The Interview



The Interview






It began to dawn on me that the healing art was not at all what people imagined it to be, that it was something very simple, too simple, in fact, for the ordinary mind to grasp. To put it in the simple way that it came to my mind I would say that it was like this: Everybody becomes a healer the moment he forgets about himself.

—HENRY MILLER, THE ROSY CRUCIFIXION BOOK ONE: SEXUS, VOL. 4, CHAPTER 14



First Principles of the Interview



  • The most important person in the room is the patient—any patient, any room.


  • Anything that the patient tells the interviewer must be held in strictest confidence. No medical person should ever say anything about any patient in a public place where laypersons, or any persons not entrusted with the care of a particular patient, are present (such as a hospital elevator).

This sign, once posted in the Medical Records Department of the Falk Outpatient Clinic at the University of Pittsburgh, should be reproduced in all medical institutions:


What you see here,

What you hear here,

When you leave here,

Let it stay here.

In the US at the present time, others such as third-party payers or officials exercising an “oversight” function may demand to access the information obtained in the course of caring for the patient. Related issues will be considered in Chapter 4. Material in this chapter assumes that the interviewer is acting as the patient’s personal physician and not as a “provider” contracted with a third party or an agent of law enforcement.


Interviewing Style


Winning the Patient’s Confidence


For the fourth-year medical students at the Philadelphia General Hospital, my father devoted a number of lectures to the nonscientific aspects of medicine. He believed that confidence in a physician was of the utmost importance both for the well-being of the patient and for the doctor’s success. Confidence, he explained, was first gained through the impression created by the doctor during the interview and physical examination.

He thought a physician should appear to be pleased to see the patient; to think of nothing but the complaint; to be sympathetic and understanding; to be confident of effecting a cure and, if not, to take a cheerful note and inspire hope; to feel privileged to treat the patient; to be courteous and considerate; and be glad to take the time to hear the patient’s problems.

He made other suggestions about the ways the interview should be conducted. When extraneous matters came up, he said, the conversation should be gently and tactfully directed to the illness. He warned against talking about oneself, no matter how trivial or innocent it might seem (Schnabel, 1983).

image Forget about yourself during the interview. Just permit yourself to get lost in the patient’s story of his illness.


The Process of the Interview

The history is the story that the physician composes to help himself and others understand the patient’s disease(s) as well as the patient’s illness(es). The interview is the interpersonal process during which the raw material of such a narrative is evoked. The process is interactional, involving both verbal and nonverbal events. As the physician is evaluating the patient, the patient is evaluating the physician. Both patient and physician tell each other what they want to discuss and what they prefer not to discuss. Sometimes the physician tells the patient exactly what answer is desired, and sometimes the patient may also let the physician know what he is ready to hear.

All of this information is conveyed as the patient is describing numbers, colors, dates, and events and as the physician is recording these facts. Yet, both are recording, almost effortlessly, impressions of each other that will govern the relationship more or less in perpetuity.

The Czech poet Milan Kundera says that much of what occurs between a man and a woman devolves from the implied rules that they agreed to in the first few weeks of their relationship. Similarly, I would say that much of what occurs between a physician and a patient derives from the first 10 minutes of their first interview.

Most sophomore medical students are acutely aware that they are being scrutinized during the interview, just as they are scrutinizing the patient. In some cases, the attendant anxiety becomes disabling
to the student. In other cases, the intensity of this new situation prompts the student to say and to do that which he can immediately recognize as ineffective and revealing of his own neurosis. Yet in other cases, just the fear of looking foolish in itself produces ineffective behavior. All of these problems resolve with experience, although some students secretly doubt that they will ever be comfortable in the interviewing situation.

It is important for the student to remember his feelings of weakness and inadequacy so that he will always be able to recognize the same feelings in his patient and thus respond in an empathetic manner.

I have found from auditing sophomore medical students in their initial clinical encounters that they usually acquit themselves very well in spite of the feelings described above. A sense of mastery comes with practice. Feelings of the most severe apprehension generally subside when the student simply jumps into the situation and starts to work.

For the Senior Student. By now you have seen so many patients that you no longer have stage fright. The hospital has become a familiar workplace, and you have developed good techniques for getting things done. Perhaps now is a good time for you to reflect upon the way you felt the first few times that you introduced yourself to a patient. Your sense of novelty and strangeness has been replaced by confidence. But the hospital is still a strange and possibly frightening place to your patient. You need to respond appropriately to the patient’s signs of anxiety, fear, or discomfort, rather than ignoring them because they are not germane to the piece of information you are trying to evoke at the moment. Although you should feel confident, you should not allow yourself to relax too much. Remember that the patient is observing your response to him and is deciding whether he will confide in you, what he will tell his family and visitors about the hospital or clinic, and to some extent whether he will agree to undergo the surgery or take the medication that you recommend.

The physician should be neatly dressed and groomed. If the interviewer is not wearing scrubs or other medical costume, dress and shoes should be appropriate for professional employment rather than a day at the beach. There are a few rare situations in which certain types of transference can be facilitated by wearing informal clothing. However, many older patients are offended by physicians who dress informally, as can be easily learned by asking them (provided that the interviewer really wants to find out the answer and is professionally attired at the time).

Remember that the patient evaluates the doctor as the doctor is evaluating the patient.


Before Beginning the Formal Interview

First introduce yourself to the patient and shake the patient’s hand. The handshaking puts the patient at ease and is a sign of cordiality and respect. Diagnoses that can be made from handshaking are discussed in Chapter 24. (If the patient shows signs of rheumatoid arthritis or other painful conditions involving the hands, do not cause him pain by displaying your firm handshake!)

