Patient-Centered Interviewing: An Exercise in Evidence, Empathy, and Engagement
Communication can play a key role in bridging the gap between evidence-based and patient-centered medicine, both in clinical practice, and in clinical science.
During one of my first years of teaching communication skills, we were going to interview an elderly male patient in a small group teaching session for medical students. The setting was an Internal Medicine ward at our University Hospital. The student assigned to conduct the interview, let us call him Tom, told us that he had a question before starting talking to the patient. “Go ahead.” I said. “What do you want to know? Tom looked at me and posed a question which has had more impact on my thinking on communication skills training than any other utterance over all these years. Tell me, Tom said, are we going to interview the patient the way we have learned in your class or the way it is done in real life?
It was a relevant question. It pointed to one of the classical dilemmas of communication skills teaching in medicine, the gap between communication skills as taught in training sessions and those that are actually practiced. The student had learned a patient-centered communication style in our classes, with an emphasis on exploring the patient’s own perspective and on meeting patient emotions with explicit empathy. Patient-centered communication was well established, even when this episode occurred in the 1990s. As early as 1984, the Association of American Medical Colleges proposed that “every effort should be directed at developing and enhancing a patient-centered humanistic attitude in medical students.”2
The first edition of the present textbook, published in 1996, was one of the main influential books in promoting a patient-centered approach in medical schools in the United States and abroad, such as for instance our medical school in Oslo, Norway. Since then, principles of patient-centered, relationship-centered,3 and person-centered care4 have become dominant in teaching of communication in most medical schools.
Another question is to what extent a patient-centered approach really has been implemented into everyday clinical care. There is some evidence that we have seen fewer changes in the communication style of physicians in general than could be expected from reading the research literature. Jozien Bensing and her colleagues in Utrecht in the Netherlands have a unique opportunity to monitor trends over time in medical communication behavior. They have over more than 30 years built up a huge data base of thousands of video-taped consultations, and have in a series of studies examined changes in communication style of doctors from the 1970s and 1980s on to 2008.5,6 For instance, they found that while physicians tended to pay more attention to psychosocial issues over time, consultations did not become more patient-centered. The researchers concluded that over time consultations had become more focused on task-oriented communication and less on showing empathy.5,6 In an American study, cancer survivors’ experience of their relationship with their physicians was studied in course of a smaller, but more recent, time span (from 2007 to 2013). There was a trend that ratings of patient-centered communication improved over time, but not significantly when other variables were controlled for. The authors concluded that many survivors continue to report suboptimal communication with their health care providers.7
The gap between a conventional doctor-centered communication and patient-centered communication illustrates a more general conflict in modern health care. Patient-centeredness is threatened not only from old conventions of paternalistic communication but also of trends in modern medicine. We witness an increasing complexity, with an emphasis on medical super-specialization and highly developed medical technology within an organizational context with increasing pressures on cost effectiveness. In this way, health care may function in a rather fragmented way.8 Questions have been asked if these developments may jeopardize basic humanistic values of medicine and the primacy of the clinician–patient relationship as the cornerstone of health care.9
To sum up: the trend toward patient-centered medicine is threatened by two different opposing forces, on one hand the old traditions of paternalistic medicine and on the other the trends of fragmentation of care. Unfortunately, Tom, the medical student, may still be right to some extent. There is still a discrepancy between what we teach and what doctors actually do.
The integrated consultation and the two levels of patient centeredness
How can we bridge the gap between ideals and realities in clinical communication practice?
One of the main qualities of the first edition of the present textbook when it first appeared under the title The Patient’s Story in 1996 was the emphasis on integrated interviewing. This is a major principle of Smith’s approach to medical interviewing. In many medical schools, courses in communication skills are often separated from basic courses in history taking and physical exams. One of the strengths of Smith’s approach is the consistent emphasis on integration. The integrated interview blends the biomedical emphasis on the disease with a systematic attention to the patient’s perspective, the patient’s story. Both these aspects are essential in all phases of the interview.
The patient-centered consultation is a fully integrated consultation in which a biomedical attention to the disease is combined with an adequate exploration of the patient perspective and a calibration to the patient’s preferences and needs. However, it is somewhat confusing that the term “patient-centered” is used both for the whole integrated consultation and for one of the elements, the patient-centered skills that are applied to elicit the patient’s perspective. It may appear inconsistent, but this terminology underscores the point that in order to provide truly patient-centered care you have to provide a combination of skills in which doctor-centered skills are blended with more specific patient-centered skills.
