In this chapter, we will introduce two advanced aspects of the medical interview: how to increase your personal awareness and how to maximize effectiveness by understanding patients’ unique personality structures. Working on both of these skill sets will allow you to strengthen the clinician–patient relationship with all of your patients. While we will address features of clinicians and patients that can affect the relationship, we will not consider more general determinants such as the sociocultural matrix, patients’ and clinicians’ roles and subcultures1 (see doc.com Module 152), nor will we address relationships in medicine outside the clinician–patient dyad, a wider area often called relationship-centered or team-based care,3–5 such as relationships among nurses, administrators, clinicians, educators, and community representatives within a hospital or outpatient setting (we refer you to doc.com Module 38 for information on communication on healthcare teams6).

The clinician–patient relationship is fundamental to good care; you will want to monitor this relationship as closely and continuously as the patient’s temperature, blood pressure, and pulse rate. First, inquire how things are going between you and the patient, both overall (eg, “You’ve been in the hospital several days now and I wanted to check how we’re doing working together”) and in the immediate interaction (“That’s a difficult problem, what’s it like talking about it with me?”). This provides direct feedback on the relationship and, in turn, allows you to make changes where necessary. It also validates the patient by showing that her reactions are important. Also observe the patient’s body language, behaviors, what she says and how she says it, how comfortable she is emotionally, and her ability to interact and negotiate. For example, a comfortable, safe, and otherwise healthy clinician–patient relationship is suggested if the patient’s arms are not folded defensively across her chest, she makes appropriate (intermittent) eye contact, arrives on time and adheres to negotiated agreements, openly expresses concerns including negative aspects of her or his care, is at ease expressing emotions, and is able to negotiate solutions for her or his care (see doc.com Module 14 for more in nonverbal communication7). When the relationship is effective, patient and clinician alike experience respect, trust, and a reciprocal interchange of information. Both feel comfortable and note more rapport, satisfaction, adherence, confidence, and openness to negotiation. The opposite features characterize an ineffective relationship.

To understand how both clinician and patient contribute to this relationship, consider the clinician’s personality and patient’s personality as two interlocking gears. The gears must mesh to establish the relationship, lest we find ourselves in an uninvolved, distant interaction, perhaps where clinician and patient address different agendas. On the other hand, if the gears engage too deeply, the mechanism itself can be destroyed, resulting in an inappropriate relationship between clinician and patient, for example, one involving sexual contact (doc.com Modules 18 and 41 discuss sexual issues and professional boundaries, respectively8,9) must understand both the patient’s personality and your own personality. This understanding allows you to adjust your behavior to better mesh with your patient.

Because patient behavior change is a complex process that may take weeks, months, or years, you must be prepared to change your interviewing style and approach to make the relationship most effective. Interviewers frequently exhibit personal responses that are counterproductive;10 changing them improves the clinician–patient relationship. Most problems occur during Steps 1–5 (beginning of the interview) because the relationship is just beginning, and because it is here that the patient expresses most of the personal information that can be stressful to hear. Nevertheless, your personal responses affect the clinician–patient relationship throughout.

We define a “personal response” as one’s internal feelings and their emotional and/or behavioral expression. For example, a student became afraid of an authoritarian patient who reminded her of her father. This led her, in turn, to become verbally and nonverbally passive during the interview, allowing the patient to dominate, even though the student knew better. Another interviewer became anxious and felt out of control when a patient began talking about death. This led him to take excessive verbal control of the interview by switching prematurely to the middle of the interview. In each instance, the student’s feelings (fear, anxiety) led to a nonproductive interviewing behavior.

Negative thoughts, feelings and emotions can be triggered by any aspect of a patient; for example, personality, job, illness, family, or odor. Some clinicians have negative feelings about people with HIV/AIDS, perhaps because of unwarranted fears of contracting the virus;10 some clinicians experience negative feelings about people who abuse alcohol or drugs, because of their seeming unwillingness to take responsibility for their actions; and some respond ineffectively to patients with no definable disease to explain their symptoms, often from frustration at their inability to make a disease diagnosis. Negative feelings produce negative behaviors such as avoidance, criticism, or superficiality.

Dysfunctional responses also can initially feel positive, as in the example already given of sexual attraction to a patient. Similarly, “liking” a patient because that patient reminds the student of a positive person in her or his life can be harmful if the feeling results in treating the patient as though she or he was that other person. Such behavior ignores the patient’s real self and needs. For example, a clinician might avoid a discussion of cancer in an elderly woman who reminds the interviewer of her or his own much loved grandmother.

The Problem

Our research involving medical students, residents, and fellows demonstrates that interviewers’ negative responses to patients are very common. Thirteen of 15 sophomore medical students11 and 16 of 19 residents and fellows12 exhibited potentially harmful responses when each was observed in a single interview. Table 8-1 lists the potentially dysfunctional outcomes and the feelings that underlie them. Commonly felt fears of losing control, of addressing psychological material, or of appearing unpleasant resulted in interviewing behaviors that were, respectively, overly controlling, avoiding of psychological material, and superficial. You can imagine their harmful potential. Consider, for example, the life-threatening impact of not asking about suicidal ideation, nonadherence to treatments, and specific symptoms—as well as the effect of these behaviors on data gathering and the relationship itself.

