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Chapter 3: The Beginning of the Interview: Patient-Centered Interviewing

INTRODUCTION

The doctor may also learn more about the illness from the way the patient tells the story than from the story itself. (1861–1954)

James B. Herrick, MD

This chapter describes a user-friendly step-by-step method for the beginning of the medical interview that has been effective in many hands for more than 25 years.1–9 Your first task is to master the 5 steps and 21 substeps shown in Table 3-1. We urge you to learn these thoroughly, to the point that they become reflexive—this is easily accomplished by studying and then practicing them. Even though this may seem like a lot to learn, just as you learn the intricacies of cardiac physiology, this is your major task in mastering the medical interview. Using these steps and substeps will make you a more scientific and more humanistic physician—and your patients will benefit (see Appendix B for a detailed humanistic and scientific rationale for being patient-centered). To assist you, we also have developed a video that demonstrates the same skills described here: www.accessmedicine.com/SmithsPCI (see Preface). (See AccessMedicine video titled “How to Interrupt”: www.accessmedicine.com/SmithsPCI.)

TABLE 3-15-Step Beginning of the Interview
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TABLE 3-1 5-Step Beginning of the Interview

Step 1: Set the stage for the interview (30–60 s)

1. Welcome/greet the patient

2. Use the patient's name

3. Introduce yourself and identify specific role

4. Ensure patient readiness and privacy

5. Address barriers to communication (sit down)

6. Ensure comfort and put the patient at ease

Step 2: Elicit chief concern and set agenda (1–2 min)

7. Indicate time available (e.g., “We've got about 20 minutes together today …”)

8. Forecast what you would like to have happen during the interview (e.g., “… and I see that we need to review the blood tests you had done yesterday, …”)

9. Obtain a list of all issues patient wants to discuss; specific symptoms, requests, expectations, understanding (e.g., “… but before we do that, let's make a list of the things you wanted to discuss today.” “Is there something else?” “What else?”)

10. Summarize and finalize the agenda; negotiate specifics if too many agenda items (e.g., “You mentioned 8 things you were hoping to cover. In the time we have together today, I don't think we can address them all. Can you tell me which one or two are most troublesome for you; we'll do a good job with those and I'll see you back soon to work on some of the others.”)

Step 3: Begin the interview with nonfocusing skills that help the patient to express her/himself (30–60 s)

11. Start with open-ended question/statement (“Tell me all about your headache.”)

12. Use nonfocusing open-ended skills (attentive listening): silence, continuers, nonverbal encouragement

13. Obtain additional data from nonverbal sources: nonverbal cues, physical characteristics, autonomic changes, accoutrements, environment, and self

Step 4: Use focusing skills ...

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