If others are present, ask the patient, “Who is with you?” In an office setting, it is especially important to make a note of the name and contact information of the patient’s companion.

In the hospital, it is wise, after introducing yourself, to turn off all radios, television sets, tape recorders, and other distractions. If the patient’s friends or relatives are present, they should be courteously asked to leave, with an estimate of how long you expect to be there. If close relatives are there, you should tell them, in the patient’s presence, that you will not discuss anything substantive about the patient’s care unless the patient is present and that they should ask the patient whatever questions they have. Close the door and pull the curtains when everyone has left.

Next, make sure that the patient is comfortable. You may need to plump up the pillows or to fetch the patient a glass of water. I have even been known to feed a patient soup or cereal, much to the amusement of house staff who believe that such tasks are suited only for nurses or other persons below the stature of a full professor. Such acts win the patient’s confidence and convince him of your interest in him. The patient may subsequently tell you things that the other doctors did not learn.

Occasionally, the patient’s family will not want to leave the room, and it is useful to find out why. On rare occasions, the interviewer may change his mind about allowing them to stay, at least for a portion of the interview, particularly if the patient is for some reason unable to tell his own story. With outpatients, the family may be most concerned about understanding the instructions for treatment, so that they may help a forgetful patient to cooperate. In that case, they will usually leave cheerfully if you promise to invite them back at the end, when you are explaining your instructions. (You should also write them down clearly and in large letters that a presbyopic patient can see.) The patient usually does not want his family to be present, even though you may not be able to determine that fact until the family has departed. The most important person in the room is the patient.

Just as relatives should be physically excluded from participation in the patient’s personal interview, so should we also subtly diminish their roles as diagnosticians of the patient. Many patients are so dependent upon significant others that the physician’s reasonable recommendations are ignored because of the counterrecommendations of a relative. The physician should not defer to a relative’s opinion early in the interview. Although this attitude seems to be authoritarian in an egalitarian age, students who are to be taught to seize responsibility with one hand must also be given the opportunity to grasp authority with the other.

This advice is not meant to provoke confrontations with relatives. Mature physicians exert their authority subtly, kindly, gently, and unconsciously. If you smile at the relatives when you ask them to leave the room, they will usually not be offended.

Occasionally, a family member will insist on speaking to you— often by telephone—without the patient being present. The reason is frequently to confide information that he thinks the patient will not tell you, such as the amount of alcohol consumption. This information can be extremely helpful, and it might not be obtainable in any other way. (The same family member might deny the alcohol consumption if asked about it in the patient’s presence.) However, it should not be accepted without skepticism; it may actually be a ploy to obtain information about the patient from you.

Circumstances in an outpatient practice are different, and physicians may prefer to handle family members and significant others differently (vide infra).

One way in which persons other than the patient can help in obtaining historic information in cases of poisoning is in performing
the box test (Fig. 2-1). Give the relative, or whoever found the patient, an empty box and ask him to collect all the empty and partially empty containers in the place where the patient was found, including those in the wastebaskets, under the bed, in the night table, and so forth.






FIGURE 2-1 The “box test.” A patient presented with an unusual picture of impaired consciousness, so a “box test” was requested. It was initially reported as “negative” for any drugs. In fact, the family member who had been sent home with the box was intoxicated and had returned with three onions! When the test was repeated the next day by a sober family member, the above medications were found in the apartment occupied solely by the patient. The major psychoactive material eventually identified in his blood was benzodiazepine for which six replicate prescriptions were found, shown here in the front row. Not surprisingly, a large number of the medications were indigestion remedies.


Methods to Facilitate the Interview

Sit in a chair close to the head of the bed so that your head is down at the level of the patient’s head, or as close to that level as you can comfortably get. It helps to raise the bed; this will also facilitate your movements during the subsequent physical exam and will reduce your own low back strain.

Lean toward the patient. Make eye contact. Ask an open-ended question and just maintain eye contact until something in the patient’s narrative particularly draws your attention. Forget about anyone else at the bedside. There should be no one in the universe but you and the patient.

Allow no interruptions. Do not allow anyone to break into the interview. This is a rule that is very difficult to put into practice but that best teaches us its value when it is violated.

If at all possible, touch the patient during the interview. I find it useful to take the patient’s pulse during the interview.

An Illustrative Story. There is an old story about the Arabic physician Ibn Sinna, who was consulted to see the king’s only son. The son had fallen into a severe melancholia and was so withdrawn that he would not even speak to the physician. While the wise physician took the patient’s pulse, he asked him, “Are you thinking about something happening here in the palace or something in the city?” The prince said nothing, but the physician noticed that the pulse rate increased just after the words “or in the city.”

“Are you thinking about something on this side of the river or across the river?” asked the wise physician. Again, the young prince said nothing, but his pulse increased at the words “across the river.” In this manner, the wise physician continued to examine the young man, learning that the young man had been smitten in love by a young woman he had seen in the town. The physician was even able to determine the exact location of the woman’s house, although the young man had given not a single verbal answer.

Upon hearing the physician’s report, the king had his guards send for the young woman. The king’s son experienced a miraculous recovery as soon as she was brought into his bedroom. The wise physician was rewarded handsomely.

Question: What does this teach us about medical practice? (Write your answer before reading on.)

Answer: First, the story teaches us that all reactions are important, including nonverbal communication. Also, we learn that it is very difficult to maintain confidentiality, especially when powerful third-party payers are involved. It also teaches us that dealing with third-party payers is sometimes financially rewarding to the physician. And, of course, it teaches us to stay in tune with the patient throughout the interview—the answer that you should have written down.


