Smith's Patient-Centered Interviewing

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a LANGE medical book

Smith's Patient-Centered Interviewing
An Evidence-Based Method
Fourth Edition

Auguste H. Fortin VI, MD, MPH
Professor of Medicine
Division of General Internal Medicine
Yale School of Medicine
Director ofPsychosocial Communication
Yale Primary Care Internal Medicine Residency Program
New Haven, Connecticut

Francesca C. Dwamena, MD, MS

Brenda Lovegrove Lepisto, PsyD

Professor and Chair
Department ofMedicine
Michigan State University
East Lansing, Michigan

Director ofPsychosocial Communication
Hurley Medical Center
Assistant Professor of Medicine
Department ofInternal Medicine
College of Human Medicine, Michigan State University
Flint, Michigan

Richard M. Frankel, PhD
Professor of Medicine
Department of Internal Medicine
Indiana University School ofMedicine
Senior Research Scientist, Center for Healthcare
Information and Communication (CHIC)
Richard L. Roudebush Veterans Affairs Medical Center
Indianapolis, Indiana
Education Institute
Cleveland Clinic
Cleveland, Ohio

Robert C. Smith, MD, MS
University Distinguished Professor
Professor ofMedicine and Psychiatry
Division of General Internal Medicine
College of Human Medicine, Michigan State University
East Lansing, Michigan

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Copyright© 2019 by McGraw-Hill Education. Third edition copyright© 2012, by The McGraw-Hill Companies, Inc. Second
edition copyright© 2002 by Lippincott Williams & Wilkins. First edition by Smith RC. The Patient's Story: Integrated PatientDoctor Interviewing by Little, Brown and Company copyright© 1996. Printed in the United States of America. All rights
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Dedication
We dedicate this book to George L. Engel, the giant on whose shoulders we all humbly stand.
Each author also dedicates the book as follows:
To my parents, Auguste and Louise Fortin, for their life-long example of service to others; to my
wife, Oi, and our daughter, Camille, for their love, support, and forbearance; to Bob Smith, whose
generous mentorship has made all the difference in my career; and to my colleagues, students, and
residents at Yale School of Medicine and the Yale Primary Care Internal Medicine Residency
Program for their uncompromising scholarship, support, friendship, compassion, and
commitment to being the best clinicians they can be.
-Auguste H. Fortin VI
To my parents Emmanuel and Victoria Colecraft and my four siblings for their unconditional
love; my husband Ben, for teaching me how to love. To Bob, the other co-authors of this book,
my patients, and all my learners over the years; thank you for teaching me everything
I know about patient-centered interviewing and for giving so much meaning to my work.

-Francesca C. Dwamena
To the loves of my life, Michelle and our five children, and to the hundreds of residents, practicing
physicians, and patients whose interviews I have been fortunate enough to be able to record, analyze,
and ultimately transform into programs to help them achieve what we all want from medical care:
better communication, more meaningful relationships, and better health outcomes.
-Richard M. Frankel
To my husband, Larry, and our children, Douglas and Scott along with our grandchildren Mackenzie
and Landon, who are the joys of my life; to my mentors Sophie L. Lovinger, PhD and Bob Smith,
MD who provided empathic support for my personal and professional growth; and to the many
physician, residents, and students from whom I had the good fortune to learn.
-Brenda Lovegrove Lepisto
To my first medical influence, my father, Elmer M. Smith; to my first teacher of humanity,
my mother, Mary Louise Smith; to my guide, friend, and the love of my life, my wife,
Susan Sleeper-Smith; and to the many residents, students, friends, and colleagues
from whom I've learned so much over the years.
-Robert C. Smith

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Contents
Foreword ........................................................................................................................ ix
Preface......................................................................................................................... xvii
Instructors' Preface ...................................................................................................... xxv
Acknowledgments ..................................................................................................... xxvii
Chapter 1
The Medical Interview ........................................................................... 1

Chapter 2
Data-Gathering and Empathy Skills ...................................................... 13

Chapter 3
The Beginning of the Interview: Patient-Centered Interviewing ................ 33

Chapter 4
Symptom-Defining Skills ...................................................................... 71

Chapter 5
The Middle of the Interview: Clinician-Centered Interviewing ................... 89

Chapter 6
Step 11: The End of the Interview ...................................................... 143

Chapter 7
Adapting the Interview to Different Situations and
Other Practical Issues ....................................................................... 169

Chapter 8
The Clinician-Patient Relationship ..................................................... 207

Chapter 9
Summarizing and Presenting the Patient's Story ................................. 235

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Contents

Chapter 10
Remaining Patient-Centered in the Digital Age .................................... 255

Appendices
Appendix A. Foreword to the First Edition ............................................ 269
Appendix B. Research and Humanistic Rationale for
Patient-Centered Interviewing ............................................................ 281
Appendix C. Feelings and Emotions ................................................... 289
Appendix D. Complete Write-up of Ms. Jones' Initial Evaluation ............ 293
Appendix E. Mental Status Evaluation ................................................ 303
Index ........................................................................................................................... 309

Foreword
Patient-Centered Interviewing: An Exercise in Evidence, Empathy, and
Engagement
Communication can play a key role in bridging the gap
between evidence-based and patient-centered medicine,
both in clinical practice, and in clinical science.

Jozien Bensing1
During one of my first years of teaching communication skills, we were
going to interview an elderly male patient in a small group teaching session for medical students. The setting was an Internal Medicine ward at our
University Hospital. The student assigned to conduct the interview, let us call
him Tom, told us that he had a question before starting talking to the patient.
"Go ahead:' I said. "What do you want to know? Tom looked at me and posed
a question which has had more impact on my thinking on communication
skills training than any other utterance over all these years. Tell me, Tom said,
are we going to interview the patient the way we have learned in your class or
the way it is done in real life?
It was a relevant question. It pointed to one of the classical dilemmas of
communication skills teaching in medicine, the gap between communication
skills as taught in training sessions and those that are actually practiced. The
student had learned a patient-centered communication style in our classes,
with an emphasis on exploring the patient's own perspective and on meeting patient emotions with explicit empathy. Patient-centered communication
was well established, even when this episode occurred in the 1990s. As early
as 1984, the Association of American Medical Colleges proposed that "every
effort should be directed at developing and enhancing a patient -centered
humanistic attitude in medical students:'2
The first edition of the present textbook, published in 1996, was one of
the main influential books in promoting a patient-centered approach in
medical schools in the United States and abroad, such as for instance our
medical school in Oslo, Norway. Since then, principles of patient-centered,

ix

x

Foreword

relationship-centered,3 and person-centered care4 have become dominant in
teaching of communication in most medical schools.
Another question is to what extent a patient-centered approach really has
been implemented into everyday clinical care. There is some evidence that we
have seen fewer changes in the communication style of physicians in general
than could be expected from reading the research literature. Jozien Bensing
and her colleagues in Utrecht in the Netherlands have a unique opportunity
to monitor trends over time in medical communication behavior. They have
over more than 30 years built up a huge data base ofthousands ofvideo-taped
consultations, and have in a series of studies examined changes in communication style of doctors from the 1970s and 1980s on to 2008.5•6 For instance,
they found that while physicians tended to pay more attention to psychosocial
issues over time, consultations did not become more patient-centered. The
researchers concluded that over time consultations had become more focused
on task-oriented communication and less on showing empathy. 5•6 In an
American study, cancer survivors' experience of their relationship with their
physicians was studied in course of a smaller, but more recent, time span
(from 2007 to 2013). There was a trend that ratings of patient-centered communication improved over time, but not significantly when other variables
were controlled for. The authors concluded that many survivors continue to
report suboptimal communication with their health care providers.7
The gap between a conventional doctor-centered communication and
patient-centered communication illustrates a more general conflict in modem health care. Patient-centeredness is threatened not only from old conventions of paternalistic communication but also of trends in modern medicine.
We witness an increasing complexity, with an emphasis on medical superspecialization and highly developed medical technology within an organizational context with increasing pressures on cost effectiveness. In this way,
health care may function in a rather fragmented way. 8 Questions have been
asked if these developments may jeopardize basic humanistic values of medicine and the primacy of the clinician-patient relationship as the cornerstone
of health care. 9
To sum up: the trend toward patient-centered medicine is threatened by
two different opposing forces, on one hand the old traditions of paternalistic
medicine and on the other the trends of fragmentation of care. Unfortunately,
Tom, the medical student, may still be right to some extent. There is still a
discrepancy between what we teach and what doctors actually do.
The integrated consultation and the two levels of patient centeredness
How can we bridge the gap between ideals and realities in clinical communication practice?

Foreword

xl

One of the main qualities of the first edition of the present textbook when
it first appeared under the title The Patient's Story in 1996 was the emphasis
on integrated interviewing. This is a major principle of Smith's approach to
medical interviewing. In many medical schools, courses in communication
skills are often separated from basic courses in history taking and physical
exams. One of the strengths of Smith's approach is the consistent emphasis on
integration. The integrated interview blends the biomedical emphasis on the
disease with a systematic attention to the patient's perspective, the patient's
story. Both these aspects are essential in all phases of the interview.
The patient-centered consultation is a fully integrated consultation in
which a biomedical attention to the disease is combined with an adequate
exploration of the patient perspective and a calibration to the patient's preferences and needs. However, it is somewhat confusing that the term "patientcentered" is used both for the whole integrated consultation and for one of
the elements, the patient-centered skills that are applied to elicit the patient's
perspective. It may appear inconsistent, but this terminology underscores the
point that in order to provide truly patient-centered care you have to provide
a combination of skills in which doctor-centered skills are blended with more
specific patient-centered skills.
This distinction between patient-centered approach and specific patientcentered skills is important. Patient-centeredness as a general approach has a
normative component. The core value of patient-centered communication is
to be attentive and receptive toward the patient and to tailor communication
and treatment to patient needs. Patient-centered communication does not
mean to employ a specific set of communication skills. There is no one sizefits-all in communication. It is always right from a professional and ethical
point of view to tailor communication and treatment to the patient's needs.
Specific patient-centered skills, however, are merely means to reach a goal. A
skills approach is very fruitful in teaching communication, but skills may be
used in different ways and to different ends, depending on the patient's needs.
Hanneke de Haes has discussed this dilemma in an interesting article. 10 She
pointed out how specific patient-centered skills may not necessarily correspond to patient needs and preferences. A truly patient-centered approach is
characterized by the tailoring of communication to the patient, not by inflexible adherence to specific skills.
Interestingly, research on patients' trust in physicians does not emphasize
the importance of a fixed set of skills. The sense of "being taken seriously"
is often found as the most important criterion for patients' trust in doctors,9
often in combination with patients' perception of the doctor's competence
in technical skills. 10 Such fmdings highlight the emphasis on the integrated

xll

Foreword

interview, a combination of patient-centeredness and technical competence
is important to prevent the split observed by Tom, the medical student in our
little story above.

Evidence, empathy, and engagement
So what are the hallmarks of a patient-centered approach to interviewing, of an integrated interview taUored to the needs of the patient? I shall
briefly point to three important qualities: a solid base in evidence, emphasis
on empathy. and promoting patient engagement.
Evidence. Evidence-based medicine is an important principle in modern
medical science and health care. In a seminal paper published some years ago,
Jozien Bensing suggested that evidence-based and patient-centered medicine
represented the two most important paradigms in modern medical care. She
pointed to a gap between the two models. 1 While evidence-based medicine
traditionally represents a positivistic approach with a basically biomedical
perspective, the patient-centered approach developed as an alternative to the
biomedical model, based on humanistic values and principles, rather than
evidence. Bensing pointed to a need to bridge the gap between the two paradigms and suggested that communication skills are important in overcoming
the split.
I suggest two ways to bridge the gap between evidence and patientcenteredness in the medical interview. First of all, in the integrated interview, biomedical evidence plays an important role in its own right. Teaching
communication skills should include teaching students how to use their biomedical knowledge in history taking and diagnostic reasoning. Moreover,
in giving information and negotiating treatment decisions the doctor must
know how to convey and explain medical evidence to patients.
Second, several of the principles of integrated interviewing within a framework of basic patient-centered principles are increasingly being based on
emerging evidence. Evidence-based medicine is not any longer limited to a
strictly biomedical understanding of disease. For instance, Smith and colleagues have argued how research on medical interviewing has an important
role in developing a knowledge base for the biopsychosocial modeL 11 This
attitude is central to the present textbook, and reflected in the subtitle of the
book "an evidence-based method."
Empathy. Medical consultations are often quite emotional affairs. However,
emotions are most often expressed implicitly. in terms of more or less subtle
cues to underlying emotions, often missed by the physician. 12 Sensitivity to
cues is important in order to realize the emotional state of the patient. A subtle cue may be the first element in a sequence including a gradual buildup to
a more explicit emotion, hopefully an empathic response by the physician,

Foreword

xlll

and sometimes with a continued exchange related to the emotional concern
before a more or less abrupt topic change. 13
One of the strengths of Smith's approach to interviewing is the emphasis
on emotional communication and on empathy as an integrated skill of the
medical interview. There is increasing evidence that an active acknowledgment of patients' concerns as advocated in this textbook may have surprisingly strong impact on outcome variables. A number of studies have found
that empathic communication in medical consultations are associated with
better patient satisfaction and adherence, less distress and better coping and
quality oflife, 1.,15 and even physiological parameters, for instance for patients
with diabetes.16 These and other studies are excellent examples ofthe bridging
of the gap between patient-centeredness and evidence.
Engagement. An interesting and important development that has taken
place since the first edition of Smith's textbook came out in 1996 is the
increased emphasis on patient engagement in medical care, reflected in
terms such as empowerment, patient participation, and patient engagement. All these terms are in a way cousins of the term patient-centered, but
with a special emphasis on the active patient. In a number of recent papers
in Patient Education and Counseling, these engagement-oriented terms have
been discussed. 17 Patient Empowerment is less specifically related to health
care, more to the individual process of taking responsibility for one's own
health. 18, 19 Patient Participation is a rather broad term, often related to active
engagement and partnership and decision making in health care?0 The term
Patient Engagement is also often applied in literature on shared decision making. In this last edition of the present textbook there is a strong emphasis on
engaging patients in shared decision making, more so than in the first edition, reflecting the increasing emphasis on shared decision making in the last
15 years. But patient engagement goes beyond decision making. Graffigna et al.21
describe patient engagement as a process from passivity and denial in relation to illness and health to an active and committed stance, from "I am in a
blackout" to "I am a person."
In a conceptual paper on patient engagement, Higgins et al. 22 pointed
to four important attributes of the concept. One of them is the individual
patient's personal commitment, including cognitive and emotional factors to
participate in treatment activities. From the first edition on, this aspect of
patient engagement has been strongly emphasized in the present textbook.
But promoting the patient's commitment to change must be anchored in an
exploration of the patient's perspective. A successful engagement may have to
be based on a sincere acknowledgment of the patient's emotions. In the integrated interview, all elements are parts of an integrated whole.

xlv

Foreword

Hopefully, the principles of the integrated, patient-centered interview will
gradually become standard practice in health care. Hopefully, medical students such as Tom will someday fmd that the patient-centered skills they learn
in medical school are actually the same as those they observe "in real life."
Arnstein Finset, PhD
Professor Emeritus
Department of Behavioral Sciences in Medicine
Institute ofBasic Medical Sciences
Faculty ofMedicine
University of Oslo, Norway
Editor-in-Chief
Patient Education and Counseling

REFERENCES
l. Bensing J. Bridging the gap: the separate worlds ofevidence-based medicine and patient-

centered medicine. Patient Educ Couns. 2000;39(1):17-25.
2. Association of American Medical Colleges: physicians for the 21st century: report of the
Project Panel on the General Professional for Medicine (GPEP Report). Washington,
DC: Association of American Medical Colleges; 1984.
3. Mak.oul G. Essential elements of communication in medical encounters: the Kalamazoo
consensus statement. Acad Med. 2001;76(4):390-393.
4. Mezzich J, Snaedal J, Van Weel C, Heath I. Toward person-centered medicine: from disease to patient to person. Mt Sinai J Med. 2010;77(3):304-306.
5. Butalid L, Bensing JM, Verhaak PFM. Talking about psychosocial problems: an observational study on changes in doctor-patient communication in general practice between
1977 and 2008. Patient Educ Couns. 2014;94(3):314-321.
6. Butalid L, Verhaak PFM, Bensing JM. Changes in general practitioners' sensitivity
to patients' distress in low back pain consultations. Patient Educ Couns. 2015;98(10):
1207-1213.
7. Blanc.h-Hartigan D, Chawla N, Moser RP, Finney Rutten LJ, Hesse BW, Arora NK.
Trends in cancer survivors' experience of patient-centered communication: results from
the Health Information National Trends Survey (HINTS). J Cancer Surviv. 2016;10(6):
1067-1077.
8. Miller BF, Hubley SH. The history of fragmentation and the promise of integration: a
primer on behavioral health and primary care. In: Maruish ME, ed. Handbook of Psychological Assessment in Primary Care Settings. 2nd ed. New York, NY: Routledge; 2017:
55-74.
9. Finset A. Patient education and counseling in a changing era of health care. Patient Educ
Couns. 2007;66(1):2-3.
10. de Haes H. Dilemmas in patient centeredness and shared decision making: a case for
vulnerability. Patient Educ Couns. 2006;62(3):291-298.

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11. Smith RC, Fortin AH, Dwamena F, Frankel RM. An evidence-based patient-centered
method makes the biopsychosocial model scientific. Patient Educ Couns. 2013;91(3):
265-270.
12. Zimmermann C, Del Piccolo L, Finset ACues and concerns by patients in medical consultations: a literature review. Psychol BuU. 2007;133(3):438-463.
13. Mellblom AV, Korsvold L, Ruud E, Lie HC, Loge JH, Finset A Sequences of talk about
emotional concerns in follow-up consultations with adolescent childhood cancer survivors. P Patient Educ Couns. 2016;99{1):77-84.
14. Neumann M, Scheffer C, Tauschel D, Lutz G, Wirtz M, Ede1bii.user F. Physician empathy:
definition, outcome-relevance and its measurement in patient care and medical education. GMS Z Med Ausbild. 2012;29{1):Docll.
15. Derksen F, Bensing J, Lagro-Janssen A. Effectiveness of empathy in general practice: a
systematic review. Br J Gen Pract. 2013;63(606):e76-e84.
16. Canale SD, Louis DZ, Maio V, et al. The relationship between physician empathy and
disease complications: an empirical study of primary care physicians and their diabetic
patients in Parma, Italy.Acad Med. 2012;87(9):1243-1249.
17. Finset A. Patient participation, engagement and activation: increased emphasis on the
role of patients in healthcare. Patient Educ Couns. 20 17; 100(7):1245-1246.
18. Malterud K. Power inequalities in health care-empowerment revisited Patient Educ
Couns. 2010;79(2):139-140.
19. Funnell MM. Patient empowerment: what does it really mean? Patient Educ Couns.
2016;99(12):1921-1922.
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D~gostino TA, Atkinson TM, Latella LE, et al. Promoting patient participation in
healthcare interactions through communication skills training: a systematic review.
Patient Educ Couns. 2017;100(7):1247-1257.

21. Graffigna G, Barello S, Bonanomi A, Lozza E. Measuring patient engagement: development and psychometric properties of the patient health engagement (PHE) scale. Front
Psychol. 2015;6:274.
22. Higgins T, Larson E, Schnall R. Unraveling the meaning of patient engagement: a concept analysis. Patient Educ Couns. 2017;100(1):30-36.

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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- 3 Based on
General System Theory,3- 5 Engel argued that the BPS model could simultaneously make medicine more scientific and more humanistic by incorporating
elements of self- and situation/contextual awareness to the interview process.
Shortly after Engel described the BPS model and under the influence of the
psychologist Carl Rogers and others,6 Joseph Levenstein, Ian McWhinney, and
colleagues7' 8 proposed the general concept that clinicians become "patientcentered" 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. It also differed by asserting that the personhood of the
clinician and the patient was key and grounded the relationship in a communication-based conversational context. While the role and expectations of
each differed, the biopsychosocial model stressed the importance of mutual
influence and reciprocity in building and maintaining healthy, healing clinician-patient relationships.
Wide dissemination of patient-centered practices was promoted by the
Academy of Communication in Healthcare (ACH), 9 EACH-International
Association for Communication in Healthcare, 10 and the Institute for
Healthcare Communication, 11 as well as by many other groups including several primary care organizations. Medical schools, accreditation groups, and

xvii

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Preface

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. 12
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 Engel13 and several authors of this book,3 noted that a specific definition of the patient-centered interview and explicit directions for
its practice were lacking,8•13- 22 limiting research and teachin(3.24 and producing variable, sometimes contradictory, recommendations. 15•18- 20 Scholars
warned that researchers and learners needed to know exactly what to say, with
behaviorally defmed patient-centered skills broken down into specific, definable components. 15.21•22 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. 15•25•26
In addition, virtually all educational experts endorsed specific behavioral
models for teaching any complex topic,17•21 •27- 34 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,35•36 Robert C. Smith, developed a behaviorally defmed,
replicable patient-centered method based on empirical evidence,25.26.33.37 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.25.26 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. 37 A subsequent pilot RCT corroborated these findings. 38 The 5-step patient-centered
method became the first comprehensive, behaviorally defined, evidencebased method for teaching and learning the medical interview. In a typical
outpatient encounter, no more than 3 to 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.39
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 patientcentered 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

Preface

xlx

are central. We have discovered from feedback on previous three 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. 26.40.~ 1
In this new fourth edition, an additional author, Brenda Lovegrove Lepisto,
PsyD, has joined Drs. Fortin, Dwamena, Frankel, and Smith. All five authors
are long-time members ofthe ACH 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 ACH and its activities. Another ACH product, DocCom, 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 www.doccom.org.
Importantly, McGraw-Hill is making available an Instructor~ Teaching
Supplement and Companion Videos at no additional cost at www.accessmedicine.com/SmithsPCI. The Teaching Supplement is designed expressly for
teachers conducting training in interviewing, while the videos are designed for
both teachers and learners. Based on recent research, we have added measures
teachers can use to evaluate learners' mastery of patient-centered interviewing: (1) a coding scheme by which they can directly evaluate patient-centered
practices and (2) a patient satisfaction questionnaire by which patients can
evaluate their interaction with the interviewer.42·~3
The McGraw-Hill AccessMedicine website continues to present three videos available with the third edition: Building Efficiency and Effectiveness
Through Patient-Centered Interviewing; Clinician-Centered Interviewing;
and Patient-Centered Interviewing. The latter two are long, hour-length
videos providing detailed demonstrations of all parts of the medical interview.
Newly prepared for this edition, the AccessMedicine website now also contains seven brief (2-5 minutes) videotape demonstrations of unique, sometimes difficult interviewing situations: New Inpatient Interview; Follow-up
Inpatient Interview; Acutely Ill Patient; Patient with a Mental Health

xx

Preface

Disorder; How to Interrupt; Follow-up Outpatient; and Using the Electronic
Health Record. The seven recent videos are conducted by medical residents
to provide learners with a better approximation of themselves. AlllO videos are cross-referenced in the textbook All videos can be found at www.
accessmedicine.com/SmithsPCI.
We have 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 (DataGathering and Empathy 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: ClinicianCentered Interviewing) as the clinician-centered process of integrated interviewing; this chapter presents the basic clinician-centered infrastructure of
the medical interview. Chapter 6 (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 fme-tuning one's
interviewing skills in widely varied circumstances. Chapter 8 (The ClinicianPatient 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. Chapter 10 (Remaining Patient-Centered in
the Digital Age) is a new chapter describing how to remain patient-centered
while using the electronic health record. 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 Ms. 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 to 3 (basic
patient-centered interviewing) are typically taught first. Chapters 4 and 5

Preface

xxl

(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. The book ends with Chapter 10 (remaining
patient-centered while using the electronic health record), and it is designed
for use in 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 find the fourth edition ofSmith's Patient-Centered Interviewing
to be an exciting and helpful guide to becoming a complete medical interviewer and clinician. We wish you Godspeed on your biopsychosocial journey
of becoming a health care professional committed to caring for your patients.
REFERENCES
1. Engel GL. The need for a new medical model: a challenge for biomedicine. Science.
1977;196:129-136.
2. Engel GL. The clinical application of the biopsychosocial model Am I Psychiatry.
1980;137:535-544.
3. Smith R, Fortin AH VI, Dwamena F, Frankel R. An evidence-based patient-centered
method makes the biopsychosocial model scientific. Patient Educ Couns. 2013;90:
265-270.
4. von Bertalanffy L. General System Theory: Foundations, Development, Applications. New
York. NY: G. Braziller; 1968.
5. Capra F, Luisi P. The Systems View of Lift-A Unifying Vision. Cambridge, UK: Cambridge University Press; 2014.
6. Rogers CR. Client-Centered Therapy. Boston, MA: Houghton Mifflin Company; 1951.
7. McWhinney I. The need for a transformed clinical method. In: Stewart M, Roter D, eds.
Communicating with Medical Patients. London: Sage Publications; 1989:25-42.
8. Levenstein JH, Brown JB, Weston WW, Stewart M, McCracken EC, McWhinney I.
Patient-centered clinical interviewing. In: Stewart M, Roter D, eds. Communicating with
Medical Patients. London: Sage Publications; 1989:107-120.
9. Academy of Communication in Healthcare (ACH). Available at: www.ACHonline.org.
Accessed October 23,2017.

