Preface

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 Joseph Levenstein, Ian McWhinney, and colleagues^5,6 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 Communication,⁹ 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 teaching^21,22 and 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

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 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 and learners.

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 Patient-Centered Interviewing 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.

REFERENCES

1. Engel, G.L., The need for a new medical model: a challenge for biomedicine. Science, 1977; 196: 129–136.
2. Engel, G.L., The clinical application of the biopsychosocial model. Am. J. Psychiatry, 1980; 137: 535–544.
3. von Bertalanffy, L., General System Theory: Foundations, Development, Applications. 1968, New York: G. Braziller.
4. Rogers, C.R., Client-Centered Therapy. 1951, Boston: Houghton Mifflin Company.
5. McWhinney, I., The need for a transformed clinical method. In: Communicating with Medical Patients, M. Stewart and D. Roter, Editors. 1989, London: Sage Publications, pp. 25–42.
6. Levenstein, J.H., et al, Patient-centered clinical interviewing. In: Communicating with Medical Patients, M. Stewart and D. Roter, Editors. 1989, London: Sage Publications, pp. 107–120.
7. American Academy on Communication in Healthcare (AACH). www.AACHonline.org. 2011; last accessed 1/2/11.
8. European Association for Communication in Healthcare (EACH). NIVEL (Netherlands Institute for Health Services Research). www.NIVEL.nl. 2011; last accessed 1/2/11.
9. Institute for Healthcare Communication (IHC). http://www.healthcarecomm.org/index.php?sec=who. 2010; last accessed 1/4/11.
10. Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century. 2001, Washington, DC: National Academy Press.
11. Engel, G.L., Foreword – being scientific in the human domain: from biomedical to biopsychosocial. In: The Patient's Story: Integrated Patient–Doctor Interviewing, R.C. Smith, Editor. 1996, Boston: Little, Brown and Co., pp. ix–xxi.
12. Epstein, R.M., et al., Measuring patient-centered communication in patient–physician consultations: theoretical and practical issues. Soc. Sci. Med., 2005; 61(7): 1516–1528.
13. Headly, A., Communication skills: a call for teaching to the test. Am. J. Med., 2007; 120(10): 912–915.
14. Inui, T.S. and W.B. Carter, Problems and prospects for health services research on provider–patient communication. Med. Care., 1985; 23(5): 521–538.
15. Maguire, P., Teaching interviewing skills to medical students. Med. Encounter, 1992; 8: 4–5.
16. Mead, N. and P. Bower, Patient-centredness: a conceptual framework and review of the empirical literature. Soc. Sci. Med., 2000; 51(7): 1087–1110.
17. Mead, N. and P. Bower, Patient-centred consultations and outcomes in primary care: a review of the literature. Patient Educ. Couns., 2002; 48(1): 51–61.
18. Mead, N., P. Bower, and M. Hann, The impact of general practitioners' patient-centeredness on patients' post-consultation satisfaction and enablement. Soc. Sci. Med., 2002; 55: 283–299.
19. Stewart, M. and D. Roter, Conclusions. In: Communicating with Medical Patients, M. Stewart and D. Roter, Editors. 1989, London: Sage Publications, pp. 252–255.
20. Cegala, D.J. and S.L. Broz, Physician communication skills training: a review of theoretical backgrounds, objectives and skills. Med. Educ., 2002; 36: 1004–1016.
21. Griffin, S.J., et al., Effect on health-related outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials. Ann. Fam. Med., 2004; 2(6): 595–608.
22. Lewin, S., Skea, Z., Entwistle, V.A., Zwarenstein, M. and Dick, J. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.: CD003267. DOI: 10.1002/14651858.CD003267.
23. Smith, R.C., et al., Evidence-based guidelines for teaching patient-centered interviewing. Patient Educ. Couns., 2000; 39: 27–36.
24. Smith, R.C., et al., The effectiveness of intensive training for residents in interviewing: a randomized, controlled study. Ann. Intern. Med., 1998; 128: 118–126.
25. Schunk, D.H., Goal setting and self-efficacy during self-regulated learning. Educ. Psychol., 1990; 25: 71–86.
26. McHugh, P.R. and P.R. Slavney, The Perspectives of Psychiatry. 1986, Baltimore, MD: The Johns Hopkins University Press.
27. Schunk, D.H., Self-efficacy and classroom learning. Psychol. Schools, 1985; 22: 208–223.
28. McKeachie, W.J., et al., Teaching and Learning in the College Classroom, 2nd edition. 1990, Ann Arbor, MI: Regents of the University of Michigan.
29. Feinstein, A.R., Clinical judgement revisited: the distraction of quantitative models. Ann. Intern. Med., 1994; 120: 799–805.
30. Flaherty, J.A., Education and evaluation of interpersonal skills. In: The Interpersonal Dimension in Medical Education, A.G. Rezler and J.A. Flaherty, Editors. 1985, New York: Springer, pp. 101–146.
31. Westberg, J. and H. Jason, Teaching Creatively with Video: Fostering Reflection, Communication and Other Clinical Skills. 1994, New York: Springer.
32. Carroll, J.G. and J. Monroe, Teaching clinical interviewing in the health professions—a review of empirical research. Eval. Health Prof., 1980; 3: 21–45.
33. Smith, R.C., The Patient's Story: Integrated Patient–Doctor Interviewing. 1996, Boston: Little, Brown and Company (now Lippincott Williams & Wilkins).
34. Smith, R.C., Patient-Centered Interviewing: An Evidence-Based Method, 2nd edition. 2002, Philadelphia: Lippincott Williams & Wilkins.
35. Smith, R.C., et al., Primary care clinicians treat patients with medically unexplained symptoms – a randomized controlled trial. J. Gen. Intern. Med., 2006; 21: 671–677.
36. Smith, R., et al., Primary care physicians treat somatization. J. Gen. Int. Med., 2009; 24: 829–832.
37. Levinson, W. and D. Roter, Physicians' psychosocial beliefs correlate with their patient communication skills. J. Gen. Int. Med., 1995; 10: 375–379.
38. Smith, R.C., et al., Improving residents' confidence in using psychosocial skills. J. Gen. Intern. Med., 1995; 10: 315–320.
39. Smith, R.C., et al., A strategy for improving patient satisfaction by the intensive training of residents in psychosocial medicine: a controlled, randomized study. Acad. Med., 1995; 70: 729–732.