Basic Principles

Good communication skills are the foundation of excellent medical care. Even with the exciting new technology that has appeared since 2000, communicative behavior is still paramount in the care of patients. Studies have shown that good communication improves health outcomes by resolving symptoms and reducing patients' psychological distress and anxiety. Technologic medicine cannot substitute for words and behavior in serving the ill. The quality of patient care depends greatly on the skills of interviewing, because the relationship that a patient has with a physician is one of the most extraordinary relationships between two human beings. Within a matter of minutes, two strangers—the patient and the healer—begin to discuss intimate details about a person's life. Once trust is established, the patient feels at ease discussing the most personal details of the illness. Clearly, a strong bond, a therapeutic alliance, has to have been established.

The main purpose of an interview is to gather all basic information pertinent to the patient's illness and the patient's adaptation to illness. An assessment of the patient's condition can then be made. An experienced interviewer considers all the aspects of the patient's presentation and then follows the leads that appear to merit the most attention. The interviewer should also be aware of the influence of social, economic, and cultural factors in shaping the nature of the patient's problems. Other important aspects of the interview are educating the patient about the diagnosis, negotiating a management plan, and counseling about behavioral changes.

Any patient who seeks consultation from a clinician needs to be evaluated in the broadest sense. The clinician must be keenly aware of all clues, obvious or subtle. Although body language is important, the spoken word remains the central diagnostic tool in medicine. For this reason, the art of speaking and listening continues to be the central part of the doctor-patient interaction. Once all the clues from the history have been gathered, the assimilation of those clues into an ultimate diagnosis is relatively easy.

Communication is the key to a successful interview. The interviewer must be able to ask questions of the patient freely. These questions must always be easily understood and adjusted to the medical sophistication of the patient. If necessary, slang words describing certain conditions may be used to facilitate communication and avoid misunderstanding.

Health care providers are increasingly treating patients across language barriors. For any patient who speaks a language other than that of the clinician, it is important to seek the help of a trained medical interpreter. Unless fluent in the patient's language and culture, the clinician should always use an interpreter. The interpreter can be thought of as a bridge, spanning the ideas, mores, biases, emotions, and problems of the clinician and patient. The communication is very much influenced by the extent to which the patient, the interpreter, and the clinician share the same understanding and beliefs regarding the patient's problem. The best interpreters are those who are familiar with the patient's culture. The interpreter's presence, however, adds another variable in the doctor-patient relationship;for example, a family member who translates for the patient may alter the meaning of what has been said. When a family member is the interpreter, the patient may be reluctant to provide information about sensitive issues, such as sexual history or substance abuse. It is therefore advantageous to have a disinterested observer act as interpreter. On occasion, the patient may request that a family member be the interpreter. In such a case, clinicians should respect the patient's wishes. Friends of the patient, although helpful in times of emergency, should not be relied upon as translators because their skills are unknown and confidentiality is a concern. The clinician should also master a number of key words and phrases in several common languages to gain the respect and confidence of patients. When using an interpreter, clinicians should remember the following guidelines:

1. Choose an individual trained in medical terminology.

2. Choose a person of the same sex as the patient and of comparable age.

3. Talk with the interpreter beforehand to establish an approach.

4. When speaking to the patient, watch the patient, not the interpreter.

5. Do not expect a word-for-word translation.

6. Ask the interpreter about the patient's fears and expectations.

7. Use short questions.

8. Use simple language.

9. Keep your explanations brief.

10. Avoid questions using ''if,'' ''would,'' and ''could,'' because these require nuances of language.

11. Avoid idiomatic expressions.

Even with a trained translator, health care workers are ultimately responsible for ensuring safe and effective communication with their patients. A recent article (Schenker et al., 2008) describes a conceptual framework of when to call for an interpreter and what to do when one is not available.

When speaking with the patient, the interviewer must determine not only the main medical problems but also the patient's reaction to the illness. This is of great importance. How has the illness affected the patient? How has he or she reacted to it? What impact has it had on the family? work? social life?