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10. EACH-International Association for Communication in Healthcare. Available at:
https://www.each.eu. Accessed October 23,2017.
11. Institute for Healthcare Communication (IHC). Available at: http://www.healthcare
comm.org/index.php?sec=who. 2010. Accessed October 23,2017.
12. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st
Century. Washington, DC: National Academy Press; 2001.
13. Engel GL. Foreword-being scientific in the human domain: from biomedical to biopsychosocial. In: Smith RC, ed The Patients Story: Integrated Patient-Doctor Interviewing.
Boston, MA: Little, Brown and Co.; 1996:ix-xxi.
14. Epstein RM, Franks P, Fiscella K, et al. Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues. Soc Sci Med.
2005;61(7):1516-1528.
15. Healy A. Communication skills: a call for teaching to the test. Am JMed. 2007;120(10):
912-915.
16. Inui TS, Carter WB. Problems and prospects for health services research on providerpatient communication. Med Care. 1985;23(5):521-538.
17. Maguire P. Teaching interviewing skills to medical students. Med Encounter. 1992;8:4-5.
18. Mead N, Bower P. Patient-centredness: a conceptual framework and review of the
empirical literature. Soc Sci Med. 2000;51 (7): 1087-1110.
19. Mead N, Bower P. Patient-centred consultations and outcomes in primary care: a review
of the literature. Patient Educ Couns. 2002;48(1):51-61.
20. Mead N, Bower P, Hann M. The impact of general practitioners' patient-centeredness on
patients' post-consultation satisfaction and enablement. Soc Sci Med. 2002;55:283-299.
21. Stewart M, Rater D. Conclusions. In: Stewart M, Rater D, eds. Communicating with Medical Patients. London: Sage Publications; 1989:252-255.
22. Cegala DJ, Broz SL. Physician communication skills training: a review of theoretical
backgrounds, objectives and skills. Med Educ. 2002;36:1004-1016.
23. Griffin SJ, Kinmonth AL, Veltman Mw, Gillard S, Grant J, Stewart M. Effect on healthrelated outcomes of interventions to alter the interaction between patients and practitioners: a systematic review of trials. Ann Pam Med. 2004;2(6):595-608.
24. Lewin S, Skea Z, Entwistle VA, Zwarenstein M, Dick J. Interventions for providers to
promote a patient-centred approach in clinical consultations. Cochrane Database Syst
Rev. 2001;(4):CD003267.
25. Smith RC, Marshall-Dorsey AA, Osborn GG, et al. Evidence-based guidelines for teaching patient-centered interviewing. Patient Educ Couns. 2000;39:27-36.
26. Smith RC, Lyles JS, Mettler J, et al. The effectiveness of intensive training for residents in
interviewing: a randomized. controlled study. Ann Intern Med. 1998;128:118-126.
27. Schunk DH. Goal setting and self-efficacy during self-regulated learning. Educ PsychoL
1990;25:71-86.
28. McHugh PR, Slavney PR. The Perspectives ofPsychiatry. Baltimore, MD: Johns Hopkins
University Press; 1986.
29. Schunk DH. Self-efficacy and classroom learning. Psychol Schools. 1985;22:208-223.

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30. McKeachie WJ, Pintrich PR, Lin Y-G, Smith DAF. Teaching and Learning in the College
Classroom. 2nd ed Ann Arbor, Ml: Regents of the University of Michigan; 1990.
31. Feinstein AR. Clinical judgement revisited: the distraction of quantitative models. Ann
Intern Med. 1994;120:799-805.
32. Flaherty JA. Education and evaluation of interpersonal skills. In: Rezler AG, Flaherty
JA, eds. The Interpersonal Dimension in Medical Education. New York, NY: Springer;
1985:101-146.
33. Westberg J, Jason H. Teaching Creatively with Video: Fostering Reflection, Communication
and Other Clinical Skills. New York, NY: Springer; 1994.
34. Carroll JG, Monroe J. Teaching clinical interviewing in the health professions-a review
of empirical research. Eval Health Prof. 1980;3:21-45.
35. Smith RC. The Patient's Story: Integrated Patient-Doctor Interviewing. Boston, MA: Little, Brown and Company; 1996.
36. Smith RC. Patient-Centered Interviewing: An Evidence-Based Method. 2nd ed. Philadelphia, PA: Lippincott Williams & Wllkins; 2002.
37. Smith RC, Lyles JS, Gardiner JC, et al. Primary care clinicians treat patients with
medically unexplained symptoms-a randomized controlled trial. J Gen Intern Med.
2006;21:671-677.
38. Smith RC, Gardiner JC, Luo Z, SchooleyS, Lamerato L, Rost K. Primary care physicians
treat somatization. J Gen Int Med. 2009;24:829-832.
39. Levinson W. Roter D. Physicians' psychosocial beliefs correlate with their patient communication skills. I Gen Int Med. 1995;10:375-379.
40. Smith RC, Mettler JA, Stoffelmayr BE, et al. Improving residents' confidence in using
psychosocial skills. I Gen Intern Med. 1995;10:315-320.
41. Smith RC, Lyles S, Mettler JA, 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.
42. Grayson-Sneed K, Smith S, Smith R. A research coding method for the basic patientcentered interview. Patient Educ Couns. 2016;100:518-525.
43. Grayson-Sneed K, Dwamena F, Smith S, Laird-Fick H, Freilich L, Smith R. A questionnaire identifying four key components of patient satisfaction with physician communication. Patient Educ Couns. 2016;99:1054-1061.

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The Companion Teaching Supplementfor Smith's Patient-Centered Interviewing:
An Evidence-Based Method is designed to facilitate instruction of learners at
all levels. For example, it offers useful suggestions for how to teach the material presented in Chapters 1 to 3 of this book (The Beginning of the Interview:
Patient-Centered Interviewing) to beginning students in various medicine/
nursing disciplines-in 10 sessions, each with a 1-hour lecture/demonstration followed by a 2-hour skills-oriented small group experience. The
Teaching Supplement also describes how to teach the material in Chapters 4
and 5 (The Middle of the Interview: Clinician-Centered Interviewing) over
six additional sessions. This includes recommendations for teaching how to
summarize and present the entire interview, outlined in Chapter 9. However,
clinician -centered interviewing can be taught in the second semester or year
rather than in one course as presented in the Supplement. Further, the new
Chapter 10 can guide teaching in how best to use the electronic health record.
The Instructor's Teaching Supplement is available at no additional cost from
McGraw-Hill at www.accessmedicine.com/SmithsPCI.
We invite questions and feedback via e-mail: auguste.fortin@yale.edu;
francesca.dwamena@ht.msu.edu; rfrankel@iupui.edu; BLepist1@hurleymc.
com; robert.smith@ht.msu.edu.
We have also developed Companion Teaching Videos that are available at no
additional cost from McGraw-Hill at www.accessmedicine.com/SmithsPCI.
These videos have proven invaluable for instruction in the entire interview.
They provide nonrehearsed and nonscripted demonstrations by authors Robert
C. Smith and Auguste H. Fortin VI, demonstrating all requisite skills as well as
all the steps and substeps in the patient- and clinician-centered components of
the interview. The video demonstrations have been useful to review as learners progress through the teaching material, especially for those having difficulty
or for those progressing into new, more challenging areas. Newly prepared for
this addition, seven brief videotapes, conducted by medical residents to provide a realistic approximation of what new learners can do, demonstrate how to
remain patient-centered in unique, sometimes difficult situations: new inpatient,
follow-up outpatient, acutely ill patient, patient with a mental health disorder,
how to interrupt, follow-up outpatient, and using the electronic health record.
XXV

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Acknowledgments
The fourth edition of this textbook would not have been possible without the
groundbreaking achievements of Dr. George L. Engel who, among other things,
introduced a new theoretical foundation for medicine in the biopsychosocial
model. Research and education in the biopsychosocial tradition continue to
this day and are reflected in such important publications as the Institute of
Medicine's influential report: Crossing the Quality Chasm. Dr. Engel also
established the University of Rochester Program in Biopsychosocial Medicine
(formerly the Medical-Psychiatric Liaison Group). Dr. Engel attracted and/
or trained many like-minded colleagues in this program; Art Schmale, Bill
Greene, Bob Ader, Bob Klein, Joe Messina, Leon Canapary, Mack Lipkin,
and Manual Brontman were key to Dr. Smith's intellectual development and
scholarship, first as a fellow and then as faculty in the program.
We also would like to thank our own universities (Yale, Michigan State,
and Indiana) for encouraging us to publish the fourth edition of the book and
for fostering education and practice in the Engel tradition. After Rochester,
Michigan State was an early adopter of the model; Indiana and Yale have followed and are making dramatic impacts on the field. The book and other
biopsychosocial work can occur only in such fertile environs.
We acknowledge the support of the Fetzer Institute in Kalamazoo, MI in providing the financial support to develop the method described in the book, the
National Institute of Mental Health for their support of research that allowed us
to demonstrate the effectiveness of the patient-centered approach, the Academy
of Communication in Healthcare (ACH) for being a spiritual home for clinicians eager to improve relationships with patients and each other, and the
Health Resources and Services Administration for recent generous support.
We are grateful for the opportunity to work with publisher Jim Shanahan,
and his superb team at McGraw-Hill: Amanda Fielding, Senior Editor; Kim
Davis, Managing Editor; Catherine Saggese, Senior Production Supervisor;
and Anubhav Siddhu, Project Manager. Each has been remarkably helpful,
diligent, and patient; this book is very much improved because of their efforts
and attention to detail.
Finally, we would like to thank Drs. Mohamed Hassanein and Ashley
Bartell for their help with the literature review.
xxvii

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The Medical Interview
The good physician treats the disease; the great physician treats the patient who
has the disease.
Sir William Osler, circa 1900
The position of clinician is one of privilege. Patients entrust clinicians with the
most intimate details of their lives, and society rewards them with prestige, job
stability, and a decent standard of living. With this privilege comes responsibility. Patients expect support, understanding, explanation, relief from their
symptoms and/ or cure of their ailments, and society expects clinicians to act
in the best interest of their patients, subordinating their own self-interest. 1
Modern medicine was built on the foundations of the biological sciences
to improve the diagnosis and treatment of human suffering. The resulting
biomedical model focused narrowly on the pathophysiology of disease caused
by anatomic, biochemical, and/or neurophysiologic deviations from the
norm. Within this framework the clinician's task was to focus on identifying,
describing, and determining the cause of diseases and then preventing, managing, and/ or curing them. This focus led to the discovery and management
of many genetic, infectious, and other medical diseases. However, scholarship
over the past nearly four decades has underscored some critical limitations
of the biomedical model. For example, the model did not address symptoms
that are caused by factors other than disease or abnormalities in anatomical,
biological, and/or neurophysiologic states. The model also largely ignored the
social, psychological, and behavioral dimensions of illness. 2•3 Indeed, some
medical professionals believed that "mental illness is a myth:' and some
argued that it was not appropriate for medical professionals to attend topsychosocial issues-a stance that perpetuated the suffering of many patients and
the healthcare professionals whom they sought for help. 4

1

2

SMITH'S PATIENT-CENTERED INTERVIEWING

Hierarchy of Natural! Systems
1

Culture

Com~unity

SOCIAL

Nervous System

t

Tissues

cJ1s
t

Organelles

I

FIGURE 1.-1.. The hierarchy of natural systems.

By the latter part of the 20th century, it had become clear that the biomedical model was "no longer adequate for the scientific tasks and social responsibilities" of medicine.4 The human condition was noted to be too complex to
be fully described and explained by the biomedical model. Engel4•5 proposed
a biopsychosocial model to better explain how the symptoms and course of
one patient with a particular disease can be completely different from those
of another individual with the same disease. The biopsychosocial model
explicitly acknowledges the interdependence of patients' biological (disease),
psychological, and social characteristics, making it consistent with general
system theory (Fig. 1-1) (see Appendix A for Engel's foreword to the first edition of this text to learn more about the biopsychosocial model).
According to general system theory. disturbances in a system at one level
have implications for other levels in the hierarchy of natural systems. &-s
A person is part of a hierarchy of systems that ranges from the smallest organelle to the largest community and culture and can be profoundly affected by
changes in any of these systems. Unlike the biomedical mode~ the biopsychosocial model makes dear that the patient's relationships (including the
clinician-patient relationship) can be as important to the illness experience
as the patient's disease. It also explains why a person with no discernible
pathology or significant aberration in physiology can experience debilitating
symptoms and physical illness in the absence of disease.
Disease implies a disruption in normal biologic function. Disease
is objective: you can see disease processes under a microscope and in

Chapter 1

THE MEDICAL INTERVIEW

3

abnormal laboratory or imaging tests. Illness is subjective: people feel a sense of
"'dis-ease"; they identify themselves as sick; they behave in accordance with
the way they feel, which is different from how they act when they feel healthy.
In many cases, they seek medical care. A patient can have disease without
illness, as in an individual with hypertension who does not experience any
symptoms; and illness without disease, as in an individual with illness anxiety disorder who is convinced that the slight and transient discomfort in his
abdomen is due to cancer, not peristalsis.9
Most patients who seek medical care have both disease and illness, in varying degrees. Some stoic patients can have serious disease but exhibit little
illness behavior, while other more demonstrative patients may have little biologic disease yet be incapacitated. These are important distinctions relevant
to daily clinical work, since patients come to clinicians with their illness experiences seeking relief of symptoms, and clinicians were traditionally taught
to find and treat diseases. The distinctions between curing and healing now
become dearer: we cure diseases with medications, surgery, and biotechnology; we heal illnesses mainly through our words and the therapeutic relationships we establish with our patients. To be most effective as clinicians we must
be able to combine both curing and healing to benefit our patients.
Medical interviewing is the process of gathering and sharing information
in the context of a trustworthy relationship that takes into account both disease, if present, and illness. Even in this age of medical advances, the medical
interview remains the single most effective diagnostic tool, contributing to the
correct diagnosis more often than physical examination or laboratory tests.
Healthcare professionals conduct well over 100,000 interviews during their
careers making the interview, by far, the most frequently performed medical
procedure. Even a small improvement in your skills will have significant longterm benefits for you and your patients. The medical interview is what makes
the clinician. Through your interviewing skill you will establish relationships
with your patients that are meaningful, intimate, and caring. Your patients
will tell you secrets they share with no one else. You will have a window on
the world of human suffering and resilience and will develop respect for your
patients' courage and humanity. You will feel honored and privileged to be a
healing presence in your patients' lives.
This book describes an 11-step, evidence-based interviewing method used
to obtain a complete biopsychosocial story that describes the person's illness
experience as well as his/her disease state and will guide you in ways to educate the patient and help change health-related behaviors. The patient's story
can include pertinent personal features of the patient, the effectiveness of the
clinician-patient relationship, the family, the community, and the patient's
spirituality or lack thereof (Table 1-1),4.5

• TABLE 1-1. Evidence-Based Interviewing Method
Step 1: Set the stage for the interview
1. Welcome the patient
2. Use the patient's name
3. Introduce self and identify specific role (student
nurse/student doctorjresidentjfellow)
4. Ensure patient readiness and privacy
5. Remove barriers to communication
6. Ensure comfort and put the patient at ease
Step 2: Elicit chief concern and set agenda
7. Indicate time available
8. Forecast what you would like to have happen
during the interview
9. Obtain list of all issues patient wants to discuss;
specific symptoms, requests, expectations,
understanding
10. Summarize and finalize the agenda; negotiate
specifics if too many agenda items
Step 3: Begin the interview with nonfocusing skills
that help the patient to express her/himself
11. Start with open-ended request; question
12. Use nonfocusing open-ended skills
13. Obtain additional data from nonverbal sources:
nonverbal cues, physical characteristics,
accoutrements, environment, self
Step 4: Use focusing skills to elicit three things:
symptom story, personal context, and emotional
context
14. Further elicit symptom story
• Description of symptoms, using focusing openended skills
15. Elicit personal context
• Broader personal/psychosocial context of
symptoms, patient beliefs/attributions, again
using focusing open-ended skills

16. Elicit emotional context
• Use emotion-seeking skills
Direct
Indirect
Impact
Belief
Triggers
Self-disclosure
Resonate with unexpressed feeling
17. Respond to feelings/emotions
• Use empathy skills to address the
feelings and emotions (naming, understanding, respecting, and supporting
[NURS])
18. Expand the story
• Continue eliciting further personal and emotional context; address feelings and emotions
(NURS)
Step 5: Transition to middle of the interview
19. Brief summary
20. Check accuracy
21. Indicate that both content and style of inquiry
will change if the patient is ready
• Continue with middle of the interview
Step 6: Complete a chronological description of
HPI/OAP
Step 7: Past medical history
Step 8: Social history
Step 9: Family history
Step 10: Review of systems

(Physical examination)
Step 11: End of the interview

• THE HISTORY OF PATIENT-CENTERED INTERVIEWING
Clinicians who were trained in the last century under the biomedical model
were taught to interview patients using only clinician-centered interviewing
skills to elicit symptoms of disease. Clinician-centered interviewing means
the clinician takes charge of the entire interaction to acquire the details of the
patient's symptoms and other data that will help the clinician to identify a disease. This is often done through the use of closed-ended questions, the answer

Chapter 1

THE MEDICAL INTERVIEW

5

to which is yes, no, or a short phrase. This usually meant that the patient's
concerns and what the interviewer perceived as nonmedical data were largely
ignored or even discouraged in the clinician's quest for a biomedical diagnosis. Closed-ended questions also made the interview feel more like an interrogation. In a typical clinician-centered interview, the clinician controlled
the flow of information, kept the focus away from the patient's experience
of illness, and prevented most personal information, feelings, and emotions
from emerging, limiting the clinician's ability to form an adequate relationship with the patient or develop a biopsychosocial description of the patient's
problem.2.3 As noted in Appendix B, this leads to poor patient satisfaction,
physician frustration, and worse health outcomes.
Recognizing these limitations, patient-centered interviewing was developed 10- 14 as part of the relationship-centered care approach. 15•16 In a general
sense, every action with the patient is patient centered; everything is done in
the patient's interest. As a technical term, patient-centered interviewing skills
encourage patients to express what is most important to them. In addition to
symptoms, the patient-centered approach also recognizes the importance of
patients' expressions of personal concerns, feelings, and emotions. With these
personal data, the interviewer can synthesize a biopsychosodal description of
the patient. Not only does the clinician avoid an isolated focus on symptoms,
but s/he also allows the patient to lead and direct portions of the conversation. 17 This means the patient's ideas, concerns, and expectations, rather than
the clinician's, are drawn out. The clinical benefits of this theoretical improvement have been substantiated by significant research (see Appendix B).
Patient-centered interviewing skills were developed to complement
clinician-centered interviewing skills. Like clinician-centered interviewing,
patient-centered interviewing should not be used in isolation. The method

described in this book integrates the patient-centered and clinician-centered
interviewing skills you wiU need to elicit symptom, personal, and emotional
information. You must then interpret and synthesize these data, using your
knowledge of medicine, along with available data from physical examination
and laboratory and imaging tests, to produce a biopsychosocial descriptionthe patient's story.

• THE PATIENT-CENTERED APPROACH
The patient-centered approach is built on several premises:

• Patients often do not seek healthcare only because of a symptom
Clinicians trained in the era of biomedicine assumed that their role was
solely to diagnose a patient's symptom and treat the disease. They did not
recognize that often there were more complex reasons behind the patient's

8

SMITH'S PATIENT-CENTERED INTERVIEWING

decision to seek healthcare-the personal context of a symptom story often
drives healthcare-seeking behavior, rather than the symptom per se. For
example, a 19-year-old man develops low back pain that, if he worked at
a desk job, would not cause him to see his clinician. However, because he
works on a loading dock, the pain is interfering with his job and he makes
an appointment to be seen.
The emotional context of a symptom is another common factor leading
patients to see their clinicians. This same young man recently bought a
home for his new family. He is worried that if he cannot perform his work
duties he will be fired and will not be able to keep up with his mortgage
payments. Clinicians increase their effectiveness and their patients' satisfaction when they seek to understand the personal and emotional context
of patients' symptom stories.

• Patients usually bring more than one concern to their clinician
Research shows that patients in outpatient primary care settings average
three or more concerns per visit. 18- 20 Interestingly, the first concern mentioned may not be the most important one to the patient (or to the clinician) and sometimes the last concern raised is the most important one,
but was saved for last because it is frightening or shameful. Clinicians who
assume the first concern is the patient's only one will likely hear the additional concem(s) voiced at the very end of the visit, which is frustrating
and inefficient. It also results in low patient satisfaction.

• Allowing the patient to tell his/her symptom story is diagnostically useful
Clinicians who encourage patients to tell the story of their symptom arrive
at the correct diagnosis more often and more quickly than clinicians who
learn about the symptom only through the use of clinician-centered interviewing skills. The way the patient describes the symptom is as important
as the facts that are stated. This observation is not new-the physician Sir
William Osler urged his students in 1910, "Listen to the patient, he is telling you the diagnosis."

• Allowing the patient to tell his/her symptom story is therapeutic
When patients are allowed to tell their illness narrative rather than only
respond to multiple clinician-centered questions, they experience a catharsis-simply getting the story off one's chest can result in feeling better. Most
of us have experienced feeling unburdened and less alone after sharing a
story of difficulty with a good listener.
• Patients do not want us to try to "fix" everything they tell us about
Many clinicians have a strong "curative need;' wanting to fix things and
make them right. This need can cause them anxiety when a patient mentions something (such as being unable to do work duties and feeling worried about losing the job) that is not "fixable." Patient-centered clinicians

• TABLE 1-2. Needs Communicated by Patients
1. Very common: Needs to express symptoms, personal context of illness,
feelings and emotions, interests, desire for information, and other ideas;
e.g., worry about cancer; sore throat; can't work with this back pain; feeling
down; want to lose weight; fever; refill medications•
2. Common: Special communication needsb; e.g., non-English speaker, deaf,
blind, cognitively impaired
3. Uncommon: Urgent, sometimes life-threatening needs requiring immediate
attention°
a. Biomedical; e.g., unconscious, hematemesis, symptoms of acute
myocardial infarction, recent history of syncope, severe pain, severe
nausea and vomiting, marked shortness of breath, multiple trauma
b. Psychosocial; e.g., suicidal, homicidal, very disruptive, overtly psychotic,
severe organic brain syndrome, very agitated or very anxious
"Addressed in Chapters 1 to 5.
bAddressed in Chapter 7.
•Not addressed in this book.

8

SMITH'S PATIENT-CENTERED INTERVIEWING

Most patients in outpatient and inpatient settings do not have such critical
problems. They are able to communicate; are not prohibitively anxious; and
want to talk about their symptoms, interests, fears, and concerns. In these
more common situations, you will meet these needs, not by controlling, but
by allowing the patient to lead the conversation and to discuss the symptoms
or personal issues s/he prefers. Ideas in the initial dialogue originate in the
patient's mind rather than in the clinician's; later, the clinician will insert his/
her ideas into the exchange.
We will next introduce the process (timeline) and content (components) of
the basic medical interview. In Chapters 2 to 6, we will discuss how to conduct
the interview, and will consider how to handle communication problems in
Chapter 7; you will learn the approach to emergency medical and psychological conditions elsewhere in your clinical training.