In one study, board-certified physicians with an average age of 50 years exhibited potentially dysfunctional responses to patients, particularly when they felt that their integrity or self-esteem was threatened.13 While these seasoned practitioners reacted adversely to fewer patient encounters than did students, residents, and fellows, their reactions did not diminish with age or experience. Once established, patterns remain. This suggests that experience alone will not change potentially harmful behaviors unless we attempt specific educational interventions.

We studied internal medicine residents who were learning patient-centered interviewing and associated psychosocial skills.14 Of 53, 50 had negative reactions that interfered with learning interviewing and were harmful to patients. Happily, with instruction, 44 of 50 were able to change these negative reactions and to improve their communication and relationship skills.

Because these personal responses are part of the human condition, we consider them normal.11,12,14 Nonetheless, unrecognized thoughts, feelings and emotions have harmful potential and should be addressed. Why? Unlike most disciplines, where the relationship is not as central, the clinician–patient relationship is key to effective medical care and these very human reactions can interfere with learning as well as care. Troublesome unrecognized responses often override or interfere with new learning. Patient-centered interviewing skills require clinicians to relinquish some control and address patients’ emotions but because of ineffective personal responses, many interviewers attempt to seize control of the interview and avoid exploring patients’ emotional worlds.

What You Can Do About Unrecognized Personal Responses (See Also doc.com Module 215)

Effective coaching by a teacher16 will best help you become aware of previously unrecognized responses, but you can nevertheless make significant progress working alone or with colleagues.

Diagnosing the Problem

To diagnose difficulties with your personal responses you must make your reactions more conscious and recognizable. You can reexperience emotions by recalling negative or otherwise difficult experiences with patients, clinical situations, peers, and family. By thinking individually or talking freely with peers, you can become more aware and begin to understand your personal responses. First identify the thought or feeling. Then link it/them to a specific emotion or behavioral outcome: one student was angry about a slight and shunned the provocateur. In considering many difficult situations, the student identified a common pattern: perceived slights caused him to feel anger and the result was to withdraw from nurses, friends, spouse, and a teacher.

Another exercise to better recognize your interfering thoughts and feelings relates specifically to the interview. A good first question to ask yourself following any interaction is, “What was my emotional reaction to the patient, and how did it affect my interviewing behavior?” Look for one positive and one negative reaction to each patient, and identify the behavioral responses involved. Consider imagined as well as actual behaviors; for example, wanting to shake a patient abusing alcohol “for being so stupid.” Reviewing a video or audio recording of the interaction will allow you to reexperience your feelings and to more carefully observe any untoward responses, such as unnecessarily changing the direction of the interview or avoiding certain topics. Students who are not yet seeing patients can increase their affective awareness by considering other medical encounters: working on cadavers, operating on animals, having blood drawn, drawing blood, watching an uncomfortable procedure, reading about awful diseases, experiencing difficult interactions with teachers or peers, and the general educational atmosphere.

There are be other routes to increase awareness of emotions, such as reading stories of patients’ courage in the face of severe pain and/or suffering. Other strategies include keeping a journal, reading emotion-laden biographies and fiction, watching movies with high emotion, recalling personal experiences, enjoying music and art, working with actors who can mimic emotional moments, or considering likely emotional events in the future (such as births or deaths). It is useful to seek positive as well as negative emotions. Self-help or centering measures can be valuable for hard-working students and clinicians. Regular exercise, relaxation,17 meditation,18–21 taking personal time, nonintellectual pursuits, hobbies, creative endeavors, meeting different people, altruistic activities, and spiritual practices are all useful methods for increasing affective awareness and the mindful practice of medicine.

Addressing the Previously Unrecognized Affect and Emotion

Repeatedly acknowledging a problem with thoughts, feelings, and emotions sometimes leads to improvement; for example, the student recollects before each interview that “discussing death and other painful issues is difficult and I need to be on the lookout for how this could change the course and direction of the interview.” Selecting a specific healthier behavior to work on is frequently useful. Progressing one step at a time, for example, learning to make just a few comments, is a good start for someone who has trouble talking in the presence of a professor. Rehearse the desired new behavior in your mind and then in role play with a peer, taking your own and then the other person’s (or patient’s) role in the problematic situation. Then reperform both roles using the planned new behavior. This provides important reinforcement and insight about the old pattern and promotes satisfactory change in the new one.

Changing affective responses is more difficult. Sometimes self-supportive statements help; for example, “He simply reminds me of my father. I have important things I want to begin saying.” Using empathy skills with oneself helps. Consciously recognize that the work is uncomfortable, that you are working hard and trying new behaviors, and that progress, while slow, is occurring. Reinforce your self-esteem with positive self-talk and recall that this work will make you a better clinician.

Students can make remarkable changes as they get to know themselves better, take some risks, and stretch personally. Interviewers’ innate capacity for adult growth and maturation uncovers unexpected strengths and capabilities that can lead to more effective relationships with patients—and others.22,23

Doing this work with a few colleagues produces the best results. You can provide each other support using open, honest feedback, and insightful suggestions for new behaviors. Table 8-2 lists useful guidelines for teachers and students within such groups (or pairs24). (See also doc.com Module 4025).

