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.1,2
Based in General System Theory,3
Engel argued that the BPS model
could simultaneously make medicine more scientific and more humanistic.
Shortly after Engel described the BPS model and under the
influence of the psychologist Carl Rogers and others,4
Levenstein, Ian McWhinney, and colleagues5,6
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.
Wide dissemination of
patient-centered practices was promoted by the American Academy on
Communication in Healthcare (AACH),7
the European Association for
Communication in Healthcare,8
and the Institute for Healthcare
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.10
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 Engel,11
noted that a specific
definition of the patient-centered interview and explicit directions for its
practice were lacking,6,11–20
limiting research and teaching21,22
producing variable, sometimes contradictory, recommendations.13,16–18
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.13,19,20
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.13,23,24
In addition, virtually all educational experts endorsed specific behavioral
models for teaching any complex topic,15,19,25,–32
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,33,34
Robert C. Smith, developed a behaviorally defined, replicable
patient-centered method based on empirical evidence,23,24,31,35
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.23,24
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.35
A subsequent pilot RCT
corroborated these findings.36
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 3–6 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.37
in this text is to present in a logical, step-by-step fashion the behaviors
that are necessary to conduct an effective and efficient BPS 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 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.24,38,39
In this new third edition, three additional authors,
Auguste H. Fortin VI, Francesca C. Dwamena, and Richard M. Frankel, have
joined Dr. Smith. All have long-standing interests in the medical interview
and have worked with Dr. Smith as frequent advisors, research colleagues,
and regular copresenters at national and international conferences. It was
natural to recognize their contributions to this work by including them as
authors. Similarly, all four authors are long-time members of the AACH 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 AACH and its
activities. Another AACH product, doc.com, 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 http://webcampus.drexelmed.edu/doccom/user/
Importantly, McGraw-Hill is making available a Companion
Teaching Supplement and Companion Videos
at no additional cost at http://www.mhprofessional.com/patient-centered-interviewing
The Teaching Supplement is designed expressly for teachers conducting
training in interviewing, while the videos are designed for both teachers
We have extensively 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
Relationship-Building 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 (Step 11: 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. 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 Mrs. 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 1–3 (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. 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 will find the third edition of Smith's
to be as exciting and helpful to use and
learn from as it has been to develop and write about. We wish you all the
best on your biopsychosocial journey of becoming a healthcare professional
committed to caring for your patients.
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