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INTRODUCTION

Human behavior flows from three main sources: desire, emotion, and knowledge.

Plato

In this chapter, we will introduce two advanced aspects of the medical interview: how to increase your personal awareness and how to maximize effectiveness by understanding patients’ unique personality structures. Working on both skill sets will allow you to strengthen the clinician–patient relationship with all of your patients. While we will address features of clinicians and patients that can affect the relationship, we will not consider more general determinants such as the sociocultural matrix, patients’ and clinicians’ roles, and subcultures1 (see DocCom Module 152), nor will we address relationships in medicine outside the clinician–patient dyad, a wider area often called relationship-centered or team-based care.35 These include relationships among nurses, administrators, clinicians, educators, and community representatives within a hospital or outpatient setting (we refer you to DocCom Module 38 for information on communication in healthcare teams6).

The relationship between clinician and patient is fundamental to good care; you will want to monitor this relationship as closely and continuously as the patient's temperature, blood pressure, and pulse rate. First, inquire how things are going between you and the patient, both overall (e.g., “You've been in the hospital several days now and I wanted to check how we're doing working together”) and in the immediate interaction (“That's a difficult problem, what's it like talking about it with me?”). This provides direct feedback on the relationship and, in turn, allows you to make changes where necessary, validating the patient by showing that his/her reactions are important. Also observe the patient's body language, behaviors, what s/he says and how s/he says it, how comfortable s/he is emotionally, and his/her ability to interact and negotiate. For example, a comfortable, safe, and otherwise healthy clinician–patient relationship is suggested if the patient's arms are not folded defensively across her chest, she makes appropriate (intermittent) eye contact, arrives on time and adheres to negotiated agreements, openly expresses concerns including negative aspects of her care, is at ease expressing emotions, and is able to negotiate solutions for her care (see DocCom Module 14 for more in nonverbal communication7). When the relationship is effective, patient and clinician alike experience respect, trust, and a reciprocal exchange of information. Both feel comfortable and note more rapport, satisfaction, adherence, confidence, and openness to negotiation. The opposite features characterize an ineffective relationship.

To understand how both clinician and patient contribute to this relationship, consider the clinician's communication style and personality and the patient's as two interlocking gears. The gears must mesh to establish the relationship, lest we find ourselves in an uninvolved, distant interaction, perhaps where clinician and patient address different agendas. On the other hand, if the gears engage too deeply, the mechanism itself can be destroyed, resulting in an inappropriate relationship between clinician and patient, for example, one involving sexual contact (DocCom Modules ...

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