Ask an Open-ended Question

The best way to begin the interview is with an open-ended question. Skill at asking such questions probably determines one’s success as a physician more than any other factor.

Two requisites must be satisfied, in the given order. First, the patient must know who you are. The introduction may be performed by one of the patient’s physicians:



  • “Mr. Smith, these are the two medical students I told you about. They are going to spend about 2 hours with you this afternoon, if that’s still all right with you.” Or:


  • “Mr. Smith, this is Dr Blue. He is our attending physician. I mentioned to you earlier that we would be bringing him around to meet you.” Or one may introduce oneself:


  • “Mr. Smith, I’m medical student Jones, and this is my partner, Mr. Black.” Or:


  • “Mr. Smith, I’m Dr White. I’m a consultant in endocrinology. Your doctor, Dr Green, asked me to come by and see you about your diabetes, your sugar problem.”

After the introduction, pause to give the patient a chance to ask a question, if he has one ready. If not, as is usually the case, proceed with the interview.

The second requirement for success is that the patient must know what you are doing. With a brand new patient, I like to explain: “I’m going to take the story of your life. I’m going to ask you an awful lot of questions. Then from your answers, I’m going to have some general idea of what the problem may be. Then, when I’ve finished asking you most of the questions, I’m going to examine you. When I finish that examination of your body, I’ll have a much better idea of what the problem may be. At that time, I’ll also have an idea of what laboratory tests and/or X-rays we’ll need to solve your problem. Do you have any questions now about how I’m going to proceed?”

Continuing the four dialogues begun above, this second stage might be accomplished by the following statements:



  • “We’re Jones and Black. We’re sophomore medical students, and we won’t be participating in your medical care after today. We’re only student doctors, and we’re your doctors just for this afternoon. Before we get started, is there anything you need to make you comfortable?”



  • “Hello, Mr. Smith. We’ve been discussing you in the conference this morning, and I felt it very important that I actually meet you and go over the details of your story. I also want to examine your heart to double-check a few things.”


  • “We are going to talk with you and go over the details of your medical history, and then we are going to examine you just as your other doctors did.”


  • “Dr Green is a bit puzzled as to why your sugar has been swinging up and down so much, and I am going to try to help him and you, if I can.”

Each of these statements is followed by a pause and a check to see that the patient understands what has been said.

Finally, the stage is set for the first of many open-ended questions. To continue the four dialogues, they might be



  • “Can you tell us what brought you to the hospital?”

    “Yes. It was my nephew’s Ford.” (This patient has examined many sophomore students.)

    “No. I mean, what was bothering you? What were your symptoms?” (A double question. See later in this chapter.)

    “What was bothering me? My mother-in-law.”

    “No, we meant why did you come to the hospital?”

    “Well, I’m a Korean War veteran. And this is the Veterans Hospital, isn’t it?”

    “No, we meant why come to the hospital at all? In what way did you feel sick?” (Another double question.)

    “I always feel this way when I’m sick.”

    “Well, when did you last feel well?” (An excellent open-ended question.)


  • “Could you begin by telling me when was the very first time you noticed anything that might be related to your heart trouble in any way?”


  • “When was the last time you felt in perfect health?”


  • “When was the very first time you were aware that there was anything different about your sugar?”

Notice that the second and fourth questions would not be open-ended for an initial evaluation but in reality are open-ended for an interviewer who has already heard a complete history secondhand. To see what I mean, consider the following counterexamples of unhelpful “closed” questions:



  • “When did a doctor first tell you what was wrong?”


  • “Did you have orthopnea before last January?”


  • “Have you ever been in the hospital before for the same problem you are having now?”


  • “When did Dr Green first tell you your sugar was too high?”

For the Neophyte. Much of the material in this chapter may seem quite formal and rigid to the thoughtful reader. However, those students who initially learn to be very obsessive, rigid, compulsive, and thorough will develop excellent interviewing skills; later, they can discard any excrescences. On the other hand, individuals who initially use a sloppy interviewing technique tend later to have a smaller repertoire of adjustments for the individuality of patients.

To illustrate the value of the rules, I like to tell the following story to my students.

There was an extremely busy physician who had a large and ever-increasing general practice, which included many families. One night he was running late as usual. After his office nurse had helped him an hour past her quitting time, he asked whether there was anyone left in the waiting room.

“Just Mrs. Smith,” she said.

“Well, you can go home,” said the doctor. “I can gown her and put her on the examining table as well as you, and you have worked long enough.”

The doctor finished what he was doing, put away the previous patient’s chart, and went to the waiting room, where he saw a man and a woman sitting together.

“Come in,” he said, holding the door open as they walked in and sat in the two chairs opposite the doctor’s desk.

He seated himself and asked, “What seems to be the problem?”

“Well, doctor,” said the man, “to tell you the truth it’s a little bit embarrassing.” The man then launched into a description of a skin lesion that seemed related to some sexual difficulties. The patient explained in great detail the highly unusual things he had done in the course of acquiring his lesion.

“Well,” said the doctor, “just go into the examining room, take off all your clothes, and lie down on the table. I will come in and examine you.”

When the man had left the consulting room, the physician turned toward Mrs Smith, whom he had never imagined would engage in such unusual practices. “Is all this true?”

“I don’t know, doctor,” said the woman. “I’ve never seen that man before.”

This apocryphal story demonstrates that if you violate too many of the rules given in this book, you will sooner or later get into trouble. It also demonstrates the enormous authority afforded a physician in his area of expertise, as well as the physician’s ability to sanction social behavior.

The patient-centered principles underlying this style of interviewing will serve one well in other circumstances, including seemingly unrelated cases. For example, consider the following story in which the student had to decide what to do when the patient’s biopsy was positive for disseminated carcinoma.


