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)
  • Dr. Roman: Good morning, my name is Dr. Roman and may I could just confirm your name?

    Victoria: Yes, I’m Victoria Sharp.

    Dr. Roman: Yes, I noticed that you’re new to our clinic.

    Victoria: Yes, yes, we just moved to this community.

    Dr. Roman: Well it’s really nice to have you here. May I ask how old you are?

    Victoria: Yes, I’m 60.

    Dr. Roman: 60. And are you married?

    Victoria: Yes.

    Dr. Roman: Okay well, Mrs. Sharp why are you here this morning? What’s brought you to our clinic?

    Victoria: Well, I am just not feeling quite right. I’m feeling very tired and short of breath.

    Dr. Roman: And how long has this been going on?

    Victoria: Well, I’m very good at keeping track of my body and I noticed about a month ago.

    Dr. Roman: About a month?

    Victoria: Yes that it started then.

    Dr. Roman: And has it been getting any worse?

    Victoria: No, it’s just that I feel so tired.

    Dr. Roman: Well now this shortness of breath when that happens do you start wheezing? Do you get pain in your chest or down your arm? Anything like that? No?

    Victoria: No.

    Dr. Roman: What about dizziness? Do you get dizzy?

    Victoria: No.

    Dr. Roman: Okay, well that’s good. Well Mrs. Sharp, do you have any idea what’s going on, what’s behind this?

    Victoria: Well at first, I thought it was because I gained about eight pounds very quickly and so a couple of weeks ago I started counting on my… down on my calories and I managed to lose three pounds but I’m still feeling the same, just sluggish.

    Dr. Roman: Okay. So, you didn’t lose all of it, it was eight pounds. Have you had your thyroid checked?

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

    Dr. Roman: The thing is thyroid can be a factor in weight gain, so we should definitely check that out. Does anyone in your family have thyroid problems that you know of?

    Victoria: No, not that I know of.

    Dr. Roman: Okay well that’s good. The other thing with tiredness is diabetes, do you or anyone in your family have a diagnosis of diabetes?

    Victoria: Me.

    Dr. Roman: You have it?

    Victoria: Yes.

    Dr. Roman: Alright. And how long have you been dealing with that?

    Victoria: Oh… For seven years now.

    Dr. Roman: Okay. What medication are you on?

    Victoria: They put me on Glyburide.

    Dr. Roman: Glyburide, okay. And how’s that going?

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

    Dr. Roman: What? Really, why?

    Victoria: Well because they put me on a very good diet and I started exercising and I managed to lose some weight.

    Dr. Roman: I understand. Okay I see. But we might have to check that out. I mean, if you’re feeling tired it could be that something’s going on there again. While we’re on that subject how’s your vision?

    Victoria: Oh it’s fine.

    Dr. Roman: No problem and what about peeing? Do you find yourself going to the bathroom more often? Thirsty more than usual?

    Victoria: No.

    Dr. Roman: Okay. What about your feet, any ulcers?

    Victoria: No.

    Dr. Roman: Nothing like that. So, you’re not taking the Glyburide, are you on any other prescription medications?

    Victoria: Yes, I am taking Lisinopril.

    Dr. Roman: Lisinopril for blood pressure?

    Victoria: Yeah, I have that too.

    Dr. Roman: Okay, well how long ago… When have you had it checked?

    Victoria: Well that was before we moved, so that was about six months ago.

    Dr. Roman: Six months ago and how was it then?

    Victoria: Well, I think it was okay. You know I just haven’t had the time to do anything or check things because when I feel kind of lousy I don’t have much energy when I feel out of breath.

    Dr. Roman: Out of breath, yes. Okay, so six months ago you had your blood pressure checked. What about your blood sugar?

    Victoria: Oh that was also about six months ago before we moved.

    Dr. Roman: Okay. Alright, so they were both done at the same time then and was your blood sugar okay then?

    Victoria: Yes, I think it’s under control.

    Dr. Roman: All right. Well, we’ll need to check both of those again. Right now I’d like to ask you about your family history though. Is there anybody else in your family who’s had problems with blood pressure, cholesterol, stroke anything like that? Kidney problems sometimes they’re all related?

    Victoria: No, not kidney problems but just about a year ago I had a bladder infection but they gave me antibiotics and it cleared up.

    Dr. Roman: It cleared up, okay. Okay.

    Victoria: Thank goodness because my poor husband he’s having to do everything. I just don’t have any energy to do any stuff around the house.

