The interview we have presented thus far in the vignette with Mrs. Jones is just one example of how the interaction between a clinician and a patient can unfold. You might be wondering how to adapt the interview to different clinical settings, such as the hospital or emergency department. Perhaps you worry about interviewing a patient who cannot seem to stop talking, or one who it feels hard to pull information from. In this chapter, we will discuss how to adjust the interview to different clinical situations. Such fine tuning occurs primarily in the beginning of the interview (Steps 1–5: setting the stage, agenda setting, opening the history of present illness (HPI), continuing the HPI, and transition). This chapter focuses only on how you can tailor the process of the interview and does not consider the content that needs to be addressed in specific clinical situations. Clinical texts will help you obtain the details that must be incorporated into many of the encounters discussed here.1

There is no fixed rule on how to distribute the time you have for an interview between the beginning of the interview, the middle, and the end. Based on the patient’s needs, you will determine the initial balance during Steps 1–5. You might average 10% of your time in the beginning of the interview for most patients, but this allocation of time can vary from 2% for, say, a patient who needs a medication refill and has no personal issues to more than 50% with, for example, a patient with severe marital problems. As you can see the amount will depend on the severity and urgency of the patient’s personal issues. It may also be necessary to return again and again to using patient-centered interviewing skills even late in the interview.

In the beginning of the interview, the main block of controllable time lies in Step 4, continuing the HPI. Steps 1–3 and Step 5 usually take little time and are similar from patient to patient. Consider the following examples.

New Patient without Urgent or Complex Personal Problems

First consider a typical new patient, like Mrs. Jones, who comes to the clinician without urgent (where immediate action is required) or complex personal problems. Physical symptom complaints often predominate and we usually devote about 10% of our time to the initial patient-centered process of the interview. This will be your experience with many new patients in a medical setting, whether in- or outpatient. Such patients, like Mrs. Jones, have definite personal issues but they are not urgent or overwhelming; for example, a patient with known cancer is admitted to the hospital for chemotherapy but is more worried about his wife being home alone with the flu; an outpatient presents with a weight loss of 5 pounds and is somewhat concerned about possible cancer and wants “to be sure.”

New Patient with Urgent or Complex Personal Problems

There are, however, new in- or outpatient where with more urgent and complex personal problems present; for example, acute marital discord led to sleeplessness, depression, headaches, and diarrhea for this outpatient who requested a “checkup”; or a recent unexpected business set-back immediately preceded the admission to the hospital of this now very angry man with chest pain; or a patient admitted for pneumonia who is overwhelmed and crying after being informed that his HIV test came back positive. In these instances, you will give more time to exploring personal and emotional issues by increasing time in Step 4 and, very likely, you also will spend time during the middle of the interview (especially in Steps 6 and 7) to better understand details of what could be a serious psychological problem (see Chapter 5).

Follow-Up Patient without Urgent or Complex Personal Problems

Just as with new patients, most follow-up (return) patients do not have urgent or complex personal problems but these encounters differ because they are much briefer. Consider a 5–15 minute follow-up visit, either in- or outpatient, for predominantly physical concerns. You progress through Steps 1–4 but Step 4 will be rather brief, since the patient offers no pressing personal issues or emotional burdens. You will then make a transition (Step 5) to the middle of the interview (Steps 6 and 7) where you will fill-in the HPI of the patient’s physical symptoms; for example, any worsening or new symptoms after treating the patient’s strep throat 1 week ago or any change from the preceding day in this inpatient’s chest pain. In both instances, you must listen for new personal contextual information (want to get back to work, want to go home) and respond empathically, but most personal data already will be known and the patient’s symptoms will be your primary focus. The personal issues of follow-up patients frequently concern treatment and disposition; these are often addressed in the end of the interview, as we saw in Chapter 6.

Vignette of MR. Gomez

(Ward rounds by a student on a patient with primarily physical symptoms on his second day of hospitalization with no more than 15 minutes available at this time)

This vignette demonstrates that a predominantly clinician-centered follow-up interaction also can address personal issues.

Follow-Up Patient with Urgent or Complex Personal Problems

You may have a follow-up patient with urgent or complex personal issues, often but not always with no physical complaints. You will quickly determine this during Steps 1–4, and then take more time in Step 4 to better develop the personal issues, resulting in a predominantly patient-centered interview. Even with no physical concern expressed by the patient, you will still make a transition to the Middle of the interview and use clinician-centered skills to, for example, ask more about symptoms of depression (see Chapter 5, Section entitled “Addressing a Predominantly Psychological Problem”), and/or briefly inquire about the patient’s physical health; for example, “Any more problems with the heartburn? The constipation?”, that is, always integrating the personal and symptom data.

