1: The Medical Interview

The medical interview, the major medium of patient care, is of central importance to practitioners. A successful interview elicits accurate and complete data. It represents a dialogue that determines whether the patient agrees to take a medication, undergo a test, or change a diet. More than 80% of diagnoses are derived from the interview. The doctor–patient interaction is the keystone of patient satisfaction; moreover, interview-related factors impact major outcomes of care, including physiologic responses, symptom resolution, pain control, functional status, propensity to sue in the event of an adverse outcome, and emotional health. The medical interview also influences the quality of care, including malpractice suits and their resolution, the amount of patient disclosure of difficult or stigmatized information, time efficiency, and the elimination of "doorknob" questions as the interview ends.

Clearly, the interview is a major determinant of professional success. Yet, fewer than 10% of medical practitioners have spent time, since medical school, working on their interviewing ability. When asked, most physicians indicate that they have no plan or approach to monitoring, maintaining, or improving this critical skill. Can you imagine a professional musician, athlete, or pilot not practicing? One would question their commitment and competence or potential for remaining successful.

The interview is also key to a practitioner's sense of professional well-being, as it is the factor that most influences satisfaction with each encounter. Physicians with high career dissatisfaction most often attribute this to unsatisfying communication and relationships with patients. Physicians with high job satisfaction have a significant interest in the psychosocial aspects of care, relate effectively with patients, and are able to manage difficult patient situations.

The Ubiquitous Interview

The central role of the interview derives from its epidemiology as well as its "one-on-one" impact. For most physicians, it is more prevalent than any other activity in their work or their lives. The average length of time per ambulatory patient visit for internists, family practitioners, and pediatricians is about 20 minutes, and these groups account for 75% of doctor visits. The average visit time for all physicians is 6 minutes, a rate curiously constant in the United States, the United Kingdom, The Netherlands, and elsewhere. Physicians who bring the average down to 6 minutes are moving scarily fast.

Making conservative estimates about how many hours a practitioner will work over a 40-year professional lifetime, a generalist will have around 250,000 patient encounters. Each interview can be the source of satisfaction or frustration, of learning or apathy, of efficiency or wasted effort (Table 1-1), of personal growth and inspiration or dispiriting discouragement. Despite the importance of performing this complex skill expertly, few physicians plan, or even think about, how to improve patient encounters to reach the desirable goals of satisfaction, learning, and efficiency.

Each discipline or special interest, such as psychiatry, occupational health, women's health, or domestic violence support has a specialized set of questions that must be asked of every patient for the interview to be complete and to elicit that patient's particular problems. (If an interviewer were to ask every question recommended by each specialty the interview would take hours.) In most cases, these questionnaires have neither been validated nor shown to be sensitive or specific. Notable exceptions include the CAGE Questionnaire (Table 1-2), which is a highly specific, sensitive, and efficient screening test for alcoholism (see Chapter 24); the two-question depression screen (see Chapter 25); and the one-question domestic violence screen (see Chapter 38).

Rather than the use of a series of over-specific, narrowly focused questions, it is more effective to use a patient-centered approach. First, elicit the patient's complete set of concerns and questions. Then explore the priority, negotiated problem by asking open-to-closed-ended questions to encourage elaboration on the information and elicit the needed data about each concern. Lists of open-ended questions elicit information more efficiently than lists of closed-ended questions. A patient-centered approach ensures that the patient's concerns are understood and accepted—a predictor of increased compliance. Because open-ended questions allow the patient to frame the response, the nature of framing reveals how the patient is processing the issue under discussion information is rarely available from closed-ended questions.

This approach is efficient for several reasons. First, patients usually have a sense of what is relevant and will include key information and data not anticipated by the interviewer. A physician who is thinking of the next question rather than listening to what is being said loses the ability to attend and hear on multiple levels. If the interviewer is talking then the patient is not talking, and so, is not providing data. The physician can always refer to specific items to round out the data once the patient's story is told. If the same format is used for each interview, the variations in responses can be attributed to the patient, thereby providing significant insight.