    Dr. Roman: Yeah, that’s too bad. Well, I hope we can get to the bottom of it to find out what’s causing that. I mean, obviously there are quite a few things going on here that could possibly be involved. By the way, do you smoke?

    Victoria: Oh no.

    Dr. Roman: And what about alcohol, do you drink?

    Victoria: Yes, I have an occasional glass of wine maybe a couple of beers on the weekend.

    Dr. Roman: Okay, so you’re a social drinker. Alright. Well it’s good to know that. We will need to do some tests because there’s a lot happening here. I’d like to do your blood pressure, check that. Check your blood sugar levels because of the diabetes. We must check your thyroid as well. Make sure there’s nothing wrong there.

    Victoria: Hopefully not.

    Dr. Roman: And then we should test for kidney problems to make sure that’s okay. I know, it seems like a lot but with the fact, the symptoms you’re describing fatigue, we’re going to have to check them all out just so we can eliminate some. Okay?

    Victoria: Okay.

    Dr. Roman: We can start that right now if that’s okay with you, start that today?

    Victoria: Yes, that’ll be good just so we can find out exactly what’s going on.

    Dr. Roman: Exactly. Exactly.

    Victoria: Because I am feeling like a bit of a burden to my husband. You know?

    Dr. Roman: Yeah, a burden… I understand but I’m sure he understands. You know, when your health is the issue.

    Victoria: I don’t know.

    Dr. Roman: It’s not your fault. I’m sure he understands that. You’re doing everything you can. So why don’t we start today and try and get to the bottom of some of this stuff, all right? I’ll let the nurse know the things that have to happen today. I’d like to get your file, your old file from your previous doctor perhaps you could make an appointment for two weeks from now. By then, I’ll have your test results. I’ll have your previous information and we’ll do a full physical that day just so I could figure out what’s going on.

    Victoria: Thank you.

    Dr. Roman: Not at all, Mrs. Sharp.

    Victoria: Well hopefully I can get my energy back.

    Dr. Roman: Well, I’d like to see you get your energy back. So I’ll let the nurse know what needs to be done today. I’ll see you in two weeks then.

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. He obtains the patient’s name and notes she is new to the clinic. He does all this pleasantly, with a smile and “nice to have you here.” Then he 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?” He 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-ended questions. Note that the information he 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. He 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 he 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, he goes through a checklist type of inquiry related to each symptom or disease. If he 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 his 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 he does not use jargon. But his choice of questioning style about kidney problems is interesting. Hearing that the patient was told of problems two years ago, he 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 he 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. He explains why he is asking questions about the thyroid and diabetes. He repeats some of the patient’s answers to his questions, seemingly to make sure he has got it right as he makes chart notes. He facilitates with lots of “uh-huhs.” He 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 he have a good idea of the biomedical problem?
  • Did he 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 he friendly? Is he cheerful? Is he confident? Yes, we would probably agree that he is all three. But he also appears somewhat brisk and detached (e.g., “Another patient to get through in 10 minutes.”) Note that he does not introduce himself 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 his eye on the chart and his medical focus is expressed in his 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-centred 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-ended and closed-ended 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-ended 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-ended 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 he 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 he 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 his mind exclusively on the various differential diagnoses?
  • Is the physician looking at the patient? Would he recognize the patient’s non-verbal cues?
  • Do his responses sound like he 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. He 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 he say “It’s not your fault” when he really knows nothing about the patient’s situation?
  • Is this an empathic statement?
  • Is he 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 his 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 his failure to obtain adequate information leads to flaws in his 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 he is making a number of assumptions and comes to premature conclusions on several issues. While he is not judgmental, his failure to follow up on patient cues and adjust his 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? He’s experienced, not a beginner at interviewing. He 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 persistent 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-ended and closed-ended 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 interest of good patient care (lab results, consultations) (2.2.1)

 

  • Dr. Couteau: (coming into room) Hello, sorry you are Marie Kovach?

    Marie: That’s right.

    Dr. Couteau: (sitting down) Ok. Hi, I’m Dr. Couteau by the way. It says here you have migraines. Those can be really bad, I know. I’m glad you came in today. Now, before we talk about them though, I just need some personal information from you, if that’s alright?

    Marie: That’s okay.

    Dr. Couteau: Ok, how old are you?

    Marie: Forty-seven.

    Dr. Couteau: Forty-seven. Are you single, married, in a relationship?

    Marie: Married.

    Dr. Couteau: Married. And do you work from home or outside?

    Marie: I work outside.

    Dr. Couteau: Outside. Ok, so, tell me how long have you had these headaches?