• INTEGRATED INTERVIEWING
Figure 1-2 shows a timeline of the medical interview. In the beginning of the
interview, patient-centered skills are used (covered in Chapters 2 and 3); in
the middle of the interview clinician-centered skills predominate (detailed in
Chapters 4 and 5); ending the interview involves a return to patient-centered

Integrated Medical Interviewing
(PatientCentered
Skills)

9911nlcian-Cento9
9

3,4,5,
HPI---

6,
7,
8, 9, 10,
-- HPVOAP, PMH, SH, FH, ROS]

I! eg In n In g
Set
the

Set
the
Stage Agenda

Steps: 1,

2,

Components: [CC,

Middle

centered

Skills)

Pallentcenlerad

Beginning: Patient-Centered =
Psychosocial and
Symptom Data

'

Physical
Exam

End

11

Middle: Clinician-Centered
Symptom and
Psychosocial Data
Clinician
Synthesizes

/

BIOPSYCHOSOCIAL STORY

FIGURE 1-2. 1he Integrated medical Interview.

=

Chapter 1

THE MEDICAL INTERVIEW

9

skills (discussed in Chapter 6). The amount of time spent in each varies with
the circumstances but, generally, the middle of the interview takes much longer. We discourage you from starting the interview with the clinician-centered
skills except in the rare emergency situations noted earlier. Even if you were
to later attempt to use patient-centered interview skills to hear the patient's
concerns, your having started with clinician-centered skills would suggest
that your agenda was more important than the patient's. Additionally, there
is evidence that patients have difficulty providing information in a narrative
fashion after they have been interrogated by clinician-centered questions; this
has been called the "question-answer trap."21
Because Fig. 1-2 depicts a first-time interview with a new patient, all components of the history are included: chief concern (CC), history of present illness (HPI), other active problems (OAP), past medical history (PMH), social
history (SH), family history (FH), and review of systems (ROS). You will learn
more about these in the chapters that follow. In patients whom you have previously evaluated, you will usually need only the CC and HPI because other
data are already known, although sometimes a brief updating of the other
components is necessary.
The CC is the patient's most bothersome concern. The HPI usually is the
most helpful historical component and is where the patient gives the story of
this concern, describing both the symptoms of possible disease and the personal and emotional context in which they occur. When patients have more
than one current medical concern, you will obtain these in OAP. The PMH
is where the patient gives important past medical information that does not
pertain to the HPI or OAP. In the SH, you will ask the patient about healthpromoting behaviors, health hazards, routine personal data, relevant ethicalsocial-spiritual issues, and functional capacity. The FH does the same with
routine family medical information. The ROS screens for any symptoms or
other problems not already discussed.
Ordinarily the CC/HPI/OAP takes approximately half the total time available. The CC and initial portions of HPI/OAP are developed in the beginning of the interview using patient-centered interviewing skills while in the
middle of the interview the latter portions of the HPI/OAP and the remainder of the sections are elicited using clinician-centered skills. The PMH, FH,
SH, and ROS are elicited largely by using clinician -centered skills, but as the
islands of patient-centeredness in Fig. 1-2 show, you will not remain entirely
clinician centered during this time, but will periodically return to patientcentered skills as needed. For example, while obtaining the FH, if you ask
the patient for his father's age and he begins to cry, saying that his father died
last month, your next question is not "How old is your mother?"! Rather,

1.0

SMITH'S PATIENT-CENTERED INTERVIEWING

you use patient-centered interviewing skills to empathize with the patient
and try to further understand his sadness before going on with additional
clinician-centered questions, such as the mother's age. If the beginning of the
interview has been conducted effectively, most emotionally charged issues
will already have arisen and use of patient-centered interviewing skills will
tend to be brief.
The patient-centered skills used in the beginning of the interview allow
you to gather the patient's unique perspective on her symptoms and important psychosocial information. In contrast, the clinician-centered interviewing skills used in the middle of the interview produce mostly symptom
information and, to a lesser extent, psychosocial data (which also are of a
more routine type than psychosocial data obtained in the beginning of the
interview). Using your knowledge of medicine, you then synthesize these data
into a biopsychosocial description of the patient.
Integrated interviewing is used for most medical interactions-new or
return patients, hospital settings or clinics, surgical or medical services, tertiary care or primary care, and emergency room or consultation visits.
Having introduced the process and content of the medical interview, it
is logical to ask about its intended functions. There are three distinct functions of the interview: (a) creating a safe atmosphere and establishing a
trustworthy relationship with the patient; (b) gathering information; and (c)
informing and motivating the patient (patient education).22- 24 Most clinical
encounters will contain all three. In Chapters 2 to 5, you will learn skills that
help you to establish a safe and trustworthy relationship with your patient,
and to gather diagnostically important data. The third function, patient education, is covered in Chapter 6. Chapters 7 to 9 will address advanced interviewing issues and Chapter 10 will discuss how to summarize and present
the patient's story.
Throughout the book we will refer you to modules in DocCom, a webbased curriculum resource where you can get more in-depth information on
over 40 important medical interview topics. Many schools provide access to
DocCom for their students; individual licenses can also be purchased. The
website is doccom.org. Module 1 of DocCom provides a good overview of
DocCom25 and Module 5 discusses the integrated patient-centered interviewing module presented in this book. 26
We have identified the general interviewing process, its content, and functions, but we still are left with an unanswered question: What actually goes on
at the bedside or in the clinic? What do we say and how do we say it? We are
now ready to begin.

KNOWLEDGE EXERCISES
1. Define medical interviewing.
2. Define the biopsychosocial model,
patient-centered interviewing, and cliniciancentered interviewing. How are they
related?
3. Give examples of some patient needs that
can be overlooked with isolated cliniciancentered interviewing.
4. Under what circumstances would you not
begin an interaction with a patient-centered
approach?
5. Describe three problems encountered with isolated clinician-centered
interviewing.
6. List the benefits from integrating patientcentered and clinician-centered interviewing that make this more scientific and
more humanistic, as compared to isolated

clinician-centered interviewing. See
Appendix B.
7. Draw the full diagram of the interview and
label the following: beginning, middle,
physical examination, and end; CC and
HPI/OAP, PMH, SH, FH, ROS.
8. What do each of the components of the
interview listed in question #7 contribute?
9. Where does important disease information first arise in the interview? Would you
expect personal and psychosocial information to arise in the clinician-centered
process?
10. How do you think the interviewer might feel
in an isolated clinician-centered interview
compared to an interview integrating
patient-centered with clinician-centered
processes? Why is that the case?

REFERENCES
1. LoB. Resolving Ethical Dilemmas: A Guide for Clinicians. 3rd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2005.
2. Feinstein AR. The intellectual crisis in clinical science: medaled models and muddled
mettle. Perspect Bioi Med. 1987;30:215-230.
3. Schwartz MA, Wiggins 0. Science, humanism, and the nature of medical practice: a
phenomenological view. Perspect Bioi Med. 1985;28:331-361.
4. Engel GL. The need for a new medical model: a challenge for biomedicine. Science.
1977;196:129-136.
5. Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry.
1980;137:535-544.
6. Capra F, Luisi P. The Systems View of Life-A Unifying Vision. Cambridge, UK: Cambridge University Press; 2014.
7. von Bertalanffy L. General System Theory: Foundations, Development, Application,
Revised. New York, NY: George Braziller; 1968.
8. Smith R, Fortin AH, Dwamena F, Frankel R. An evidence-based patient-centered
method makes the biopsychosocial model scientific. Patient Educ Couns. 2013;90:265270.
9. Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from
anthropological and cross-cultural research. Ann Intern Med. 1978;88:251.

1.2

SMITH'S PATIENT-CENTERED INTERVIEWING

10. Levenstein JH, Brown JB, Weston WW. Patient centered clinical interviewing. In: Stewart M, Rater D, eds. Communicating with Medical Patients. London: Sage Publications;
1989:107-120.
11. Levenstein JH, McCracken EC, McWhinney IR, Stewart MA, Brown JB. The patientcentered clinical method. 1. A model for the doctor-patient interaction in family medicine. J Pam Pract. 1986;3:24-30.
12. McWhinney I. An Introduction to Family Medicine. New York, NY: Oxford University
Press; 1981.
13. McWhinney I. The need for a transformed clinical method. In: Stewart M, Rater D, eds.
Communicating with Medical Patients. London: Sage Publications; 1989:25-42.
14. Rogers CR Client-Centered Therapy. Boston, MA: Houghton Mifflin Company; 1951.
15. Inui TS. What are the sciences of relationship-centered primary care. J Fam Pract.
1996;42(2): 171-177.
16. 'IIesolini CP, Pew-Fetzer Task F. Health Professions Education and Relationship-Centered
Care. San Francisco, CA: Pew Health Professions Commission; 1994:72.
17. Watzlawick P, Bavelas JB, Jackson DD. Pragmatics ofHuman Communication: A Study of
Interactional Patterns, Pathologies, and Paradoxes. New York, NY: WW Norton & Company; 1967:294.
18. Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient's agenda: have
we improved? JAMA. 1999;281(3):283-287.
19. Heritage J, Robinson JD, Elliott MN, Beckett M, Wilkes M. Reducing patients' unmet
concerns in primary care: the difference one word can make. J Gen Intern Med.
2007;22(10):1429-1433.
20. Kaplan SH, Gandek B, Greenfield S, Rogers W. Ware JE. Patient and visit characteristics related to physicians' participatory decision-making style. Results from the Medical
Outcomes Study. Med Care. 1995;33(12):1176-1187.
21. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. New
York, NY: Guilford Press; 2002:55-56, 73.
22. Bird J, Cohen-Cole SA. The three-function model of the medical interview: an educational device. In: Hale M, ed. Models of Teaching Consultation-Liaison Psychiatry. Basel:
Karger; 1991:65-88.
23. Cohen -Cole SA, Bird]. Interviewing the cardiac patient: II. A practical guide for helping
patients cope with their emotions. Qual Life Cardiovascular Care. 1986;3:53-65.
24. Lazare A, Putnam S, Lipkin M. Three functions of the medical interview. In: Lipkin
M, Putnam S, Lazare A, eds. The Medical Interview. New York, NY: Springer-Verlag;
1995;3-19.
25. Gordon G. Module 1: Overview. In: Novack D, Daetwyler C, Saizow R, Lewis B, Hewson
M, Levy J, eds. DocCom - an Online Communication Skills Curriculum[Intemet]. Lexington, KY: Academy of Communication in Healthcare and Drexel University College of
Medicine; 2018. Available from: www.DocCom.org.
26. Fortin AH 6th, Dwamena F, Smith RC. Module 5: Integrated Patient-centered and
Doctor-centered Interviewing-Structure and Content of the Interview. In: Novack D,
Daetwyler C, Saizow R, Lewis B, Hewson M, Levy J, eds. DocCom - an Online Communication Skills Curriculum[lntemet]. Lexington, KY: Academy of Communication
in Healthcare and Drexel University College of Medicine; 2018. Available from: www
.DocCom.org.

Data-Gathering
and Empathy Skills
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 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

13

1A

SMITH'S PATIENT-CENTERED INTERVIEWING

FIGURE 2-:1.. The clinician Is being patient-centered when the Information "on
the table" has been placed there by the patient.

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, closedended) 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

Chapter 2

DATA-GATHERING AND EMPATHY SKILLS

:15

Core Skills: Patient-Centered
Open-Ended Skills

Emotion Seeking

Empathy

1. Nonfocusing

1. Direct

1. Name

• Silence
•Nonwrbal
encouragement
• Conti''IUers

'

2. Focusing
• Echoing
• Requesting
• Summarizing

! If Necessary
2.1ndirect
• Impact on life, others
• Beliefs about the
problem
• Intuit how the patient
might be feeling
•Triggers

''

2. Understand
3. Respect

'

4. Support

FIGURE 2-2. Dynamic use of facilitating skills.

•

DATA-GATHERING SKILLS

Open-Ended Skills

Open-ended skills encourage the patient to freely express what is on his/her
mind. There are two types of open-ended skills: (1) nonfocusing skills (silence,
nonverbal encouragement, and continuers) and (2) focusing skills (echoing,
open-ended requests, summaries). Nonfocusing open-ended skills are used
liberally throughout the interview to encourage the patient to expand, elaborate, and raise important issues without interference from the clinician's questions. These skills are critical at the beginning of the interview. As the patient
talks freely, s/he will introduce many topics that may or may not coalesce into
a coherent story. As long as the patient is giving a coherent and nonrepetitive
story, nonfocusing skills are effective. Later, focusing open-ended skills are
necessary for most patients to help them develop their narrative beyond the
opening statement, an invitation to expand and elaborate on topics that they
raised already-topics placed on the table for discussion. When the patient's
narrative becomes hard to follow, gets off-track, or overwhelming, focusing
skills are used to help restore structure and balance to the interview-to focus
the patient's story.
Open-Ended Nonfocuslng Skills

Nonfocusing skills encourage the patient to put more and more information
"on the table" (Fig. 2-3).

16

SMITH'S PATIENT-CENTERED INTERVIEWING

FIGURE 2-3. Nonfocuslng open-ended skills encourage the patient to put
information "on the table."

Silence Remaining silent-saying nothing-while continuing to be nonverbally atten-

tive and responsive (using appropriate eye contact and an open body posture, leaning
forward with legs and arms uncrossed) prompts the patient to continue talking and
signals that you are interested in what s/he is saying. For example, the clinician's silence
in the following vignette encourages the patient to express what is really on his mind:

Patient: ... and it rolled down and hit me here (pause).
Clinician: (attentive but silent for 4 seconds)
Patient: ... so I called you, thinking you'd be in, but you were not. I was
hoping to have heard from you sooner ...

Chapter 2

DATA-GATHERING AND EMPATHY SKILLS

1.7

Silence can make some patients uncomfortable, a discomfort they may
indicate by shifting about or looking away. If 3 to 4 seconds of silence do not
prompt further information or the patient appears uncomfortable, move on
to another skill. Often pairing silence with another nonfocusing skill provides
the comfort needed for the patient to continue.
Nonverbal encouragement Nonverbal encouragement often paired with silence,
urges patients to talk freely. Typically; the clinician makes a sympathetic facial expression (expectation to continue), nods, or simply indicates by body language that the
patient should continue speaking (leaning forward):

Patient: ... so that it hurt his feelings (pause).
Clinician: (leans forward with expectant expression while remaining
silent)
Patient: Well then I felt bad too and ...
Continuers Integrated with silence and nonverbal encouragement, continuers are
brief, noncommittal statements such as '1 see;' llh-huh,"' "Yes:· or "Mmm" that

encourage the patient to talk without directing the conversation; they let the patient
know you are following what slhe is saying:

Patient: ... and later the pain went in the front part, right here ...
Clinician: Uh-huh.
Patient: Yeah, and it hurt like crazy.
Clinician: Mmm.
Open-Ended Focusing Skills
Focusing skills encourage the patient to expand on specific parts of the information they have already "placed on the table" (Fig. 2-4). In essence, the clinician uses these skills to pick things up "off the table" in order to learn more
about them.

Echoing Echoing is a type of reflection, accomplished by repeating a word or phrase
"placed on the table'' by the patient; this not only lets the patient know slhe is heard, but
also provides encouragement to focus, expand, and elaborate on the word or phrase.

Patient: After the pain let up, I still couldn't find him.
Clinician: The pain? (Invites the patient to talk more about the symptom
of pain.)
-OR-

Couldn't find him? (Invites the patient to describe a personal
aspect ofhis story.)

18

SMITH'S PATIENT-CENTERED INTERVIEWING

FIGURE 2-4. Use focusing open-ended skills to learn more about what the
patient has put "on the table."

Open-ended requests Open-ended requests are used to focus the patient on an
already mentioned area that the clinician wants to expand upon, such as "Tell me
more about the daughter you mentioned:'

Patient: Then my pain came back because I couldn't afford the medicine.
Clinician: Go on (encourages patient to continue without additional

focusing).
-OR-

Tell me about not affording it (focuses patient on the personal
problem).
-OR-

Tell me about the pain (focuses patient on a symptom).

Chapter 2

DATA-GATHERING AND EMPATHY SKILLS

1.9

Like other focusing skills, open-ended requests move the patient to deeper
levels of his/her story by focusing on something that the patient has already
mentioned. They should not be used to direct the patient to a topic they have
not already mentioned, for example, "Tell me about your family" when the
patient has not said anything about her or his family. Remember the table
analogy? Family was not on the table, so the clinician should not introduce a
new topic.
Summarizing, paraphrasing Summarizing by paraphrasing what the patient said
invites the patient to focus on and expand the material provided, but also is an
accuracy check. Basically, summarizing allows the patient to know that the clinician has followed the conversation, heard the details, and is ready for more information.

Patient: (Long story about difficulty getting in to see clinician)
Clinician: So, you had the nausea but couldn't get me on the phone. Then
it got worse and your wife still couldn't get a hold of me until
today.
Patient: Yeah, I was really more upset than sick by now.
As shown in the examples above, focusing open-ended skills encourage the patient to further explore areas that you are curious about. They
allow you to actively develop a coherent, narrative thread in the patient's
own words and to take control of the interview if necessary, while remaining
patient-centered.
With open -ended focusing skills the clinician can refocus the patient on an
important topic that may have slipped by too quickly. Often patients mention
an emotionally loaded topic, such as death, but rapidly move away from it.
You can return to the topic by saying, for example, "You mentioned death a
minute ago, tell me more about that:' Because the patient initially introduced
the topic of death by "placing it on the table; the clinician can comment
on it, even though it may interrupt the immediate thread of conversation.
Using these open-ended skills, the clinician learns information, feelings, and
thoughts important to the patient-patient-centered material-with less contamination from the clinician.

Closed-Ended Data-Gathering Skills (Used In the Middle Portion
of Interview)

Closed-ended questions, typically answered with yes, no, or a choice among
provided answers, are used primarily to confirm or refute specific issues,
rather than expand the conversation in the way that open-ended questions do.

20

SMITH'S PATIENT-CENTERED INTERVIEWING

This makes closed-ended questions ideal for the middle of the interview
where specific information is required from the patient. Closed-ended questions can enhance the precision of information. In the beginning, that is in
the patient-centered part of the interview, they usually are counterproductive because they discourage information originating in the patient's mind
and force the patient to respond to the clinician's concerns and ideas. Closedended questions are appropriate in the beginning ofthe interview only if used
sparingly and to obtain clarification of an issue raised by the patient, rather
than inserting new information; for example, "When did you come to the
hospital?" "When did this begin, yesterday or a week ago? I'm confused." Used
excessively or inappropriately, not only do closed-ended skills have a deleterious effect upon the clinician-patient relationship, they greatly diminish the
quantity and quality of data about the patient. Close-ended questions imply
that the clinician knows what is important to the patient, and possibly that
the patient's concerns are trivial. Patients who are chronically exposed to this
type of questioning during the encounter are less satisfied with the clinician
and the interaction.
There are three types of closed-ended skills, very familiar and reflexive,
and helpful in the proper part of the interview.
1. Questions PI'Oducl~ Yes/No Answers
These questions are asked with a specific issue to be answered. They can be
used to clarify a patient's statement or introduce a new topic.

Patient: My pain is right here.
Clinician: Is it just in your left arm?
-ORDid you have shortness of breath with the pain?

Patient: No.
Clinician: Did you come in this morning?
Patient: Yes.
2. Questions

PI'Oducl~

Brief Answers

These questions also direct the patient to answer with a word or phrase.

Clinician: How old are you?
Patient: Thirty-one.
Clinician: How high was the fever?
Patient: I don't know.
-OR103 degrees.

Chapter 2

DATA-GATHERING AND EMPATHY SKILLS

21

3. Multiple-Choice Questions
These questions are asked with a specific issue to be answered by choosing
among choices provided. They can be used to clarify a patient's statement or
introduce a new topic:
Patient:

My pain is right here.

Clinician: Is it just in your left or right arm?
-ORWas the pain sharp, stabbing, or throbbing?
Patient: Sharp.
Clinician: Did you notice the pain this morning, during the day, or at
night?
Patient: Early morning.
Integrating Open-Ended and Closed-Ended Skills

Open- and closed-ended skills complement each other. During the patientcentered beginning of the interview, open-ended skills predominate and are
used repeatedly, primarily for developing information about symptoms and
personal and emotional concerns expressed by the patient. Closed-ended
questions are used sparingly during the beginning of the interview to clarify the patient's utterances. As you will learn in Chapter 3, at the end of the
patient-centered part of the interview a clear transitional statement is made
alerting the patient to a change in interview style. Then, during the cliniciancentered middle of the interview, open-ended questions are fewer and used
primarily at the start of each step for brief but repeated scanning purposes.
Closed-ended questions predominate and are used to pin down details and
often place new information "on the table."
Thus far, we have described the fundamental communication skills used
for data-gathering. Next, we will discuss how to use these and other skills to
build positive, strong relationships with patients. Then, in Chapter 3, we will
show how to integrate these skills into a method to conduct a patient-centered
interview in a systematic manner.
•

EMPATHY SKILLS

One of the most important goals of patient-centered interviewing is to form
a therapeutic relationship with the patient. Emotions maximize human communication and connection.
Expressing needs through emotion antedates language and is a basic form
ofhuman communication at personal and sociallevels.6- 8 Emotions, and the

22

SMITH'S PATIENT-CENTERED INTERVIEWING

thoughts and feelings they often represent, are central to effective decision
making'·9 and, perhaps, to consciousness itsel£.8•10 Responding to feelings and
emotions leads to strong and therapeutic clinician-patient relationships and
results in the most effective communication.11•12 It is the essence of how we
achieve the benefits ofbeing patient-centered, detailed in Appendix B.
The patient can express feelings verbally (e.g., "I was upset"), and/
or emotions nonverbally (e.g., depressed face, slumped shoulders) or by
acting them out (e.g., crying). Charles Darwin first drew attention to the
expression of emotions in man and animals in 1872.7 More recently, Paul
Ekman has identified 15 distinct emotions that can be read from a person's
face: amusement, anger, contempt, contentment, disgust, embarrassment,
excitement, fear, guilt, pride in achievement, relief, sadness/distress, satisfaction, sensory pleasure, and shame. 13 Feelings, being the conscious,
subjective experience of emotion, are more numerous. We have listed the 15
emotions and a host of derivative feelings in Appendix C. Most learners are
surprised to learn how many different feelings and emotions there are. For
the beginning clinician, drawing out and addressing either emotions or feelings produces the same benefits, so we will often use the terms interchangeably throughout this text.
When the clinician uses patient-centered skills, patients feel encouraged
to share the information needed to understand their emotional world, made
up of thoughts, feelings, and emotions. Communicating this understanding to
patients is termed empathy. 14 As clinicians, we must identify and respond
to emotions in order to form a connection with patients.
Clinicians often miss or ignore patients' emotions and feelings, focusing instead upon establishing a disease diagnosis. Research has shown that
patients seek and welcome inquiry about their thoughts and feelings, and
that the clues they give through emotional expression are often subtle
and fleeting. 15 It is important, therefore, to stay on the alert for these clues
throughout the interview, but especially at the beginning, to quickly establish
the clinician-patient relationship.