The evidence favoring a patient-centered approach goes beyond the practical advantages: outcomes of care are also favorable. More complete and higher quality information—with an attendant reduction in procedures and tests—reduces cost, side effects, and complications. Increased patient adherence to diagnostic and therapeutic plans leads to greater clinical efficiency and effectiveness, and patients take a more active role in their own care.

Efficiency & Active Listening

A number of factors enhance interview efficiency, a growing concern, as the corporatization of health care leads doctors and patients to experience care as more rushed. Actual visit lengths have remained constant. However, as knowledge and regulation grow exponentially, tasks to accomplish in a given visit multiply—more diseases and risks to evaluate, more treatments to choose among and explain, and more computer screens and bureaucratic hoops to negotiate. These trends will undoubtedly prove counterproductive: when the visit is jammed with too much to do, psychosocial discussion suffers. This can result in unnecessary testing, patient dissatisfaction, and hazardous or needless procedures and treatments. Challenges to efficiency and effectiveness are exacerbated when behavioral medicine is removed from the medical visit by outsourcing to an external "behavioral management" company. Then both sides compete not to care for the patient, and predictably the relationship and quality of care deteriorate.

Specific techniques enhance cost-effectiveness and efficiency. Open-ended questions allow patients to elaborate on responses, provide additional information, and make interviews shorter. "Active listening" involves listening to what is said on multiple levels—how it is said, what is included and what is left out, how what is said reflects the person's culture, personality, mental status, affect, conscious and unconscious motivation, cognitive style, and so on. Acknowledging or repeating the essence of the information shared, whether clinical or emotional, allows the patient to feel understood and provides an opportunity to correct misperceptions. A skilled active listener acquires data quickly and continuously. Like a jazz musician, an active skilled practitioner creates a harmonious flow in sync with the patient's themes, rhythms, and style to enhance the ability of each to contribute to the complex, shifting improvisation of the interview. The experienced listener gives his or her observations the appropriate weight of clear data, hypotheses, or biases. This creates a complex and textured portrait of the patient that can be used in generating hypotheses, crafting replies, giving information, managing affective responses and nonverbal behaviors, and questioning further.

Recent literature on the medical interview runs to more than 50,000 articles, chapters, and books. Although only a modest portion of these are derived from empirical bases, sufficient work has been done to describe the interview's conceptual framework as having "structure" and "functions." Behavioral observations and detailed, reproducible analyses of interviews have related specific behaviors and skills to both structural elements and functions; performance of these behaviors and skills improves clinical outcomes. The following description of essential structural elements and their associated behaviors or techniques, although comprehensive, is not so exhaustive as to be impractical. Key behaviors are summarized in Table 1-3. One comprehensive model of this approach is shown in Figure 1-1.

Preparing the Physical Environment

Architects and designers believe that form follows function. Similarly, how practitioners organize their physical environment reveals core characteristics of their practice: how they view the importance of the patient's comfort and ease; how they want to be regarded; and how they as practitioners control their own environment. Does the patient have a choice of seating? Do both patient and provider sit at comparable eye level? Is the room accessible, quiet, and private? Optimal environments reduce anxiety and instill calm and a sense of well-being.

Preparing Oneself

Humans can process about seven bits of information simultaneously. Given this limitation, it is advisable to consider how many of these bits are consumed by distractions or trivia in a clinical encounter. The hypnotic concept of focus or the recently accepted psychological concepts of centering or flow apply to the clinical encounter (see Chapter 5). Thoughts about the last or next patient, yesterday's mistake, last night's argument, passion, or movie can affect concentration; information and opportunity are lost. In contrast, a focused practitioner, without external or internal distractions, can expect the interview to be a challenging, fascinating, and unique experience.

Achieving a focused state of mind is personal and related to each situation. Nevertheless, successful centering includes: eliminating outside intrusion by beepers and phone calls, tuning out extraneous sound, eliminating internal distraction and intrusive thoughts by resolving not to work on other matters, letting intrusive thoughts simply pass through your mind for the moment, and controlling distracting reactions within the interview by noting them, considering their origins, and putting them aside.

Such skills do not just happen. We teach our residents self-hypnosis; practitioners are routinely and efficiently able to get to a place of heightened, alert, and energetic focus. Using this skill together with the suggestions in Table 1-4, practitioners can enhance the opportunity for something profound to happen in each patient encounter.

