburide anymore. Are you on any other regular prescription medications for anything?

    Patient: Yeah I’m on Lisinopril.

    Physician: Lisinopril okay, for blood pressure?

    Patient: Ach. Yeah. I have that too.

    Physician: Okay. How is your blood pressure? Have you had it checked recently?

    Patient: Well not since we moved here about six months ago.

    Physician: Six months ago, okay. And how was it then, the last time you had it checked?

    Patient: Well it was okay, I guess. I just haven’t got any time to do anything. You know, I feel so helpless, can’t do much, when I feel out of breath.

    Physician: Yeah, okay. So six months ago you had your blood pressure … Oh I forgot to ask you, when was the last time you had your blood sugar tested?

    Patient: That was also before we moved …

    Physician: Yeah, yeah.

    Patient: … about six months ago.

    Physician: Okay so that was all done at the same time. And was it okay, your blood sugar?

    Patient: Yeah, I think it’s under control.

    Physician: Yeah, okay. Alright well we’ll have to have a peek into both of those things. I just want to ask you about your family history too. Anybody else in your family have blood pressure problems, or cholesterol, stroke, anything like that or … kidney problems, sometimes they’re all related.

    Patient: Well, two years ago they told me I had kidney problems.

    Physician: You, okay. And how’s that going? Have you had any symptoms? Or …

    Patient: Well no just about a year ago I had a bladder infection, but they gave me antibiotics and it cleared.

    Physician: It cleared up? Good … alright …

    Patient: Thank god because, my poor husband, he’s doing everything.

    Physician: Yeah?

    Patient: I just don’t feel any energy to do stuff around the house.

    Physician: Yeah … Well that’s too bad, well I hope we can get to the bottom of this.

    Physician: Um … now, there’s obviously quite a few things possibly going on here. By the way do you smoke?

    Patient: No.

    Physician: No okay, how about alcohol? Do you drink alcohol?

    Patient: Well I have an occasional glass of wine. Maybe a couple of beers on the weekend.

    Physician: Yeah, yeah, okay so you’re just a social drinker. Yeah, okay …

    Physician: Alright, well it’s important we know that. Well okay. There’s lots happening here. So I think we need to do some tests, Yeah? Okay. I’d like to actually check your blood pressure today, make sure that’s okay. But we need to do some blood tests too to check your diabetes out, and we’ll check your blood sugar. We should probably do a thyroid check just to see if there’s anything going on there.

    Patient: Hopefully not.

    Physician: Yeah, and we need to do some tests for kidney problems too, just to see if that’s … there’s anything going on there that needs to be checked out. With these troubles, you know, with the tiredness, we need to check all these things. And we could actually do some of those today.

    Patient: Oh that’d be good.

    Physician: Yeah so I’m …

    Patient: So to find out exactly what’s going on.

    Physician: Yeah, yeah.

    Patient: I just feel like a burden to my husband you know.

    Physician: Oh you know what, I’m sure he understands. When your health is an issue …

    Patient: I don’t know.

    Physician: It’s not your fault, you know.

    And I’m sure he understands that, you know, you’re doing all you can. So why don’t we try and get to the bottom of some of this stuff. We’ll do some blood tests today. I’ll send a list of things out to the nurse that need to happen today. And then, I think I would like to get your charts from the other doctor as well. So maybe you should make an appointment for two weeks from now, and we’ll have the results of your tests back by then, and I’ll have the other chart information, and we’ll do a full physical that day, and see if we can figure out what’s going on for you, make you feel better.

    Patient: Thank you.

    Physician: Yeah? Okay.

    Patient: Thank you. Hopefully I can get some energy back.

    Physician: Yeah well that would be great, I would like to see that happen for you. So I’ll let the nurse know the tests we need done and you make an appointment for two weeks and we’ll see you then.

    Patient: Well, thank you.

    Physician: Yeah. Okay, thanks for coming in, bye Mrs. Sharp.

Application commentary

The first 16 seconds sets the tone for the whole interview. The physician is dressed professionally in a white lab coat, carrying the chart note on a clipboard. She obtains the patient’s name and notes she is new to the clinic. She does all this pleasantly, with a smile and “nice to have you here.” Then she asks two very specific questions: “How old are you?” and “Are you married?”

  • What do you think of these questions being used at this point in the interview?
  • What impression might such questions have on a patient who does not know the physician?
  • Did you note the physician’s eye contact and non-verbal style on your observation guide?

Next the physician begins with a commonly used open-ended question: “Tell me why you’ve come in?” She repeats the patient’s words to clarify what “not quite right” means and elicits that the patient’s “chief complaint” is of fatigue and dyspnea. As Victoria starts to explain her symptoms, the physician interrupts several times, beginning with “How long has that been going on?”