Vignette of Mrs. Wong

(An outpatient previously seen for other problems now presents with a predominantly personal problem in a 15 minute appointment slot.)

When a patient relates personal issues that cannot be “fixed,” students can feel overwhelmed. The key to successfully managing the encounter is to recognize the power of simply connecting with the patient through careful listening (which begins in Step 3), drawing out the emotional context of the personal issue and responding empathically, using NURS (Step 4). Most often patients merely want to express their problems with empathic witnessing, and do not wish to undergo therapy or ‘fixing.’ Of course, as in this case when a diagnosis such as depression is made, specific treatments can be offered, but they should never replace this patient-centered connection.

Disease-Prevention Visit

Patients often come without a particular problem to focus upon and want to address how they might prevent health problems in the future, frequently called an “annual physical.” In this case, you will proceed in the same stepwise fashion that has been outlined. In Step 2, the patient often has a large number of issues she or he wants to discuss; for example, flu shot, exercise program, diet, mammograms, and Pap smear. Because the patient has no particular complaint and may have many agenda items, it is essential to keep asking, “Is there something else?” or “What other concerns do you have?” until all the concerns have been elicited. It is often fruitful to ask why the patient has come in at this particular time. You might learn that some health problems have occurred in a family member or friends, or that the patient has noted some alteration in body function, and that she or he wants to be sure there is nothing wrong such as cancer, high cholesterol, diabetes. Upon eliciting this story in an open-ended manner, use the emotion-seeking skills to explore the attendant worry and anxiety. Then, you can use naming, understanding, respecting, and supporting (NURS), often especially a respect statement praising the patient for coming in and working to achieve maximum health status. On the other hand, many patients simply come in for routine visits without a specific reason. In that instance, the beginning of the interview may be no more than 1–2 minutes of largely agenda-setting and praising the patient for coming in. In all disease prevention visits, much time is spent in the middle and end of the interview, using clinician-centered skills in the middle to pin down details of the patient’s health-related activities; for example, (a) present exercise pattern, how many minutes, how vigorous, or any related injuries; (b) specific daily diet, understanding of caloric and fat content, interest in making major changes, and prior attempts to diet. Chapter 6 addressed how to educate and motivate patients to change harmful behaviors such as smoking. In addition, even though the patient may not have it as an agenda item, you will want to determine her or his interest in pursuing routine age-appropriate health prevention recommendations, such as colon cancer screening, immunizations, and mammograms. During such visits, address all pertinent (to the patient’s age, gender, and status) aspects of social history (Chapter 5): ethical-social-spiritual practices, functional status, health-promoting and health-maintenance activities, and health hazards.

Of course there is a spectrum of patients between the urgent and less urgent personal categories, and there is no way to predict how many physical symptoms will be present in either category. In the difficult situation where both personal and symptom data are plentiful, urgent, and complex careful agenda setting (Step 2) will define what seems most important to both you and the patient. Even so, some issues may have to be deferred to a later appointment.

Even after you learn how to distribute time between the beginning, middle, and end of the interview, there are still patient communication styles and clinical situations that influence interviewing and affect how time will be spent. Patients interact with clinicians in diverse ways—some assertive, some passive, some informed, some less so. For example, a loquacious patient can require more time, more interruption, and less encouragement to talk than a reticent patient would to give the same story. These different interactional styles are influenced by many factors, including age, gender, education level, personality style (see Chapter 8, Section entitled “Dimensions of the Patient That Affect the Relationship—the Patient’s Personality Style”), and cultural upbringing (see Section entitled “Cultural Competence”). We now consider some of these challenges below noting that most decisions about the available time are made during Steps 1–5.

The Reticent Patient

It is important to get reticent patients talking, about anything, whatever it takes. Typically, the agenda items (Step 2) are limited and focused on physical symptoms, and there is little response on the patient’s part to initial open-ended inquiry (Step 3). The nonfocusing open-ended skills (silence, nonverbal encouragement, neutral utterances) may be ineffective and, in Step 4, you must rely on the focusing open-ended skills (echoing, requests, summary) and emotion-seeking skills (direct, indirect). Among the latter, self-disclosure may be particularly effective; for example, “I once had back pain and was very frustrated, how about you?” Even though the patient may express no emotion, you can direct empathy skills toward what you do know about the patient, for example, “It sounds like some difficult problems you’ve had; you were right to come in so we could help out (naming, respecting, supporting).” The reticent patient will often share additional information in response.