Self-study

A woman was admitted to the hospital for a diagnostic evaluation. Both she and her husband were aware that the doctors might find a terminal form of cancer. The husband, a patriarchal Sicilian, took the doctors aside and said that if the biopsy was positive, the patient was to learn of the diagnosis only from him, the husband. The woman separately told the doctors that she wanted them to tell her the biopsy result if it was positive for malignancy.

The biopsy was positive, and the medical student told the patient the results, as she had requested. When the husband learned that the information had not been “filtered” through him, he became furious with the medical student. The student was castigated by the house officer for not considering the cultural traditions of the patient and her husband.

What would you have done?


Discussion

While the house officer is to be commended for his consideration of cultural factors in the management of patients (if not for his delegation of such a responsibility to a third-year medical student),
we must return to the patient’s wishes. Obviously, in this situation, the patient herself was not willing to maintain total dependency in her relationship with her husband; thus, she may be considered to have abrogated any obligation of the physician to adhere to any (putative) culturally determined sequencing of the presentation of information. In other words, she was better aware of her own culture than anyone else and yet had clearly stated whom she wished to be informed first of the diagnosis—herself.


Interviewing versus Interrogation

Thirteen Rue Madeleine, a World War II motion picture, formerly popular on late-night television, is named for the address of the Gestapo headquarters in Paris. In the final scene, an American spy (played by James Cagney) is interrogated by the head of the Gestapo (played by Richard Conte). Cagney has called in a bomber strike on 13 Rue Madeleine that will destroy the Gestapo operations in occupied France but will just as surely destroy the patriotic Cagney. Conte is torturing Cagney to find out what radio message he had sent back to the Allied Forces.

I use this scene in teaching because there is a certain style and rhythm to that interview as it becomes an interrogation. Conte’s voice and attitude are those of a superior figure addressing one who is in a dependent position. Furthermore, the superior figure is obviously indifferent to Cagney’s suffering, and he is hostile and wantonly cruel.

Except in the movies, I have heard that interviewing style only in hospitals when I have been thrust into the role of unintended eavesdropper on medical house staff and, sad to say, some medical students. This style is not suitable for physicians. It is certainly not the way to elicit sensitive information. Students should choose to identify with a more desirable mode of behavior and to overcome any latent tendency to become brusque with patients.


Avoid “Leading the Witness”

Interviewing is a two-way street. The patient responds to the doctor’s wishes, and sometimes doctors with a poor interviewing style insist on being told what they want to hear, as the following story illustrates.

A patient was transferred to the medical service of a tertiary care hospital, instead of the neurologic service, despite the fact that he was suffering from a stroke. At the referring hospital, no one had been interested in his paralysis, but they had been interested in chest pain. In fact, the patient had experienced no chest pain, but after vigorous and repetitive questioning about this symptom, “They talked me into having chest pain.” Because the doctors at the tertiary hospital were also concerned about the paralysis, it again became permissible for him not to “have” chest pain. Remember that you are interviewing the patient, not the medical record or the patient’s previous physicians.


Choice of Language

Always use words that the patient understands. Never use technical or medical terms in the interview. This seems like good common sense, but you need to be aware that because you are just beginning your own mastery of these words they will slip into the clinical interview, and the patient may not tell you that he does not understand. If you are sure that you would never make such a mistake, audit tape recordings of your own interviews. Sooner or later, you too will use a medical term the patient does not understand. As in so much of medicine, awareness of the problem is an obligatory first step toward its solution.

On the other hand, try not to go overboard in the opposite direction. When interviewing a patient who belongs to a subculture with its own jargon (such as a drug abuser or a prisoner), one should not enter into the patient’s argot (see later in this chapter). First of all, language serves important ego-defensive functions. Second, the physician should never interview in an unnatural style any more than he should attempt to perform surgery from an unnatural posture.

Of course, the problem of misunderstanding the terminology can go in the other direction as well. Certain obscure slang terms and abstruse euphemisms are used by patients, especially when the disease may have social significance. For example, “bad blood” was a term used to denote syphilis and, later, by augmentation, any venereal disease. (At other times, “a hair cut” had the same meaning.) But “bad blood” had to be distinguished from “low blood,” which could be either anemia or psychasthenia in a patient with a normal blood pressure. Worse, in different parts of the country, the same phenomenon may have different names. Lymph nodes have been variously referred to as “knots,” “lungs,” “kernels,” and “risings” (the last may also be an abscess). Even within one locality, the names may change from time to time. For instance, when I started work at the hospital for drug addicts then in Lexington, Kentucky, I found a glossary of terms that someone had compiled a few years earlier, apparently to distribute to new medical officers. However, half of the terms were arcane or forgotten and many had been replaced by new ones.


“Can You Tell Me What Bothers You the Most?”