Emotion-seeking Skills
Because feelings and emotions are so important, you must actively seek
them even when they have not been "placed on the table" -or when they
have only been hinted at. The emotion-seeking skills serve this purpose.
Once feelings and emotions are "on the table" and you have understood
them via open-ended skills, you employ the subsequently described empathy skills.
Use the emotion-seeking skills initially in the order given below, and then
intersperse them freely. Typically, the first skill of direct inquiry suffices to

Chapter 2

DATA-GATHERING AND EMPATHY SKILLS

23

elicit the initial feeling or emotion and the second further develops it. In more
reticent patients, indirect emotion-seeking skills are sometimes required to
initiate the expression of emotions or feelings from the patient.
Direct Inquiry

One of the most important questions in patient-centered interviewing is some
variation of "How did that make you feel?" 16 For example, you may suspect
an emotion (anger) from the patient's statement ("she got my job"), nonverbal
behavior (furrowed eyebrows), or actions (looking away from you). You can
let the patient identify the specific feeling by asking how s/he feels about the
situation (e.g., "I noticed that you have been looking away. Can you tell me
how you are feeling?"). Most patients respond to this invitation. Some patients
may not understand that you are seeking an emotion and may respond with
how they feel physically ("sick to my stomach"). You can clarify or prevent this
by asking "What emotions are you feeling?"
Patient: (Has just been told he needs surgery)
Clinician: How are you feeling about this, emotionally?
Patient: Surprised, I guess (but looking anxious).
Clinician: How are you feeling right now, talking about it?
Patient: I guess I'm pretty worried.
Indirect Inquiry

Patients do not always respond to direct emotion-seeking skills with an
expression of feeling or emotion; this does not necessarily mean that the
patient does not have or want to share them. Because emotion is important, it
is crucial to continue to seek feelings/emotions. There are four indirect ways,
in no particular order, to encourage a patient to express emotion or feelings:
1. Inquiring about impact: Asking about how the illness or other situation
in question has affected the life of the patient, family member, or friend
also uncovers important information and increases emotional expression
("How has your back pain affected your day-to-day life?" or "How has your
wife's death affected your life?" or "How has your wife's death affected your
daughter?").
2. Eliciting beliefs/attributions: Asking what the patient thinks caused the
problem is not only helpful for understanding the patient's medical explanatory model17 but it may also uncover an underlying feeling or emotion,
particularly if the patient believes that a serious condition may be causing
the symptom.
3. Intuiting how the patient might be feeling: Sharing how you or others
might feel in similar circumstances can help the patient identify her or his
own emotions and feelings ("I think if that happened to me I would feel

24

SMITH'S PATIENT-CENTERED INTERVIEWING

upset:'). Avoid strong affective terms like "angry" or "depressed" because
the patient may not feel comfortable endorsing them; instead use less
intense terms like "upset;' "unhappy," or "frustrated." If a patient describes
a situation that clearly hints at an emotion without clearly naming one,
you can express your intuition with a statement like, "I get the idea that
this might have been difficult for you:' In using this technique, say "might"
or "could;' rather than "must." This encourages the patient to express his/
her actual feeling, rather than believing that your inaccurate guess is the
"correct'' feeling. For example, if you were to say, "You must be very scared
about this; the patient may believe that s/he should be scared. Better to say,
"I can imagine that this might be worrying for you" or "The idea that your
neighbor died of the same disease could be frightening." In this way, if you
guess that the patient would have felt worry, but s/he actually felt anger, s/
he will likely correct you.
4. Asking about triggers: Determining why the patient is seeking care at this
precise time, especially if the problem has been present for more than a few
days, can uncover the underlying reason for the visit and provide a window
into the patient's feelings and emotions ("What made you decide to see me
today for this [symptom]?"). A common trigger that can lead to emotional
expression is interpersonal crisis. When people are in crisis they are worried and distressed, which increases their sensitivity to pain and awareness of bodily symptoms. They often do not make the link between their
stress and their symptoms. Asking, "What else is going on in your life?" can
uncover the distress and allow for expression of feelings and emotions.
These indirect questions have value in learning about the patient's perspective, presented in Chapter 5, but are used here as indirect methods of eliciting
an emotional expression. Be careful using these because some early-career
clinicians and learners get distracted by the responses and forget to actually
elicit the associated emotion. If a patient doesn't name an emotion, it may be
useful to reiterate your interest in helping elicit it.
Patient:

(Patient has just been told he has leukemia but acknowledges no
emotion with direct inquiry.)
Clinician: How's it going to affect your life?
Patient: I don't know. Will I be able to work?
Clinician: Well, we'll have to talk about that. How do you feel about not
being able to work?
Empathy Skills

When the patient expresses an emotion, first follow it up with sufficient openended inquiry to be able to genuinely have some understanding of the situation. For example, if a patient says, "I'm so angry!~ you can reply, "Tell me
more about that; or "Angry?':

Chapter 2

DATA-GATHERING AND EMPATHY SKILLS

25

Sometimes patients express feelings that are initially difficult to understand. In these cases, you need to learn more before you can respond with
genuine empathy. For example, a patient, describing the recent death of her
brother, says, "To tell you the truth, I feel relieved." The clinician, perhaps
expecting an expression of sadness, may not yet understand why the patient
feels this way and so needs to inquire further: "Tell me more about feeling
relieved." As the patient explains that her brother had been suffering worsening pain from terminal cancer, which had been increasingly difficult for
the patient to bear, the clinician comes to understand her relief and can now
respond empathically.
Seeking clarification of emotions as well as feelings is also important. For
example, crying is a manifestation of several emotions such as sadness, anger,
relief, joy, frustration; clarifying the emotion by asking a few open-ended
questions aids in expressing empathy accurately.
Once you can understand why the patient is feeling the ways/he is feeling,
you should express that understanding with verbal empathy. Remaining silent
or changing the subject can lead the patient to believe, for example, that you
disapprove of the patient's feelings, that you believe slhe should have had a
different feeling, that feelings should not be discussed with you, that you don't
care about the patient, or that the patient's expression of emotion has made
you uncomfortable. Empathy skills communicate that you have heard the
patient; they result in the patient feeling heard, understood, and cared for. As
important as empathy skills are, it is important to track the patient's emotional
response so that you can adjust communication to enhance the patient feeling of being understood. 18 Empathy skills are essential for developing a positive clinician-patient relationship and being patient-centered. You can use the
mnemonic NURS to help recall them: naming, understanding, respecting,
and supporting. Using the four skills in order will help you become proficient
in communicating empathy with patients. Once learned, the skills can be used
singly or in pairs every time the patient expresses an emotion.
Naming the Feeling/Emotion

To name the feeling or emotion, you simply repeat the feeling expressed by
the patient, "You felt sad" or the emotion you observe, "You look a little tearyeyed." This signals to the patient that you have heard the feeling/ observed the
emotion in him/her; and that these are okay to express.
Understanding

An "understanding" statement acknowledges that the patient's emotional
reaction is understood by the clinician; for example, "Given what happened
it makes sense to me; I can sure understand why." It legitimizes, accepts, and
validates the patient's expressed emotion. Because the occasional patient may

28

SMITH'S PATIENT-CENTERED INTERVIEWING

counter with, "You can't understand what I'm going through!~ it can be more
effective to express understanding without using the word "understand; for
example, "Given what you've told me, I can see why you are feeling this way:'
or "I get it; that makes sense to me."
You need not have had the same experiences to be able to understand the
patient's emotion; such understanding usually arises after asking the patient
to say more about the feeling they stated. Alternatively, one can indicate lack
of comparable experiences with equal impact in appropriate circumstances;
for example, when the patient describes being scared that his chest pain was
signaling a possible heart attack, the learner's response might be, "I've never
had that happen, but I can see how that would scare you."
Respecting (Praising or Appreclatl~ the Patient anti/or
Aclmowledtlnt His/Her Situation)
Respecting is the least natural of the NURS quartet for most learners. Many

clinicians already are behaving respectfully via their nonverbal behaviors, and
do not understand what else is needed. Verbal respect appreciates the patient
("Thanks for being so open"), clearly acknowledges how difficult things
have been ("You've really been through a lot"), or praises the patient's efforts
("I appreciate the way you've hung in there and kept fighting"). This often
involves emphasizing the positive, finding what people have done well, and
reinforcing it.
Supportl~

Supporting statements signal to the patient that you are prepared to work
together as a team (i.e., form a partnership with him/her) and help in whatever way you can; for example, "I'm here to help in any way I can. I'll make
sure the attending physician is aware of your specific concerns:'
Brief VIgnette Using NURS Quartet

Patient: (Has just indicated feeling lonely since his dog died)
Clinician: So, that's been pretty lonesome for you. [Naming]
We grieve all our losses-dogs as well as people. It makes sense
to me. [Understanding]
I can see it's been a difficult time. [Respecting]
Sometimes it helps talking about it. [Supporting]
Patient: It does feel better. I was embarrassed to mention it to anyone else.

You do not have to agree with the feeling or emotion for which you indicate
understanding, respect. or support Rather, you are expressing your understanding and appreciation of the patient's point of view and circumstance.

Chapter 2

DATA-GATHERING AND EMPATHY SKILLS

27

For example, to an abusive parent you might say "I understand how all her
crying upset you," or "It's really been hard on you;' or "I'm here to help you do
what's best" -without condoning or reinforcing abusive behavior.
Empathy means recognizing an emotion without the clinician necessarily
experiencing it her/himself. Empathy involves three components: understanding, communicating the understanding, and an intending to provide assistance with this understanding. 12.19 Sympathy, on the other hand, is having the
same emotional response as the patient or family member, usually emerging
from discomfort that is relieved by helping the patient/family member. 19 Both
are legitimate forms of affective expression. Empathy is more under conscious
control and essentially allows the patient to have and express his/her emotion
while the clinician is a witness or nonanxious presence to the patient's suffering. 20 Some learners worry that empathy will turn to sympathy and that, in
experiencing the patient's emotion, worry that they are being unprofessional.
Eliciting and empathizing with emotions provokes anxiety in some clinicians,
for example, raising fears about harming patients or of being intrusive. Some
learners worry that the interactions will get out of control. However, when
they check with patients, they realize that these fears are unfounded.21
Patients know how to protect themselves and they usually are forthright
when they do not want to engage in a line of conversation. Indeed, most
patients feel supported and relieved when they are allowed and encouraged to
express emotion. Clinicians must guard against the understandable impulse
to shut them down or change the subject. Many early-career clinicians
and learners fmd this a difficult new area due to a fear of experiencing an
intense emotion, possibly crying and subsequendy appearing unprofessional.
Experiencing strong emotions accompanies working with people in need.
Crying by students studying healthcare is rather common in the hospital.
Talking with your teammates or a trusted faculty member can help you better
understand yourself and your reactions. Chapter 8 of this book and Modules
2 to 4 and 13 in DocCom provide more details about this important area.
In Chapter 3 we describe how to put these skills together to conduct the
beginning of the medical interview in a sequential, behaviorally based and
systematic manner. Now, we encourage you to practice patient-centered skills
before moving on to the next chapter.

• PRACTICING PATIENT-CENTERED SKILLS

like "Tell me all about your (patient's
chief concern)."
2. Continuing directly without breaking, use nonfocusing open-ended skills
alone for 15 to 30 seconds. Basically, this means being quiet (silence) and
1. Begin with an open-ended question

28

SMITH'S PATIENT-CENTERED INTERVIEWING

3.

4.

5.

6.

7.

•

using encouraging nonverbal gestures and continuers. That is, you just sit
and listen attentively.
Continuing without a break, change to a more active style by responding
verbally to exactly what the patient already placed "on the table; using
the focusing open-ended skills to encourage additional conversation. For
about 2 minutes, intersperse echoing, requests, and summaries to draw
out the patient's now evolving story. Simply "follow your nose" and apply
the skills to whatever the patient says, be it vision problems, chest pain, a
job problem, or the famUy pet. You don't have to work hard figuring out
what to say but, rather, simply follow the patient's lead using focusing
skills. This will generate some sort of story, which can be medical, personal, or both.
Without breaking, now change from focusing skills to find what emotion
attends the story you've elicited. Ifthe patient has not spontaneously placed
emotion "on the table; use direct emotion-seeking skills ("So, how does all
that make you feel, emotionally?"). This will produce some emotion, such
as fear (of cancer) or worry (about job), which you then develop a little
further by going back to the focusing skills with an open-ended request
such as, "Tell me more about that (fear of cancer, worry about losing job)."
Continue to use the focusing open-ended skills untU you can understand
the situation well enough to genuinely say you understand it (next), usually
taking 1 to 2 minutes.
Proceeding directly without breaking, you now switch to empathy skills
and use these for 1 minute. To aid learning these skills, use all four of them
in the order given (NURS). Once you've learned them, you will use them
one or two at a time.
You could continue at this point or stop. To continue is easy because using
NURS generates additional information from the patient. You then return
to the focusing skills and elicit what will become the second chapter of the
story, following that with another round of emotion seeking and, in turn,
empathy skills to complete the second chapter. As many chapters as you
wish to develop will then follow by simply continuing to use this sequence
of skills.
Also practice a situation where the patient expresses no emotion so that
you have to use the indirect emotion-seeking skills.
SUMMARY

The data-gathering and empathy skills described in this chapter are the tools
for all interviewing. As fully described in Chapters 3 and 5, they are integrated in both the beginning and middle of the interview but are used in
different balances and for different purposes. The empathy skills, because of
their close link to patients' emotional lives, are the key elements in efficiently
eliciting information and establishing a relationship. Open-ended skills,

SKILLS EXERCISES
1. Ask your colleague to discuss a topic of interest (e.g., her or his career plans). When
your colleague pauses, remain silent for
10 seconds, while looking at him/her. Then
try the same thing while looking over your
colleague's shoulder; ask your colleague to
describe the results of both scenarios.
2. In role play, practice individual data-gathering
and empathy skills for 5 to 10 minutes.
3. Now practice integrating all data-gathering
and empathy skills in role play or with a simulated patient, as outlined in the text and

summarized in Fig. 2-2. Use the book initially, but you should be able to integrate the
skills without aids before proceeding. This
takes a little practice and good feedback
from teachers and colleagues. You often
can master this in one teaching session but
follow-up at a later date helps.
4. Do the same exercise but have the person
in the patient role give no emotion when
asked. The challenge is to then use the
indirect emotion-seeking skills to find some
emotion.

30

SMITH'S PATIENT-CENTERED INTERVIEWING

REFERENCES
1. Heisenberg W. Physics and Philosophy: The Revolution in Modern Science. New York,
NY: Harper; 1958.
2. Lucchiari C, Pravettoni G. Cognitive balanced model: a conceptual scheme of diagnostic
decision making. J Eval Clin Pract. 2012;18:82-88.
3. Bird J, Cohen-Cole SA. The three-function model of the medical interview: an educational device. In: Hale M, ed Models of Teaching Consultation-Liaison Psychiatry. Basel:
Karger; 1991:65-88.
4. Cole SA, Bird J. The Medical Interview. New York. NY: Elsevier-Saunders; 2013.
5. Lazare A, Putnam S, Lipkin M. Three functions of the medical interview. In: Lipkin M,
Putnam S, Lazare A. eds. The Medical Interview. New York. NY: Springer-Verlag; 1995:
3-19.
6. Cacioppo J, Amaral D, Blanchard J, et al. Sod.al neuroscience-progress and implications for mental health. In: Social Neuroscience and Behavior: From Basic to Clinical Science. Washington, DC: National Institute of Mental Health; 2007.
7. Darwin C. The Expression of the Emotions in Man and Animals. Chicago, IL: University
of Chicago Press; 1965. Reprinted from the authorized edition of D. Appleton and Company, New York.
8. Kandel E. Psychiatry, Psychoanalysis, and the New Biology
American Psychiatric Publishing, Inc.; 2005.

of Mind.

Washington, DC:

9. Power TE, Swartzman LC, Robinson Jw. Cognitive-emotional decision making
(CEDM): a framework of patient medical decision making. Patient Educ Couns. 2011 ;83:
163-169.
10. Eccles ]C. Evolution ofthe Brain; Creation ofthe Self London: Routledge; 1989.
11. Hojat M, Louis D, Kaye M, Markham F, Wender R, Gonnella J. Patient perceptions of
physician empathy, satisfaction with physician, interpersonal trust and compliance. Int
] Med Educ. 2010;1:83-87.
12. Hojat M. Empathy in Health Professions Education and Patient Care. Switzerland:
Springer International Publishing Co.; 2016.
13. Ekman P. Basic emotions. In: Dalgleish T, Power M, eds. Handbook of Cognition and
Emotion. Chichester: John Wiley and Sons; 1999:45-60.
14. Halpern J. From idealized clinical empathy to empathic communication in medical care.
Med Health Care Philos. 2014;17:301-311.
15 Lang F, Floyd MR, Beine KL. Clues to patients' explanations and concerns about illnesses. Arch Fam Med. 2000;9:222-227.
16. Koo K. Six words. l Gen Intern Med. 2010;25:1253-1254.
17. Kleinman A. Explanatory models in health-care relationships: a conceptual frame for
research on family-based health-care activities in relation to folk and professional forms
of clinical care. In: Stoeckle JD, ed. Encounters Between Patients and Doctors. Cambridge:
The MIT Press; 1987:273-283.

Chapter 2

DATA-GATHERING AND EMPATHY SKILLS

31

18. Back AL, Arnold RM. ·Isn't there anything more you can do?": When empathic statements work, and when they don't. J Palliat Med. 2013;16:1429-1432.
19. Hojat M, Spandorfer J, Louis DZ, Gonnella JS. Empathic and sympathetic orientations
toward patient care: conceptualization, measurement, and psychometrics. Acad Med.
20 11;86:989-995.
20. Rogers CR. On Becoming a Person. Boston, MA: Houghton-Mifflin; 1961.
21. Smith RC, Dwamena FC, Fortin AH. Teaching personal awareness. J Gen Intern Med.
2005;20:201-207.

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The Beginning of the
Interview: PatientCentered Interviewing
The doctor may also learn more about the illness from the way the patient tells
the story than from the story itself. (1861-1954)
James B. Herrick, MD
This chapter describes a user-friendly step-by-step method for the beginning
of the medical interview that has been effective in many hands for more than
25 years. 1- 9 Your first task is to master the 5 steps and 21 substeps shown
in Table 3-1. We urge you to learn these thoroughly, to the point that they
become reflexive-this is easily accomplished by studying and then practicing
them. Even though this may seem like a lot to learn, just as you learn the intricacies of cardiac physiology, this is your major task in mastering the medical
interview. Using these steps and substeps will make you a more scientific and
more humanistic physician-and your patients will benefit (see Appendix B
for a detailed humanistic and scientific rationale for being patient-centered).
To assist you, we also have developed a video that demonstrates the same
skills described here: www.accessmedicine.com/SmithsPCI (see Preface).
(See AccessMedicine video titled "How to Interrupt": www.accessmedicine
.com/SmithsPCI.)
When first learning these steps, use them in the order presented, primarily
as a learning tool. As you become more skilled, you can vary the steps and
substeps to experiment as well as to adapt to specific occasions and needs.
You may find that some substeps can be omitted and, in other instances, you
may want to change the ordering as you follow the patient's lead. 10 The steps
and substeps are simply a pathway to lead you through the interview; use
them flexibly to individualize and enhance your own style and the patient's
individuality.

33

• TABLE 3-1. 5-Step Beginning of the Interview
5-Step Patient-Centered Interviewing
Step 1: Set the stage for the interview {30-60 s)

Welcomejgreet the patient
Use the patient's name
Introduce yourself and identify specific role
Ensure patient readiness and privacy
5. Address barriers to communication (sit down)
6. Ensure comfort and put the patient at ease

1.
2.
3.
4.

Step 2: Elicit chief concern and set agenda {1-2 min)
7. Indicate time available (e.g., "We've got about 20 minutes together today ... ")
8. Forecast what you would like to have happen during the Interview (e.g., " ... and I see that we need to review
the blood tests you had done yesterday, ... ")
9. Obtain a list of all issues patient wants to discuss; specific symptoms, requests, expectations, understanding
(e.g., • ... but before we do that, let's make a list of the things you wanted to discuss today." "Is there
something else?" "What else?")
10. Summarize and finalize the agenda; negotiate specifics if too many agenda items (e.g., "You mentioned 8
things you were hoping to cover. In the time we have together today, I don't think we can address them all. Can
you tell me which one or two are most troublesome for you; we'll do a good job with those and I'll see you back
soon to work on some of the others.")
Step 3: Begin the interview with nonfocusing skills that help the patient to express her/himself {30-60 s)
11. Start with open-ended question/statement ("Tell me all about your headache.")
12. Use nonfocusing open-ended skills (attentive listening): silence, continuers, nonverbal encouragement
13. Obtain additional data from nonverbal sources: nonverbal cues, physical characteristics, autonomic changes,
accoutrements, environment, and self
Step 4: Use focusing skills to learn 3 things: symptom story, personal context, and emotional context {3-10 min)
14. Obtain a further description of the symptom
• Description of symptoms, using focusing open-ended skills such as:
Echoes (repeat the patient's words, e.g., "excruciating pain?'')
Requests ("That sounds important; can you say more about it?")
Summaries ("First you had a fever, then 2 days later your knee began to hurt, and yesterday you began to limp.")
15. Ellcltjdevelop personal context
• Broader personaVpsychosocial context of symptoms, patient beliefs/attributions, again using focusing openended skills.
16. Elicitjdevelop emotional context
• Use emotion-seeking skills.
Direct: "How are you doing with this?" "How does this make you feel?" "How has this affected you, emotionally?"
Indirect: Impact (e.g., "How has this affected your day-to-day life?" "What has your knee pain been like for
your family?"); Beliefs about the problem (e.g., "What do you think might be causing your knee pain?'');
Intuit how the patient might be feeling (e.g., "I think I might be frustrated if that happened to me; "I can
imagine that this might be worrying for you."); Triggers (e.g., "What made you decide to come in now for
your ... ?" "What else is going on in your life?")
17. Respond to feelings and emotions with empathy skills
• Respond with words that empathically address the emotion (NURS):
Name: "You say being disabled by this knee pain makes you angry."
Understand: "I can see how you could feel this way."
Respect: "This has been a difficult time for you." "You show a lot of courage."
Support: "I want to help you get to the bottom of this and see what we can do."
18. Expand the story to new chapters
• Continue eliciting further personal and emotional context, address feelings/emotion with NURS.
Step 5: Transition to middle of the Interview {clinician-centered phase) {30-60 s)
19. Brief summary.
20. Check accuracy.
21. Indicate that both content and style of inquiry will change if the patient is ready (''I'd like to switch gears now
and ask you some questions to better understand what might be going on."). Continue with middle of interview.

Chapter 3

THE BEGINNING OF THE INTERVIEW: PATIENT-CENTERED INTERVIEWING

35

The five steps in the beginning of the interview establish the clinicianpatient relationship and encourage the patient to express what is most
important to him/her. Throughout this book, an ongoing interview with
"'Ms. Joanne Jones" illustrates each step; this and other examples are derived
from real patients and situations; we changed all names and identifying information to protect the confidentiality of our patients.
Let's first talk about the preparatory skills of setting the stage (Step 1)
and determining the agenda (including the chief concern) for the interview
(Step 2). These steps prepare both you and the patient for the patient-centered
interviewing skills you will use in Steps 3 and 4, where the data-gathering and
relationship-building skills you learned in Chapter 2 are incorporated.

• STEP 1: SETTING THE STAGE FOR THE INTERVIEW
Setting the stage for the interview begins before entering the patient's room. It
is helpful to prepare for the interview, much as an athlete or musician might
prepare for a performance. 11 Begin by reviewing the patient's record, getting
a sense of the patient's problem list, medications, allergies, and reading notes
from recent visits/hospitalizations. However, do not allow this information
to bias you before you meet the patient-every clinician-patient encounter is
unique and medical records may contain inaccuracies.
Determine your agenda for the encounter; for example, you may want
to update the patient's immunizations or follow-up on chronic conditions.
As you will learn, the patient will also have an agenda that may differ from
yours.
We recommend taking a "mindful moment" before entering the patient's
room to mentally prepare yourself to be fully present to whomever is
behind the door. Some clinicians take a breath in and "breathe out" the
last patient, making the intention to be open to the next patient. Others
use hand sanitizer or soap and water as an ablution to "wash away'' the
last encounter and ready themselves for next. Mindful practice has been
demonstrated to reduce clinician burnout and improve empathy. 12.13 (See
DocCom Module 2.)
The skills in Step 1 are simple, but often overlooked14- 16 courtesies that
ensure a patient-centered atmosphere. Table 3-2 lists these substeps in their
usual order of use at the first meeting with a patient; appropriate adjustments
are made when the patient is already known to the clinician. These skills
establish or reaffirm participants' identities, put both the clinician and the
patient at ease, and ensure that the setting is appropriate for the interview.
These preparatory steps should take no more than 30 to 60 seconds.