Observing the Patient

A great deal can be learned by thoughtfully observing the patient's behavior and body language both before and during the encounter. Although initial behavioral observations are purely heuristic—used to generate testable hypotheses about the patient—non-verbal behaviors can reveal as much about the patient's state of mind as their verbal behavior. Physicians who are unaware of being influenced by initial reactions and observations in the patient interview may note that when they themselves get on a bus or an airplane, they instantly recognize the person next to whom they would prefer—or not—to sit. Such responses integrate multiple non-verbal cues. Similar input from patients relates to their overall health, vital signs, cardiac and pulmonary compensation, liver function, and more. Observations about grooming, state-of-rest, alertness, and style of presentation reveal the patient's self-confidence, presence of psychosis, depression, or anxiety, as well as the patient's personality style, culture or sub-culture, and important changes from prior visits. The physician may also detect signs of possible alcohol or drug use. Escorting patients from the waiting area, letting them walk slightly ahead into the office, allows the physician to observe gait, how patients use their waiting time, companions, and clues to the relationship with companions. Often, especially with new patients, the very first words spoken by the patient may be epigraphic or may foreshadow the encounter.

Maximizing clinical observation skills starts with the commitment to do so. Developing the habit of systematically retaining and integrating initial observations will provide the physician with important data typically overlooked. Asking pertinent questions about behavioral cues will increase observation speed and comprehensiveness. Practicing in crowds, at rounds or lectures, on the airplane, or at parties will help train oneself to become a more astute observer. It is the physician's equivalent of practicing scales on the piano or taking batting practice.

Greeting the Patient

The greeting serves to identify each party, to set the social tone, to indicate intentions concerning equality or dominance, and to prevent mistaken identity. It also allows the practitioner to establish an immediate connection with patients, presenting a confident, compassionate professional the patient can trust. It enables the physician to learn how patients assert their own identity and how to pronounce their names. Using a standard greeting—saying virtually the same thing each time—provides data based on the individuality in a patient's response.

Beginning the Interview

The introductory phase of a medical encounter provides an opportunity for both parties to express their understanding of the purpose and condition of the encounter, to check each other's expectations, and to negotiate differences. For example, the patient may expect to be seen by the head of the clinic, but the physician is only a year out of residency. The patient wants relief from back pain and the practitioner is worried about the high blood pressure of the patient that day. The cardiologist expects the consultation to lead to cardiac catheterization, whereas the patient thinks the cardiologist's opinions will be sent to his primary care physician for a decision. Perhaps, the physician planned a 15-minute visit, but the patient feels an hour is needed.

One of the best predictors of the outcome of a dyadic relationship is concordance of expectations; therefore, clarifying and reconciling these is extremely valuable before proceeding to the main part of the interview.

The beginning of the interview, especially with a new patient, sets the interactional tone (although one can always change tone by changing one's behavior). Although many attempt idle social chat, bland social questions may confuse the professional focus or make the patient feel compelled to present a positive tone. It is useful to consider using a fairly stereotyped beginning, such as "what brings you in to see me today?" (As opposed to "… how may I help you" which prejudges the purpose of the interview).

Detecting & Overcoming Barriers to Communication

Many factors that interfere with communication place even more barriers between the doctor and the patient. Sometimes these are tangible barriers: delirium, dementia, deafness, aphasia, intoxication (patient or physician), or ambient noise. Psychological barriers include depression, anxiety, psychosis, paranoia, and distrust. Social barriers often involve language, cultural differences, and fears about immigration status, stigma, cost of the visit, or legal issues. It is essential to detect barriers early in an encounter. Failure to do so not only wastes time but can seriously and, sometimes, dangerously mislead the physician. For example, residents and students often spend an hour or more trying to extract history from a delirious patient, resulting in an hour lost and highly unreliable historical data. In addition, detecting barriers is the first step toward correction, whether by waiting until delirium or intoxication has cleared, finding a professional interpreter or signer, moving to a quiet place, or deferring difficult issues until trust is established.

