In an important series of research and conceptual papers in the 1970s and 1980s, George L. Engel expanded the centuries old (and very successful) biomedical model by demonstrating the importance of psychological and social factors in disease and illness and how these factors affect care processes and outcomes. While patients continue to be understood partly in biological terms, the biopsychosocial (BPS) model underscores the importance of the medical interview in diagnosis, treatment, and therapy by integrating the psychosocial dimensions of the patient and their experience of illness.1–3 Based on General System Theory,3–5 Engel argued that the BPS model could simultaneously make medicine more scientific and more humanistic by incorporating elements of self- and situation/contextual awareness to the interview process.
Shortly after Engel described the BPS model and under the influence of the psychologist Carl Rogers and others,6 Joseph Levenstein, Ian McWhinney, and colleagues7,8 proposed the general concept that clinicians become “patient-centered” in their interviewing approach. Recommendations for patient-centered interviewing included suggestions that the clinician follow the patient’s lead and interests to reach common ground and uncover important psychosocial issues relevant to their care. Other suggestions included inquiry that avoided interruption, and the use of open-ended and nondirective questions. The patient-centered method differed from the standard “clinician-centered” approach that used closed-ended, clinician-directed questions to diagnose and treat diseases. It also differed by asserting that the personhood of the clinician and the patient was key and grounded the relationship in a communication-based conversational context. While the role and expectations of each differed, the biopsychosocial model stressed the importance of mutual influence and reciprocity in building and maintaining healthy, healing clinician–patient relationships.
Wide dissemination of patient-centered practices was promoted by the Academy of Communication in Healthcare (ACH),9 EACH—International Association for Communication in Healthcare,10 and the Institute for Healthcare Communication,11 as well as by many other groups including several primary care organizations. Medical schools, accreditation groups, and governing boards embraced BPS/patient-centered ideas and sought to implement them. In 2001, the Institute of Medicine identified patient-centered care as one of six domains of quality, thereby establishing the concept as a key to patient safety and effective, efficient care.12
Teachers, scholars, and researchers moved the BPS field rapidly ahead in many areas to provide initial scientific support for the BPS model. But many, including Engel13 and several authors of this book,3 noted that a specific definition of the patient-centered interview and explicit directions for its practice were lacking,8,13–22 limiting research and teaching23,24 and producing variable, sometimes contradictory, recommendations.15,18–20 Scholars warned that researchers and learners needed to know exactly what to say, with behaviorally defined patient-centered skills broken down into specific, definable components.15,21,22 Research based on this approach demonstrated that well-defined methods produced flexible, skilled students and clinicians able to understand the unique personal and social aspects of their patients.15,25,26 In addition, virtually all educational experts endorsed specific behavioral models for teaching any complex topic,17,21,27–34 and there is no more complex topic in medicine than the interview.
The Michigan State University (MSU) group, under the direction of this text’s original author,35,36 Robert C. Smith, developed a behaviorally defined, replicable patient-centered method based on empirical evidence,25,26,33,37 literature review, consultation with others, and their own experiences. The result was the 5-step, 21-substep method presented in Chapter 3. In a randomized controlled trial (RCT), the MSU group demonstrated that the method was easily learned, efficient, and replicable.25,26 In a subsequent RCT, using the approach as part of treating patients with medically unexplained symptoms, they demonstrated clinically significant improvement in multiple measures of patients’ health status and very high levels of patient satisfaction.37 A subsequent pilot RCT corroborated these findings.38 The 5-step patient-centered method became the first comprehensive, behaviorally defined, evidence-based method for teaching and learning the medical interview. In a typical outpatient encounter, no more than 3 to 6 minutes of patient-centered interviewing is necessary (additional time is needed for clinician-centered interviewing). Others have demonstrated that patient-centered practices do not add time to the visit.39
Our goal in this text is to present in a logical, step-by-step fashion the behaviors that are necessary to conduct an effective and efficient patient-centered interview. Interviewing is the most important and most difficult skill learners must master in their clinical careers. The book is designed for learners in medicine, advanced-practice nursing, physician assistant, and other health-related disciplines where communication and relational skills are central. We have discovered from feedback on previous three editions of the book that learners and their teachers have particularly valued two unique features of the approach. First, the 5-step method is very user-friendly and easily learned. Historically, learners and teachers using the method have been pleased with the structure provided. Users report that they typically learn the basic skills in one session and the requisite interviewing steps in the next two teaching sessions and progress rapidly thereafter. Teachers comment, for example, that the method is “more substantive” and “less diffuse” than other approaches. Learners with prior interviewing training say things like “now I see how this all fits together.” Both learners and teachers have commented on their increased ability to track progress and confidence in skills. Second, teachers using the method report that it fosters both the interviewer’s and the patient’s individuality—greatly enhancing the humanistic dimension for each, as shown by the research also.26,40,41
In this new fourth edition, an additional author, Brenda Lovegrove Lepisto, PsyD, has joined Drs. Fortin, Dwamena, Frankel, and Smith. All five authors are long-time members of the ACH and have benefited from the support provided to them by the organization over many years. As our way of recognizing this important organization, all royalties from the sale of the book will go to support the ACH and its activities. Another ACH product, DocCom, a multimedia, web-based curriculum resource providing expanded coverage of a wide variety of interview types and situations, is cross-referenced to the text. It is available at www.doccom.org.