The best interview is conducted by an interviewer who is cheerful, friendly, and genuinely concerned about the patient. This type of approach is clearly better than that of the interviewer who acts like an interrogator shooting questions from a standard list at the poor, defenseless patient. Bombarding patients with rapid-fire questions is a technique that should not be used.

In the beginning, the patient brings up the subjects that are easiest to discuss. More painful experiences can be elicited by tactful questioning. The novice interviewer needs to gain experience to feel comfortable asking questions about subjects that are more painful, delicate, or unpleasant. Timing of such questions is critical.

A cardinal principle of interviewing is to permit patients to express their stories in their own words. The manner in which patients tell their stories reveals much about the nature of their illnesses. Careful observation of a patient's facial expressions, as well as body movements, may provide valuable nonverbal clues. The interviewer may also use body language such as a smile, nod, silence, hand gesture, or questioning look to encourage the patient to continue the story.

Listening without interruption is important and requires skill. If given the chance, patients often disclose their problems spontaneously. Interviewers need to hear what is being said. They must allow the patient to finish his or her answer even if there are pauses while the patient processes his or her feelings. All too often, an interview may fail to reveal all the clues because the interviewer did not listen adequately to the patient. Several studies have shown that clinicians commonly do not listen adequately to their patients. One study showed that clinicians interrupt the patient within the first 15 seconds of the interview! The interviewers are abrupt, appear uninterested in the patient's distress, and are prone to control the interview.

The best clinical interview focuses on the patient, not on the clinician's agenda. An important rule for improved interviewing is to listen more, talk less, and interrupt infrequently.

Interrupting disrupts the patient's train of thought. Allow the patient, at least in part, to control the interview.

Interviewers should be attentive to how patients use their words to conceal or reveal their thoughts and history. Interviewers should be wary of quick, very positive statements such as, ''Everything's fine,'' ''I'm very happy,'' or ''No problems.'' If interviewers have reason to doubt these statements, they may respond by saying, ''Is everything really as fine as it could be?''

If the history given is vague, the interviewer may use direct questioning. Asking ''how,'' ''where,'' or ''when'' is generally more effective than asking ''why,'' which tends to put patients on the defensive. The interviewer must be particularly careful not to disapprove of certain aspects of the patient's story. Different cultures have different mores, and the interviewer must listen without any suggestion of prejudice.

Always treat the patient with respect. Do not contradict or impose your own moral standards on the patient. Knowledge of the patient's social and economic background will make the interview progress more smoothly. Respect all patients regardless of their age, gender, beliefs, intelligence, educational background, legal status, practices, culture, illness, body habitus, emotional condition, or economic state.

Clinicians must be compassionate and interested in the patient's story. They must create an atmosphere of openness in which the patient feels comfortable and is encouraged to describe the problem. These guidelines set the foundation for effective interviewing.

The interviewer's appearance can influence the success of the interview. Patients have an image of clinicians. Neatness counts;a slovenly interviewer might be considered immature or careless, and his or her competence may be questioned from the start. Surveys of patients indicate that patients prefer medical personnel to dress in white coats and to wear shoes instead of sneakers.

As a rule, patients like to respond to questions in a way that satisfies the clinician to gain his or her approval. This may represent fear on the part of patients. The clinician should be aware of this phenomenon.

The interviewer must be able to question patients about subjects that may be distressing or embarrassing to the interviewer, the patient, or both. Answers to many routine questions may cause embarrassment to interviewers and leave them speechless. Therefore, there is a tendency to avoid such questions. The interviewer's ability to be open and frank about such topics promotes the likelihood of discussion in those areas.

Very often, patients feel comfortable discussing what an interviewer might consider antisocial behavior. This may include drug addiction, unlawful actions, or sexual behavior that does not conform to societal norms. Interviewers must be careful not to pass judgment on such behavior. Should an interviewer pass judgment, the patient may reject him or her as an unsuitable listener. Acceptance, however, indicates to the patient that the interviewer is sensitive. It is important not to imply approval of behavior; this may reinforce behavior that is actually destructive.