• TABLE 3-2. Step 1: Setting the Stage (30-60 s)
1.
2.
3.
4.
5.
6.

Welcome/greet the patient
Use the patient's name
Introduce yourself and identify specific role
Ensure patient readiness and privacy
Address barriers to communication (sit down)
Ensure comfort and put the patient at ease

Welcome/Greet the Patient

As noted above, maintain patient safety and hygiene by washing your hands
before entering the patient's room.
When people become patients and enter our healthcare system, they experience many "micro-aggressions"-such as being partially clothed or being
barged in on while using the commode-that can negatively affect their experience of care. Knocking and then waiting for permission to enter is a "microcourtesy" that can help to re-empower the patient and restore dignity.
Greetings set the stage for relationships and their absence can make the
relationship difficult to salvage. The clinician who enters the patient's room
and says, "So what seems to be the problem here?" is missing an opportunity
to use the relationship as therapy.
In day-to-day life, we often greet others by saying, "How are you?" or "How
are you doing?': We suggest not using these words in healthcare settings. Why?
When a clinician, simply trying to greet a patient, asks, "How are you?': many
patients begin to talk about their ailment. Others will say (or think), "If I was
well I sure wouldn't be here!': We recommend using different greetings with
patients, such as, "It's nice to meet you" or "Nice to see you again!" This keeps
the interview from jumping ahead to Step 2 before you are ready.
A handshake is an important part of greetings in many cultures. Because
of cultural taboos about touch, a male clinician should generally wait for a
female patient to begin to extend her hand first, before reaching out to shake it.
Women clinicians should also be sensitive to nonverbal cues and cultural
norms that indicate that the patient may not be open to a handshake. 14
For example, among some Muslims and orthodox Jews shaking hands in a
cross-gender situation is viewed as culturally inappropriate. When it is not
possible to shake hands, for example with very ill patients, a friendly pat on
the hand or arm is equally beneficial to the relationship. You can develop
some important initial nonverbal impressions about the patient from the
handshake; for example, a hearty handshake suggesting a confident person,

Chapter 3

THE BEGINNING OF THE INTERVIEW: PATIENT-CENTERED INTERVIEWING

37

a cold sweaty palm suggesting anxiety, and the feeble handshake of someone very ill. Healthcare professionals have mixed feelings whether to ban,
change, or allow handshaking due to hygiene risk. 17- 19 We suggest you make
your own informed decision on handshaking as a greeting. Remember that
the patient is also reading your nonverbal cues, so personal awareness is
crucial. 14•20- 22 Smiling; having a friendly, personable, polite, and respectful
demeanor; being attentive and calm; making eye contact; and making the
patient feel like a priority will enhance the relationship with the patient.
Alternatively, fidgeting, frequently glancing at your watch or mobile device,
avoiding eye contact, or looking distracted may be interpreted negatively by
the patient.23
Use the Patient's Name
Patients are divided on how they want to be addressed. 14•24- 26 Some patients
want their first name to be used when they are greeted; but others prefer
either their last name or both their first and last names. We recommend that
you use formal terms of address, Mr., Miss., Mrs., or Ms., and the patient's
first and last name in your initial greeting. It is easier to go from more formal
to less formal terms of address than the reverse. If the patient has an unusual
name, you may need to ask how to pronounce it. It is sometimes useful as a
way of creating a welcoming atmosphere to ask if a non-English name, for
example, Rakesh, Ming, Ganady, Kwesi, has a translation into English and
what it means.
Some patients reject or do not conform to the male-female gender binary.
To avoid misperceiving the gender identity or expression of gender nonconforming patients, you can ask. "Out of respect for my patients' right to selfidentify, I ask all patients what gender pronoun they'd prefer I use for them.
What pronoun would you like me to use for you?"27
Introduce Yourself and Identify Your Specific Role
When introducing yourself, be sure to match identity terms to avoid suggesting an unequal relationship. 24 As with patients, initially use your full name"Hi Mr. James Brown, I'm Dr. Jane Smith." You should not say, for example,
"Hi George, I'm Dr. Smith" or "Welcome Mr. Brown, I'm Betty:' Occasionally
at the beginning but more often after some time, a relationship on first-name
basis may develop. After you introduce yourself, mention your official role,
for example, "resident physician," "medical student:' "PA student," or "nursing student." Medical students can use the term "student doctor" or "student
physician'' after they pass USMLE Step 1.28 However, it is not appropriate to

38

SMITH'S PATIENT-CENTERED INTERVIEWING

use a professional label like "doctor," "nurse; "nurse practitioner," or "physician assistant" until you have been certified to do so.
It is common for new learners, particularly preclinical students, to feel
uncomfortable in their first patient interviews. You may feel like an imposter, that you are intruding or being voyeuristic, or that you are not playing a
meaningful role in the patient's care. Remember that every clinician learned
to interview through the generosity of patients. Patients often are quite
happy to help a young clinician learn if you politely ask, express thanks, and
understand why some patients may feel too ill to participate in this way. As
a clinical trainee however, you are an important and legitimate member of
the medical team, so you should not apologize or otherwise devalue yourself
("I'm just a student, thanks for letting me talk to you."). The annals of medicine are replete with stories of new learners' contributions to care, as they
are with stories of patients deferring to trainees' opinions; for example, when
the resident or attending physician makes a recommendation directly to the
patient, the patient may say, "I'll have to ask Ms. Burns [the trainee] first."
To respect patient autonomy, your supervisor/attending physician should
ensure that the patient has no reservations about being interviewed or cared
for by a trainee. 28
When visitors are in the room, ask the patient to introduce them and their
relationship to the patient; this allows the patient to control the flow of information. Greet each person by name as above. Ask the patient if visitors or
family members should remain in the room during the interview. You might
ask, '"''m going to be asking you a lot of questions; some of them are very personal. Should we ask your brother to wait in the family room while we talk or
would prefer that he stay?" If the patient elects to have the visitor(s) stay, you
may need to ask sensitive questions at another time when you can be alone
with the patient. This is particularly important if intimate partner violence is
suspected (see Chapter 5).
Substeps 1, 2, and 3 of Step 1 can be combined in a single statement like
"Mr. George Brown? Hello, I'm Larry Burns. I'm the medical (or nurse practitioner, PA) student on the team that will be looking after you."
Ensure Patient Readiness and Privacy
Clinicians often assume that patients are always ready to speak with them
but, especially in hospital settings and with very ill patients, it is important to
determine ifthe patient is ready for the interview. Sometimes it is necessary to
postpone the interview; for example, until after the patient has eaten dinner or
relatives have departed; or until the vomiting from recent chemotherapy has
abated. Severe pain, severe nausea, need for a medication, and a soiled bed,

Chapter 3

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39

for example, are physical problems that must be addressed before an interview is appropriate. It is also important to monitor the patient's circumstances
for nonphysical, potentially interfering problems; for example, a patient may
have lost his car keys in the waiting room, just received a disturbing telephone
call, or be worried that the baby sitter will have to leave before she gets home.
With all patients, it is important to determine if there are pressing needs that
might require a brief delay in the interview; for example, to use the bathroom, get a drink of water. These courtesies not only help the patient directly
but enhance patients' acceptance of you as a caring professional. Once ready,
some actions that will improve the patient's readiness and privacy are shutting
the door, pulling a curtain around the hospital bed, or respectfully excusing
extra visitors from the room.

Address Barriers to Communication
You may have to ask permission to turn off a noisy air conditioner or TV set, or
make efforts requiring more insight such as recognizing that the patient hears
best out of one ear or needs to be able to directly see the clinician's mouth in
order to speech-read. If there is any question, ask the patient whether s/he can
hear you well. Strategies for addressing specific communication problems are
outlined in Chapter 7.
Patients experience that you have spent more time with them if you sit, so
do so whenever possible, asking permission to do so in the hospital setting.29
Communication is optimal if you and the patient are at the same eye level.30
If you are both sitting, orienting the chairs at approximately a 90-degree angle
is optimal for communication (see DocCom Module 1431 ). Attention to the
nonverbal aspects of communication is important and is covered in more
detail in Chapter 8, section "Nonverbal Dimensions of the Relationship:' And
remember, at the end of the encounter, it is just as important to tum the TV
you asked permission to tum off, back on!
Exam-room computing may be one of the biggest barriers to the clinicianpatient relationship. 32.33 Ifyou plan to use a computer during the interview, be
sure that it is placed so that you both can see the screen. Explain to the patient
that you will be taking some notes or entering information into the computer
and ask whether this is okay.34 Write or enter information in the medical chart
or computer only intermittently, and not until the patient has fmished speaking. When writing or entering information, pause frequently and make eye
contact with the patient. We suggest that you focus on the patient and not
the computer during the beginning, patient-centered part of the interview
and use the computer as a communication tool.35.36 See Chapter 10 for more
details.

40

SMITH'S PATIENT-CENTERED INTERVIEWING

Ensure Comfort and Put the Patient at Ease
Determine if anything at the immediate time is interfering with the patient's
comfort. Ask. "Is that a comfortable chair for you?~ "Is the light bothering
your eyes?~ "Are you comfortable there?~ or "Can I raise the head of the bed
for you?" Continue to monitor the patient's comfort as the interview proceeds. Your task is to put the patient at ease, as much as you can. Attention to
these potential barriers fosters the patient's subsequent full attention and also
shows your caring and concern.
When clinically appropriate, a little social conversation-"small talk before
big talk"-can help put the patient at ease before discussing intimate issues
related to bodily or psychological concerns. 37 This brief social conversation
should have a patient focus such as, "I hope you got your car parked OK with
all the construction going on around here." With an inpatient, you can ask
about get well cards or flowers in the room, or the food; whatever is appropriate to the patient's situation can be briefly discussed. This allows the patient to
get more comfortable with you and shows your humanity.

• STEP 2: OBTAINING THE AGENDA (CHIEF CONCERN
AND OTHER ACTIVE PROBLEMS)
In Step 2, you will focus on the patient and setting the agenda for the interview. This fosters the patient-centered interaction to follow (Steps 3 and 4)
because it orients and empowers the patient and ensures that concerns are
properly prioritized and addressed. Some clinicians unwittingly preclude
agenda setting by saying "What brings you in today?". Patients often interpret
this as an invitation to tell the story of the first concern on their list, rather
than generating a list of concerns. This often leads clinicians to miss important information and fail to meet patients' expectations.38-42 Setting an agenda
usually takes little time, improves efficiency, empowers patients,43 and yields
more information. However, it is not necessarily easy and serious pitfalls can
arise if it is conducted improperly.14•15•44•45 The following four substeps, summarized in Table 3-3, usually are performed in the order given. It generally

takes no more than 1 to 2 minutes.
Indicate Time Available
Setting limits is difficult for many clinicians, so do not be surprised if this substep feels uncomfortable at first. Begin by indicating how much time is available
for the interaction. This orients patients by letting them know the visit length
and helps patients gauge what and how much to say.46 One common pitfall is to
use the word "only," as in, "We only have 20 minutes today," which has a negative

• TABLE 3-3. Step 2: Chief Concern/Agenda Setting (1-2 min)
1. Indicate time available
2. Forecast what you would like to have happen during the interview
3. Obtain list of all issues patient wants to discuss; e.g., specific symptoms,
concerns, requests, expectations, understanding
4. Summarize and finalize the agenda; negotiate specifics if too many agenda
items

connotation. Rather say, "Good, we've got about 20 minutes together today.'' In
the inpatient setting, where visits are not usually on a schedule, it may be easier
to use phrases such as "few:' "short:' "medium:' or "long;' for example, ''I'd like
to take a few minutes of your time to .. .': Of course, in any setting there will be
occasional times when you must extend the visit beyond what was scheduled
or you had planned, for example, if a patient has gotten bad news or where you
may be concerned about a patient's physical or emotional safety.
Forecast What You Would Like to Have Happen
During the Interview

Tell the patient what you need to do during the interview to make sure the
patient is properly cared for. For example, with a new patient, you may need to
ask many routine questions or perform a physical examination; with a returning patient, you may need to discuss the results of a recent diagnostic test.
Obtain a List of All Issues the Patient Wants to Discuss

Most importantly, you must obtain a list of all issues your patient wants to
discuss to ensure that the most important concerns are addressed during
the encounter and to minimize the chance of an important concern being
raised at the end of the conversation when time has run out.42•46 This substep
is usually combined with the first two substeps in one sentence, for example,
"Good, we've got about 40 minutes together today; I need to ask you a lot
of questions and do an examination but let's start by making a list of all the
things you want to discuss.'' Notice the use of the words "we' and "together"
that help to establish a partnership with the patient.
You may need to help the patient enumerate all problems. Possible patient
agenda items include, but are not limited to symptoms, requests (prescription for a sleeping pill), expectations (get a note for work), and understanding about the purpose of the interaction (perform an exercise stress test).

42

SMITH'S PATIENT-CENTERED INTERVIEWING

Obtaining a complete list may require some persistence.40•42•«.45•47 Often,
the patient will try to give details of the first problem. When that happens, you must respectfully interrupt and refocus the patient on setting the
agenda. The art of interrupting can be learned as any other communication
skili.48- 51 (See AccessMedicine video titled "How to Interrupt.") Holding up
fingers prominently as you count concerns helps to communicate that a
list is being sought, not details of each symptom or concern. For example,
while holding up one finger to signify the first problem given, you might
say "Sorry to interrupt, that's important and we'll get back to the leg pain in
a moment, but first I need to know if there are additional problems you'd
like to talk about. I want to be certain we get a list of all your concerns." You
may have to do this several times, asking questions like, "Is there something
else?~ 52 "What else?~47 "How did you hope I could help?", "What would
a good result from this visit today look like?", or "Was there something
else you were worried about?':53 In the outpatient setting it is unusual for
patients to have just one concern;4 2.54 one study found that diabetic patients
had on average three concerns they wanted to share with their clinician,
the third one mentioned being the most important from their perspective.
Importantly, 70% of these patients never got to share their most important
concern.55
Only if the patient raises a highly charged emotional issue while setting the
agenda should you postpone agenda-setting and encourage further discussion at that point (e.g., if the patient is acutely distraught about a recent death
in the family or a recent diagnosis of cancer in himself). In most situations,
however, you can set the agenda and briefly delay addressing the emotional
issue. Careful agenda-setting prevents patients' common complaint that they
did not get to talk about all their concerns, as well as the common clinician
complaint that the patient voiced his/her most serious concern at the end of
the appointment.46
Summarize and Finalize the Agenda

This substep allows you to prioritize the list and, if it is too long for the time
available, to empower the patient to decide what will be addressed and what
will be deferred to the next visit: "You mentioned eight concerns you wanted
to cover. I don't think we'll have time to address them all in the time we have
together today. Can you tell me which one or two are most troublesome to
you today? We'll focus on those together and I'll see you back soon to work
on the others." Of course, if one of the items is medically concerning (e.g.,
blood in the stool, substernal chest pain suggesting heart disease), you need
to address it even if not chosen by the patient.

Chapter 3

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43

Note how mentioning the time available at the beginning of Step 2 allows
you to refer to it without it being off-putting to the patient. You and the patient
are aligned against the allotted time, instead ofyou and the time being aligned
against the patient.
Usually, however, because different symptoms may be related to a common
cause it is possible to cover all the patient's concerns, in which case these are
simply summarized. This also is a good point to determine, if not already
known, which concern is most important to the patient, for example, "Which
one would you like to start with?': This identifies the chief concern ("chief
concern" is preferred over "chief complaint" because "complaint" has a pejorative connotation. In response to hearing the word "complaint; patients have
said, "I'm not complaining, it hurts!").
We now begin to follow Ms. Joanne Jones through her initial visit by providing a continuous transcript for each step; some areas are shortened as
noted for space considerations.
VIgnette of Ms. Joanne Jones
Stepl

Clinician: (Knocks)
Patient: Come in.
Clinician: (Enters examining room). Ms. Joanne Jones? Welcome to the
clinic. I'm Michael White, the medical student who will be
working with you along with Dr. Black. (Patient extends her
hand and clinician shakes it.) [Clinician uses his and her full
names, welcomes the patient, and identifies his role in her care.]
Clinician: I'll be getting much of the information about you and will be in
close contact with you about our findings and your subsequent
care.
Patient: I wasn't sure who I was going to see. This is my first time here.
Clinician: If it's OK with you, I'll close this door so we can hear each
other better and have some privacy. [The clinician now ensures
readiness for the interview and establishes as much privacy as
possible.]
Patient: Sure, that's fine.
Clinician: Anything I can help with before we get started?
Patient: Well, they didn't give my registration card back to me. I don't
want to lose it.
Clinician: We'll give that back when we're finished today. They always
keep them. Is there something else?
Patient: No.

44

SMITH'S PATIENT-CENTERED INTERVIEWING

Clinician: (Sits down) Would you like to sit in that chair? It's more comfortable than the examining table. [The clinician addressed this
barrier to communication, established equal eye level, ensured
comfort, and put the patient at ease.]
Patient: Sure. Thanks. (She moves.)
Clinician: Well, I'm glad to see you made it despite the snow. I thought
spring was here last week.
Patient: I guess not. My kids have been home the last 2 days. I'm ready
to get them back to school! I'm getting spoiled with them both
in school [Patient places the topic "kids" and her feelings about
the kids being home "on the table" for discussion.]
Clinician: People have had all kinds of trouble getting in here for their
appointments since the snow. It's no fun.
Patient: You're telling me. I don't even ski! [The stage is set, a light conversation ensued. and the patient is joking.]
Step2
Clinician: (laughs) Well, weve got about 40 minutes together today and I
know I've got a lot of questions to ask you and that we need to
do a physical exam. Before we get started, though, I(l like to get
a list of the things you wanted to address today. You know, so
we're sure everything gets covered. [Clinician gives his agenda
in one statement. Doing this first models the more difficult task
to follow: obtaining the patient's agenda.]
Patient: It's these headaches. They start behind my eye and then I get
sick to my stomach so I can't even work. My boss is really getting upset with me. He thinks that I don't have anything wrong
with me and says he's going to report me. Well, he's not really
my boss, but rather is . . . [Clinician artfully and respectfully
interrupts. She places "boss" on the table for discussion.]
Clinician: That sounds difficult and important. Before we get into the details,
though, ni like to find out if there are some other problems you'd
like to look at today, so we can be certain to cover everything you
want to. Well get back to the headache and your boss after that.
Your headache and your boss-that's two things (holding up two
fingers). Is there something else you wanted to address today?
Patient: Well, I wanted to fmd out about this cold that doesn't seem to go
away. I've been coughing for 3 weeks.
Clinician: (Holding up three fingers now): OK, cough; what other concerns do you have?

Chapter 3

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45

Well, I did want to fmd out if I need any medicine for my colitis. That's doing ok now but I've had real trouble in the past.
It started bothering me back in 2010 and I've had trouble off
and on. I used to take cortisone and ... (clinician interrupts);
[Notice that the clinician has now interrupted the patient twice
in order to complete the list of concerns. This is necessary, done
respectfully, to complete the agenda in a timely way.]
Clinician: (Holding up five fmgers): So, there are two more problems we
can look into, the colitis and the medications. We'll get back to
all these soon; they're all important. To make sure we get all
your questions covered. though, is there something else?
Patient: No. The headache is the main thing.
Clinician: So, we want to cover the headaches and the problem they
cause at work, cough, colitis, and the medications for the colitis. Is that right? [It is here that the patient and clinician would
negotiate what to cover at this visit if the clinician determined
that the patient had raised too many issues to cover on this
day.]
Patient: That's about it.
Clinician: And do I understand correctly that the headache is the worst
problem? [Ms. Jones' headache is her most bothersome concern, what we earlier defined as the chief concern.]
Patient: Yes.
Patient:

• OPENING THE HISTORY OF PRESENT ILLNESS (STEP 3)
Having set the stage (Step 1) and obtained the agenda (Step 2), we now use
the patient-centered skills learned in Chapter 2 to begin to elicit the history
of the present illness (HPI). As reviewed in Chapter 1, the HPI is the most
important component of the interview because it reflects the patient's current problem in its psychosocial and biomedical totality. The HPI begins at
the beginning of the interview (patient-centered part) and continues into the
middle of the interview (clinician-centered part), where relevant details are
clarified using clinician-centered interviewing skills.
Step 3, summarized in Table 3-4, consists of asking one open-ended question (or making one open-ended request) and then allowing the patient to
talk. It establishes an easy flow of talk from the patient, conveys that the clinician is attentively listening, and gives a feel for "what the patient is like:'
Ordinarily, Step 3 lasts no more than 30 to 60 seconds as the clinician listens
attentively, using the following substeps.

• TABLE 3-4. Step 3: Opening the HPI (30-60 s)
1. Open-ended beginning question/statement
2. "Nonfocusing" open-ended skills (attentive listening): silence, continuers,
nonverbal encouragement
3. Obtain additional data from nonverbal sources: nonverbal cues, physical
characteristics, autonomic changes, accoutrements, environment, and self

Start with Open-Ended Beginning Question/Statement

When first learning the medical interview, some new learners are so worried
about what they should say next that they don't hear what the patient is saying! Step 3 gives you the opportunity to take a deep breath, relax, and listen to
the patient. It starts with an open-ended beginning question or statement, for
example, "So headaches are the big problem, tell me more:' Avoid saying, "Tell
me a little bit about the headache;' because you do not want to hear a little bit
about the symptom, you want to encourage a detailed, chronological narrative. Sometimes, especially with reticent or disorganized patients, it is helpful
to be dear about your desire: "Tell me all about the headache, starting at the
beginning and bringing me up to now:' Sometimes an open-ended beginning
question is not necessary; having completed the agenda, especially if there are
only one or a few related items, many patients continue spontaneously.
Use "Nonfocusing" Open-Ended Skills (Attentive Listening)

Following the open-ended beginning question, allow the patient to talk freely
for 30 to 60 seconds or so to get the gist ofhis/her primary concern. Encourage
a continued free flow of information using the nonfocusing open-ended skills
described in Chapter 2. Silence, nonverbal gestures (eye contact, leaning forward, hand gestures), and continuers (e.g., uh-huh, mmm, go on) encourage the patient to continue speaking. Listen carefully to the patient's opening
statement for dues to the patient's story. Using these nonfocusing open-ended
skills encourages the patient to put information "on the table;' typically details
about the patient's symptom story and its personal and emotional context.
Some clinicians are reluctant to use nonfocusing skills in the beginning of
the interview because of fears that patients will talk incessantly, and that nothing will get accomplished. Research shows that when patients are given all the
time they need to complete their initial statement, in nearly 80% of the cases
it lasts 2 minutes or less; in the few instances where it went longer, physicians
agreed that the patients were giving important information. 56
Although uncommon, patients sometimes do not talk freely. If this occurs,
and 4 seconds or so of silence does not lead the patient to resume talking, you

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47

can use focusing open-ended skills (echoing, request, summary) to promote
a free flow of information. If focusing open-ended skills are not effective, you
can also ask closed-ended questions about the patient's problem to get a dialogue going. This may be necessary in very shy patients, especially adolescents.

Obtain Additional Data from Nonverbal Sources
Although you are verbally quiet during the brief Step 3, you should be very
mentally active, noticing the information the patient is putting "on the table"
and thinking about what it means. Observe the patient for nonverbal cues
(reviewed in Chapter 7), for example, depressed facial expression, arms
folded across the chest, toes tapping nervously that may indicate psychological conditions or a style of rdating to the clinician. Observe also for clues
in the following areas that will give additional physical information about
the patient57•58: ( 1) physical characteristics: general health, skin and hair
color, odor, deformities, habitus (e.g., emaciated and disheveled, "uremic"
breath, jaundice, amputated leg, kyphoscoliosis); (2) autonomic changes:
heart rate, skin color, pupil size, skin moisture, skin temperature (e.g., rapid
pulsation of the carotid artery observed in the neck, handshake reveals cold
and moist palms, pupils constricted but then dilate when rdaxed, sweating
at outset of interview); (3) accoutrements or accessories: clothing, jewelry,
eyeglasses, makeup (e.g., expensive suit and jewelry, thick eyeglasses, tattoos
and body piercings, no makeup or poorly applied makeup); (4) environment: in the hospital setting, items such as greeting cards, flowers, photographs (e.g., several paintings by a grandchild, photograph of spouse, or their
absence); (5) sdf: becoming aware of your own emotions and reactions to
patients in real time is an important clinical skill.4.21•59 We cover this important topic in detail in Chapter 9 (also see DocCom Module 2).

