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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 of these 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 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 such as relationships among nurses, administrators, clinicians, educators, and community representatives within a hospital or outpatient setting (we refer you to Module 38 for information on communication on healthcare teams6).

The clinician–patient relationship 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 (eg, “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. It also validates the patient by showing that her reactions are important. Also observe the patient's body language, behaviors, what she says and how she says it, how comfortable she is emotionally, and 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 or his care, is at ease expressing emotions, and is able to negotiate solutions for her or his care (see Module 14 for more in nonverbal communication7). When the relationship is effective, patient and clinician alike experience respect, trust, and a reciprocal interchange 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 personality and patient's personality 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 ( Modules 18 and 41 discuss sexual issues and professional boundaries, respectively8,9) must understand both the ...

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