  • What is the purpose of these interruptions?
  • What seems to be the patient’s response?
  • How did you assess the presence or absence of silence as an active listening style in the gathering information video?

After ascertaining the duration of symptoms, the physician chooses to pursue the dyspnea symptom first, with: “Do you get wheezing, pain in the chest or down your arm?” This is an example of using stacked, or multiple questions. The patient answers “No.”

  • Is it clear to either the physician or patient which question the patient is answering?
  • What do you think the physician will write in the chart?
  • What might be the effect of the patient’s response on the physician’s clinical reasoning?

Throughout the interview, the physician tries to obtain information about clinical symptoms through the use of other closed questions. Note that the information she gathers in this way is primarily negative (e.g., not dizzy). Think about how this contributes to the physician’s hypothesis testing.

A few seconds after the stacked questions, the physician appears to be gathering information about the patient’s experience of illness. She asks if the patient has any idea of the reason for her symptoms (see FIFE in the general commentary). The patient responds with information about weight gain and her attempt to lose it. The physician quantifies the weight gain correctly by repeating “eight pounds” and summarizes: “So you haven’t lost it all.” Or does she say “So you haven’t lost at all”? The difference in these two statements is three pounds.

  • Is that important medically?
  • Is it important in the patient’s assessment of the physician’s listening skills?

The physician asks no further questions about the chief complaint and proceeds to questions about the thyroid. This biomedical approach to clinical reasoning is apparent throughout the interview. The physician seems quite efficient and gets through a lot in a short period of time. As various symptoms or diagnoses come up, she goes through a checklist type of inquiry related to each symptom or disease. If she has forgotten to ask a certain question or the patient brings up information pertinent to a previous topic, then the topic is revisited. This is often due to premature closure of the topic in the physician’s mind.

  • What is the impact of this on the organization of the interview?
  • How did you assess the flexibility item in the Guide?

Flexibility usually refers to following patient cues, although sometimes it reflects bridging or transitional statements indicating a change in direction of the interview by the physician. (See the general commentary for more on this issue.)

As the information gathering progresses, decide what to note in the Observation Guide about the quantity and quality of biomedical information. For instance, there is an inquiry about thyroid disease. Note how many questions are asked as well as the patient’s verbal and non-verbal response: (“Another thing to add to my long list of problems”). As you think about this part of the interview, look at the categories in the Observation Guide under “Listening style.” In response to the patient’s verbal and non-verbal behaviours, the physician smiles, says “Yeah” and explains her thoughts that thyroid can cause weight gain.

  • Is this an example of finding common ground?
  • The physician then makes a decision about how to gather additional information. What is it?

There is an example of the “Speech pattern” category in the Observation Guide. The physician uses appropriate vocabulary, in that she does not use jargon. But her choice of questioning style about kidney problems is interesting. Hearing that the patient was told of problems two years ago, she then asks an open-ended question: “How’s that going … have you had any symptoms?” The patient responds with information about a bladder infection one year ago.

  • Given her response, would another questioning style have elicited more accurate information in this instance?

An example of making assumptions occurs while using the technique of clarifying in the quantifying of alcohol consumption. The physician interprets the patient’s response, saying: “So you’re just a social drinker.”

  • Has adequate information been gathered to make that statement?
  • With potentially value-laden terms such as “social drinker,” are we hearing the patient’s or physician’s view?
  • How much does this patient drink?

Examples of the patient’s verbal and non-verbal cues and the physician’s listening style occur several times during the interview, when the patient refers to “my poor husband.”

  • How does the physician respond to these cues?

Near the end of the interview, the physician states that she is sure that the patient’s husband understands: “It is not your fault.”

  • Is this an empathic statement (does the physician understand why the patient is so concerned about her husband)?
  • Do you understand, based upon what you have seen and heard?

Throughout the interview, the physician uses a number of other techniques listed in the Observation Guide. She explains why she is asking questions about the thyroid and diabetes. She repeats some of the patient’s answers to her questions, seemingly to make sure she has got it right as she makes chart notes. She facilitates with lots of “uh-huhs.” She makes a summary statement saying: “There is lots going on here.”

  • Look for examples of other techniques, such as reiteration, paraphrasing and validating.
  • Ask yourself if these techniques were used effectively and furthered the physician’s understanding of the patient’s illness.

You might have watched the entire interview before completing the “Attitudes” section of the Observation Guide since these items are shaped more by the appropriateness of techniques and styles than by the frequency of their use. As you completed this part of the Guide:

  • What attitudes were clearly expressed?
  • Think about how well the physician understood the patient’s experience of illness and her specific concerns.
  • Did she have a good idea of the biomedical problem?
  • Did she have a good idea of the patient’s worldview?

You can now watch version 1 of the interview again, read the “Interpretive commentary” or go to the next section.