Follow the ''rule of five vowels'' when conducting an interview. According to this rule, a good interview contains the elements of audition, evaluation, inquiry, observation, and understanding. Audition reminds the interviewer to listen carefully to the patient's story. Evaluation refers to sorting out relevant from irrelevant data and to the importance of the data. Inquiry leads the interviewer to probe into significant areas in which more clarification is required. Observation refers to the importance of nonverbal communication, regardless of what is said. Understanding the patient's concerns and apprehensions enables the interviewer to play a more empathetic role.

Speech patterns, referred to as paralanguage components, are relevant to the interview. By manipulating the intonation, rate, emphasis, and volume of speech, both the interviewer and the patient can convey significant emotional meaning through their dialogue. By controlling intonation, the interviewer or patient can change the entire meaning of words. Because many of these features are not under conscious control, they may provide an important statement about the patient's personal attributes. These audible parameters are useful in detecting a patient's anxiety or depression, as well as other affective and emotional states. The interviewer's use of a warm, soft tone is soothing to the patient and enhances the communication.

A broad interest in body language has evolved. This type of nonverbal communication, in association with spoken language, can provide a more comprehensive picture of the patient's behavior. It is well known that the interviewer may learn more about the patient from the way the patient tells the story than from the story itself. A patient who strikes a fist on a table while talking is dramatically emphasizing what he or she is saying. A patient who moves about in a chair and looks embarrassed is uncomfortable. A frown indicates annoyance or disapproval. A patient who slips a wedding band on and off may be ambivalent about his or her marriage.

A palm placed over the heart asserts sincerity or credibility. Many people rub or cover their eyes when they refuse to accept something that is pointed out. When patients disapprove of a statement made by the interviewer but restrain themselves from speaking, they may start to remove dust or lint from their clothing. Lack of comprehension is indicated by knitted brows.

Full interpretation of body language can be made only in the context of the patient's cultural and ethnic background, because different cultures have different standards of nonverbal behavior. Middle Eastern and Asian patients often speak with dropped eyelids. This type of body language would indicate depression or lack of attentiveness in a patient from the United States. The interviewer may use facial expressions to facilitate the interview. An appearance of attention demonstrates an interest in what the patient is describing. Attentiveness on the part of the interviewer is also indicated by leaning slightly forward toward the patient.

Touching the patient can also be very useful. Touch can communicate warmth, affection, caring, and understanding. Many factors, including gender and cultural background, as well as the location of the touch, influence the response to the touch. Although there are wide variations within each cultural group, Latinos tend to use a great deal of contact, whereas the British tend not to use contact. Scandinavians and Anglo-Saxon Americans are in the middle of this range. Be aware, however, that certain religious groups prohibit touching a person of the opposite sex. In general, the older the patient, the more important touch is. Appropriate placement of a hand on a patient's shoulder suggests support. Never place a hand on a patient's leg or thigh, because this is a threatening touch. An interviewer who walks with good posture to a patient's bedside can hope to gain the patient's respect and confidence. An interviewer who maintains eye contact with the patient conveys interest in the patient.

In this age of biomedical advancements, a new problem has arisen: a depersonalization of the doctor-patient relationship. Clinicians may order computed tomography scans or sonograms without taking the appropriate time to speak with the patient about the tests. Both doctor and patient may feel increasingly neglected, rejected, or abused. Patients may feel dehumanized on admission to the hospital. Many find themselves in a strange environment, lying naked while clothed people march in and out of the room and touch them, tell them what to do, and so forth. They may be apprehensive because they have a problem that their health-care provider considers too serious to be treated on an outpatient basis. Their future is filled with uncertainty. A patient admitted to the hospital is stripped of clothing and often of dentures, glasses, hearing aids, and other personal belongings. A name tag is placed on the patient's wrist, and he or she becomes ''the patient in 9W-310.'' This lowers the morale of the patient even more. At the same time, clinicians may be pressed for time, overworked, and sometimes unable to cope with everyday pressures. They may be irritable and pay inadequate attention to the patient's story. They may eventually come to rely on the technical results and reports. This failure to communicate weakens the doctor-patient relationship.