Some patients will come in with lists of problems, written or otherwise. They may jump from problem to disease to event to syndrome to hospitalization to symptom, without ever finishing the description of any of them. For the neophyte intent on eliciting all the dimensions (see Chapter 3), getting the correct chronology, or simply developing a clear understanding of what the patient is trying to say, this can be very annoying. The title of this section is a useful response. This question helps the patient focus on whatever he feels is really important. In some patients, it also makes it clear that a particular problem is not needed to serve as the “ticket for admission”; you are interested in whatever is making the patient ill with life, even if he is not nominally diseased. Why do patients need a “ticket of admission”? Many patients would like to talk to a sympathetic doctor about personal problems not parochially thought of as “medical problems.” In fact, the urgency to talk about such problems and to take up the physician’s time has led to the creation, in some institutions, of whole departments (psychiatry, psychology, social work, behavioral medicine, ombudsmen) devoted to listening to patients talk about what really bothers them, while the physician obliviously orders more nondiagnostic tests. The truly thoughtful physician will want to know about these concerns. However, some patients can only come to see the physician if they have something that will get the receptionist to give them an appointment or, in larger institutions, that will satisfy some bureaucratic, algorithmic guideline. Once the patients get into your office or the hospital,
there will be a natural tendency to talk about the true subject of their discomfort—as soon as they believe they can safely bring it up. The question that is the title of this section can help the patient bring up the problem. Some professors may object to this use of their time, but if they will recall the number of patients who have tried to rekindle a conversation while being shoved out of the office, they may reconsider and use the question to initiate the discussion at the beginning of the hour or quarter hour. (See the section entitled “Organ Recital,” in this chapter.) Because we insist, properly, on the patient having a chief complaint, we should not be surprised that the patient wants to satisfy us.

For a number of years, I abandoned the teaching of this question because of its misuse. Instead of using it to encourage the patient to talk, some were using it defensively to get the patient to stop talking about problems that did not interest the doctors. Furthermore, if challenged on having missed an important diagnosis, the resident might respond, “Well, I asked her what bothered her the most, and that’s what she told me.”

An important principle in medicine is that even the best teachings can be subverted. The corollary is that the thoughtful physician will choose his company wisely, associating with those who are wiser than himself, if possible. As the Talmud instructs, “If you wish to be a scholar, you must seek out the company of other scholars.”


“Tell Me More…”

In the initial open-ended portion of the interview, the patient will usually stop talking before he has told you all the details of some important event (such as the dimensions discussed in Chapter 3). He may previously have been interrogated, not interviewed; he may previously have had so many bad doctors that he is puzzled that anyone should want to spend so much time listening to him; he may simply be taciturn; or he may simply not be aware of the importance of certain details. You want to keep the patient talking, but how do you do it?

Just say to the patient, “Tell me more.” A few of these phrases sprinkled into the interview act like yeast in bread dough. Some patients will ask, “About what?” The answer is, “About what you were just telling me.” Others will ask, “What do you want to know about it?” Your answer is, “How you felt about it,” if you cannot think of a specific aspect in which you are interested.

Once the patient senses that you are truly interested in him, he will respond positively to the request, “Tell me more.”

Of course, later on in the more staccato portion of the interview, there will be events or symptoms about which you may wish to have more detail. Here too, it is a good idea to say, “Tell me more.” If you have already used the phrase effectively in the initial part of the interview, it will begin to function like a conditioned reflex.

The student must master the open-ended interview before proceeding to the decorticated checklists being promulgated by some supposed medical educators.


Assessing and Improving Your Interviewing Skills

If medicine is truly a science humanely practiced (Eichna, 1980), we must note that science inevitably depends upon measurement. In order to make measurements, one must have a method of recording events and data. One should not expect an electrocardiographer to teach a neophyte if the latter could only describe an arrhythmia as a “little wiggle, then a pause followed by a big wiggle.” But if the neophyte brought an electrocardiographic tracing, the electrocardiographer could measure, diagnose, and teach; and the neophyte could learn in a meaningful way. The same is true for interviewing; one learns best from a recording that can be played back and examined.

Videotaping is discussed later. For the time being, let us consider audiotape recorders because these are cheap and ubiquitous.


Making a Recording

Immediately after you have introduced yourself (if not before), turn on your recorder and place it where it will not interfere with eye contact between you and the patient. Experiment ahead of time to be sure that the device has an adequate microphone. Older devices may need an external microphone. Remember, the patient is the most important person in the room. Most of the interview content comes from the patient, not the interviewer.

Tell the patient, “I’m going to record what you tell me so that I am certain to get everything correct,” or words to that effect. If you are recording only for technique (form) and not for content (vide infra), the statement is not strictly true. Because we do nothing with the patient sub rosa, you might simply say. “I want to record what you say” or “I want to record our conversation,” or “I want to have a record of what we say to each other so that I can review it later.”

No matter what explanation you give for recording the interview, be sure to assure the patient of confidentiality. You might say, “I am going to review this alone, using an earpiece, so no one else will hear,” or “I am going to go over our interview with a more senior doctor who is teaching me about talking with patients,” or “No one will hear the tape recording but me,” or whatever is true. Be sure to add that the tape will be permanently erased and that no one who knows the patient will ever hear it.

Needless to say, your assurance of confidentiality must be honored. Listen to the tape privately, or only with concerned parties, as you promised. If you share lodging with a nonprofessional, you should use an earpiece. And, of course, if you promise the patient that you will erase the tape, or delete the digital file, you must do so. I have never had a patient decline to be recorded. Those situations in which students claim that the patient refused to give permission to record the interview were themselves always unrecorded. If you are truly concerned about legal issues, you may say at the end of your introductory comments, “Do you mind if I record us?” or “May I have your permission to make a recording?” If you are afraid of listening to your own interview, you will ask the question in a manner that guarantees that many patients will oblige you by refusing to give permission.

During many years of interviewing medical patients in front of small groups, I have found that, recorded or not, most patients have little hesitancy about speaking openly, with absolutely no embarrassment, if they sense that the listeners are really interested in them. The patients realize that the situation is a well-defined professional one, not a social one. If you carry yourself as a professional and treat the patient in a professional manner, the patient will treat you as a professional and will give you an amazingly sensitive and accurate account of his experiences.