This process works even better if you carefully analyze your thoughts, feelings and emotional responses by keeping a journal.26–28 Synthesize self-awareness work and identify specific issues and behaviors to address in the future. Some useful guidelines for journaling include writing about a most memorable, not necessarily dramatic, event, most important learning, experiences applying new knowledge, emotions (and resulting behaviors), how behaviors have changed, how feelings and emotions have changed, specific new learning goals including the immediate next step, successes as well as problems, and whether the personal and group work are meeting expectations and why or why not.

A little anxiety and tension can help you with this process, but if you experience depression, marked anxiety, disruption of work or relationships, or other evidence of psychological disturbance you should seek help from a mental health professional. It is worth noting that self-awareness work does not “cause” problems but, sometimes, facilitates their identification.

Finally, as noted in Step 3, awareness of your thoughts, feelings and emotions during the interview is an important part of self-aware practice. Feelings engendered in the clinician by the patient are called countertransference. These can be due to a “personal countertransference” or a “diagnostic response.”29 In a personal countertransference, your feelings when interacting with a patient have their origin in an issue elsewhere in your life. For example, feeling sadness when interviewing a patient because she reminds you of your grandmother who died when you were young is countertransference. Recognizing this response as coming from outside the clinician–patient relationship will help you provide the best possible care for your patient.

In a diagnostic response, the feelings you experience are actually coming from the patient and can help you make a diagnosis. For example, if you begin to feel down or sad while interviewing a patient, it may indicate that the patient is depressed. We urge you to hone your ability to become aware of your affective responses to patients in real time and determine if they are coming from another part of your life or from the patient.

Most of us will have several features of the basic personality styles noted next; you are encouraged to look for these in yourself. For example, many clinicians have been described as having predominantly obsessive and authoritarian styles. These are very useful for ensuring professional success, but they also can have some adverse consequences personally and in clinician–patient relationships.30

The patient’s personality is far more difficult to change than yours, and it is not your job to try to do so. Nevertheless, if you understand the patient’s personality style, you can improve the clinician–patient relationship by adjusting your behavior to the patient’s unique style. Personality style is defined as that group of enduring personal characteristics that describe how a person thinks, feels, behaves, and interacts in relationships with others and the environment.31 Personality partially determines how people respond to the various stressors in life, including illness. It determines how a patient recognizes and presents her or his illness, relates to the clinician, responds to treatments and procedures, deals with discomfort and disability, and manages chronic and disabling conditions. Knowledge of a patient’s personality can alert you to likely stressful circumstances that can perhaps be avoided or ameliorated. As noted earlier, personality styles apply to clinicians as well as patients. We can identify and name these styles but we must be careful to not use the terms pejoratively. There is growing evidence that patients who share the same personality styles and characteristics as their physicians are more satisfied with the care they receive.32

Most personalities are within the range of normal, and readers will recognize parts of themselves in most styles described. Many styles are blends; for example, many people have both dramatic and organized styles. Personality characteristics form the bedrock of psychological structure and are the basis of success as people make their way in the world: a dramatic flair can be essential for a good performer or politician while an organized style is essential for an effective professional or a good homemaker.

A personality style is abnormal only when it is maladaptive and interferes with successful functioning, then it is called a personality disorder31; for example, a histrionic patient’s overconcern about his appearance leads to mutilating surgical procedures (multiple plastic surgeries), a person with obsessive–compulsive personality disorder may count ceiling tiles and wash her hands throughout the entire day. Importantly, maladaptive patterns can be precipitated or exacerbated by illness. These patterns then may puzzle and obstruct clinicians, leading them to label the patient as a “problem,” “hateful,” or “difficult.”33

This section describes how to enhance the relationship by using knowledge of the patient’s personality style, derived from a constellation of features rather than any one or two of them. You can assess a patient’s personality style during Steps 1–3 and can use appropriate skills during this time based on your assessment. Further diagnose the style in Step 4 by focusing on corroborating features and considering whether the style is adaptive or maladaptive. The sooner the patient’s style is accommodated, the smoother the interaction will be.

After identifying a personality style, meet the needs of its predominant feature to maximize the relationship. With normal, well adapted patients this process is simply woven into each visit. Normal patients present no unique problems in the medical setting. Establishing the initial relationship with maladaptive patients, however, is just the start. Maladaptive patients usually require ongoing care by a mental health professional, with a goal of developing more adaptive traits and gradually weaning patients from their maladaptive behaviors, a topic beyond the scope of this text that will be addressed in your psychiatry clerkship. Note that each personality style has unique features that require from you different, and sometimes opposing behaviors.

We will only present summaries of some major personalities and how they affect the clinician–patient relationship.31,34 For illustrative purposes, we will emphasize the maladaptive patterns (personality disorders), but remember that normal patients exhibit minor variations of these, as we will also summarize. Further, while this review presents each type singly, you will want to consider how different patterns might be combined. Most of us exhibit features of several different personality styles.

Dependent Style