To get the conversation going, you might need to be very explicit about what you asking for. For example, to begin Step 3 you might normally say, “It sounds like the back pain is the most important thing for you today—tell me about it.” If the patient responds, “It hurts,” you will need to provide more detailed instructions: “Please tell me all about your back pain, from the time it started until today, in as much detail as you can remember. This will help me to help you.” This cueing will often get a reticent patient started. The key is to not give up on your open-ended skills too quickly. If you try them all and you still cannot get much of a symptom story from the patient, then, in Step 4 ask about the patient’s symptoms using closed-ended questions, such as, “Where exactly is the back pain located?,” “Does it go down your leg?,” “Any leg weakness?” Remember though to elicit the personal context of the symptom, looking for any thread of personal data to facilitate; for example, if the patient says “I can’t walk the dog anymore,” focus on it to get some personal conversation going and attempt to elicit the emotional context in order to respond empathically.

Ordinarily, reticent patients will talk and satisfactory stories can be elicited, albeit briefer and less complete than with other patients. Symptom data are easier to obtain during the middle and end of the interview because you have more control of the conversation. Sometimes reticent patients offer personal data during the middle or end of the interview, seemingly warmed-up by what has preceded; for example, while giving the family history (FH) or deciding on starting an exercise program, the patient begins to talk about personal issues. You of course would then alter your style to become patient-centered and further develop this personal information.

The Overly Talkative Patient

Loquacious patients make clinicians feel overwhelmed. It is important to establish a personal and emotional focus efficiently, while redirecting the patient if conversation is either too detailed or too tangential. Talkative patients may begin without you saying anything. Developing the agenda (Step 2) typically is difficult. Nevertheless, you must develop a list of concerns, often by respectfully interrupting and refocusing frequently (“I wish I could hear more about your vacation but I want to be sure that we address your needs in the time we have together. Was there something else beside your back pain you wanted to cover?”). In Step 3, you might not even need an open-ended beginning question or statement because the patient is already giving much information. Indeed, silence alone often suffices as the patient talks on. After no more than 1 minute with a new patient (sooner with follow-up patients), you will need to get actively involved, lest you become nonparticipatory.

Some patients feel the need to recount every detail of their symptoms and concerns. This sort of overinclusive talk can interfere with your getting personal and emotional data. You must respectfully and tactfully interrupt, refocus, and redirect, sometimes repeatedly. Other patients discuss issues that do not relate to themselves directly; for example, other people’s care, politics. Still others focus on remote past events with no apparent relevance to their present situation. In all instances, you will need to actively refocus the patient (Step 4) on him- or herself in the here and now (“I see you are concerned about the President’s health policy; can you tell me how it applies to you personally?”) and, in particular, their emotional reactions, using the emotion seeking skills (“Those are important details, but how did that affect you, emotionally?”). Also, you can use NURS to redirect the patient; for example, “That’s been a long spell for you. I can sure understand how upsetting it might be. Thanks for giving me that background. Let’s move on now to what happened yesterday.” On the other hand, if patients are talking about themselves in the present and giving emotional data, you will want to stay with and facilitate this focus. Once such a focus is established, your difficulty is to complete Step 4 in a timely way. A firm, clear transition statement effectively changes focus to the middle of the interview; for example, after summarizing and using NURS, “We need to change gears now so I can ask you some questions to learn more about your constipation if that’s OK.”

Talkative patients produce plentiful personal data and you may easily obtain a long story. Because of time constraints, avoid a prolonged return to personal information if the patient reintroduces it later in the middle of the interview. The most important data usually will already have arisen. Nonetheless, if the patient expresses emotion, you must address it. Briefly listening and using empathy skills usually will suffice.

Talkative patients can seem “easy” to the student inclined to passivity and “irritating” to one who likes to take control. Awareness of your personal characteristics will maximize effectiveness. In Chapter 8, we discuss further strategies for addressing your personal responses and for managing these patients.

The Patient Who Persists in Talking About Symptoms and Secondary Data during the Beginning of the Interview

We now focus on a difficult and fortunately less common problem: when the patient seems unable to discuss the personal context of her or his symptoms or the emotions connected with them and persists in describing symptoms and reciting secondary data such as results of tests she or he has had.