Continuation of Ms. Jones Visit
Patient: Yes.
Clinician: So, tell me all about the headache. [An open-ended beginning
statement that is linked to the chief concern.]
Patient: It's not bad at the moment, I guess.
Clinician: (sits forward slightly) Uh Huh.
Patient: Things weren't so good last week. though, when I made the
appointment.
Clinician: Mmmm.
Patient: That's when my boss really got on me. Well, he's kind of uptight
anyway, but he was saying how I was upsetting the whole office
operation because I was off so much. And someone had to cover
for me. I'm the lead attorney.

• TABLE 3-5. Step 4: Continuing the Patient-Centered HPI (3-10 min)
1. Use focusing open-ended skills to obtain further description of physical or
other symptom (symptom)
2. Use focusing open-ended skills to elicitjdevelop personal context of symptom
(personal context)
3. Use emotion-seeking skills to elicit/develop emotional context of symptom
and/or its personal context (emotional context)
4. Use empathy skills to address the emotion(s) expressed by naming,
understanding, respecting, and supporting (NURS)
5. Use sequences of focusing open-ended skills --+ emotion-seeking skills --+
empathy skills to expand the story to new chapters (expand story)

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49

from 3 to 10 minutes, depending on the clinical setting and the information
the patient presents.
In addition to attentive listening, use focusing open-ended skills to help
the patient continue his/her unique story of the present illness. In this step,
you are picking things up "from the table" in order to learn more about them.
First, direct the patient to talk more about the symptom (usually physical, but
can also be cognitive, emotional, or other); second, the personal context of the
symptom; and, third, the emotional context, that is, the patient's emotional
reactions to the symptom and/or the personal context. This flow mirrors the
way that patients often describe their concern to their clinician.
Use the focusing open-ended skills, emotion-seeking skills, and empathy
skills outlined in Chapter 2 to identify the story theme(s); rarely, use closedended skills for clarification. You will usually be much more active and verbally participatory in Step 4, compared with Step 3; often figuratively on the
edge of your seat during the give-and-take interaction between you and the
patient as you help the patient build the history. 60 You may initially find this
step to be the most difficult of the entire interview. To help in understanding
it, we have broken Step 4 down into five substeps, now considered in their
usual sequence. These substeps produce the overarching story themes: symptom, personal, and emotional.
Obtain a Further Description of the Symptom

In a medical setting, patients typically present with symptoms mixed with
their personal and emotional context. Because most patients expect it in a
medical setting, we recommend an initial focus on physical symptoms while
learning these skills; later, you can experiment with a different ordering. Use
focusing open-ended skills (echoing, open-ended requests, summarizing) to
help the patient to further describe the symptom(s) in his or her own words.
This usually helps uncover the personal context in which the symptom(s)
occurred. Let's pick up Ms. Jones' interview again.
Continuation of Ms. Jones VIsit

All I want to do is go home and go to bed. [Four seconds of
silence]
Clinician: Say more about the headaches. [Since silence-a nonfocusing
skill-was ineffective, the learner tries an open-ended request,
one of the focusing open-ended skills, to learn more about the
headaches.]
Patient: Well, I never had any trouble until I got here. [Comment about personal context of her symptom and how long it has been present]
Patient:

50

SMITH'S PATIENT-CENTERED INTERVIEWING

Clinician: How long's that been? [Appropriate closed-ended question for
clarification]
Patient: Only 4 months. The headache started about 3 months ago.
Clinician: Tell me more. [Keeps the focus on the headache]
Patient: Well, they just throb and throb and it seems like every time I see
my boss any more I get one of these headaches. I sometimes just
get a little nauseated and can't concentrate because of the pain.
[We learn much more of the description of the symptom and.
also, that her boss seems to precipitate the symptom.]
Clinician: Nauseated? [echoes a word he wants to learn more about]
Patient: Yeah, queasy like I might throw up, but I never have.
Clinician: What more can you tell me about the headaches or nausea?
[Continuing to use open-ended questions to elicit more details
of her symptom(s)]
Patient: That's all I can think of. [The patient's response suggests that
open-ended skills are unlikely to result in a further description
ofthe symptom. Some patients will begin to repeat themsdves in
describing their symptom(s). Either of these behaviors indicates
that it is time to devdop the personal context. We have a good
description of the symptom, know when it began, have heard
some associated symptoms, and know (from Step 3) that it occurs
in the setting of her boss. In less than a minute, the clinician has
learned how the personal context and symptom interact by facilitating (encouraging) the patient's spontaneous narration.]
Notice that at the outset of Step 4 the clinician used focusing open-ended
skills to learn the patient's description and chronology of symptoms and
learned some of the classic descriptive terms (throbbing headache and nausea
but no vomiting), continuing in this way until the patient demonstrated she
had no more details to offer. The clinician needs more diagnostic data about
possible underlying disease (e.g., any head injury, fever, vision changes, prior
investigation), but these details are not "on the table" and asking those specific
questions here would run the risk of not exploring the patient's personal and
emotion context, which are so important for diagnosis and patient satisfaction. The clinician should resist the urge to use clinician-centered skills at this
point ("Did you ever have a head injury?" or "How does the headache affect
your vision?" or pursuing other diagnostic data with closed-ended questions), and instead explore the personal and emotional context of the patient's
story-those topics that the patient has placed on the table. The clinician
will be asking closed-ended questions soon in the middle of the interview to
answer these appropriate but premature questions.

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51.

While the new learner may not be aware of this, the symptom data given
by Ms. Jones are quite suggestive of migraine headaches; that is, they are
throbbing, unilateral, periodic, and associated with nausea. When given the
chance, patients almost always provide information about their symptom that
is highly diagnostic. Indeed, it is the great diagnostic yield of the beginning
of the interview that led Sir William Osler to say, "Listen to the patient, he
(sic) is telling you the diagnosis:'61 We also know that, occasionally, information diagnostic of a disease arises here that does not arise in later cliniciancentered interviewing.62 On the other hand, even when symptom data are not
diagnostic, you will obtain a good overview of the problem, one that does not
need repeating after your transition to the middle of the interview.
Ifthere are only psychological concerns (no physical symptoms presented),
the psychological symptoms are treated in the same way as for physical symptoms; for example, if Ms. Jones was complaining of anxiety or feeling blue and
down instead ofhaving headaches, the clinician would elicit the description of
these psychological symptoms, using open-ended skills. (See AccessMedicine
video for an example of a mental health interview, titled "Patient with a Mental
Health Disorder": www.accessmedicine.com/SmithsPCI.)

Develop the Psychological and Social Context of the Symptom
(Personal Context)
Your next task is to learn about the patient and his/her illness in its broader
psychosocial/personal context. This information relates less to symptoms and
may be ofless value for diagnosing disease, but is important for understanding the patient's illness. In general, the longer the interview, the less the personal data relate to symptoms, and the more they reflect the patient's general
life situation. Nonetheless, important diagnostic data about actual diseases
can still arise, for example, stress-related disorders, occupational, or drug!
alcohol problems. This information will directly influence treatment and
prevention recommendations. Continue to rely upon focusing open-ended
skills, redirecting the patient to personal statements "on the table" that seem
most important to understanding his/her personal context-in this instance,
Ms. Jones' stressful job situation.

Continuation of Ms. Jones VIsit
Clinician: You mentioned your boss. [Invites patient to talk about how her
boss relates to the headache]
Patient: Well, I have no trouble at all when he's not there. He was gone
for 2 weeks and I didn't have any. But he's there a lot, although
I don't have to be around him all the time. [The relationship

52

SMITH'S PATIENT-CENTERED INTERVIEWING

of Ms. Jones' headaches and her boss are becoming clear and
we hear some considerations for treatment; perhaps avoiding
her boss. Such information often does not arise during isolated
clinician -centered interviewing.]
Clinician: Not around him? [Echoing, a focusing open-ended skill, maintains the focus on the relationship of boss to symptoms.]
Patient: I'm on the road a lot. No trouble then either, I guess ... except
once when he called me.
Clinician: Tell me more about him. [Encourages discussion of an important personal issue rather than keeping the focus on symptoms such as headache or nausea, because of the patient's prior
indication that further description of the symptom would be
unlikely without the use of clinician-centered interviewing
skills; the clinician also could have focused on the job itself and
accomplished the same goal of obtaining more personal data.
Rather than an open-ended request, the clinician also could
have focused the patient by echoing ("he called you") or summarizing the personal aspects; that is, any of the focusing openended skills could be used. They all lead to the same theme.]
Patient: Well, he's been there a long time and I've replaced him in every
way there is, except he is still in charge, at least in his title. He
yells at everybody. Nobody likes him and he doesn't do much.
That's why they got me in there, the Board, so something would
get done. These headaches have all come since I got this jobright here. They throb behind my eye and . . . [Note the corroboration of earlier data: the job is linked to the headaches but
Ms. Jones is now giving additional personal information about
her situation that helps the clinician better understand this connection. Note too that she is repeating herself in describing her
symptom, again indicating that patient-centered inquiry about
the symptom is unlikely to be of high yield.]
Clinician: Wait a second, I'm not following you. You say he's in charge but
you are the lead attorney? [Clinician interrupts respectfully, and
then summarizes personal issues to refocus on the job because
the patient is getting away from personal data and going back
to symptoms already discussed; also, the clinician knows he will
address symptom details just a few minutes from this point,
during the middle of the interview.]
Patient: Yeah, they are phasing him out but he's still there in the meantime. Who knows how long it'll take. I hope I last. [She is further expanding the story to personal issues less directly related

Chapter 3

THE BEGINNING OF THE INTERVIEW: PATIENT-CENTERED INTERVIEWING

53

to symptoms, allowing the clinician to begin to appreciate the
nuances and depth of how her job and headaches interact.]
Cllnician: Hope you last? [Echoing will maintain the focus in this personal/psychosocial area. Note how focusing open-ended skills
are used repeatedly to focus the patient, and that they can be
applied to the patient's immediately preceding utterances, or
they can interrupt them to focus on utterances previously mentioned-but they never introduce new data to the conversation. The clinician develops a free flow of information from the
patient, focusing the patient where intuition suggests the most
key information resides, typically emotional information.]
Patient: I'm not sure how much of this I can take. They said there
wouldn't be any problem with him and that he would be helpful. Actually, I kind of liked him at first but then all ...
Cllnician: They said? Who are they? [Clinician interrupts to focus on a
bit of information mentioned just before and redirects her to
that with echoing; if the clinician wanted her to simply proceed,
using nonfocusing skills or an open-ended request would have
sufficed, such as "Go on."]
Patient: The Board, they run the company. It's not real big, but it's a good
chance for someone like me to get experience in the corporate
world. [A new layer of data that is not directly related to her
headache but provides a deeper understanding of its context]
Cllnician: Sounds like the Board told you one thing; that you liked him
at first, but then he changed, and you're left with a problem?
[Clinician summarizes what is becoming a free flow of personal
data. This is abbreviated for space reasons, but the clinician
ordinarily would further develop this with more focusing openended inquiry.]
Although no disease explanation is found for 20% to 75% of physical symptoms,63 patients often have several personal concerns around their symptoms.
In one study,64 67% of patients worried about serious illness, 72% expected
medications, 67% wanted testing, 53% expected referral, and 62% indicated
interference with routine activities. While 47% of patients who, like Ms. Jones,
described stress and about 20% recognized depression and anxiety, only 1%
considered their problem to be psychiatric in nature. In that study clinicians
viewed the symptoms as being far less serious than patients did; and, not surprisingly, unaddressed concerns accounted for most of the patient dissatisfaction. Other patients may have disbelief/distrust of the medical system,65 grief
and other losses, concerns about becoming independent (young people) or

54

SMITH'S PATIENT-CENTERED INTERVIEWING

dependent (older or seriously ill people), issues concerning retirement, family or job problems, and administrative issues (needing an insurance form
filled out). It is these personal concerns, the personal context of your patient's
symptoms, that you want to understand. In general, whether the symptom
is physical or psychological, you can easily establish a personal focus as you
inquire into the broader personal context of the patient's illness.
To maintain the personal focus, avoid directing the patient back to previously discussed symptoms. You will focus on them when moving to the
clinician-centered interview in a few minutes. At this point in the interview,
you want to expand your understanding of the patient as a person.
Patients will occasionally share their stories without much facilitation.
Usually, however, they give small bits of personal information, one at a time,
as though testing the water to see if you are interested, comfortable, and willing to follow them into what is often a deeply personal story. Because of this
step-by-step unfolding of the account, you must use focusing open-ended
skills repeatedly to draw out the underlying narrative thread.
Early on, direct the patient to whatever bits of personal data appear to be
of most interest to the patient and you. Once you identify the narrative thread
of the patient's story and its apparent meaning. stay with it. If the patient gets
away from this theme, respectfully interrupt with focusing open-ended skills
and refocus the patient on the main story thread. Such refocusing is often
needed because patients wander back to previously discussed symptoms (or
other diagnostic or therapeutic data).
After no more than a few minutes, you will get a good sense of the broader
personal context-and have further enhanced the clinician-patient relationship by addressing features of central importance to the patient's life. If
emotions are ..placed on the table" during these early stages, address them as
discussed later.
It is here that the initial integration of symptoms and personal factors
occurs, the first view of the patient's mind-body connection, with further
integration to occur when you address feelings and emotions.
Uncommonly, patients may volunteer only physical symptom details in
response to your patient-centered inquiry. In this case, we recommend that
you "prime the pump" for personal data by using the indirect emotion-seeking skills described in Chapter 2 (impact, belief, intuiting how the patient might
be feeling, and triggers). For example, if a patient offers no personal context
of the physical symptom, you might ask, "How's that affecting your day-today life?': "How's that affecting your spouse?", "What do you think is causing the problem?': "Many patients with these sorts of symptoms are worried,"
or "What made you decide to come in now for your (symptom)?" See also
Chapter 7, section entitled "The Stoic/Unemotional Patient."

Chapter 3

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55

Develop an Emotional Focus (Emotional Context)

Just as you sought to understand the personal context of the symptoms, you
now seek to understand the emotion associated with the personal and symptom information. This further deepens the story and makes apparent the
three-way interaction among symptom, personal, and emotional dimensions.
The full mind-body link and the biopsychosocial description become clear as
you include the patient's emotional response to the illness. In developing an
emotional focus, always monitor the patient's readiness to engage by observing how he or she is responding to the process so far and for any untoward responses to inquiry about emotion; for example, changing the subject
after the clinician inquires about emotion. AI; you develop experience with
the interview you will notice that many patients will offer the personal and
emotional contexts of their story as a natural progression of describing the
symptom. This will help you recall that it is often not just the symptom that
motivates a person to seek healthcare and become a patient, but also how the
symptom interacts with the personal and emotional contexts of the person's
life. Patients often seek healthcare because they are concerned. If the patient
does not spontaneously put the emotional context "on the table," you will
need to develop an emotional focus.
To establish an emotional focus, you will need to change the style of
inquiry. Emotion-seeking skills, both direct and indirect, temporarily supplant focusing open-ended skills. Start to explore the emotional domain with
direct inquiry about how the patient feels about the personal situation so far
described ("How is this for you?~ "How does that make you feel, emotionally?").66 If the patient is uncomfortable or simply reticent, you may need to
make several efforts before emotion can be expressed. Indirect inquiry about
impact, beliefs and triggers, and intuiting how the patient might be feeling
also may be necessary and are used when direct inquiry does not reveal emotional content (see Chapter 2).
Once you identify an emotion, ask for clarification using open-ended skills
to get a good understanding of the emotion and what produced it so that you
can then respond empathically.
AI; noted earlier, emotion-seeking skUls are not needed if the patient is
already showing or expressing emotions, as many will do spontaneously following open-ended inquiry alone.
Continuation of Ms. Jones VIsit

Clinician: Sounds like the Board told you one thing; that you liked him at
first, but then he changed, and you're left with a problem?
Patient: Yeah, sounds kind ofbad, huh?

58

SMITH'S PATIENT-CENTERED INTERVIEWING

Clinician: How do you feel about that? [Direct emotion-seeking]
Patient: Oh, I don't know. The headache is what bothers me.
Clinician: But how do you feel, you know, emotionally? [She did not give
any emotion the first time and clinician uses direct emotionseeking inquiry again. It is okay to encourage emotional expression, as long as the patient does not protest or try to change the
subject.]
Patient: Oh, nothing really bothers me that much. We were taught to
turn the other cheek.
Clinician: You know, I think I would be upset if I were put in a bind like
this. [Changes strategy and tries intuiting how the patient might
be feeling.]
Patient: Well, yeah, I guess I am too, now that you mention it.
Clinician: What is the feeling? [She has acknowledged emotion (upset)
but the clinician wants to get an accurate description, returning
to a direct emotion-seeking question about feeling.]
Patient: Well, I just want to throw something at him. He makes me so
mad! I didn't do anything against him. I work really hard there
and things are going much better since I've been there. It's when
I get mad that the headaches come. The nausea is even worse
and then sometimes I get these spots in my eyes and . . . [A
more precise direct link to headaches, now not just to her job
situation but more specifically to being angry. Note the value of
encouraging emotion: she is now expressing it.]
Clinician: So you get mad when he gets on you? [Interspersing openended skills is appropriate as the clinician summarizes to continue this focus.]

Address Feelings and Emotions with Empathy Skills
When the patient names a feeling or expresses emotion, either spontaneously
during open-ended inquiry or after you use emotion-seeking skills, and once
you have clarified with open-ended skills why this patient has this feeling or
emotion, use the empathy skills outlined in Chapter 2: Naming, Understanding,
Respecting, and Supporting, recalled by the mnemonic NURS.
To address an emotion or feeling, convey to the patient that you have recognized it by naming it, that you understand it, that you respect the patient's
situation, and that you are available to help in any way possible. These skills
typically are used multiple times during the course of an interview. It may take
you considerable time to work through strong emotional reactions. Using
these skills once is seldom enough.

Chapter 3

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57

You can use all four empathy skills together as a set, in the order given; we
recommend this when first learning them. Once they are learned, however,
in addition to using all four at once, you can use one or two skills at a time to
avoid their repeated use as a quartet from striking the patient as peculiar or
scripted.
Empathy skills are used only after you have heard enough to adequately
understand the patient's feelings and emotions. For example, when a patient
expresses sadness over loss of a spouse, it is not appropriate to immediately
say you understand the patient's sadness. You must first listen to enough ofthe
story in an open-ended manner to be able to legitimately make these empathic
statements. Stating that you "understand" before the patient describes the
feeling conveys an attempt to blindly follow communication scripts rather
than real understanding. Patients may then respond, "How can you understand what I'm going through!" Allow and encourage the patient to describe
the feeling in some depth; then your statement of "understanding" the feeling
will be authentic. Words such as "see:• "appreciate; and "imagine" can also
be used to express understanding, for example, "I can see why you'O be sad:'
"Given what you've told me, I can appreciate why you are sad; "I can only
imagine how sad this makes you."
On the other hand, with reticent patients you may have to use empathy
skills with much less emotional information than is desirable. For instance,
in a very reticent patient who has lost a job and will only acknowledge being
"slightly upset:' you can still use the NURS skills effectively.
Some new learners resist emotion-seeking and empathy skills, usually
because of unfamUiarity. They worry that these skills will seem forced and
false. It may be helpful to recall the compelling scientific rationale for using
them (see Appendix B). It may indeed feel awkward and contrived at first for
some but, as self-consciousness is overcome, confidence is gained, and benefit to the patient is observed, most clinicians become converts,66 recognizing
that they feel progressively more comfortable themselves, that their responses
become quite genuine, and that patients respond favorably to this emotional
connection, sometimes even saying, "You know, I'm feeling better already."
Continuation of Ms. Jones Visit

Clinician: So, you get mad when he gets on you?
Patient: Yeah, he really gets me mad. I just get so furious I could scream
sometimes (clenches ftst and strikes table firmly).
Clinician: You get furious. It sure makes sense. It seems like you've done
so much there to help, and all you get is grief from him. I appreciate the way you're able to talk about it. Maybe you and I can

58

SMITH'S PATIENT-CENTERED INTERVIEWING

talk more later about how you might handle that. [The clinician names the feeling using her exact word-furious, expresses
understanding briefly, and spends more time expressing respect
for her: acknowledging she had been through a lot, that she was
successful at work, and praising her for talking about her emotions. Finally, the clinician supports the patient by offering to
work with her on managing her anger.]
Patient: That would probably help. Just talking about it gets me upset
and gives me a headache, right now. [This further demonstrates the association between headaches and emotional upset,
now occurring as a result of anger-laden material during the
interview.]
Clinician: I can imagine. You've put up with a lot. [Naming "mad" or
"furious" again is unnecessary because it's obvious, but the clinician again indicates understanding and makes a respecting
statement.]
Patient: You know, I think I'm even madder at that damn Board. They
didn't tell me any of this and said everything would be OK.
Who needs all this? [As a result of addressing her emotions, the
patient is now presenting new personal data and its associated
emotional material; that is, the story deepens as the narrative
thread further unfolds.]
Clinician: That's a tough situation. [Clinician again respects, using just one
of the NURS quartet.]

The rich description of symptom(s), personal context, and emotional context
obtained in the first four substeps of Step 4 provides the first chapter of the
patient's story. Subsequent chapters are developed by expanding the story as
shown in Fig. 3-1 and described in substep 5 below. As you will learn next,
subsequent chapters of the patient's story do not usually return to symptoms,
but concern just the evolving personal and emotional aspects of the storythe narrative thread.
Expand the Story to New Chapters

Let us review the sequence of skills outlined so far in Step 4: focusing openended skills followed by emotion-seeking skills and then empathy skills. This
typically produces a beginning, but still incomplete, story. To develop the
story further requires the repetitive, cyclic use of this sequence of patientcentered interviewing skills. Each cycle produces a deeper level of the story,
another chapter. Personal information and its associated emotion(s) evolve
in parallel-neither is more important than the other. This deepening of

Chapter 3

THE BEGINNING OF THE INTERVIEW: PATIENT-CENTERED INTERVIEWING

59

The Patient's Story
Chapter 1

Other Chapters

RGURE 3-:l. The patient's story.

the narrative thread occurs because empathy skills stimulate the patient to
place new personal information "on the table;" offering you an opening
to inquire about them and develop the story further. Then, you can return to
emotion-seeking and empathy skills to develop the emotional dimension of
the new data. Do this until you are satisfied with the depth of the story. The
self-reinforcing effect of patients' psychological statements and emotions is
key to obtaining the full personal and emotional story. This does not mean
that you should focus on just the personal or just the emotional aspect. Both
are developed nearly simultaneously in a progressive unfolding of the narrative theme. Returning to a symptom focus is generally not recommended,
rather, remaining in the personal, emotion realm will help you better develop
the narrative thread.
The story will develop spontaneously as you repeatedly cycle through
focusing open-ended, emotion-seeking, and empathy skills. As the patient
becomes comfortable in expressing emotion, fewer of the emotion-seeking
skills are needed and empathy and focusing open-ended skills alternate, taking the patient quickly to progressively deeper levels of his/her story.
You will find that in developing the story, you will have ideas (hypotheses) about what it implies. Paradoxically and distinct from the middle of the
interview (clinician-centered part), you should not directly ask about your
hypotheses until they have first been mentioned by the patient-only what is
placed "'on the table" for discussion by the patient can be commented on during this portion of the interview. This is a principle drawn from nondirective
psychotherapy in which the meaning of an event or experience for the patient
becomes apparent over time and without interpretations from the clinician.67
For example, if you thought a patient's story about disliking a woman who

80

SMITH'S PATIENT-CENTERED INTERVIEWING

"looks like my wife" meant that the patient disliked his wife, you should not
ask directly ("Don't you like your wife?") because it would insert new data
(dislike of wife) into the conversation. Rather, get the patient to continue talking about what he put on the table by saying, for example, "Tell me more
about your wife." The hypothesis-testing process is analogous to dancing or
playing jazz. 10 While the patient leads the dance or musical performance,
once the patient has led to a specific place, the clinician can maintain a focus
on that spot.
Continuation of Ms. Jones VIsit

Clinician: That's a tough situation.
Patient: You know the head of the Board even told me my boss is a good
guy who was looking forward to me corning so he could retire!
Clinician: The head of the Board? [The clinician shifts away from empathy to focusing open-ended inquiry with echoing to get what
appears to be new information about the situation. This will
start a new cycle of active open-ended, emotion-seeking, and
empathy skills.]
Patient: She's the one who recruited me here. I could have gone to a couple other places but came here because she convinced me it was
such a good chance for me.
Clinician: Sounds like you didn't get a full picture of this place. [Focusing
open-ended summary, still trying to learn more new
information]
Patient: Yeah, it's not really fair.
Patient: How's that for you? [Now back to emotion with a direct emotion-seeking inquiry]
Patient: Well I must sound kind of stupid, and I feel kind of sheepish;
but mostly just mad.
Clinician: It makes sense to me, but I don't understand why you feel sheepish. You did everything that you could. [Back to empathy skills
with understand and respect statements. Notice how openended and relationship-building skills are interwoven to generate both emotional and nonemotional data. Notice also that one
can indicate lack of understanding and ask for clarification.]
Patient: Yeah, I guess, but I still feel kind of dumb.
Clinician: Dumb? [Echoing; an obvious story is already present but the clinician is exploring further by again moving away from emotion.]
Patient: That's what my mother used to say, that I was smart but dumb.
You know what I mean?