Inexperienced interviewers not only must learn about the patient's problems but also must gain insight into their own feelings, attitudes, and vulnerabilities. Such introspection enhances the self-image of the interviewer and results in the interviewer's being perceived by the patient as a more careful and compassionate human being to whom the patient can turn in a time of crisis.

A good interviewing session determines what the patients comprehend about their own health problems. What do the patients think is wrong with them? Do not accept merely the diagnosis. Inquire specifically as to what the patient thinks is happening. What kind of impact does the illness have on the patient's work, family, or financial situation? Is there a feeling of loss of control? Does the patient feel guilt about the illness? Does the patient think that he or she will die? By pondering these questions, you can learn much about patients, and patients will realize that you are interested in them as whole persons, not merely as statistics among the hospital admissions.

The literature indicates that malpractice suits have increased at an alarming rate. A good doctor-patient relationship is probably the most important factor in avoiding malpractice claims. Most malpractice litigation is the result of a deterioration in communication and of patient dissatisfaction rather than of true medical negligence. The patient who is likely to sue has become dissatisfied with the clinician and may have lost respect for him or her. From the patient's point of view, the most serious barriers to a good relationship are the clinician's lack of time;seeming lack of concern for the patient's problem;inability to be reached;attitude of superiority, arrogance, or indifference; and failure to inform the patient adequately about his or her illness. Failure to discuss the patient's illness and treatment in understandable terms is viewed as a rejection by the patient. In addition, the congeniality and competence of a physician's office staff can go a long way toward avoiding malpractice suits. Physicians who have never been sued orient their patients to the process of the visit, use facilitative comments, ask the patient for opinions, use active learning, use humor and laughter, and have longer visits. A doctor-patient relationship based on honesty and understanding is thus recognized as essential for good medical practice and the well-being of the patient.

It is sometimes difficult for a novice interviewer to remember that there is no need to try to make a diagnosis out of every bit of information obtained from the interview. Accept all the clues and then work with them later when trying to establish a diagnosis.

If during the interview you cannot answer a question, do not. You can always act as the patient's advocate;listen to the question and then find someone who can provide an appropriate answer.

A very important task of communication is to engage the patient. A helpful way of building rapport with a patient is to be curious about the person as a whole. Ask, ''Before we begin, tell me something about yourself.'' When the patient returns, mention something personal that you learned from a previous visit: for instance, ''How was your trip to Seattle to see your son?'' Another part of engagement is to determine the patient's expectations from the visit;for instance, ask, ''What are you hoping to accomplish today?'' At the conclusion of the visit, ask, ''Is there anything else you are concerned about?'' If the patient has several problems, it is acceptable to say, ''We might need to discuss that problem at another visit. I want to be certain that we completely evaluate your main concern today.''

On April 14, 2003, the first federal privacy standards were put in place to protect the medical records and other health information of patients. The U.S. Congress asked the Department of Health and Human Services to issue privacy protection as part of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA regulations include provisions designed to encourage electronic transactions and to safeguard the security and confidentiality of health information. The final regulations cover health plans, health-care clearinghouses, and health-care providers who conduct financial and administrative transactions electronically. In short, these regulations regarding patient confidentiality limit the ways in which health-care providers, health plans, pharmacies, hospitals, clinics, and other entities can use patients' personal medical information. These regulations ensure that medical records and other identifiable health information, whether on paper, in computers, or orally communicated, are protected. For further information, see

In summary, the medical interview is a blend of the cognitive and technical skills of the interviewer and the feelings and personalities of both the patient and the interviewer. The interview should be flexible and spontaneous and not interrogative. When used correctly, it is a powerful diagnostic tool.

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