This distinction between patient-centered approach and specific patient-centered skills is important. Patient-centeredness as a general approach has a normative component. The core value of patient-centered communication is to be attentive and receptive toward the patient and to tailor communication and treatment to patient needs. Patient-centered communication does not mean to employ a specific set of communication skills. There is no one size-fits-all in communication. It is always right from a professional and ethical point of view to tailor communication and treatment to the patient’s needs. Specific patient-centered skills, however, are merely means to reach a goal. A skills approach is very fruitful in teaching communication, but skills may be used in different ways and to different ends, depending on the patient’s needs. Hanneke de Haes has discussed this dilemma in an interesting article.10 She pointed out how specific patient-centered skills may not necessarily correspond to patient needs and preferences. A truly patient-centered approach is characterized by the tailoring of communication to the patient, not by inflexible adherence to specific skills.
Interestingly, research on patients’ trust in physicians does not emphasize the importance of a fixed set of skills. The sense of “being taken seriously” is often found as the most important criterion for patients’ trust in doctors,9 often in combination with patients’ perception of the doctor’s competence in technical skills.10 Such findings highlight the emphasis on the integrated interview, a combination of patient-centeredness and technical competence is important to prevent the split observed by Tom, the medical student in our little story above.
Evidence, empathy, and engagement
So what are the hallmarks of a patient-centered approach to interviewing, of an integrated interview tailored to the needs of the patient? I shall briefly point to three important qualities: a solid base in evidence, emphasis on empathy, and promoting patient engagement.
Evidence. Evidence-based medicine is an important principle in modern medical science and health care. In a seminal paper published some years ago, Jozien Bensing suggested that evidence-based and patient-centered medicine represented the two most important paradigms in modern medical care. She pointed to a gap between the two models.1 While evidence-based medicine traditionally represents a positivistic approach with a basically biomedical perspective, the patient-centered approach developed as an alternative to the biomedical model, based on humanistic values and principles, rather than evidence. Bensing pointed to a need to bridge the gap between the two paradigms and suggested that communication skills are important in overcoming the split.
I suggest two ways to bridge the gap between evidence and patient-centeredness in the medical interview. First of all, in the integrated interview, biomedical evidence plays an important role in its own right. Teaching communication skills should include teaching students how to use their biomedical knowledge in history taking and diagnostic reasoning. Moreover, in giving information and negotiating treatment decisions the doctor must know how to convey and explain medical evidence to patients.
Second, several of the principles of integrated interviewing within a framework of basic patient-centered principles are increasingly being based on emerging evidence. Evidence-based medicine is not any longer limited to a strictly biomedical understanding of disease. For instance, Smith and colleagues have argued how research on medical interviewing has an important role in developing a knowledge base for the biopsychosocial model.11 This attitude is central to the present textbook, and reflected in the subtitle of the book “an evidence-based method.”
Empathy. Medical consultations are often quite emotional affairs. However, emotions are most often expressed implicitly, in terms of more or less subtle cues to underlying emotions, often missed by the physician.12 Sensitivity to cues is important in order to realize the emotional state of the patient. A subtle cue may be the first element in a sequence including a gradual buildup to a more explicit emotion, hopefully an empathic response by the physician, and sometimes with a continued exchange related to the emotional concern before a more or less abrupt topic change.13
One of the strengths of Smith’s approach to interviewing is the emphasis on emotional communication and on empathy as an integrated skill of the medical interview. There is increasing evidence that an active acknowledgment of patients’ concerns as advocated in this textbook may have surprisingly strong impact on outcome variables. A number of studies have found that empathic communication in medical consultations are associated with better patient satisfaction and adherence, less distress and better coping and quality of life,14,15 and even physiological parameters, for instance for patients with diabetes.16 These and other studies are excellent examples of the bridging of the gap between patient-centeredness and evidence.
Engagement. An interesting and important development that has taken place since the first edition of Smith’s textbook came out in 1996 is the increased emphasis on patient engagement in medical care, reflected in terms such as empowerment, patient participation, and patient engagement. All these terms are in a way cousins of the term patient-centered, but with a special emphasis on the active patient. In a number of recent papers in Patient Education and Counseling, these engagement-oriented terms have been discussed.17 Patient Empowerment is less specifically related to health care, more to the individual process of taking responsibility for one’s own health.18,19 Patient Participation is a rather broad term, often related to active engagement and partnership and decision making in health care.20 The term Patient Engagement is also often applied in literature on shared decision making. In this last edition of the present textbook there is a strong emphasis on engaging patients in shared decision making, more so than in the first edition, reflecting the increasing emphasis on shared decision making in the last 15 years. But patient engagement goes beyond decision making. Graffigna et al.21 describe patient engagement as a process from passivity and denial in relation to illness and health to an active and committed stance, from “I am in a blackout” to “I am a person.”