Surveying Problems

Patients come to medical encounters with multiple problems and, for various reasons, may not lead with the most pressing issue. Physicians typically interrupt very quickly (18–23 seconds on average). It is of vital importance not to jump in at the first important-sounding problem, but instead to elicit all problems. For example, the physician might ask, "What problems are you having?" or "What issues would you like to work on first?" After getting the initial answer or series of answers, the physician can then ask "… what else?" until the list of problems is completed and mutual priorities are established.

Negotiating Priorities

Once the physician and the patient clearly understand the full set of problems, the physician should then ask, "Which of these would you like to work on first?" If the physician believes that something else is more important, there should be a negotiation about this difference: "Our time is limited today, and I think your shortness of breath is potentially more dangerous than your back pain. Suppose we deal with that first and, if we have time, go on to your back pain. If not, we'll take that up on your next visit."

Appropriate and understandable resentment results when the physician does not ascertain and acknowledge the patient's priorities. This can lead to treatment adherence problems or failure to return to the office.

Developing a Narrative Thread

Once the physician and the patient have decided which problem has priority, exploration of that problem begins. Note the term "exploration." All too often the approaches are either to jump into a review of systems ("do you have rectal bleeding … are your gums bleeding … ?") or to elicit the seven cardinal features of the sign or symptom ("where is it, does it radiate, what makes it better or worse … ?" and so on). The most efficient method is to explore the problem by asking the patient to tell the story of the problem, as in "Tell me about your rectal bleeding." Although many will begin at an appropriate point and move toward the present, some patients may need guidance to begin when the patient last felt healthy, when the current episode began, or when the patient thinks the problem started. The patient may not appreciate the necessary level of detail and may be too inclusive or superficial. It may be necessary to interrupt to indicate a desire to hear more or less about the problem. Clarifying questions shows the patient what is needed and most patients respond with the appropriate level of detail.

Establishing the Life Context of the Patient

Once the narrative thread is established, the physician can take the opportunity to inquire about specific points. It is important to respond at the patient's first mention of psychosocial matters in order to signal to the patient that such matters are as important as biotechnical ones. Such inquiries help the physician learn in detail about the context in the patient's life—spouse, family, neighborhood, job, and culture. When enough information has been supplied, simply saying, "You were saying …" or "What happened next?" returns the patient to the narrative. This approach works because almost everyone knows how to tell a story and remembers key points intrinsically organized by what actually happened.

Creating a Safety Net

Once the problems the patient wishes to discuss have been explored, areas or questions may remain. For these, the physician may choose to ask a series of specific review of systems-type questions. Questions may take the form of the seven dimensions of a complaint, delineated as the location, duration, intensity (use a ten-point scale with zero "no pain at all" and ten "the worst possible pain"), quality, association, radiation, exacerbants, and ameliorants, or a subset of these dimensions. Such final closed-ended questions tie up loose ends and provide the safety of completeness.

Talking During the Physical Examination & Procedures

During the physical examination, there is a tension between the quiet focusing of the senses needed to observe and hear and feel findings and mutually necessary conversation. Practitioners need their senses of smell, sight, touch, and hearing to examine the patient. They need heightened sensory awareness for the encounter. Patients need an explanation of what is being done and what to expect ("this may hurt"), instruction about what to do ("please sit here" … "bring up your knees" … "hold your breath"), and a check on how they are doing and responding ("does this hurt?"). The examination often stimulates the memory of relevant experiences and problems the patient may have forgotten to mention. Some physicians like to explain what is happening in detail ("I am looking in the back of your eye because it is the one place in the body where blood vessels can be seen"). Others do their review of systems during the physical examination. In general, it is wise to minimize distractions during the physical examination or a procedure by confining talk to the task and the needs of the patient. Explanation of findings can be reserved for the end of the examination.

Presenting Findings & Options

After the history-taking and physical examination have been completed, it is time for the physician and patient to discuss what the problems or probabilities appear to be, related findings, the physician's hypotheses or conclusions, and possible approaches to further diagnostic evaluation and treatment. This should be done in language free of jargon and at a level of abstraction the patient can understand.