Interpretive commentary: Attitudes

How would you describe the physician’s general attitude to this patient at the beginning of the interview? Is she friendly? Is she cheerful? Is she confident? Yes, we would probably agree that she is all three. But she also appears somewhat brisk and detached (e.g., “Another patient to get through in 10 minutes.”) Note that she does not introduce herself or seek to make any further introductory connection with the patient, such as a handshake. A social amenity is often used early in the interview to put the patient at ease. In this case the physician appears to have her eye on the chart and her medical focus is expressed in her rather abrupt initiation of closed-ended questions (e.g., “How old are you? Are you married?”) Put yourself in the patient’s shoes.

  • In going to a new physician, what are your expectations?
  • Are you going to want to tell this stranger about yourself?
  • Will you accept his advice?

Assuming the patient knows who you are, some might say that starting with such personal questions is professional arrogance and disrespectful of the patient as an autonomous human being. Others might find such a business-like approach reassuring. This illustrates in miniature the distance that has developed between physician and patient over the past century and how a “consumer” mentality develops.

This patient’s age and marital status are important, but:

  • As the interview progresses, is this information used to guide the process?
  • The patient refers to her husband several times during the interview. What is the physician’s response?

Rather than using the information to foster a professional dialogue, the encounter starts to take on an interrogative tone, beginning with a commonly used open-ended question: “Tell me why you have come in today.” Here the physician’s tone of voice and general non-verbal behaviour colour this simple question.

  • Is this said in a welcoming tone?
  • Does it sound more like a demand?
  • How might the tone influence the patient’s response?

Such a questioning style makes it more difficult to make a connection with the patient as a person. There is a verbal directness and a rapid pace that contrasts with the patient’s slower speech pattern, making it difficult for the patient to fully express herself because the physician interrupts her throughout the interview.

People who initiate visits to physicians are seeking help and usually know what they want to say when asked their reason for coming. Here, the patient begins to explain, and, is interrupted at 27 seconds into the interview. (The physician waited longer than some do.) In one study, physicians interrupted patients at an average of 18 seconds into the interview! (H.B. Beckman and R.M. Frankel, 1984). Sometimes interruptions are appropriate and necessary, but when done at this early stage in the clinical encounter, they may send a message that the physician is not interested in the patient’s experience of her illness. The physician’s attitude with regard to information appears to be: “The answers to my questions are important, and if a part of your story does not conform to those answers, I am not interested.”

  • What constitutes valid information, i.e., that which is required to care for and manage a patient?

Physicians spend years learning the biomedical facts of disease. The point of patient-centredness is that the patient’s experience of the illness is information that is just as valuable, real and credible as the disease-focused information of importance to the physician. The skill the physician brings to the clinical encounter is twofold:

  • The knowledge to know what information might be required to find out what is wrong (diagnosis).
  • An understanding of what information might be required to manage this particular patient. Dealing competently with this issue requires understanding the patient’s experience of illness.

Many students are taught to explore the patient’s experience of illness by using the FIFE formula (feelings, ideas, function, expectations). While this information is important, as with any other technique, the FIFE formula must be used appropriately and not introduced abruptly or out of context. Some students report a formulaic behaviour: “I FIFEed the patient.”

  • Is this a patient-centred behaviour?
  • In this interview, was the FIFE question appropriate (“Any ideas about the cause …)?
  • In what other ways could this information be obtained?

Physicians who do not investigate the patient’s experience risk indicating a lack of respect for the patient as a person. Patients who feel devalued might “shut down” and fail to reveal data important to the diagnosis and/or management. The truth of this can be seen in this interview.

Interpretive commentary: Styles and techniques

A physician’s general attitude, either more physician- or more patient-centred, influences the style of interviewing and choice and timing of techniques. This brings up a general rule that normally applies in interviews between physicians and patients:

  • The physician, in a position of knowledge and expertise, must adjust to the patient and not the patient to the physician.

The importance of this rule can be seen in the questioning style used in this interview. We know that both open and closed questions should be used in gathering information but there are no rules to guide us. Decisions about which type of questions to ask and when to ask them largely determine the amount and quality of information the patient provides. We saw that multiple questions can lead to uncertainty and ambiguity about the answers.

Later in the interview, the physician used an open question about kidney disease (“How’s that going?”), eliciting some information about a past infection.

  • What do you think the patient thought of that question and how to respond? The patient also said: “They told me I had kidney problems.”, referring to an incident the year before the infection. The physician does not ask for clarification.
  • What do you think the physician writes in the chart about the infection? About the kidney problem in general?
  • If you were asking the questions, would you have used an open question at this point?
  • How might you have phrased the question to help the patient give you more accurate and complete information?
  • Would you have probed further?

A physician must not only hear the patient’s answers, but listen to them, interpret them and respond appropriately.