In a conceptual paper on patient engagement, Higgins et al.22 pointed to four important attributes of the concept. One of them is the individual patient’s personal commitment, including cognitive and emotional factors to participate in treatment activities. From the first edition on, this aspect of patient engagement has been strongly emphasized in the present textbook. But promoting the patient’s commitment to change must be anchored in an exploration of the patient’s perspective. A successful engagement may have to be based on a sincere acknowledgment of the patient’s emotions. In the integrated interview, all elements are parts of an integrated whole.
Hopefully, the principles of the integrated, patient-centered interview will gradually become standard practice in health care. Hopefully, medical students such as Tom will someday find that the patient-centered skills they learn in medical school are actually the same as those they observe “in real life.”
Department of Behavioral Sciences in Medicine
Institute of Basic Medical Sciences
University of Oslo, Norway
Patient Education and Counseling
Bensing J. Bridging the gap: the separate worlds of evidence-based medicine and patient-centered medicine. Patient Educ Couns
Association of American Medical Colleges: physicians for the 21st century: report of the Project Panel on the General Professional for Medicine (GPEP Report). Washington, DC: Association of American Medical Colleges; 1984.
Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med
Mezzich J, Snaedal J, Van Weel C, Heath I. Toward person-centered medicine: from disease to patient to person. Mt Sinai J Med
Butalid L, Bensing JM, Verhaak PFM. Talking about psychosocial problems: an observational study on changes in doctor-patient communication in general practice between 1977 and 2008. Patient Educ Couns
Butalid L, Verhaak PFM, Bensing JM. Changes in general practitioners’ sensitivity to patients’ distress in low back pain consultations. Patient Educ Couns
Blanch-Hartigan D, Chawla N, Moser RP, Finney Rutten LJ, Hesse BW, Arora NK. Trends in cancer survivors’ experience of patient-centered communication: results from the Health Information National Trends Survey (HINTS). J Cancer Surviv
Miller BF, Hubley SH. The history of fragmentation and the promise of integration: a primer on behavioral health and primary care. In: Maruish ME, ed. Handbook of Psychological Assessment in Primary Care Settings. 2nd ed. New York, NY: Routledge; 2017:55–74.
Finset A. Patient education and counseling in a changing era of health care. Patient Educ Couns
de Haes H. Dilemmas in patient centeredness and shared decision making: a case for vulnerability. Patient Educ Couns
Smith RC, Fortin AH, Dwamena F, Frankel RM. An evidence-based patient-centered method makes the biopsychosocial model scientific. Patient Educ Couns
Zimmermann C, Del Piccolo L, Finset A. Cues and concerns by patients in medical consultations: a literature review. Psychol Bull
Mellblom AV, Korsvold L, Ruud E, Lie HC, Loge JH, Finset A. Sequences of talk about emotional concerns in follow-up consultations with adolescent childhood cancer survivors. P Patient Educ Couns. 2016;99(1):77–84.
Neumann M, Scheffer C, Tauschel D, Lutz G, Wirtz M, Edelhäuser F. Physician empathy: definition, outcome-relevance and its measurement in patient care and medical education. GMS Z Med Ausbild. 2012;29(1):Doc11.
Derksen F, Bensing J, Lagro-Janssen A. Effectiveness of empathy in general practice: a systematic review. Br J Gen Pract
Canale SD, Louis DZ, Maio V,
et al. The relationship between physician empathy and disease complications: an empirical study of primary care physicians and their diabetic patients in Parma, Italy. Acad Med
Finset A. Patient participation, engagement and activation: increased emphasis on the role of patients in healthcare. Patient Educ Couns
Malterud K. Power inequalities in health care—empowerment revisited. Patient Educ Couns
Funnell MM. Patient empowerment: what does it really mean? Patient Educ Couns
D’Agostino TA, Atkinson TM, Latella LE,
et al. Promoting patient participation in healthcare interactions through communication skills training: a systematic review. Patient Educ Couns
Graffigna G, Barello S, Bonanomi A, Lozza E. Measuring patient engagement: development and psychometric properties of the patient health engagement (PHE) scale. Front Psychol
Higgins T, Larson E, Schnall R. Unraveling the meaning of patient engagement: a concept analysis. Patient Educ Couns