Reviewing the Recording

After you have made the recording, listen to it in the quiet of your own room. You can review the content of the history of the present illness; although if that were the main purpose, I would have placed this section in the chapter on history, not in the one on interviewing. The most important purpose of the recording is to improve your skills in interacting with the patient.

Studies of medical students interviewing patients have found that there are four different objectively measurable phenomena that are highly correlated with experienced clinicians’ global ratings of the quality of the interviews: interruptions, percentage of time that the interviewer speaks, pregnant pauses, and double questions.

These four criteria permit you to score your own tape recordings. However, even within one interview, different portions of the interview have somewhat different structures. Thus, to be perfectly scientific, one should randomly select samples from different portions of the entire interview. With each criterion to be discussed, we will also discuss its major variations among different portions of the interview.


Criterion 1: Interruptions

On the average, there should be no more than 1.5 interruptions per minute of interview. This is especially critical in the portion of the interview that comes at the beginning and produces content usually found in the history of present illness portion of the case record.

An interruption should be scored whenever the interviewer interrupts the patient while the patient is speaking.


Example of an Interruption

Patient: “… You know doctor, I have always wondered if that shortness of breath had anything to do with the time …”

Interviewer: “When did you say your ankles first swelled up?”

A distinction can be made between flagrant interruptions and the skillful interviewer’s shaping comments. A shaping comment gets the patient back to where the interviewer wishes to be by recounting something that the patient has already said.


Example of a Shaping Comment

Patient: “… and the following spring, regular as clockwork, I got another one of the asthmatic attacks. It was the same thing as last time, starting with coughing and spitting and getting me up at night just like the first two … there was that coughing and spitting. It seemed like every night I would get up just like the past year. Regular as clockwork at 1:00 a.m. there was that coughing and spitting …”

Interviewer: “Was that spring the first time you noticed the blood?”


What If the Doctor Did Not Interrupt?

The average patient visiting a physician in the US gets only 22 seconds for his initial statement before the doctor interrupts. Physicians are apparently afraid that they will fall behind in the schedule if they permit patients to talk as long as they would like. A Swiss study conducted in a tertiary referral center investigated how long patients would talk if allowed to do so. Physicians were trained in the basic elements of active listening and ways to encourage communication (nodding, echoing, using facilitators such as “hmmm, hmmm”) and advised to interrupt if a patient talked for longer than 5 minutes.

The mean spontaneous talking time was 92 seconds (SD 105 seconds, median 59 seconds). About 78% of the patients finished their opening statement in 2 minutes. Only 7 of 331 patients talked longer than 5 minutes, but in all cases, the physicians felt that the patients were giving important information and should not be interrupted (Langewitz et al., 2002).


Criterion 2: Percentage of Time the Interviewer Speaks

On the average, the interviewer should speak no more than 50% of the time and no less than 10% of the time. With a young, healthy person who has a completely negative review of systems, it is not uncommon for the interviewer to be speaking from 45% to 50% of the time during that portion of the interview. However, in the history of the present illness portion, the interviewer should be speaking closer to 10% of the time.

The reason for the 10% lower limit is that in certain interviews the interviewer loses control to a loquacious patient. It is true that an excellent interviewer with good nonverbal cuing can let the patient speak more than 90% of the time during fruitful portions of the interview that will produce material for the history of the present illness. But on the average, over the course of the entire interview, no skillful medical interviewer will speak less than 10% of the time.


Criterion 3: Pregnant Pauses

This is the hardest portion of the interview to learn. One must be aware of the technique and use it deliberately. A really good interviewer should be able to produce a pregnant pause, 4 or 5 seconds in length, several times during the interview.

A pregnant pause is defined as the silent interval between the apparent end of a patient’s response to the question and a thoughtful continuation, not interrupted by any comment or the next question from the interviewer. The pregnant pause is terminated by the patient himself resuming a more detailed description of whatever he was discussing, usually with an enriched context.

A pause for 4 or 5 seconds may not seem like very long, but it is long enough to make the naive interviewer very uncomfortable. It is suggested that the novice develop a nonverbal cue such as smiling, leaning forward, motioning with the hand, or taking off his glasses and motioning with them in a “continue, please” manner. Extremely skilled interviewers can leave up to 20-second pauses when asking about prior imprisonment, sexual matters, or other taboos for that particular patient. Pregnant pauses are usually found in the portions of the interview having to do with such potentially sensitive subject matter.


Criterion 4: Double Questions

Always ask one question at a time. Although this dictum seems rather obvious, you will almost inevitably violate it. If you carefully audit the recordings of your interviews, you will find instances in which you have asked a second question without waiting for a response to the first.


Examples

Interviewer: “During any of this time did you cough up any blood—did you say you once worked in shipbuilding? Were you ever exposed to asbestos?” Or:

Interviewer: “Have you noticed any change in the frequency of your bowel movements since the operation? What about the color? Did it change?”


A study of paired tape recordings and case records reveals that the answer to the first question is always omitted from the case record, and for a very good reason. The patient always answers the second question, never the first. Worse, the interviewer never goes back and repeats the first unanswered question.

If one interviews the interviewer and asks about the omitted information, the inevitable response is frustration, as he remembers asking the question but is not able to remember the patient’s answer because, of course, it was never given.


Other Criteria

Any good physician who has been in practice for a long time has a number of interview criteria of which he is not consciously aware. You might wish to play back an interview for a private physician who is willing to serve as a tutor. Physicians of experience can immediately point out technical errors even though they may never have specifically thought about the right and wrong ways to conduct an interview.


Nonverbal Communication

There are three aspects of nonverbal communication to be considered: tone of voice, body position, and facial expressions. The latter two are best taught by means of a videotape.