In these cases, open-ended skills may not be enough to encourage the patient to share the personal and emotional context of the situation, and you may have to actively direct the patient with emotion-seeking skills. The symptoms may be prominent, and these patients may be secretly fearful. Uncovering and empathically addressing the emotion can be therapeutic. First summarize the symptom information and then follow immediately with emotion-seeking skills. Direct emotion-seeking (eg, “How does that make you feel?”) is often ineffective, and indirect emotion-seeking must be used. Asking about impact (“How does this affect your life?”) can be particularly effective in getting a focus on the personal context. Then you can ask about emotion directly. Respectful interrupting often facilitates the transition as well. As with the reticent patient, the personal stories often are more truncated and less complex.

These patients can be frustrating because the interview is difficult and because they are hard to get to know personally. Simply recognizing this frustration will help you provide them the best care they will allow you to.

Vignette of MR. Swenson

In many of the common interviewing challenges, students can become frustrated and disappointed, either because the patient is reticent or because the patient’s story lacks personal and emotional information. Students sometimes lament they “didn’t get much.” Nevertheless, the patient still feels understood and a good clinician-patient relationship develops. The amount of information obtained, especially emotional, is not a marker of a successful interview. Rather than measuring a good interview by getting the patient to cry, we look for successful use of the patient-centered steps to determine success.

When Necessary Personal Information Is Not Forthcoming during the Beginning of the Interview

Thus far, we have assumed that the personal information obtained during the beginning of the interview is the most important personal information. Indeed, that is almost always so, but such data aren’t always complete, especially around topics where patients are embarrassed or fear others will perceive them to be abnormal; common examples include sexual practices, substance use, suicidal intent, and intimate partner violence.

Proceeding through Steps 1–5, you may first suspect a hidden problem, such as a story of severe depression, which causes you to wonder about suicidal intent or a story of frequent fractures, which raises the question of falls due to alcoholism. Sometimes awareness does not become apparent until later (eg, you observe unusual bruises during the physical exam leading you to consider intimate partner violence).

Clinician-centered interview skills allow you to obtain the necessary information, usually early in the middle of the interview (Step 6) although sometimes later on; for example, in the past medical history (PMH) or social history (SH). Begin with a transition statement (“I want to focus now on your use of alcohol”) and follow-up with progressively more closed-ended inquiry until all significant information is obtained. The Social History section of Chapter 5 (Step 8) shows the key data you should elicit about areas such as intimate partner violence or substance abuse.

Perform this inquiry sensitively, nonjudgmentally and respectfully. Tell the patient how important this information is for you to be able to help, and reassure confidentiality. Often, the patient has some strong feelings that you must elicit with emotion-seeking skills and address using empathy skills.

We recommend using clinician-centered interviewing skills in this way whenever pertinent personal information is not obtained in the beginning of the interview. For example, if the patient does not seem to be following your treatment recommendations, you might start the middle or end of the interview open-endedly with a question or statement such as, “Let’s talk about how you’re taking each of your medicines each day,” and followup with more narrowly focused inquiry until clarity is achieved; for example, “Let’s count how many pills you have left in the container to be sure you’re taking them like I think you are.” Thus, clinician-centered skills that are predominantly closed-ended often are required to supplement the personal database.

Clinicians usually find it difficult to address issues that patients are avoiding and have strong feelings about. It is normal to experience fear, concern, abhorrence, or voyeuristic curiosity. If you are personally aware you can keep these responses from interfering with your patient interaction, as we discuss in more detail in Chapter 8.

When More Than One Person Is Present

Although the family interview2–4 is beyond the scope of this text (see doc.com Module 205), there are other situations where the clinician involves more than one person in the interview (eg, it is estimated that about 25% of visits with older patients involve a third party care giver.6) The interviewer might decide (with the patient’s consent) to consult a patient’s relative or friend hoping to obtain unique information (eg, a father giving information about his child, what happened while the patient was unconscious, information the patient has forgotten or denied). A properly conducted interview involving a relative or other third person provides information otherwise unavailable, including how the patient interacts in this relationship; for example, domineeringly, passively, distantly, angrily, or lovingly; many hours of interviewing the individual patient would be needed to provide as much “hard data” about the patient’s interactional style. Perhaps the patient relates a story of great independence and achievement only to behave in a very dependent way when her or his spouse arrives. Or a person who appeared very sensitive and considerate during the interview becomes hostile and sharp with a family member.