Bad news includes any information that will change the patient from their idealized self-image to a lesser one. While telling someone she has diabetes may seem routine to a jaded practitioner, to a patient who has heard tough stories about diabetes, or has a relative who died of it, or is simply a fearful person, it is certainly life-altering and might seem disastrous. It is valuable to foreshadow any bad or potentially upsetting news (see Chapter 3). This prepares the patient to hear and retain the information. It may be useful to suggest the patient bring along a trusted companion (although this flags the likely news as bad). When bad news is a certainty, it is useful to record the explanation and discussion for the patient. These days, a digital recorder in the room allows the doctor to provide a copy of the encounter when it ends. The patient can review it after shock has cleared and share it with family or friends. It has been documented that listening to such recordings produces better patient understanding and improves outcomes like quality of life. It is essential not to underestimate the potential impact of both positive and negative findings on the patient. After presenting each item, the physician should explore the patient's understanding and reactions. The presentation itself should be problem-oriented and systematic—and as simple and succinct as possible. Although the dictum is "be brief," necessary content and empathy should not be sacrificed for brevity.

Negotiating a Plan

Once patients have been factually informed of the diagnosis and prognosis, it is crucial to involve them actively in making choices and in developing diagnostic and therapeutic plans. Such "activation" of patients has been shown to increase their adherence to plans and improve their medical outcome and quality of life.

When the physician and the patient disagree in emphasis or choice, negotiation is necessary. The principles of negotiation can be summarized: find and emphasize areas of mutual agreement (e.g., live as long as possible, retain dignity, and avoid suffering), and avoid the adoption of inflexible positions that lead only to conflict, wherein one side or the other loses. If physicians take time to understand patients' positions and respect concerns, the issues can usually be worked out. For example, it can be agreed upon to do a procedure after a grandchild's graduation or to do non-invasive tests first with hope they will suffice.

Closing the Interview

The closing should include: actively reviewing principal findings, plans, and agreements using a talk back or teach back in which the patient is asked to recall what decisions and recommendations have been made, making arrangements for the next visit and giving patient instructions, making sure outstanding issues have been covered, and saying good-bye. In the future, both the physician and patient may review the physician's notes together.

The three functions of the interview are the major purposes of the interview. Each is associated with skills and behaviors that inform the process and outcome. The three functions are as follows:

• Gathering information and monitoring progress.

• Developing, maintaining, and, sometimes, concluding the therapeutic relationship.

• Educating the patient and implementing a treatment plan.

These goals are interdependent. For example, patients cannot be expected to reveal personal or humiliating information until they develop trust in their physician. The physician cannot educate a patient effectively without knowing what level of abstraction, language, and literacy to employ; which concepts to use; how to frame things for clarity; and which formulations will interpose barriers to acceptance. Therefore, the three functions must be integrated and pursued in parallel rather than sequentially.

Function 1: Gathering Information & Monitoring Progress

Many physicians consider information gathering to be the principal focus of the interview. The tasks associated with this function include: acquiring knowledge of the patient's current diseases and disorders as well as psychosocial issues and illness behavior, eliciting data relevant to each problem, and generating and testing relevant hypotheses. Useful skills include: use of open-ended questions such as "Tell me about it" and gradually narrowing the queries down to more specific questions, use of minimal encouragers (i.e., "Uh huh" and "Hmmm") to facilitate flow, gentle use of direction to steer without dominating, and use of summarizing and checking ("I think you have said point a, point b, point c; is that right?").

Function 2: Developing & Maintaining the Therapeutic Relationship

The second function of the interview requires defining the nature of the relationship (short- or long-term, consultation, primary care, and disease–episode-oriented). It requires demonstrating professional expertise; communicating interest, respect, empathy, and support; recognizing and resolving relational barriers to communication; and eliciting the patient's perspective. A relationship that engenders trust and safety is pivotal to being able to gather intimate information and actively involve the patient to make lifestyle changes or difficult medical decisions.

The belief that relationships cannot be improved or manipulated has been disproven by empirical psychotherapy literature. It has been shown that the use of appropriate relationship-building skills significantly improves interview outcomes in terms of satisfaction, compliance, data disclosure, quality of life, biological outcomes, and personal growth. These issues are particularly germane in cases involving mental disorders, where skill in managing the patient in a manner compatible with healing is essential.