As another exercise, given the patient’s chief complaints of fatigue and dyspnea, write down what information you would want, and think about how you might obtain it using a combination of open and closed questions.

An important overall style feature is organization. There are several reasons why an interview might appear less than well organized. It is normal and understandable that at times we forget things and have to go back and ask a question on a topic previously discussed. In these instances, it is helpful to inform the patient of the reason for the digression. Some physicians find it difficult to be organized with their own thoughts and to also follow the patient’s cues, which may lead anywhere. The weaving of the patient’s story with the physician’s pertinent questions to form a coherent narrative is one of the arts of skillful interviewing. It requires flexibility, that is, the ability to go back and forth between the patient and the physician’s agenda. A physician’s questioning style is therefore related to and impacts upon the organization of the interview.

In this interview, the physician gathers a lot of information using closed questions, but as we have already noted, much of it is negative. This technique is appropriate when biomedical ground needs to be covered efficiently to complete the data gathering. The information might help to confirm one hypothesis and rule out others.

  • How many of the patient’s symptoms are revealed in this interview?
  • How much do the closed questions contribute to determining what is actually wrong with the patient?

The patient’s story is largely untold and this is a major deficiency of the interview. The physician is trying to locate the patient’s diagnosis — in the heart, the lungs, the thyroid or the pancreas. Meanwhile, the physician fails to follow patient cues, sometimes jumps around in the conversation, changes topic abruptly and revisits previously explored areas because she has forgotten to ask about something. This is due in part to premature closure on information and in part due to a lack of transitional and bridging statements. Use of such statements might help provide a “road map” for both physician and patient. In not using these techniques, the physician displays a lack of flexibility, as it is defined in the Observation Guide. Such a formulaic, checklist approach, combined with premature closure in clinical reasoning, can lead to management errors.

Focused on classificatory patterns and categories rather than on the specific individual patient, the doctor risks not understanding the particular interactions between this patient and the basic pathologic mechanisms that constitute just this person with just this disease. Thus, the doctor risks finding out what he or she already knows and missing precisely what the individual patient actually presents for diagnosis and therapy. (R. Zaner, 1988, p. 103)

By failing to take into account the patient’s illness experience, the physician misses important data and the quality of the data she does obtain is uncertain and incomplete. Whether intended or not, this is a manifestation of a lack of consideration for the patient’s point of view. There are several other times when the patient expresses her major concerns. At one point in the dialogue she says: “I feel so helpless when I’m out of breath.” At another point, she says: “my poor husband.” The physician does not respond to either of these statements. What are some possible reasons why the physician misses these important cues?

  • Is her mind exclusively on the various differential diagnoses?
  • Is the physician looking at the patient? Would she recognize the patient’s non-verbal cues?
  • Do her responses sound like she has actually heard the patient or are they automatic?

Watch the video for additional examples of failure to actively listen and attend to the patient’s cues. She does try to validate the patient’s feelings of concern for her husband with: “It’s not your fault … you’re doing the best you can.”

  • How can she say “It’s not your fault” when she really knows nothing about the patient’s situation?
  • Is this an empathic statement?
  • Is she really attempting to understand or interpret the patient’s life experience or does it sound belittling and patronizing?

By ignoring the patient’s story, the physician fails to gather an adequate quantity and quality of psychosocial information. This also contributed to the physician’s inability to gather the necessary medical information. In spite of several references to her personal concerns, the patient has not been able to reveal the full context of her situation. The patient mentions her worries about her husband several times.

  • Why is it important to the patient to mention her worries?
  • Is she allowed to speak about it?
  • Would it possibly make a difference to the management of this patient if her husband were also ill, perhaps with early Alzheimer’s?

Throughout the interview, the physician appears to be working exclusively from her own medical agenda, rather than with the patient. While this may eventually result in correct medical management, it is unfocused and inefficient. There is substantial evidence that finding common ground results in better patient adherence to treatment, fewer follow-up complaints and reduced inappropriate use of resources. The point is that the information gathered in the interview focuses and guides not only the physical examination but also the number and kind of laboratory tests that are ordered.

As seen in this interview, techniques used in the absence of patient-centred styles and attitudes are usually less successful for both the physician and the patient. Gathering and integrating information is more likely to be inaccurate and/or incomplete. As well, it creates an environment in which the physician might appear insincere or uninterested in the patient.

The pacing is fast throughout this interview, as if the physician is busy and has only so much time. By failing to note and follow patient cues, and by pursuing questions based solely on the testing of diagnostic hypotheses, the physician has failed to gather information relevant not only to making a medical diagnosis but to managing the patient. The physician has not been open-minded and flexible about the case, thus there can be little integration of information into a plan appropriate for the patient. The physician might very well come to the correct medical diagnosis by doing the tests that are discussed, but her failure to obtain adequate information leads to flaws in her clinical reasoning.