    Marie: Well, I started having bad headaches as a teenager, but about 12 years ago, I was told…

    Dr. Couteau: Twelve years. That’s a long time. This has been diagnosed though, you must have gotten treatment?

    Marie: I’ve tried a lot of things. They either don’t work, or there are side effects, or they make the headache worse or well I just can’t take them as I am supposed to — and the last physician told me I have to take them as prescribed and if I don’t well, what I can expect… And there’s the Triptan stuff there, those are pretty expensive. I throw most of them away.

    Dr. Couteau: Okay, I think I get the picture here. So…

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. 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

  • Dr. Couteau: You said you took Triptan… There are several kinds of that medication. Do you remember the name?

    Marie: No, I can’t remember.

    Dr. Couteau: Okay, well maybe you still have the bottle, I mean I need to know what that was exactly. And why was it so hard to take?

    Marie: Well I’m supposed to take it right away when the headache starts. It isn’t always possible.

    Dr. Couteau: Can you explain?

    Marie: If I work at the counter or we’re busy, I can’t just disappear.

    Dr. Couteau: Can’t you just keep the pills with you and take them anytime you need them?

    Marie: I’ve tried that, but what would the customers think if they see me pull out some pills and then I need water. That doesn’t look okay.

    Dr. Couteau: Okay, well, we may need to talk about that some more. Let’s talk about triggers. What causes your headaches?

    Marie: Like I said, I get them at work, especially on a Thursday. And there’s the smell…

    Dr. Couteau: The smell? Where do you work exactly?

    Marie: I’m the manager at the Baxter’s Bakery. Maybe you’ve heard of it.

    Dr. Couteau: Oh actually yes! I’ve been there quite a few times, but I don’t remember seeing you there though. How long ago did you start working there?

    Marie: About six months.

    Dr. Couteau: Oh, okay. No, I haven’t been there in a while. Stepping back a bit, if you don’t mind, are there any other sources of stress in your life?

    Marie: Like what?

    Dr. Couteau: Well, maybe people at home? I don’t know, do you have a husband? Children? How are the relationships?

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

    Dr. Couteau: Oh this must be a happy time for you… Or do you not approve of the situation?

    Marie: (rather angry and impatient) She’s single, she lives at home and she doesn’t know who the father is. So, what else?

    Dr. Couteau: I can see how this can be stressful for you. How does your husband feel about it?

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

    Dr. Couteau: When he’s home, are things good between you?

    Marie: Yeah, I guess. He pays the bills.

    Dr. Couteau: Ok, now I’m sorry I have to ask this to everyone, but has he abused you in any way?

    Marie: No! Listen, I’ve got migraines.

    Dr. Couteau: I understand. Listen, I’d like to talk about auras. You know what those are?

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

  • Dr. Couteau: We are almost out of time for today, but I certainly want you to come back soon so we can talk about this some more. We still have lots to discuss. Now in the meantime, I’m going to give you some medication that I usually find useful, and I want you to really try and take it as directed. I know it might seem difficult, but this is really important. Now try and find a way to take them. I’m sure you can find a way.

    Also, I’m pretty sure you must understand that with chronic pain like this, we can’t just make it all go away. We’ll do our best. We’ll try and find some way to give you as much relief as possible so that you can carry on with your life.

    And if there’s any problems with the pills, if you have any side effects, just give me a call right away and we’ll talk about it. Okay?

    Sounds like a good plan for you?

    (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

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

    Marie: That’s right.

    Dr. Couteau: Did I pronounce your last name correctly?

    (patient nods)

    Dr. Couteau: Good. I understand you suffer from migraine headaches. This has been diagnosed before?

    Marie: Oh yes, I’ve had them for years. They come and go, so on off, on off. And right now they’re back on and nothing seems to work.

    Dr. Couteau: So you’ve had problems with the medication?

    Marie: I’ve tried a lot of things. They either don’t work, or they have side effects, or they make my headache worse, or I just can’t take them the right way — that was the last doctor who said if I can’t take them the right way, what can I expect… And all these pills… They’re so expensive, and I throw most of them away anyways.

    Dr. Couteau: Looks like this is really frustrating for you.

    Marie: Yeah.

    Dr. Couteau: I want to talk about this treatment some more, but first, can you give me a feel for what your headaches are like?

    Marie: Well, they start like a sharp pain behind the eyes, and then it just gets worse and worse, and then, there’s nothing I can do. And then I was asked about the aura stuff, but I don’t understand that. But they can last for hours and hours. And then I get nauseated, I can’t concentrate. And I can do nothing. And they’re a real, 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

  • Dr. Couteau: Now, you said the headaches have been bothering you more just now. How often do you get them, say in a week?

