What we observe is not nature itself, but nature exposed to our method of questioning.1
Werner Heisenberg, 1958
In Chapter 1, we introduced two types of interviewing skills: “patient-centered skills” and “clinician-centered skills.” Patient-centered interviewing skills are used at the beginning of the interaction to obtain the patient's perspective. They elicit unique symptom, personal, and emotional information from the patient. They are also used throughout the interview to continue building and maintaining the clinician–patient relationship. Clinician-centered skills may be used sparingly during patient-centered interviewing but, mainly, are used in the middle portion of the interview to provide more control for the clinician. They elicit information the clinician needs to know that has not already arisen during the initial patient-centered portion. In this chapter, both skills are discussed with the emphasis on using the more difficult patient-centered skills.
As stated in Chapter 1, the fundamental patient-centered communication skills discussed in this chapter are integrated, sequenced, and prioritized to create a behaviorally defined model that is used at the beginning of the interview. Patient-centered interviewing assists patients in expressing what is most important to them, recognizing the importance of personal concerns, thoughts, feelings, and emotions. A useful analogy is to view each piece of new information during the interview, as being placed on a table between the clinician and patient (Fig. 2-1).
The clinician is being patient-centered when the information “on the table” has been placed there by the patient.
The clinician succeeds in being patient-centered when the information on the table has been placed there by the patient. When the clinician places new ideas “on the table,” this defines clinician-centered interviewing. Regardless of effort to not introduce new topics, clinicians using patient-centered skills can still influence the type and amount of information patients disclose through gestures, comments, and selectively attending to certain topics.
Used prematurely during the beginning of the interview, clinician-centered skills can contaminate the patient's story with what is on the clinician's mind, creating a cognitive bias. This is sometimes referred to as premature hypothesis testing by focusing only on the initial piece of information to make subsequent judgments. This can lead to an inaccurate or skewed view of the problem(s) and therefore lead to erroneous treatment.2 Individualized care relies on an accurate patient report of symptoms and, especially, their context in the history of the illness. Contextual errors occur when elements of the patient's environment, behavior, or emotions are not considered when making diagnosis and treatment plans.
In this chapter, we focus on the specific data-gathering (open-ended, closed-ended) and empathy (emotion-seeking, emotion-handling) skills that are the clinician's tools on a moment-to-moment basis, the core patient-centered skills (see Fig. 2-2).3–5
Dynamic use of facilitating ...