Interpretive commentary: Attitudes revisited

In this interview we have seen how a physician-centred attitude can influence the expression of styles and use of techniques. Many styles and techniques are actually used, but not in a patient-centred way, and that makes the interview less successful than it might have been.

As seen in the “Attitudes” section of the Observation Guide, not all items are apparent or used in an interview. For instance, there might not be an appropriate place for an empathic statement, but you should be able to demonstrate empathy in every interview, such as by active listening and attentiveness to the patient.

  • Did you note any empathic statements in this case?
  • What did you think when the physician said “Too bad. We’ll get to the bottom of this”?
  • Does this sound genuine, as if the physician really means it? Or does the statement sound routine, something the physician says without really connecting to the patient’s meaning?

With regard to self-awareness, we have already noted that the physician seems unaware that she is making a number of assumptions and comes to premature conclusions on several issues. While she is not judgmental, her failure to follow up on patient cues and adjust her pacing and tone to that of the patient reveals a narrow approach. Open-minded interviewers are flexible and ready to receive and respond to anything they hear and see. They are not focused on just their agenda and attempt to connect with the patient to find common ground. We can see in this interview that the attitudes are the basis for a non-patient-centred style.

  • Commentary

  • You should now have watched the core interview and gone through the application commentary. Interpretation does involve making some assumptions and judgments on what we see. We will be analyzing the case by referring to the patient-centred model, and pointing out where the physician-centred model differs. So who is the physician here? She’s experienced, not a beginner at interviewing. She utilizes many of the techniques in the Observation Guide. So what’s wrong with this interview? Many might say nothing. It is physician-centred, and that is quite common. And at times it is appropriate to be more physician-centred (e.g., a comatose patient, in some emergency situations).

    This commentary is intended to:

    • Show how you might learn to objectively analyze components of an interview in a patient-centred framework
    • Point out specific instances of physician-centred behaviours and their effect on the patient
    • Show how the cumulative effect of persistently physician-centred behaviour may shape an interview, including patient responses and physician clinical reasoning
    • Point out that it is the appropriateness of a technique or style, and not just the use of it, that is important

    You may want to read this Interpretive commentary more than once, as there are many points about interviewing skills to think about. You may also want to watch the interview several times.

    Since decisions to use tools to express styles are based on our underlying values and beliefs, e.g., attitudes about the purpose of the task, let’s look first at the attitudes expressed at the beginning of this interview, and how they might affect how things develop.

Chronic pain, version 1, scenario 1

MCC role objectives

Communicator

  • Initiate an interview with the patient by greeting with respect, attending to comfort and to the need for an interpreter if applicable, orienting to the interview, and consulting with the patient to establish the reason for the visit (1.1)
  • Use appropriate non-verbal communication (positioning, posture, facial expression) (1.2)
  • Elicit patient information through active listening and the appropriate use of open and closed questions, as well as using clear language appropriate to the patient’s understanding (2.1)
  • Gather information about the patient’s concerns, beliefs, expectations, and illness experience (2.3)

 

Professional

  • Recognize that the complexity of the health care system requires attention to follow-up in the interests of good patient care (lab results, consultations) (2.2.1)

 

  • Physician: (coming into room) Hello, you are Marie Kovach?

    Patient: That’s right.

    Physician: (sitting down) Hi, I’m Dr. Couteau. It says here you have migraines. Those can be really bad, I know. I’m glad you came in. Before we talk about them, I just need to get a little personal information, if that’s alright?

    Patient: Okay.

    Physician: How old are you?

    Patient: Forty-seven.

    Physician: Are you single, married, in a relationship?

    Patient: Married.

    Physician: And do you work in the home, or outside?

    Patient: I work outside.

    Physician: Thank you.

    Physician: So, how long have you had them? The headaches, I mean.

    Patient: Well, I had sick headaches as a teenager, but maybe about 12 years ago I was told …

    Physician: Twelve years. That’s a long time. You were diagnosed, so you must have gotten treatment?

    Patient: I’ve tried a lot of different things. They either don’t work, or have side effects, or cause worse headaches, or I can’t take them the right way — that was the last physician who said if I didn’t do it right, what could I expect … All these pills, especially the Triptan stuff are expensive, and I throw most of them away.

    Physician: Okay, I think I get the picture.

Application commentary

Let us examine the first few moments of this interview.

The physician checks the patient’s name and introduces himself.

He does not shake hands with the patient. That is probably the most common situation. Shaking hands is a more formal approach, but is also appropriate, if the physician feels comfortable and usually does it.