    Marie: Well, recently, I get them maybe two or three times a week. That’s what happens… For a while, all is good and then you get spells of them. The last few months though, they’ve gotten worse.

    Dr. Couteau: So they have been more frequent lately. Any idea why?

    Marie: Always asking about the triggers. Well before my period, when I get upset or stressed out. Or maybe the almonds.

    Dr. Couteau: The almonds?

    Marie: Yes. I work as a manager at the Baxter’s Bakery for about six months now. And I’ve noticed that on Thursdays, that’s when my headache starts. And that’s the day that we prepare all the almond danish for the weekend. Now, just the thought of the smell can trigger one.

    Dr. Couteau: Wow. Well, that’s certainly a new trigger for me. I never thought of almonds before. But you get these at other occasions as well, not just on Thursdays?

    Marie: Oh yes well the job is busy and stressful so… But I like it. And I really need it…

    Dr. Couteau: So are you a single wage earner? Do you have a family?

    Marie: Yes, I have a husband who’s a truck driver. He doesn’t make much money and he drinks most of it. And I have a daughter who’s going through some things and I’m worried.

    Dr. Couteau: How so?

    Marie: She’s pregnant! And she can’t seem to cope with it or do anything about it, so now she moved back home with mother!

    Dr. Couteau: It certainly sounds like you’ve got a lot on your plate here. I want to hear more about this in a moment, but first, I want to make sure we talk about your headache medication, because this seems to be a major issue for you.

    You mentioned you tried several different medications. Do you remember the names?

    Marie: Well, I started with Tylenol, then Naprosyn, and then the doctor gave me Cafergot. That made me really sick. Then there’s was another one… oh what was it… Then there were Tylenols with codeine. That constipated me. And well I’m worried about the addiction.

    Dr. Couteau: Well that is quite a list. What was the latest one… you know the one you mentioned your doctor said you weren’t taking properly?

    Marie: Oh — Triptan something. Yeah, that was suppose to be so good. Yeah — so expensive.

    Dr. Couteau: And it didn’t work?

    Marie: I can’t seem to take it right away when the migraine starts so…

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

  • Dr. Couteau: There are several things we still need to discuss. We could do this at our next meeting if you’re willing. But for today, I think it’s important we try and make up a plan to deal with your immediate problem — the headaches.

    Now you, you have days off at work right?

    Marie: Yes, I usually get Sundays and Mondays — but, if it’s very busy, I still have to go in.

    Dr. Couteau: Of course. I was wondering, would it be possible perhaps to switch to taking Thursdays off instead.

    Marie: Oh… That might be difficult. It’s a very busy day and we’ve got staff problems.

    Dr. Couteau: Yes, but if you can find a way of avoiding some of those triggers, like the almond smell, that’s the best way of preventing migraines, don’t you think? Anyway, we can always think about this and it would be a solution that does not involve any medication.

    Also, well, I don’t want to do anything too drastic with the pills yet, but if you agree, I could give you just a small amount of medication. It’s something I have been using lately. And well, it may have fewer side effects… it’s one of those newer medications. And of course, trying just a few wouldn’t be too expensive for you. What do you think?

    Marie: Yeah, that could be a possibility. It feels like everyone is trying to give me pills that don’t work.

    Dr. Couteau: That certainly seems to be the case, but with chronic migraines like you have, we usually use a combination of lifestyle modification and medication. Also, if you could possibly keep a diary of when you get the headaches, and what’s going on right then, that could be helpful. We could discuss it, and try to find ways of avoiding some of those triggers. Could you do that?

    Marie: Sure, I can try, yeah.

    Dr. Couteau: Great. Also, if the pills I prescribe for you can help you even just a little bit, then we have a start. So perhaps you can try just a few and if you find them helpful, I’ll prescribe some more for you. Again, try and keep track of when you take the pills in relation to when you get the headaches. That could really be helpful next time. Do you think that could be a good plan? And of course, we would be meeting again next couple of weeks to discuss things.

    Marie: Yeah, okay.

    Dr. Couteau: Perfect. Oh and one more thing. About your daughter… How old is she?

    Marie: Old enough to know better!

    Dr. Couteau: Well, this certainly seems to be a worry for you. And if you’re open to it, perhaps I could give you some resources that you could share with your daughter.

    Marie: Oh sure yes, I’d like that. I’d take some.

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 individual 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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