In general, naming feelings, communicating unconditional positive regard, expressing empathy and understanding, and being emotionally congruent (what you say is actually what you mean and feel) produce the best outcomes. Other skills include reflection, legitimization, partnership, nonverbal skills of touch and eye contact, use of open posture, and avoidance of shame or humiliation (see Chapter 2).

Function 3: Educating the Patient

Patient education and implementation of treatment plans require: an awareness of the patient's level of knowledge, understanding, motivation and cognitive style; a receptive patient who is neither in shock nor disagreement; and the use of plain language that avoids jargon or undue complexity. The tasks associated with this function include: communicating the diagnostic significance of the problems; negotiating and recommending appropriate diagnostic and treatment options, appropriate prevention and lifestyle change recommendations; and enhancing the patient's coping ability by understanding and communicating the psychological and social impacts of the illness. Involving the patient in choices, clarifying uncertainties, and eliciting fears and concerns markedly improve outcomes. Having the patient actively review what has been discussed and decided upon (use of a teach-back or talk-back) is critical to check for understanding and to reinforce memory, thus maximizing the likelihood that the patient can and will do what has been agreed upon (see Chapter 20).

In some cases, the issue is a high-risk health behavior, habit, or addiction such as overeating, smoking, gambling, or medication nonadherence. Two approaches have been demonstrated to be helpful in such situations: (1) the stages of change model and (2) motivational interviewing (see Chapter 19).

A "Stages of Change Model" described by Prochaska and DiClemente involves ascertaining the patient's readiness for change stage and adapting one's interaction to the patient's stage. Stages assess whether patients have begun to think about changing behavior (precontemplative vs. contemplative). If they have, then it is appropriate to move forward with an action plan by setting key milestones such as a quit date for smokers. A plan includes discussion of barriers and how to respond when relapse occurs. Acceptance of the notion that change may involve several cycles that eventually lead to success unloads the weight and shame of the common first failures, reframes them as learning experiences, and may improve the likelihood and stability of eventual success (see Chapter 19).

Motivational interviewing, developed by Miller and Rollnick, is a directive, patient-centered counseling approach designed to motivate people for change by helping them clarify goals, explore perceived barriers to behavior change, and commit to such changes. Motivational interviewing has been used widely for health behavior change in areas such as adherence to behavioral weight control programs, dietary and medication adherence, fruit and vegetable intake, and physical activity. Providing objective feedback about behaviors, acknowledging beliefs, minimizing control, and offering behavioral alternatives have been shown to increase patient self-efficacy and intrinsic motivation to adopt recommended health behaviors. Developed initially for use with addictive behaviors, it uses reflective listening to reframe patients' resistance as self-motivational statements by using such devices as the "readiness ruler," which asks the patient to rate on a scale of 1 to 10 (10 highly and 1 very little) how motivated he or she is to modify behavior. Even if the patient ranks motivation to lose weight at 2, leverage can be gained by asking, "Why wasn't that a 1?" and building on whatever slim reeds of motivation are there. In this way, the approach subtly shifts the physician–patient encounter from confrontation to partnership.

Although the preceding principles are applicable to most situations, some circumstances require a modified approach to maximize the usefulness and durability of the interview. Early detection of special situations is crucial, so that appropriate changes in technique can be made. Most special situations require meticulous attention to the particular needs of the patient; for example, with a paranoid or psychotic patient.

Aids to Diagnosing Mental Disorders

There are a variety of tools to diagnose and monitor mental disorders. The simplest aids have relatively high sensitivity (they detect most cases) but lower specificity (they pick up cases that do not meet diagnostic criteria). Screening devices for depression include the Patient Health Questionnaire-9 (PHQ-9), Beck, Zung, and Hamilton scales. The PHQ-9 is a nine-question quantitative scoring method with an abbreviated two-question (PHQ-2) screen. It is useful for depression in primary-care settings (see Chapter 25). Some physicians administer these with the packet of materials to be filled out prior to each initial visit. As with any questionnaire, however, these carry the time-consuming burden to evaluate false positives. The Primary Care Screen for Mental Disorders (PRIME-MD) was developed (with pharmaceutical company support) to screen for common mental disorders. Reasonably sensitive and specific, it is available for telephone use and for computerized administration. However, empathic physicians have two problems with its use: the program asks about feelings but cannot respond and scoring takes several minutes. The role for these screening adjuncts is still evolving.