The physician then mentions the reason for the visit, that is, the diagnosis told by the patient to the receptionist, and adds two comments often used:

  • The physician made an attempt at an empathic statement: “They can be really bad,” and an attempt to help the patient feel welcomed and cared for: “I’m glad you came in.”
  • The first statement is true in general, but makes assumptions about this particular patient. The physician does not yet know why she is here. At this point, the empathy does not seem genuine.

Does telling the patient you are glad she came in accomplish anything? A better approach in the introductory moments is to be attentive to the patient and show your interest.

The physician then uses another frequently taught and used technique, that is, asking for basic personal information before starting the interview proper. It may be that getting some context is important, but on the other hand, does this sound like an interrogation? Does the patient understand the reason for the questions? Notice that her responses are brief and she does not make eye contact. Is any connection being developed? How important is the information gathered at this stage? When patients go to physicians, they expect and want to tell their stories and, if necessary, to be examined. As the interview continues, recall this point and decide if the information was required at this time, or could have been obtained later as the story unfolded.

The physician then begins the interview with a very specific question: “How long have you had them?” This anticipates a specific, short answer, and when the patient tries to tell part of her story, the physician interrupts her. He has his answer and goes on to questions about treatment without collecting a complete picture of the symptoms.

The physician elicits a lot of information about her previous experience with medications, to which he responds: “I think I get the picture.” Does he really? How do you think the patient feels about that statement? This is similar to a frequently used empathic statement: “I understand.” Patients may not say so, but often think that the physician does not really understand their situation.

There is a lot going on in these first few moments, and the way the physician handles it will set the tone for the rest of the encounter. Establishing a good tone is especially important in dealing with a patient who has a chronic or complex problem.

Let us continue with the interview.

Chronic pain, version 1, scenario 2

  • Physician: So you did take a Triptan … There are several kinds of that medicine. Do you know the name?

    Patient: I can’t remember

    Physician: Well okay, but if you have the bottle, I need to know exactly what it is. So, why is it hard to take?

    Patient: The doctor said I had to take it right away when the headache starts, and that isn’t always possible.

    Physician: Can you explain?

    Patient: If I’m working the counter, and we’re busy, I can’t just disappear.

    Physician: And you can’t keep the pills with you? So you can take them anytime?

    Patient: I tried that, but what would the customers think if I pulled out some pills and then I needed water. It doesn’t look right.

    Physician: Okay, well, we may need to talk more about that. Let’s talk about triggers. What causes the headaches?

    Patient: Like I said, I get them at work, especially on Thursdays. It’s the smell …

    Physician: Smell? Where do you work, by the way?

    Patient: I’m the manager of Baxter’s Bakery. You may have heard of it.

    Physician: Yes! I’ve been there many times, but I haven’t seen you there. How long have you worked there?

    Patient: About six months.

    Physician: Oh, Okay. I haven’t been there lately. Can we take a step back … are there any other stresses in your life?

    Patient: Like what?

    Physician: Well, who all is at home? Do you have a partner? Children? How are the relationships?

    Patient: They’re okay, I guess. My husband is a truck driver. He’s away a lot. My daughter is going through a rough patch — she’s pregnant.

    Physician: And that should be a happy time. Is this something you don’t approve of?

    Patient: (rather angry and impatient) She’s single, living at home, and won’t tell me who the father is. Isn’t that enough?

    Physician: I see. That can certainly be stressful. How does your husband feel about it?

    Patient: He doesn’t know yet. Like I said, he’s away a lot.

    Physician: When he’s home, are things good between you?

    Patient: Good enough. He pays the bills.

    Physician: I ask this of everyone. Has he abused you?

    Patient: No! Look, I get migraines.

    Physician: I understand. Now, let me ask you about auras. Do you know what that is?

Interpretive commentary

Let us look at this middle part of the interview. The physician recognizes that executing a medication history and asking about triggers is essential. After gathering some important information about the difficulties the patient has had with her current medications, the physician elects not to pursue that topic. Perhaps he feels he has enough information or perhaps he is worried about time. In any event, her work history is not completely explored. Will the physician remember to come back to it?

Physicians frequently have to make decisions about the focus of an interview. When a topic comes up, do you explore it thoroughly then, or go on to gather other important information? The outcome is not always clear: sometimes useful information emerges and sometimes you get bogged down in irrelevant detail.

In this instance, the physician chooses to go on to try to explore stress as a trigger, making an assumption that the patient’s job is stressful. The psychosocial environment is explored by first asking three questions at once. As is often the case, this confuses the patient and she chooses to answer the last question.

The physician does try to pick up on patient cues, following up on the last comment the patient makes. Some information comes out, but the interview seems to drift off course, and the possible connection between the family situation and the migraines is not made clear. The physician fails to tell her why he is asking the questions, and the patient becomes frustrated. In an attempt to get back on track, the physician switches to questions about auras.

Let us look at the end of the interview.