Tone of Voice

While the importance of this factor is rather obvious, persons who do not use tape recorders often do not realize that their tone of voice is sometimes not what they believe it to be. Many students, upon hearing themselves for the first time interviewing a patient, remember the patient’s voice but wonder who the person asking the questions is! Again, the simple use of the recorder will solve this problem, given a student of intelligence and sensitivity.


Body Position

The interviewer’s body position with respect to the patient determines much about the content of the interview. Physicians who always stand above a supine patient are perhaps unconsciously reinforcing the patient’s dependent position and the authoritarian position of the physician. While some physicians know how to utilize this discrepancy to the ultimate advantage of the patient, others may abuse it. In later years, I have always attempted to spend at least some time sitting by the bedside at eye level with the patient. My having the chair at the bedside, while the rest of the team is standing, is often misinterpreted by the junior members of the team. But it makes better eye contact possible, and it shows the patient that I plan to sit and listen to him. Patients also perceive that physicians who sit at the bedside are spending more time with them than physicians who stand, whether or not that is true by objective measurements.

The physician’s body position can be consciously used to control certain aspects of the interview. Conversely, body movements of which you may be unaware can be counterproductive. For example, breaking eye contact, turning your body away from the patient, looking at your wristwatch, or staring into the corner will decrease communication, both quantitatively and qualitatively. Conversely, if you wish to get a reticent patient to talk, kinesic encouragements could include the following: holding your body so that your line of vision is in line with that of the patient’s, leaning forward slightly but comfortably, and using skillfully placed signs or motions of encouragement when the patient stops talking. The last include, but are not limited to, a “come here” motion with the hands; taking off one’s glasses and using them in a “hooking the patient in like a fish” movement, with or without accompanying head movement; nonverbally saying, “Yes, go ahead” by smiling; head nodding, which also indicates approval; and a rotary mixing-in motion of pen or pencil with the fast component moving from the patient to the interviewer.


Suggested Teaching Exercise

Videotape an interview but with the camera pointing at the interviewer rather than the patient. Play it back first with sound but no picture. Then play back the picture with no sound. Finally, play the sound and picture together.

When listening to sound only, note what unexplained pauses occur. When looking at the picture only, analyze the body signals. Do you see any negative ones? When listening to the sound with the picture, do you see any correlations or contradictions between the patient’s verbal behaviors and the interviewer’s physical behavior? What other obvious mismatches could you detect with sound and picture that were not apparent viewing just one?


Facial Expressions

Frowning at the patient will decrease communication. Smiling at the patient will encourage the patient to talk. Salesmen of all types use this technique.


Autognosis

Autognosis is a combination word from auto (meaning self) and diagnosis. It refers to diagnosis through awareness of the feelings that the patient engenders in oneself. While it may be formally taught as part of the specialty known as psychiatry, its application need not be limited to psychiatrists, any more than the interpretation of chest films need be left to radiologists. Autognosis is useful in certain specific disorders (see Chapter 26). Some depressed patients tend to make the physician feel depressed by the end of the encounter; similarly, some manic patients tend to be amusing, making the physician smile or laugh. Patients with less well defined psychiatric disorders (or no psychiatric disorder at all) may evoke in the physician feelings similar to those they evoke in their employers, employees, associates, parents, children, siblings, or spouses.

Being aware of your emotional reaction to the patient also helps you to guard against what Groopman calls “affective errors”— concentrating more on data supporting a desired outcome (Groopman, 2007), such as a benign diagnosis in a patient one especially cares for, or quick dismissal of a troublesome patient.

Again, I emphasize that interviewing is an interactive process. The physician can learn to take advantage of a spontaneous, free, and noninvasive diagnostic aid: His own emotional response.



Last Question in the Interview

As you move from the open-ended questions at the beginning of the interview to the more specific kinds of questions that are covered in the next chapter, you will be formulating differential diagnoses in your head. Then you will move on to the physical examination. When you finish the physical examination, you will be considering which laboratory tests you wish to order. I would suggest interrupting the sequence by inserting, just before the physical examination, the following question: “Is there anything else you want to tell me?”

Some British-trained physicians say, “What do you think is wrong with you, Mr. Smith?” in order to get the patient to think of more diagnostically related material and to learn the patient’s as yet unspoken fears, but this is not really the same question. The “anything else” question is not limited to diagnosis but includes prognosis, therapeutics, fears, worries, terrors, and even trivia (from the physician’s standpoint) such as information concerning rest rooms, visiting hours, or parking near the office. The question does not guarantee the quality of the diagnostic content of the response, but it does facilitate the patient-physician relationship.

This closes the interview in an open-ended style. It also prepares the patient to begin the next interview in an open-ended fashion.

One difference between psychoanalysis and the interview is that the interview never terminates and lasts for the life of the patient-physician relationship. (See Freud’s essay on the subject of psychoanalysis, terminable or interminable [Freud, 1937].)


The Psychodynamic Termination of the Physical Examination

This section is not out of sequence. There is a portion of the interview, or a potential portion of the interview, that actually occurs at the very end of the patient-physician contact. Of course, everyone realizes that we continue to talk to the patient (to perform an interview) even as we perform the physical examination. However, most people do not understand that the termination of the physical examination is also the termination of the interview and is psychologically very important.

Patients often say very important things to you as you are leaving the room. As an aid, I suggest that you leave your tape recorder running as you exit, since you may be inattentive to the patient’s comments after you have said good-bye. You may not want to leave your tape recorder running all through the physical examination for logistic reasons. In that case, turn it back on just before you leave, and study the last part of the recording carefully.

From a psychodynamic standpoint, the most important part of the interview occurs as the physician and patient part company. The phenomenon is much easier to observe in an office setting.