Chapter 3

THE BEGINNING OF THE INTERVIEW: PATIENT-CENTERED INTERVIEWING

61.

Clinician: Smart with books but not so much with people? [A combination of a summary and an educated guess]
Patient: Yeah, maybe she's right.
Clinician: Howa that feel, when she'd say that? [Back to emotion with
direct emotion-seeking]
Patient: I felt mad! Seems like a pattern, huh? And I used to get headaches as a kid too when shea get on me. I'd forgotten that.
[Additional supportive data about the association of headaches
and anger]
Clinician: So that made you mad, too. I'm impressed at how you're able
to talk about it and put this together. [Clinician uses a name
and a respect statement. Depending on the time available, the
clinician could have further addressed another obvious clue, the
patient's mother, perhaps with an open-ended request such as
"Tell me more about your mother." Note in this vignette that
another cycle of focusing open-ended, emotion-seeking, and
empathy skills has been used to further develop the story.]
Patient: Well, I appreciate your saying that. Actually, it feels kind of good
talking. [A positive response to this interaction and an indication of a good clinician-patient relationship.]
Clinician: Say more about that. [An open-ended request]
Patient: Well, I just haven't talked much about it. My husband doesn't
want to talk about it.
Clinician: He doesn't want to talk about it? [Echoing]
Patient: No. I think he feels bad because he thought this was the best
place for me to come.
Clinician: Well, I'm glad it's been helpful here. You've really been open.
[A support statement followed by a respect statement. An obvious new area for further discussion has been introduced, the
patient's husband, and this could be pursued further if time
allowed. The patient also has referred positively to their present interaction. Simply acknowledging it, as the clinician did is
appropriate.]
Patient: Thanks. My headache's better now. It does help.
The first three chapters of Ms. Jones' story are illustrated in Fig. 3-2.
Given the importance of the clinician-patient relationship, it is important to check how the interaction is going if the patient does not raise it. You
can inquire directly, such as "So how are we doing here so far?" If you have
been patient-centered, the response usually will be positive and you simply

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SMITH'S PATIENT-CENTERED INTERVIEWING

Ms. Jones' Story
Chapter 2

Chapter 1

Chapter 3

FIGURE 3-2. Ms. Jones' story.

acknowledge this; for example, "Good, it seemed like things were going OK to
me, but I wanted to check." When the patient mentions the clinician-patient
relationship, as Ms. Jones did, this provides the answer about the relationship
and you can simply acknowledge it. Of course, if the patient raises problems
with the interaction, for example, getting tired, address these.
If an urgent personal problem exists, easily determined in 5 to 15 minutes,
the patient may require additional time, even immediate action. For example,
if you discover a patient is a victim of intimate partner violence, you may have
to take additional time to ensure his/her immediate safety. In the absence of
an urgent problem, the usual situation, prepare to transition into the middle
portion of the interview when you have an understanding-not of the entire
story, but of the most salient, immediate aspects of the patient's story; that is,
the first few chapters. Certainly, there is more to Ms. Jones' story but, given
time constraints and lack of urgency, these areas can be explored another

G

63

>ortant,
; is usuor past
g about
rou and

p 5)
ewpro[ou can
dcheck
ms,you
ituation
•ility.69
W

to 60

importerwise,
entered
:tion.

ike you
;et with
i I miss
tone to
eded; if
d high-

• TABLE 3-6. Step 5: Transition to the Middle of the Interview
(30-60 s)
1. Brief summary
2. Check accuracy
3. Indicate that both content and style of inquiry will change if the
patient is ready. Continue with middle of interview.

84

SMITH'S PATIENT-CENTERED INTERVIEWING

Clinician: If it's OK then, I'd like to shift gears and ask you some specific
questions about your headaches and colitis, as well as a lot of
questions to get to know you better as a person. [The clinician is
checking if it is satisfactory to change the subject and indicating
what is going to occur.]
Patient: Sure, that's what I carne in for.
(Ms. Jones' visit continues in Chapter 5)

•

BEYOND BASIC INTERVIEWING

We have already begun to develop a dear understanding of the patient's story
and the psychological, social, and emotional meaning it has for him/her.
It is at this point that you can clarify your understanding of the story and
begin developing preliminary hypotheses about what might be causing the
problem(s) and what opportunities there might be to remedy them. Focusing
open-ended skills, emotion-seeking skills, and empathy skills are essential for
eliciting the required data, but there are many more skills in the experienced
clinician's toolbox. Prejudices, time pressures, and preoccupation with other
issues, for example, can interfere with hearing the patient's story. Take care of
pressing personal or professional issues beforehand, relax, dear other issues
from your mind, and focus on the patient. As noted above, it is often useful
to breathe deeply or simply dose your eyes and become aware of your state of
mind and what you would most like to accomplish with this patient for a few
seconds before entering the clinic or hospital room. This will help you listen at
multiple levels,11•70·71 a skill that will improve over time as the basics described
in this text become reflexive.
Attention to multiple levels means going beyond the obvious content and
emotion presented by the patient to consider how the patient says something,
what is left unsaid, and what is implied. This requires attention to subtleties
of grammar, syntax, verb tense, changes of subject, tone of voice, nonverbal
cues, incongruity in verbal and emotional content, and understanding metaphors.72•73 These areas are addressed using the same basic skills; for example,
"What do you mean when you say, 'my daughter's father'?"; "I've noticed you
often say; 'You can't win for losing.'"

•

SUMMARY

The beginning ofthe medical interview consists of two preparatory steps during which we set the stage (Step 1) and the agenda (Step 2); followed by an
open-ended beginning of the HPI (step 3), continuation of the HPI (Step 4),

Chapter 3

THE BEGINNING OF THE INTERVIEW: PATIENT-CENTERED INTERVIEWING

65

FIGURE 3-3. Summary of the beginning of the Interview.

and transition to the middle of the interview (Step 5). The transition (Step 5)
prepares the patient for the more direct clinician-centered style of the middle of the interview. In Steps 3 and 4, you use the following patient-centered
skills to "build the patient's history"60: nonfocusing and focusing open-ended
inquiry, rare closed-ended questions, emotion-seeking and empathy skills.
The cyclic, integrated use of these patient-centered skills occurs in Step 4.
These tools allow you to begin to understand the richness and complexity of
the human condition.
Figure 3-3 summarizes the major events in the beginning of the medical
interview. Usually, preparing the patient takes 1 to 3 minutes, eliciting the
beginning of HPI (symptoms with personal and emotional contexts) takes
4 to 12 minutes, and making the transition takes 30 seconds. Using patientcentered interviewing skills primarily and delaying clinician-centered skills for
6 to 15 minutes will lead to the remarkable benefits described in Appendix B,
for example, improved patient satisfaction, decreased risk of malpractice law
suits, and improved health outcomes. Mter this investment, you will find the
rest of the interview to be fairly easy and routine. The data you generate will
be easily understood and usually describe the primary symptoms and their
personal context. The mind-body connection will be established; data that
will lead to a biopsychosocial story will begin to emerge; and, most important,
the patient will feel listened to, understood, and cared for.

SKILLS EXERCISES
(Likely spread over several sessions)
1. Practice Steps 1 and 2 together in role play
until you can do them without looking at
the book to recall all the substeps. Work on
simple opening statements for each step,
including several substeps in one sentence
or so. See the vignette of Ms. Jones and the
demonstration video.
2. When question #1 is mastered, practice
Steps 1 to 5 together in role play, covering all 21 substeps. Conduct the entire
patient-centered interview in 10 to 15
minutes, spending about 1 minute each in
Steps 1 to 3 and 5-with 5 to 10 minutes
in Step 4.
3. After you can complete all steps and substeps in role play, conduct the same exercise with a real or a simulated patient.
A. Problems to watch out for:
a. Hurrying into the interview rather than
engaging in some small talk to let the
patient get comfortable with you.
b. Inefficient agenda-setting, omitting
repeated "what else" statements until
you know all items the patient wants
to discuss.
c. Excessive time spent in Step 3 which
is just a 30 to 60 second step where

you simply listen attentively-after an
initial open-ended question-the next
comment you make that isn't a continuer starts Step 4.
d. Not touching the key bases in Step 4:
symptoms, personal concerns, emotions
e. Too little emotion-seeking
f. Not enough NURS
g. Not adequately signaling the transition
B. With time and practice, you will notice the
following markers of success:
a. Smooth, seamless flow of data
b. Understand mind-body links
c. Ability to focus wherever you wish
d. Ability to effectively and respectfully
interrupt
e. Control of the interview
f. Skilled critiquing ability of your own
and others' interviews
g. Efficient interview. Once facile with
the 5 steps and 21 substeps, you
will be able to conduct the patientcentered process in 6 to 15 minutes.
With further mastery, you will be
able to be equally effective in 3 to
6 minutes.

Chapter 3

THE BEGINNING OF THE INTERVIEW: PATIENT-CENTERED INTERVIEWING

67

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Symptom-Defining
Skills
I keep six honest serving-men
(They taught me all I knew);
Their names are What and Why and When
And How and Where and Who.

Rudyard Kipling,
The Elephant's Child. In: Just So Stories. 1
In the beginning of the interview, you greeted the patient (Step 1) and set the
agenda for the visit (Step 2). You then obtained the first portion of the history
of present illness (HPI) by eliciting the patient's unique description of his/her
chief concern and its personal and emotional contexts (Steps 3 and 4); you
responded to the patient's emotions with empathy. In Step 5, you informed
the patient of the transition to the middle of the interview.
The data you collected in the beginning of the interview, while essential, are
rarely complete. In the middle of the interview, you will gather more detailed
information on the patient's HPI and other active problems (OAP). You will
also ask about other symptoms, the patient's life and medical history to help
you make a diagnosis, identify medical issues other than the chief concern,
assess for disease risk, and come to know the patient better. This additional
information falls under the headings of past medical history (PMH), social
history (SH), family history (FH), and review of systems (ROS). We will cover
each of these in detail in Chapter 5.
In the middle of the interview, you will be more directive, guiding the topics discussed by using the clinician-centered interviewing skills as contrasted
with the patient-centered interviewing skills you used in the beginning of
the interview. Clinician-centered skills, such as "coning-down'' -following

71

72

SMITH'S PATIENT-CENTERED INTERVIEWING

open-ended questions with closed-ended ones (see Chapter 2)-help you to
clarify and explore details of the patient's symptoms to test hypotheses and
make a diagnosis, as well as to efficiently gather the large amount of data
required. Even though you will often be asking lists of clinician-centered
questions, it is important to remain alert to the patient's emotional state and
any verbal or nonverbal cues of emotion, and respond with emotion-seeking
and empathy skills (NURS) as needed.
Your first goal in the middle of the interview is to develop as complete
and precise a characterization as possible of the patient's symptom story. To
do this, you will use symptom-defining skills. Just as you learned facilitating
skills before conducting the beginning of the interview, symptom-defming
skills will help you perform the middle of the interview.
But first, what is a symptom? Generally speaking, a symptom is an indicator
of the existence of something else. In medicine, we take it to mean the subjective evidence of the patient's underlying problem. In this way, it differs from a
sign, which is the objective evidence of a disease or disorder. The patient tells
the clinician about a symptom (chest pain, shortness of breath), while the clinician observes a sign on physical examination (tender ribs, heart murmur).
You will learn about signs in physical diagnosis courses and on clinical rotations. But, before you can learn all you can about the patient's symptom, you
need to ask: Is the patient describing a symptom?

• THE REVIEW OF SYSTEMS LISTS THE SYMPTOMS
OF MOST DISEASES
We introduce the ROS (Table 4-1) here because it lists and organizes most
known symptoms related to underlying diseases. Symptoms are important
because they are the language you will use to convert a patient's concerns
to a diagnosis. Table 4-1 lists symptoms according to the body system they
are usually associated with, although many occur in more than one system. The ROS listing is not exhaustive. Beginning clinicians should not
worry if they don't understand what diagnosis a given symptom points to.
You can make a diagnosis only after you have obtained and synthesized
enough data about the patient. Medical terminology for some symptoms
is noted in parentheses. Remember, though, that you need to remain bilingual, using technical terms with your colleagues and plain lay language
with your patients.
Beginning clinicians should learn all 19 categories of the ROS and know
a few symptoms in each. All clinicians are advised to memorize all symptoms in each category, a necessary prerequisite for effective clinician-centered
interviewing.2

• TABLE 4-1. Review of Systems•
General
Usual state of health
Fever
Chills
Night sweats
Appetite
Weight change
Weakness
Fatigue
Pain
Skin
Sores/skin ulcers
Rashes
Itching (pruritus)
Hives
Easy bruising
Change in size or color of moles
Lumps
Loss of pigment
Change in hair pattern
Change in nails
Hematopoietic
Enlarged lymph nodes (lymphadenopathy)
Urge to eat dirt (pica) or ice
Abnormal bleeding or excessive bruising
Frequent or unusual infections
Head
Dizziness
Headaches
Fainting or loss of consciousness
Head injuries
Eyes
Use of glasses
Change in vision
Double vision (diplopia)
Pain
Redness
Discharge
History of glaucoma
Cataracts
Dryness

Ears
Hearing loss
Use of hearing aid
Discharge
Pain
Ringing (tinnitus)
Nose
Nosebleeds (epistaxis)
Discharge
Loss of smell (anosmia)
Mouth and throat
Bleeding gums
Sore throat
Painful swallowing (odynophagia)
Difficulty swallowing (dysphagia)
Hoarseness
Tongue burning (glossodynia)
Tooth pain
Neck
Lumps
Goiter
Stiffness

Breasts
Lumps
Milky discharge (galactorrhea)
Bleeding from the nipple
Pain
Cardiac and pulmonary
Cough
Shortness of breath (dyspnea)
Shortness of breath with activity (exertional dyspnea)
Shortness of breath when lying down and need to sit
to breathe (orthopnea)
Awaking at night with shortness of breath (paroxysmal nocturnal dyspnea)
Sputum production
Coughing blood (hemoptysis)
Wheezing
Chest pain
Pounding or fluttering sensation in the chest
(palpitations)
continued

• TABLE 4-1. Review of Systems8 (continued)
Cardiac and pulmonary (continued)
Shortness of breath on exertion
Swelling of feet or other regions (edema)

Blood in urine (gross hematuria)
Pain or burning on urination (dysuria)
Particulate matter in urine (urinary gravel)

Vascular
Pain in legs, calves, thighs, hips, or buttocks when
walking (claudication)
Leg swelling
Blood clots (thrombophlebitis)
Leg ulcers

Female genital
Lesions/discharge/itching
Age at menarche
Interval between menses
Duration of menses
Amount of flow
Last menses
Painful menses (dysmenorrhea)
Absence of menses (amenorrhea)
Irregular, heavy menses (menometrorrhagia)
Bleeding between periods
Pregnancies
Abortions/miscarriages
Libido
Painful intercourse (dyspareunia)
Orgasm function
Age at menopause
Menopausal symptoms
Postmenopausal bleeding

Gastrointestinal
Loss of appetite
Weight change
Nausea
Vomiting (emesis)
Vomiting blood (hematemesis)
Difficulty swallowing (dysphagia)
Painful swallowing (odynophagia)
Heartburn (dyspepsia)
Abdominal pain
Difficult or infrequent bowel movements
(constipation)
Loose, frequent bowel movements (diarrhea)
Passing mucus
Change in stool color/caliber
Black, tarry stools (melena)
Rectal bleeding (hematochezia)
Hemorrhoids
Rectal pain (proctalgia)
Rectal discharge
Rectal itching (pruritus ani)
Yellow discoloration of sclerae and skin Oaundice)
Dark urine-the color of tea or cola drink
Excessive upper (belching or eructation) or lower
(flatus) bowel gas
Lump in groin or scrotum
Urinary
Frequent urination (polyuria)
Awakening at night to urinate (nocturia)
Infrequent urination
Abrupt urge to urinate (urinary urgency)
Difficulty starting stream (urinary hesitancy)
Loss of control of urination (incontinence)

Male genital
Lesions/discharge
Erectile function
Orgasm function
Bloody ejaculation (hematospermia)
Testis swelling/pain
Libido
Hernia
Neuropsychiatric
(See headings Head, Eyes, Ears, Nose, Mouth, and
Throat for cranial nerves)
(See heading Musculoskeletal for motor function)
Fainting
Paralysis
Tingling (paresthesia)
Decreased sensation (hypesthesia)
Absent sensation (anesthesia)
Tremors
Loss of memory
continued

• TABLE 4-1. Review of Systems• (continued)
Neuropsychiatric (continued)

Depression
Mania
Apathy or loss of interest
Loss of enjoyment of life (anhedonia)
Suicidal thoughts
Sleep
Anxiety/nervousness
Speech disorders
Dizziness or vertigo
Poor balance (ataxia)
Inability to get to sleep or stay asleep (insomnia)
Excessive sleep (hypersomnolence), nightmares
Symptoms without an explanation (somatization)
Bizarre or unrealistic thoughts (intrusive thoughts)
Bizarre or unrealistic perceptions (hallucinations)
Seizures

Endocrine
Excessive thirst
Frequent urination
Numbness or tingling of hands/feet
Weight gain or loss
Episodes of confusion, sweating, light-headedness
(hypoglycemic reaction)
Blurred vision
Date of last eye exam
Swelling in neck
Weight gain or loss
Palpitations or racing heart
Tremulousness
Hair loss (alopecia)
Dry skin
Heat or cold intolerance
Loss of skin pigment (vitiligo)
Constipation or diarrhea

Musculoskeletal
Weakness
Muscle pain (myalgia)
Stiffness
"Many of these symptoms can be caused by diseases in several systems (including other than where listed}.
Medical terms (used in oral and written presentations} are in parentheses.

•

DISTINGUISHING CLOSELY RELATED MATERIAL
(SECONDARY DATA) FROM SYMPTOMS (PRIMARY DATA)

Sometimes, instead of describing a symptom such as, "My head aches" or "My
big toe is hurting:' a patient will say, "I have a migraine:' or "I think it's the
gout:' While the patient may well be correct, s/he is describing a disease in
each case, not a symptom. Symptoms are the patient's area of expertise and no
verification is necessary. This is primary data. 3 Secondary data are any data
apart from a patient's direct experiences. They are less reliable and more in
need of verification. Non-symptom information obtained from the patient
(such as a disease or disorder, treatment, procedure, medication, cause of the
problem, or a laboratory test result) are secondary data that differ from the
patient's actual symptoms. While these secondary data are less important,3
they often guide the clinician to areas requiring verification and additional
information. We discuss how to incorporate secondary data into the interview
in Chapter 5.

• TABLE 4-2. Some Common Concerns Needing Conversion to Symptoms
in the Review of Systems
•
•
•
•
•
•
•
•
•
•

•

Blahs
Dragged-out
Bad blood
I've got a "bunch"
Really weird
Funny smelling urine
Wrung-out
Midlife crisis
Menopause
Old age

•
•
•
•
•
•
•
•
•
•

Terrible two's
A rod in my head
Wigged-out
Sun troubles
Chronic fatigue syndrome
Heart murmur
Indigestion
The flu
Dizzy
Allergies

TRANSLATING CONCERNS INTO SPECIFIC
MEDICAL SYMPTOMS

Patients often speak in nonmedical terms (Table 4-2) that you must convert
to medically meaningful symptom terms. When the patient tells you that
s/he has the "blahs;' a "wrung-out feeling;' or "bad blood;' what does s/he
mean and how is the information to be used medically? If you couldn't clarify
it in the beginning of the interview using patient-centered facilitating skills,
you need to use symptom-defining skills in the middle of the interview: start
with a brief open-ended question (focused on the patient's term) and followup with enough dosed-ended questions to adequately understand:
Clinician: Say more about what you mean by the blahs. [A focused, openended request]
Patient: Well, you know, the nausea all the time and no appetite. [Nausea
and no appetite are medically meaningful symptoms (see GI
System in ROS).]
Clinician: Any vomiting? [Closed-ended question drawn from the GI
System in ROS]
Patient: No.
Clinician: How's your weight been? [The clinician would continue to better define what the patient calls the blahs but has already identified at least two commonly understood medical symptoms in
theROS.]

Likewise, certain medical terms are ambiguous or are used by patients in an
unconventional way. For example, "dizzy" usually means vertigo, a sensation

Chapter 4

SYMPTOM-DEFINING SKILLS

77

of whirling, as though one had just gotten off a merry-go-round or had too
much alcohol to drink. But, some clinicians and many lay people use the term
dizziness to mean a faint or light-headed feeling unattended by vertigo. This
distinction is important because one approaches the patient with vertigo differently from the patient who is light-headed:
Clinician: Tell me what you mean by dizzy. [Focused, open-ended request;
this could also be phrased as a question such as, "What do you
mean by dizzy?"]
Patient: I get wobbly on my feet. [Still not very specific]
Clinician: Do you get a sensation of whirling about, like you'd just stepped
off a merry-go-round? [Closed-ended question to get necessary
details]
Patient: Yeah, that's it. I feel like I'm going around the room.
Clinician: Do you feel light-headed, like you might faint or have to put
your head down between your knees to get relief? [Closedended inquiry to determine if "dizzy" means light-headedness
to the patient.]
Patient: No, that makes it worse to put my head down. [The interviewer
has identified the medical symptom vertigo as the meaning
of the complaint of dizziness, although many more questions
remain about associated symptoms and other details of the
problem.]
Other examples include "diarrhea," which means frequent liquid stools, but
which lay people often use to mean frequent stools, regardless of consistency;
and "constipation," which traditionally has been defmed as fewer than three
stools per week. Patients have a broader definition for this term, using it to
also describe having to strain at stool or a sense of incomplete evacuation. In
fact, the medical definition of constipation was broadened to include patients'
usage of the word.4

• CHARACTERIZING SYMPTOMS
Once the symptom is clear, you want to learn as much about its characteristics
as possible. To fully understand a symptom, you need to know its descriptors or "cardinal features": Onset and chronology, Position, Precipitating
factors, Quality, Quantification, Radiation, Related symptoms, Setting, and
Transforming factors (aggravating/alleviating). Some use the mnemonic
OPPQQRRST to recall these (Table 4-3). These descriptors incorporate the
"classic seven" attributes of symptoms.5

• TABLE 4-3. The Descriptors of Symptoms-OPPQQRRST
1. Onset and chronology ("When does [did] it begin?" "How long does it last?" "How often does it happen?")
a. Time of onset of symptom and intervals between recurrences
b. Duration of symptom
c. Periodicity and frequency of symptom
d. Time course of symptom
i. Short term
ii. Long term
2. Position ("Where is it located?")
a. Precise location
b. Deep or superficial
c. Localized or diffuse
3. Precipitating factors ("What brings it on?" "What were you doing when it started?")
4. Quality ("What is it like?")
a. Usual descriptors
b. Unusual descriptors
5. Quantification ("How bad is it?" For pain, "On a scale of 1 to 10, with 1 being no pain and 10 being the
worst pain you can imagine, like surgery without anesthesia, what number would you give your pain?'')
a. Rate of onset
b. Intensity or severity
c. Impairment or disability
d. Numeric description
i. Number of events
ii. Size
iii. Volume
6. Radiation ("Does it travel anywhere?")
7. Related symptoms ("Have you noticed anything else that occurs with it?")
8. Setting (circumstances that contribute to or precipitate the symptom)
a. Environmental factors
b. Social factors
c. Activity
d. Emotions
9. Transforming factors ("What makes it better?" "What makes it worse?")
a. Aggravating factors
b. Relieving factors

Onset and Chronology-Course of Individual Symptoms Over Time

Understanding the precise sequence of symptoms and other events is key to
making a correct diagnosis and should be asked about first. Here we focus on
the chronology and timing of individual symptoms and discuss how to integrate these data into the overall chronology of all symptoms and other data
in Chapter 5.