Chronic pain, version 1, scenario 3

  • Physician: We are almost out of time for today, but I certainly want you to come back soon and talk some more. We have lots to discuss. In the meantime, I will give you the medication I usually find helpful, and I want you to really try to take it as directed. That’s very important, no matter how difficult it may seem. Think about how you can do that. I’m sure there must be a way.

    Also, I’m sure you understand that with chronic pain like this, we can’t make it all go away. The goal is to get as much relief as possible, so that you can carry on with your life.

    If you have any difficulty with the pills, that is, side effects, please call me at once so we can discuss it.

    Sound like a plan?

    (patient looks down)

Interpretive commentary

It is difficult to conduct an initial short interview with a patient with a complex chronic problem. A reasonable goal is to hear the patient’s concerns, find out a little about what you need to know, and formulate an initial management plan that is acceptable to both physician and patient. That is, a therapeutic alliance must be developed or else the patient could feel this is just like the last unsatisfactory visit.

How did this physician do? Do you think the patient feels she has had an opportunity to voice her concerns? Has a therapeutic alliance been formed? What is the plan? Does the patient agree to the telephone support if medication problems occur?

Chronic pain, version 2, scenario 1

  • Physician: Hello, I’m Dr. Couteau. And you are Marie Kovach?

    Patient: Yes.

    Physician: Did I pronounce your last name correctly?

    (patient nods)

    Physician: Good, so I understand you have migraine headaches. This has been diagnosed before?

    Patient: Yes, I’ve had them for years, off and on anyway. They’re on again now, and nothing seems to work.

    Physician: So you’ve had problems with medication?

    Patient: Yes. I’ve tried a lot of different things. They either don’t work, or have side effects, or cause worse headaches, or I can’t take them the right way — that was the last doctor who said if I didn’t do it right, what could I expect … All these pills are expensive, and I throw most of them away.

    Physician: It sounds as if you’ve gotten really frustrated.

    Patient: Yeah.

    Physician: I want to hear more about the treatment, but first, can you give me a feel for what the headaches are like.

    Patient: They start as a dull ache, behind my eyes, and then just get worse and worse, so I can’t really do anything. I’ve been asked about the aura stuff, and I don’t get that. They can last for hours sometimes. I get nauseated, I can’t concentrate. They’re a real pain.

Interpretive commentary

The beginning of this version starts, as in version 1, with the physician introducing himself. He then checks the patient’s name, although he chooses, as before, not to use it. He does not ask: “How would you like me to address you?,” which is a commonly used question. It is better to ask the patient than to make an assumption about something as important as a name. In most interviews, however, the patient’s name is not used, even though checking on the patient’s name can be done anytime later in the conversation.

The reason for the visit is known, so the physician then asks what might be considered a semi-open question to get things started. He picks up on and follows the patient’s cue that frequency of headaches and problems with medication are her concerns.

The physician’s response to the patient’s experience with the medications is quite different from that in version 1, which sounds somewhat condescending. He makes an empathic statement that is more genuine because he does not make assumptions (“It sounds as if”). The patient confirms, and is more likely to feel heard than in version 1.

Perhaps conscious of time, the physician then reassures the patient that the medication issue will not be forgotten, and gathers information about the symptomatology. Had the physician not told the patient the reason for changing the subject, she might have felt that the medication — an important topic — was left unexplored. Telling patients why you are asking certain questions at certain times helps them understand your organization and purpose. Is the physician asking about the headaches to confirm the diagnosis? Possibly, but more important, he wants to hear how they affect this particular individual, that is, to find out about her illness experience.

Let us rejoin the interview.

Chronic pain, version 2, scenario 2

  • Physician: You said they are bothering you more just now. How often do you get them, say in a week?

    Patient: Recently, two or three times a week. That’s what happens … I’m pretty good for a while, then get spells of them. I wasn’t too bad until a few months ago.

    Physician: So they are more frequent lately. Any idea why?

    Patient: I’m always asked about triggers. I guess before periods. When I get upset, or stressed out. But this time, I think it’s almonds.

    Physician: Almonds?

    Patient: Yeah. I’m the manager of Baxter’s Bakery — this past six months. And I noticed that I started to get headaches on Thursdays. That’s when they bake the almond danish for the weekend. Now, just the thought of the smell can start one.

    Physician: Wow. That’s a new trigger for me. But you’re getting them at other times? That is … not on Thursdays?

    Patient: Yes. The job is busy, stressful. But I like it. I need it …

    Physician: So are you the single wage earner? Do you have family?

    Patient: Oh yes, my husband is a truck driver, and doesn’t make much money and he drinks part of that. I have a daughter at home she’s … well, she’s a worry.

    Physician: How so?

    Patient: She got pregnant! And can’t seem to cope and do anything about it, so she came home to mother!