When the Patient Uses Another Language or Is From Another Culture: Using Interpreters and Eliciting Explanatory Models

Everywhere in the United States, practitioners frequently encounter patients whose first or only language is not English and who adhere to cultural beliefs, which may be divergent from the practitioner's own. As a result, patients' health-related–behaviors are tied more closely to their own health beliefs than to their physician's advice. Kleinman, Leventhal, and others define a patient's health beliefs, or explanatory model, as the conceptual and behavioral framework patients develop to understand the cause of an illness, its likely course, the meaning of specific symptoms, and the implications of these for treatment and recovery. Patient explanatory models tend to be rooted in the experience of their social network, family, ethnicity, and culture, thus reflecting the way people think about their world, themselves, and their health. Physician explanatory models reflect professional ideologies grounded in their medical training (see Chapter 15). For many patients, health beliefs and values intersect with language and acculturation to form a context of experience and expectation discordant from the biomedical model of disease. Patients whose cultural setting is in transition may be confronted with the need to reconcile (or make sense of) the differences between health beliefs that were commonly held in their original culture and the new ones of their current setting. Table 1-5 provides a question set to elicit a patient's health beliefs. Practitioners need to assess patients' salient health beliefs in order to be sure that their teaching, recommendations, and negotiations are not doomed to failure because the patient's cultural beliefs and values suggest that they are contraindicated or irrelevant. Asking about health beliefs enables one to understand them, adjust one's discussion to reflect and respect the patient's cultural concepts and language, and attain mutual agreement consistent with both patient's and physician's belief systems.

The issues of explanatory model differences virtually always apply when the patient is using another language (akin to the Sapir–Whorf hypothesis which postulates that language inextricably influences and guides the attitudes, cultural beliefs, and views of the user). They are magnified by interpreter variability and bias. In general, use of interpreters introduces the likelihood of errors and misunderstandings. A tight control of interpreter use standards is essential. Where possible, an interpreter should be a professional. Use of a friend or family member raises issues of accuracy and privacy. Remote simultaneous interpretation has the advantages of speed, anonymity, and less adventitious relationship building compared to telephone support or a person in the room. An interpreter in the room should be positioned behind the patient or out of the patient's sight line to keep the focus between doctor and patient. Interpreters should provide literal translation, not rephrase, or become cultural brokers; however, they can be prompted to let you know when a cultural issue is perceived. Principles and standards of interpretation have been defined by the National Council on Interpreting in Health Care (see website below).

Electronic Technology: Gateway or Barrier to Effective Communication?

In today's society, electronic technologies are ubiquitous and becoming increasingly central to daily functions including the medical encounter. With more around the corner, three technologies have already achieved significant presence in the medical encounter: the computer and its associated electronic health record (EHR), the telephone, and electronic communication with patients, such as secure messaging by e-mail. Technologies such as telemedicine and telesurgery may soon allow physicians to practice remotely. Predictably, they evoke conflicting sentiments. Promoters and marketers claim that electronic technology provides greater quality, efficiency, cost-effectiveness and satisfaction. Detractors claim loss of warmth and touch, depersonalization, detraction from patient-centeredness, wasted time, heightened rigidity in practice, and unjustified costs.

The public (i.e., patients), generally likes technology, finds computers easier or safer to "talk" with than practitioners, and accepts technologies as inevitable and related to quality. Physicians may resist most changes and salutatory shifts, such as moving from a paper to an EHR. Consternation is followed by ambivalent acceptance. Practitioners commonly agree that on the one hand, EHR use enhances legibility, completeness, sharing of records, and data organization. On the other hand, it slows the encounter and divides the attention between the patient and computer display. Computers magnify the positive and negative attributes of a physician's communication skills. In general, with a computer in the room, practitioners shift away from patients' psychosocial issues and from patient participation and relationship-building in the medical encounter to a more physician-dominated biomedical information giving, history taking, and attention to computerized note taking. An increase in computer use is also associated with longer medical visits, less dialogue between patient and physician, and lower emotional responsiveness by the physician. How much these impacts alter patient outcomes remains to be proven. So, beware of extravagant claims.