Importantly, McGraw-Hill is making available an Instructor’s Teaching Supplement and Companion Videos at no additional cost at www.accessmedicine.com/SmithsPCI. The Teaching Supplement is designed expressly for teachers conducting training in interviewing, while the videos are designed for both teachers and learners. Based on recent research, we have added measures teachers can use to evaluate learners’ mastery of patient-centered interviewing: (1) a coding scheme by which they can directly evaluate patient-centered practices and (2) a patient satisfaction questionnaire by which patients can evaluate their interaction with the interviewer.42,43
The McGraw-Hill AccessMedicine website continues to present three videos available with the third edition: Building Efficiency and Effectiveness Through Patient-Centered Interviewing; Clinician-Centered Interviewing; and Patient-Centered Interviewing. The latter two are long, hour-length videos providing detailed demonstrations of all parts of the medical interview. Newly prepared for this edition, the AccessMedicine website now also contains seven brief (2–5 minutes) videotape demonstrations of unique, sometimes difficult interviewing situations: New Inpatient Interview; Follow-up Inpatient Interview; Acutely Ill Patient; Patient with a Mental Health Disorder; How to Interrupt; Follow-up Outpatient; and Using the Electronic Health Record. The seven recent videos are conducted by medical residents to provide learners with a better approximation of themselves. All 10 videos are cross-referenced in the textbook. All videos can be found at www.accessmedicine.com/SmithsPCI.
We have reformatted the text and added more graphics to enhance learning. Each chapter and its references have been revised and updated. The text works best when used in the order presented. Chapter 1 (The Medical Interview) orients the learner to interviewing and the BPS model, provides necessary background material, and presents an overview of integrated patient-centered and clinician-centered interviewing. Chapter 2 (Data-Gathering and Empathy Skills) describes the requisite individual skills needed for interviewing. These are synthesized in Chapter 3 (The Beginning of the Interview: Patient-Centered Interviewing) as the patient-centered process of integrated interviewing; this chapter presents the basic patient-centered infrastructure of the medical interview. Chapter 4 (Symptom-Defining Skills) outlines the requisite skills needed for clinician-centered interviewing. These are then synthesized in Chapter 5 (The Middle of the Interview: Clinician-Centered Interviewing) as the clinician-centered process of integrated interviewing; this chapter presents the basic clinician-centered infrastructure of the medical interview. Chapter 6 (The End of the Interview) presents the patient-centered treatment process; it describes how to present information to patients and motivate them for behavior change when necessary. Chapter 7 (Adapting the Interview to Different Situations and Other Practical Issues) addresses more advanced interviewing issues, especially fine-tuning one’s interviewing skills in widely varied circumstances. Chapter 8 (The Clinician–Patient Relationship) addresses advanced interviewing issues concerning the clinician–patient relationship, with a focus on interviewer personal awareness, patient personality styles, and nonverbal communication. Chapter 9 (Summarizing and Presenting the Patient’s Story) describes how interviewers synthesize the information obtained from the patient and, in turn, present it to others verbally and in writing. Chapter 10 (Remaining Patient-Centered in the Digital Age) is a new chapter describing how to remain patient-centered while using the electronic health record. Appendix A is Dr. George L. Engel’s foreword to the first edition. Appendix B provides the research and humanistic rationale for being patient-centered. Appendix C provides examples of feelings and emotions. Appendix D introduces a complete write-up of the case of Ms. Jones (presented throughout the text) as an example of the interviewing process. Appendix E presents the mental status evaluation.
We intend the book for use in all phases of training. Chapters 1 to 3 (basic patient-centered interviewing) are typically taught first. Chapters 4 and 5 (basic clinician-centered interviewing) usually are taught a year later or later in the same year. Chapter 6 (patient education) requires expertise with the preceding chapters and usually is presented in clinical years, although sometimes introduced sooner. Chapters 7 (adapting the interview to many different situations) and 8 (the clinician–patient relationship) follow and, while sometimes introduced with earlier chapters, are designed to be used later in training, often for advanced interviewing experiences during clinical training. Chapter 9 (presenting the patient’s story verbally and as a write-up) is taught during students’ clinical years. The book ends with Chapter 10 (remaining patient-centered while using the electronic health record), and it is designed for use in clinical years. Training graduate learners and learners outside medical/nursing professions typically does not involve Chapters 4, 5, and 9, either because learners are already familiar with this material or because interviewing for disease diagnosis is not part of their discipline. Other chapters are relevant to all learners.
We hope you find the fourth edition of Smith’s Patient-Centered Interviewing to be an exciting and helpful guide to becoming a complete medical interviewer and clinician. We wish you Godspeed on your biopsychosocial journey of becoming a health care professional committed to caring for your patients.
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