    Physician: Sounds like you’ve got a lot on your plate. I want to hear more about that in a moment, but I want to make sure we talk about the headache pills, because that seems to be a major issue for you.

    You said you’ve tried various medications. Can you remember the names?

    Patient: I started with Tylenol, then Naprosyn, then a doctor gave me Cafergot, which made me sick, then something else … can’t remember the name, then Tylenol with codeine, which made me constipated, and I worry about addiction.

    Physician: That’s quite a list. What was the latest one … you mentioned the doctor said you didn’t take it properly?

    Patient: Oh yes — Triptan something. Supposed to be so good. Yeah — so expensive.

    Physician: And it didn’t work?

    Patient: I can’t always get to it right away, when the headache starts. Then I took more, and got the worst headache ever. The doctor … well, wasn’t helpful.

Interpretive commentary

A lot of useful information is revealed in this middle part of the interview. How does the physician do this? Who is doing most of the talking — the patient or the physician? By listening carefully and following the patient’s cues, more information comes out about frequency, triggers and the psychosocial environment. Also, the interview stays on topic by following the patient’s cues. While there are a number of other questions and issues to be explored, decisions always have to be made about how much can be accomplished in the time available. Trying to do everything (e.g., asking about abuse, drinking, past medical history) will simply frustrate both physician and patient, and make the conversation feel rushed.

There will need to be future meetings, but the important point is that both the physician and the patient need to agree on what should happen in this first meeting. That is, a therapeutic alliance should be developed. Let us see how that might happen.

Chronic pain, version 2, scenario 3

  • Physician: There are several things we need to discuss, perhaps at our next meeting, if you are willing. But first, we need to try to make a plan to deal with the immediate problem — your headaches.

    So … You have days off — at the bakery?

    Patient: Yes, I usually take Sunday and Monday — sometimes I have to go in then, if it’s busy.

    Physician: Of course. But I wonder … any chance you could switch to taking Thursdays off?

    Patient: Oh … I don’t know, it’s pretty busy. Staffing is a problem.

    Physician: Yes, but if you can avoid the triggers, like the almond smell, that’s the best way of preventing migraines … don’t you think? Anyway, it’s something to think about, that wouldn’t involve medication.

    I don’t want to do anything too drastic with pills yet, but if you agree, I could give you a small amount of one of the medications I have used. It may have fewer side effects … it’s a newer one. Trying a few wouldn’t be too expensive. What do you think?

    Patient: I don’t know. All anyone seems to do is give me pills, which don’t work.

    Physician: That certainly seems to be the case, but with chronic migraines, we usually use a combination of lifestyle modification and medication. It might help if you kept a diary, of when you get the headaches, and what is going on right then. We could discuss it, and try to find ways of avoiding some of the triggers. Could you do that?

    Patient: I guess so.

    Physician: Also, if the pills I prescribe help even a little, then we have a start. Try a few, and if they are helpful, I can prescribe more. Again, try to keep track of when you take them in relation to when you get headaches. That will help us next time. Does this sound like a plan, with another meeting in the next couple of weeks?

    Patient: Okay.

    Physician: One more thing. About your daughter … How old is she?

    Patient: Old enough to know better!

    Physician: This must be a worry for you. If you’re open to it, I can give you some resources that you can share with your daughter.

    Patient: Well, thanks. I’d like that.

Interpretive commentary

In discussing management, the physician makes four suggestions:

  1. Change the day off
  2. Keep a diary
  3. Try new medication
  4. Provide resources for her daughter

The patient must take an active role in the management of her care. Doing so might enable the patient to start taking more control of her situation, which is an important factor in dealing with chronic problems. The physician is also sensitive to her skepticism about the medication efficacy and expense.

The interview ends with a discussion not of the patient’s problems, but of her daughter. Is this non patient-centred? No. It is clear to both the physician and the patient that the daughter’s pregnancy is part of the patient’s stressful environment and something that she seems to be having difficulty coping with. By offering to assist with that situation, the physician is supporting both the patient and her daughter.

Much has been left unsaid in this initial meeting. However, if the patient feels she has been heard and has a plan she can follow, she will return for further conversations. At that time, the physician can gather more information and refine a management plan that they can both agree on.

Summary of the core interviews

  • Commentary

  • It is important to understand that these two interviews are not templates or how-to guides. They are examples of two different types of interviews, illustrating how subtle differences in technique, style and behaviour can shape the dialogue between physician and patient. All physicians develop their own interviewing style, facing the challenge that each interview is different and unique; never to be repeated.

    However, understanding how to conduct a patient-centred interview is an expectation of physicians practicing in Canada. Empathy consists of listening with genuine interest to the patient, without the need to use phrases learned for such occasions.

    Engaging the patient in shared decision-making supports adherence to management plans, and forms the base for the therapeutic alliance.


 

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