Nevertheless, certain computer-related behaviors seem sensible and can enhance the medical encounter, if utilized properly. First, EHRs can allow physicians to prepare for the visit prior to the patient's entry, saving time during the interview searching for data. Second, with increasing experience (and commitment), physicians can alternate between talking directly to the patient, with good eye contact and open posture, and making explicit breaks to use the EHR for data entry ("I'm sorry, I need to take a minute to …"). Third, physicians can use natural breaks in the encounter, such as when the patient is changing or at the end of the visit, for the majority of typing or dictating using voice recognition software. Fourth, physicians can choose to share the screen to enhance collaboration by sharing lab results, providing patient education and showing useful images (where the pathology is, what the procedure will do, dietary portions, etc.). Physicians should avoid typing while the patient is talking, since nonverbal cues will be missed and patients will often interpret too great a focus on the computer as a sign of not caring.

An important, recently completed large scale study (OpenNotes) examined the impact of sharing EHR records with patients. Preliminary findings indicate that such transparency helps patients feel more in charge of their care, promotes increased adherence to treatment plans, reduces content errors, shifts the patient–physician relationship toward greater trust and partnership, and has little adverse impact on the physician's work life. It will take time, however, to understand if and how sharing visit notes affects outcomes and the efficiency of care.

The telephone is not new; it remains a core means of contact between physician and patient, accounting for as much as 25% of interactions. Use of telephones has extended beyond requests for prescription refills and lab results. Phones are now used by practitioners for reminders, monitoring chronic care, delivering manualized treatments, screening, and data transmission from in-home instruments. Cell phones extend access further, including texting and image-sharing capabilities. Phone answering systems are now emblematic of depersonalization, with patients and physicians frustrated by attempts to reach practitioners behind the unbreachable, automated moat of "please listen to the following options, as they have changed."

Talking with a patient on the phone is rather like looking at a photograph in black and white instead of color. The phone (although it may soon include video) removes the ability to observe nonverbal cues (including lip reading) and forces both parties to listen more, making it possible to hear more. This a-visual quality can be beneficial, especially with patients whose physicality is distracting, but it may be at the expense of nonverbal cues.

While patient acceptance of and satisfaction with e-mail is high, use of e-mail between physicians and patients remains low. Patient barriers include literacy, computer access, language (if discordant), and comfort with writing skills. Physicians resist e-mail out of fear that it will become intrusive, pose a nonreimbursed time sink, be mistaken for real contact in an emergency, enable patients to avoid reimbursable visits, deny the opportunity for verbal interaction and physical examination, and make the physician accountable 24/7 with a permanent written record. However, many of these perceptions are unfounded. The majority of patients sends an average of one e-mail per day and perceives their physician to be more accessible and informed of their individual health-care needs when e-mail is used. More importantly, e-mail messages do not totally eradicate the psychosocial and emotional quality of communication. Patients display higher levels of engagement and attentiveness to detail in their e-mail messages than in actual visits. Most physicians have a tendency to exhibit curtness on e-mail, with a majority of the content focused on information giving. As a consequence, it is easier to forget to match language level with the patient when writing in a medium most often used with peers.

E-mail communication must follow the Health Insurance Portability and Accountability Act (HIPAA) of 1996 guidelines. Patients should be aware of the risks associated with e-mail and informed how confidentiality and privacy will be ensured. Each patient should consent to e-mail use and that consent should be recorded. E-mail should be encrypted. The AMA has published guidelines for e-mail usage.

The medical interview is the most commonly used diagnostic and therapeutic procedure in medicine. As such it deserves continued attention and skill enhancement throughout a clinician's professional career. The quality of the clinician–patient encounter, patient satisfaction, the accuracy and completeness of data, patient adherence to treatment regimens, health outcomes, and clinician satisfaction are all influenced by a skillful approach to the medical interview. Attention to both the structure and functions of the interview provides a framework for developing mastery in this most central clinical procedure. It also will ensure that the core relationship between physician and patient remains at the center of all advancements in medicine, including the new technologies of electronic communication and information management.