There are several reasons why patients give psychologically important material as they are leaving. You are distracted, unguarded, and not really concentrating on the patient. You may have put away his chart and pulled out the chart of the next patient, to whom you are, appropriately, switching your attention. The patient, for his part, is in a relatively safe position. He is no longer recumbent, dependent, prone, or under your gaze. He can throw out a comment and observe your response. If he does not like your look, gesture, or tone of voice, he already has his hand on the doorknob and will soon be safely outside. His remark may be a new symptom (see “Organ Recital,” this chapter).

What can be done about this situation? First, use a tape recorder in the outpatient department to convince yourself that the above is true. Second, awareness in itself is helpful, as in so much of medicine. One way to handle the situation is to look up at the patient and say, “That would be a good place for us to start next time,” assuming of course that there is to be a next time and that you will start there.

Understanding the nuances of the patient’s parting remarks requires some training in psychodynamics. The lack of availability of such training in most medical residencies is a serious deficiency.

For the Attending (a Rounding Ploy). As the rounding group leaves the bedside, turn your back to the patient and begin washing your hands. (Those who believe in the germ theory think that this is a good idea in any case.) This will permit you to eavesdrop upon the rest of the group as they leave the patient’s bedside. Listen to the patient’s last words to the group. After you have left the patient’s room, ask whether anyone can remember the last thing the patient said. If no one can, remind them of what it was, and possibly also comment on why some people cannot remember. It will probably not be difficult to interpret the patient’s comments, if they did have some especially significant meaning. Experienced attending physicians know far more about human behavior and patient-doctor interactions than they realize. These insights should be shared with younger colleagues, because one of the purposes of civilization is to spare the young of the species from having to learn everything the hard way.


Notes on Office-based Practice

Physicians with a patient-centered office-based practice disagree with some of the advice given above, particularly with respect to accommodation of the patient’s spouse, relatives, or significant other. Some physicians prefer to have the companion present for at least part of the interview, if the patient wishes, as well as the sessions explaining findings and treatment options. The companion’s participation in the discussion is permitted and encouraged. The arrangement of the consulting room, with provision for comfortable accommodation of a family member or friend, reflects this preference. Observing the interaction with the companion is a critical part of the assessment. Moreover, the cooperation of people the patient trusts may be essential to the success of the therapy. It is also important for the patient to have an opportunity to share confidences with the physician alone, say when the companion is asked to wait in the reception area during the physical examination, treatment session, or at another time.

It is helpful to start with the question “Who is with you?” even if the patient comes into the consulting room alone. Taking obvious note of the person’s telephone number conveys to the patient that the chosen companion is a partner in the healing enterprise.
The questions “Who is at home with you?” and “Who is the person closest to you?” can uncover much about the patient’s social situation without being intrusive or appearing voyeuristic.

A comprehensive evaluation as described in these chapters is not necessarily appropriate for every patient who consults a physician, particularly a specialist. Private patients may not wish to spend the amount of money required for such an evaluation. Or they are simply too reticent to share sensitive details. Some private physicians ask “What would you like me to help you with?” early in the interview. Part of a physician’s skill is in knowing what information he needs to accomplish the mutual objectives. The physician who has an ongoing relationship with a patient also knows that not everything can be done in a single visit. This follows from the belief that the “one diagnosis, one treatment” paradigm is flawed. Patients often have a number of interacting problems that can be sorted out only in a process of trial and error or successive approximations. The physician cannot just write a diagnosis on a “problem list” (see Chapter 4), prescribe a pill or combination of pills, and schedule subsequent visits simply for refills or adjustments.

I learned a unique use of the tape recorder from a physician in private practice. After the initial interview and examination, he explains his synthesis of findings and recommendations to the patient and companion. This session is recorded on audiotape, after the procedure is explained, and the only cassette is given to the patient at its conclusion. The patient can then review the discussion as often as desired, and allow others of his choosing to listen also. This procedure enhances informed consent, allows patients to review instructions they may not remember well, and demonstrates the physician’s trust and confidence in himself and the patient. This probably helps to protect against lawsuits as well as to improve patient understanding and concordance.


Interviewing Patients Who Are Forgetful or Confused


Recognizing the Presence of an Organic Brain Syndrome

The most common cause of forgetfulness is cerebral (or cognitive) insufficiency, which has been called an organic mental disorder or organic brain syndrome. These are unfortunate terms (see the definition of organic in Chapter 1). The concepts are still useful, however, especially in the emergency department, or before the physician is able to characterize the condition more precisely. In my view, there is no completely satisfactory substitute that encompasses degenerative conditions, metabolic encephalopathies, and other conditions with a known structural or physiologic substrate that may call for medical investigation and intervention, as opposed to psychiatric consultation, behavioral intervention, or psychotherapeutic drugs.


A Historical Note on Terminology

The term organic mental disorders/organic brain syndromes was included in the diagnostic and statistical manual of mental disorders III (DSM-III) of the American Psychiatric Association to encompass conditions falling in the no-man’s-land between psychiatry and neurology. The schism that occurred in the mid-20th century between psychiatry and neurology isolated and ignored an entire group of patients with behavioral changes related to neurophysiologic changes rather than psychic background and social pressures (Strub and Black, 1981).

The term was deleted from the DSM-IV because it implied that serious psychiatric disorders such as schizophrenia did not have a biologic basis. The conditions formerly listed in that category were regrouped under a hodgepodge of other classifications, including cognitive disorders such as Alzheimer disease and “Mental Disorders due to a General Medical Condition.”

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Aug 10, 2020 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on The Interview
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