Chapter 4

SYMPTOM-DEFINING SKILLS

79

Time of Symptom Onset and Intervals Between Its Occurrences
The time of onset of the symptom and the time intervals between occurrences of the symptom are diagnostically significant; for example, the onset
of a cough 6 months earlier that recurs at intervals of 1 to 2 days suggests a
chronic pulmonary problem such as cancer or tuberculosis, while the onset
of a cough 2 days ago that is continuous suggests an acute process such as
bronchitis or pneumonia. Recalling Ms. Jones' clinic visit from Chapter 3,
migraine headaches characteristically have specific times of onset and painfree intervals of days to weeks, whereas a brain tumor or tension headaches
usually cause daily and non-remitting pain.
Rate of Onset

Whether the symptom began gradually or suddenly has diagnostic significance; the latter suggests an acute but not necessarily more important disease
process. You might hear a patient with polymyositis say, "the weakness just
gradually developed in my shoulders and thighs over a couple months" or a
patient with pulmonary embolus or heart failure might say "the shortness of
breath had been kind of gradual over that day but the chest pain and coughing
blood came all of a sudden."
Focused open-ended inquiry often suffices, although patients sometimes
benefit from being given examples:
Clinician: How did this begin?
Patient: What do you mean?
Clinician: You know, slow or all of a sudden.
Patient: Gradual, a little bit at a time.
Duration of Symptom

The duration of a symptom also is of diagnostic importance. Precise understanding is essential; is the duration a few seconds, 5 minutes, 2 hours, 10
days, 3 years? To illustrate, typical substernal crushing chest pain of coronary
disease lasting only 5 to 10 minutes suggests angina pectoris without myocardial infarction (heart attack) while a similar pain lasting an hour or so is more
consistent with myocardial infarction. Similarly, migraine headaches typically
last from 1 to 12 hours in contrast to the more constant headaches of a brain
tumor or tension headaches.
Periodicity and Frequency of the Symptom

The pattern of symptoms can be diagnostically important. To illustrate, the
fever and chills of malaria occur at distinctive and sometimes diagnostic frequencies. Body cycles also can affect symptoms; for example, premenstrual

80

SMITH'S PATIENT-CENTERED INTERVIEWING

syndrome happens around menses and nocturnal myoclonus occurs during
non-rapid eye movement sleep. External influences can also have a cyclic
impact; regular stressful events such as work or the anniversary of a loss can
exacerbate migraine or depression, and allergic rhinitis and asthma can have
a seasonal association.

Course of the Symptom
You will want to learn the course of the symptom over an individual episode

Time

and its pattern of occurrence over a longer period. For instance, pain stemming from obstruction of a hollow organ progressively increases and then
subsides, often to complete relief, only to be followed at varying intervals by
recurrence of the same pattern. This course is often described as crampy or
colicky and is seen, for example, in biliary colic, ureteral colic, and labor. A
migraine headache, on the other hand, typically pursues a slow but progressive buildup of a constant throbbing pain.
The overall course of a symptom is equally important, as we will describe
more extensively in Chapter 5. A patient with headaches of 20 years duration that are unchanged will seldom have a brain tumor while a progressively
worsening headache over several weeks or months is more suggestive of a
tumor or other intracranial disease process.
You will usually obtain much of the chronology of a symptom in Step 4,
using open-ended patient-centered skills. If more detail is needed, you will
pursue it with mostly closed-ended questions as shown here:
Clinician: When did the burning in the stomach begin?
Patient: About a year ago. [Onset]
Clinician: Do you have pain every day?
Patient: No, sometimes it will be gone for weeks at a time. [Intervals
between symptom occurrences]
Clinician: And how long do they last each time?
Patient: Quite a whUe.
Clinician: How long is that? I need to understand your pain in detaU.
Patient: Oh, I don't know. Maybe a couple hours.
Clinician: What's the shortest they might last and the longest?
Patient: Well, some of them are gone in just a few minutes. But most are
about an hour I guess.
Clinician: What's the longest?
Patient: The worst one I ever had lasted from supper untU just before
bedtime, about 4 hours. [Longest and shortest duration of
symptom]
Clinician: What seems to determine that?

Chapter 4

SYMPTOM-DEFINING SKILLS

81.

Patient:

I don't know, but it's always worse in the Spring, and it's not
there on weekends when I'm not working. [Frequency and
periodicity]
Clinician: What happens to the pain over the course of each episode?
Patient: It just gradually comes on and then gets a little worse. [Shortterm course of symptom]
Clinician: Overall, how is the pain doing?
Patient: It seems worse to me.
Clinician: How's that?
Patient: Well, it's not more pain, but it's more often. It used to be just once
every day or so but now it's four or five times a day. [Overall
course of symptom]
Position of the Symptom and Its Radiation

Determine the precise locations of symptoms when possible. Both the location and area of radiation of the symptom can have diagnostic significance.
For example, generalized chest pain without radiation is nonspecific, but
chest pain located in the substernal area that radiates into the neck, jaw, and
left arm is suggestive of angina pectoris. Similarly, low back pain radiating
into the left buttock and posterior thigh and down into the lateral aspect of
the calf and over the dorsum of the foot into the great toe is highly suggestive
ofLS-S 1 nerve root impingement from a herniated lumbar disc. Ifthe patient
does not do so automatically, ask him/her to point to the area of discomfort.
Ask whether the pain is deep or on the surface, specific in location or more
diffuse. For example, a patient with headache who locates his pain over the
course of the left temporal artery and describes the pain as "on the surface" may
be suffering from temporal arteritis, rather than tension headache or migraines.
To locate the symptom and its radiation, begin with a focused, open-ended
request or question such as, "Can you describe or point to the location for
me?" If the patient does not provide a precise description, use closed-ended
inquiry to get sufficient specificity:

Clinician: So, as part of the blahs you've got this stomach pain. Can you
describe its location for me? [A focused open-ended request,
phrased as a question, to be followed by several closed-ended
questions.]
Patient: It's in my stomach.
Clinician: Where exactly is it? Point at it, if you can [Always be as specific
as possible.]
Patient: (points to upper mid-abdomen, the epigastrium)

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SMITH'S PATIENT-CENTERED INTERVIEWING

Clinician: How big an area? Can you draw a circle around it?
Patient: (draws an outline) This big.
Clinician: Does it move anywhere else, like your back or chest? [Giving
examples is helpful as long as the answer is not suggested.]
Patient: No.
Clinician: Is it deep down, or does it feel more like it's right on the surface?
Patient: Down inside.
Quality of the Symptom

You can often achieve additional diagnostic specificity from knowing what
the symptom feels like. A patient with burning chest pain may have gastroesophageal reflux, whereas tearing chest pain might be a symptom of a dissecting thoracic aortic aneurysm. Here are some other descriptors and the
diagnoses that are frequently associated with them: burning (gastritis or peptic ulcer when substernal or epigastric), crushing (acute coronary syndrome
when substernal), throbbing (migraine when in head, or localized infection
anywhere), burning, electrical, shooting, or numb (neuropathic pain), or
cramping (disorder of a hollow organ such as the ureter, intestine, or uterus).
Unusual descriptions can signify psychological problems or stress, and can
sometimes be understood metaphorically. 6 For example, psychotic people
have said such things as "it feels like my intestines have grown shut" or "it
feels like they left a surgical instrument in there." Similarly, comments like "it's
pushing up through my soul and tearing my heart out" are extraordinary and
suggest the presence of some associated psychological issues.
Learn the quality of the symptom by starting with a focused, open-ended
request such as, "Tell me what the pain is like." Use closed-ended inquiry as
necessary to pin down details:
Clinician: What does it feel like? [A focused open-ended request, again
phrased as a question]
Patient: Pretty bad.
Clinician: Well, how would you describe it: aching, sharp, dull? [It is
appropriate, if necessary, to give examples, as long as several
options are given without emphasizing any of them, so as not to
influence the patient.]
Patient: Kind of burning, like hot or on fire.
Quantify the Symptom

You will gain further precision and specificity for disease diagnosis by quantifying the symptom in the following ways.

Chapter 4

SYMPTOM-DEFINING SKILLS

83

Severity

You can obtain a measure of intensity or severity by asking for comparisons
to prior experiences (toothache, delivering a baby) or getting a rating on a 1
to 10 scale where 1 is no pain and a 10 rating is the worst pain ever. In general, the more severe the symptom, the more serious the problem; however,
a patient who animatedly describes his pain as a 10 while seeming at ease
may have a psychological problem, be opiate-seeking, or have learned that he
needs to amplify his symptom in order to get adequate pain relief. Less intense
pain does not signify an unimportant problem. Angina pectoris reflects serious disease but the pain is not always severe. In addition, certain pains are
characteristically more severe than others, for example, testicular injury, renal
calculus, and labor pains.
You can begin open-endedly with a question like, "Give me an idea how
bad it was," but closed-ended questions usually are necessary to get the needed
details:
Clinician: Tell me how severe it is.
Patient: Well, it wasn't too bad.
Clinician: On a 1 to 10 scale, where 10 is the worst ever, like surgery without anesthesia, how would you rate it?
Patient: Not so bad, really. I guess a 3.
Clinician: How is it compared to a toothache?
Patient: Not that bad.
Impairment or Disability Resulting from the Symptom

Another measure of severity is how the symptom has affected the patient on
a daily basis. For example, a minor episode of hoarseness could be a severe
hardship for an opera singer or public speaker while it might be ofless consequence to a writer or night watchman.
You should have learned this from the patient while eliciting the personal
context of the problem in the beginning of the interview, but if you did not,
you can begin here with a focused, open-ended question such as, "What effect
is this having on your day-to-day life?" Use closed-ended questions for detail.
Asking about what the patient is no longer able to do helps clarify the situation; for example, "Since the chest pain started, what have you had to give
up?'' Comparing the patient's daily activities before and after the symptom
further clarifies this. Many of these data will often have been obtained in the
beginning of the interview and, if so, they are not repeated:
Clinician: How's this affecting what you do?
Patient: Well, it's caused a lot of problems.

84

SMITH'S PATIENT-CENTERED INTERVIEWING

Clinician: Is it keeping you off work or anything? [A closed-ended question to get accurate details. The interviewer could also have tried
an open-ended request such as, "'Tell me about the problems."]
Patient: No, nothing like that really. I haven't missed a day of work. I'm
just getting tired of it and snapping at the wife at home. She's
getting sick of it.
Obtain Numerical Data Where Possible

You can usually identify or closely estimate the total number of occurrences of
the symptom; for example, there have been about 20 such episodes of chest pain
in the last week after no more than one weekly during the preceding year. It also
can be necessary to precisely quantify symptoms in other ways when applicable:
"It swells to the size of a softball at times but then goes back down to like a golf
ball" (inguinal hernia); "'Only passed about a glassful of urine all day" (renal
failure, urinary obstruction, dehydration). You will find that patients seldom
respond with precise numbers, preferring "quite a bit" or "not too much'' to
precise quantities. It is your job to find out details without alienating the patient.
You will obtain these data almost entirely by closed-ended inquiry. You will
often have to follow-up on answers that are not precise enough; for example,
upon being asked how many times a pain occurs, the patient answers "'A lot"
to which the clinician might respond, "'Can you be more specific, you know,
how many times in a day or week?"
Clinician: How many times a day do you have the pain?
Patient: A lot
Clinician: Can you be more specific, you know, how many times in a day?
Patient: Oh, three or four or five
Clinician: What's the most you've had?
Patient: Seven or eight times
Clinician: And the least?
Patient: One or even none sometimes
Related Symptoms

As you learn more clinical medicine, you will find that it is uncommon to
have only one symptom with an underlying disease. Rather, there often are
several specific symptoms and, in addition, there may be secondary symptoms reflecting the general impact of the disease; for instance, in a patient
with pneumonia, cough and chest pain are likely specific symptoms from
the pneumonia while fatigue and irritability are nonspecific symptoms due
to the general effect of the pneumonia on the body. Related symptoms (also
called associated symptoms) are important because different combinations

Chapter 4

SYMPTOM-DEFINING SKILLS

85

have diagnostic importance; for example, in a patient with weight loss, a good
appetite often suggests diabetes mellitus or hyperthyroidism while a poor
appetite might suggest infection, depression, or cancer.
Ask about associated symptoms by beginning in an open-ended manner, such
as "Tell me any other symptoms that go along with this:' Closed-ended questions usually are required, however, as you ask about the presence or absence of
symptoms that might be expected in association with the main symptom:
Clinician: Tell me any other symptoms that go with this burning pain.
Patient: Well, a little diarrhea when it's bad. [The clinician would fully
develop this new symptom and its descriptors, just as was done
for the epigastric burning pain.]
Clinician: Any other symptoms with it?
Patient: Not really.
Clinician: Any nausea? [After the patient gives no additional symptoms,
the clinician uses his/her knowledge of common associations to
make further specific inquiry, as expanded upon in Chapter 5.]
Setting

Here you move away from understanding the symptom itself to considering
external influences on the symptom that can have diagnostic significance.
Patients will usually describe the setting while describing their symptoms in
the beginning of the interview, or when you ask about the onset and chronology of the symptom in the middle of the interview. If this does not happen,
you can elicit the setting with questions such as, "Where were you?" or "Who
else was present?"' or "What exactly were you doing when you first noticed
it?"' or "Where was this?"'
As always, begin with an open-ended question like, ..Can you tell me the
background of the symptom, you know, what you were doing at the time and
who was there?" If this does not suffice, closed-ended inquiry can help:
Clinician: Can you give me some of the background for the pain, like who's
around and where you are when it happens?
Patient: Almost always at work-there's been a lot of stress lately.
Clinician: Not at home?
Patient: Never. Isn't that funny?
Clinician: Who's around at work?
Patient: Well, it's just since I transferred to the parts department. [If you
had not elicited this information while drawing out the personal context of the patient's symptom in the beginning of the
interview, you would further develop it here.]

88

SMITH'S PATIENT-CENTERED INTERVIEWING

Precipitating and Transforming Factors
Additional external influences on the symptom that can have diagnostic significance include what brings the symptom on, what aggravates it once present,
and what relieves it. For example, aspirin, alcohol, tobacco, spicy foods, and
caffeine all are known to precipitate and aggravate gastritis or gastroesophageal reflux disease, while relief is typically obtained by drinking milk, eating
bland food, and using antacids. Similarly, angina is brought on and aggravated
by exertion, mental or emotional stress, or cold air blowing in the face, while it
is relieved, usually in less than 10 minutes, by rest and the use of nitroglycerin.
Begin open-endedly, but most of this information is obtained through
closed-ended questioning, the specific content of which reflects your knowledge of individual diseases:
Clinician: Tell me about anything that seems to aggravate or bring these
pains on.
Patient: Well, coffee does sometimes.
Clinician: What about aspirin, does that cause it? [The clinician would
continue closed-endedly to ask about what s/he knows can
cause epigastric burning: other medications, tea, alcohol,
tobacco, spicy foods.]
Clinician: (continuing after completing the preceding inquiry) Have you
noticed anything that helps, you know that relieves it?
Patient: Eating almost anything, especially milk.
Clinician: What about antacids?
Patient: Yeah, they help a lot.
Often the patient is unable to describe transforming factors but can say
what s/he does (or avoids) during the symptoms, for example, walk about, lie
down, and quit eating.
Like a good journalist you want to understand all aspects of the patient's
story. Reporters use the memory aid "What? Why? When? How? Why? Who?"
Combining this aid with the descriptors of a symptom will ensure that you
obtain the full story. Also note that the answers to some of these questions are
usually offered by the patient during the beginning of the interview, as occurred
in the vignette of Ms. Jones. If so, there is no need to repeat them here.

•

SUMMARY

Use open- and closed-ended skills to establish a medical understanding of
the individual symptom and then to refine it using the seven descriptors
to enhance its diagnostic specificity. Remember, individual symptoms are

SKILLS EXERCISES
1. Each member of the group reads about a
specific disease in a standard textbook7 with
pain as a major symptom; for example, low
back pain in sciatica, headache in migraine,
flank pain in renal colic, chest pain in angina
pectoris, abdominal pain in intestinal obstruction, and headache in temporal arteritis.

2. This member then acts as the "patient" in
a role-play and portrays the pain problem
sjhe just read about to another group member who elicits the descriptors of pain.
3. Elicit the symptoms and their descriptors
from a real or simulated patient.

REFERENCES
1. Kipling R. Just So Stories. Garden City, NY: Doubleday, Doran and Company; 1907.

2. Barrows HS, Pickell GC. Developing Clinical Problem-Solving Skills-A Guide to More
Effective Diagnosis and Treatment. New York, NY: Norton Medical Books; 1991:226.
3. Platt FW. Conversation Failure: Case Studies in Doctor-Patient Communication. Tacoma,
WA: Life Sciences Press; 1992:183.
4. Sandler RS, Drossman DA. Bowel habits in young adults not seeking health care. Dig Dis
Sci. 1987;32:841-845.
5. Bickley LS. Bates' Guide to Physical Examination and History Taking. 12th ed. Philadelphia, PA: Wolters Kluwer; 2017.
6. Melzack R. Pain Measurement and Assessment. New York, NY: Raven Press; 1983:293.

7. Longo DL, Fauci AS, Kasper DL, et al., eds. Harrison's Principles of Internal Medicine.
18th ed. New York, NY: McGraw-Hill; 2011.

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The Middle of the
Interview: ClinicianCentered Interviewing
Give each patient enough of your time. Sit down; listen; ask thoughtful questions; examine carefully. ... Be appropriately critical ofwhat you read or hear. ...
Follow the example set by William Osler: "Do the kind thing and do it first."
Paul Beeson, MD
This chapter describes the steps involved in conducting the middle of the
interview using clinician-centered interviewing skills. This part of the interview includes the latter part of the history of the present illness (HPI) and
other active problems (OAP), continuing directly from the patient-centered
HPI, and the past medical history (PMH), social history (SH), family history
(FH), and review of systems (ROS).
Recall our progress to this point. During the beginning of the interview
you used patient-centered interviewing skills to begin eliciting the HPI
(Steps 1-5): you set the stage; obtained the chief concern and agenda; drew
out the symptom story, personal context, and emotional context; responded
with empathy, and made a transition to the middle of the interview, the point
where we now find ourselves. There are five additional steps (Steps 6-10) in
the middle of the interview, as shown in Fig. 5-l. To illustrate each step, we
will continue to follow Ms. Jones .
•

COMPLETE A CHRONOLOGICAL DESCRIPTION OF
THE PATIENT'S CHIEF CONCERN AND OTHER ACTIVE
PROBLEMS-STEP 6

Step 6 (Table 5-l) is the most important and most challenging part of the middle of the interview. By the end of this step, you often will be able to make a disease diagnosis or, if not, you can greatly narrow the range of possible disease

89

90

SMITH'S PATIENT-CENTERED INTERVIEWING

Integrated Medical Interviewing
BegIn n In g
Set

Set

the

the
Stage Agenda

{PatientCentered
Skills)

9911nlclan-cente9
9
Middle
Skills)

Patient-

Physical
Exam

End

ered

Steps: 1,

2,

Components: [CC,

3,4,5,
HPI ----

6,
7,
8, 9, 10,
-- HPI/OAP, PMH, SH, FH, ROS]

Middle: Clinician-Centered=
Symptom and
Psychosocial Data

Beginning: Patient-Centered =
Psychosocial and
Symptom Data

'

11

Clinician
Synthesizes

/

BIOPSYCHOSOCIAL STORY

FIGURE 5-.1. Tbe Integrated medical Interview.

explanations for the symptom(s). This will guide your physical examination
and the subsequent laboratory evaluation, if any. The companion video tided
"Clinician-Centered Interviewing: An Evidence-Based Approach; available
on the McGraw-Hill website (www.accessmedicine.com/SmithsPCI) demonstrates what we will now describe. Module 8 in DocCom provides additional
information about developing and clarifying the patient's HPI. 1
In almost all instances, you will have obtained a satisfactory overview of
the HPI during Steps 2 to 4 but sometimes the patient's description of the
personal or emotional context of the symptom was urgent enough that you
will not have gotten a good symptom description in Step 4. If this is the case,
you can begin Step 6 by obtaining an overview of the major symptoms, when
they began, and the most pressing current issue, using both open- and closedended skills.
Otherwise, as presented in Chapter 4, begin by converting each of the
patient's concerns to a standard symptom and further clarify it according to
the descriptors (OPPQQRRST: onset and chronology, position, precipitating factors, quality, quantification, radiation, related symptoms, setting, and
transforming factors [aggravating/alleviating]). You will also need to know
what other symptoms occurred before, during, or after the symptom under
discussion.

• TABLE 5-1. Continuing the HPijOAP
Step 6-Complete a Chronological Description of the Patient's Chief Concern and
Other Active Problems
1. Obtaining and describing data without interpreting it
A. Expand the description of symptoms already introduced by the patient
B. Describe symptoms not yet introduced in the already identified body system
(and general health symptoms)
2. Interpreting data while obtaining it: Testing hypotheses about the possible
diseases causing symptoms8
C. Describe relevant symptoms outside the body system involved in the HPI
D. Inquire about the presence or absence of relevant non-symptom data
(secondary data) not yet introduced by the patient
3. Understand the patient's perspective
Impact (meaning) of illness on self/others
Health beliefs
Triggers for seeking care
•only clinical-level students are expected to be proficient with this style of inquiry.

As you talk with patients, you may begin to have ideas about what is causing the patient's problems, and how the symptoms may be affecting physical
functioning or activities of daily life. These ideas are known as "hypotheses"
and the process of asking questions that make them more or less likely is
called hypothesis testing. When you first learn how to interview patients, you
may not have sufficient medical knowledge to test hypotheses, but you can
still conduct an effective interview. Focus on first collecting as much data as
you need to comprehensively describe the patient's problem(s). Beginners
often need to postpone hypothesis testing to a second interview after they
have had time to read about the problems that have been described. 2- 4 As you
become experienced and learn more about specific diseases and conditions,
you will become faster, more efficient, and more accurate at gathering data
and will learn to recognize patterns in the patient's story that suggest certain
diagnoses. 5 Chest pain, for example, has well over 20 possible disease causes,
such as, angina pectoris, myocardial infarction, pericarditis, esophagitis,
pneumonia, pleurisy, pulmonary embolus, costochondritis, and rib fracture.
Each diagnosis has unique symptom and other diagnostic features and, often,
different related symptom patterns. In the meantime, just ask the questions
that will help you to comprehensively describe the patient's symptoms.
As a beginning clinician, you can still test hypotheses during the interview
but comprehensive questioning gives you data from which you can generate

92

SMITH'S PATIENT-CENTERED INTERVIEWING

better and more hypotheses.2 Comprehensively question only in relevant
areas, do not ask the same questions of every patient, and do not simply elicit
all known symptoms from the entire ROS.2 As you acquire clinical experience and your knowledge base grows, you will use more hypothesis testing
and comprehensive questioning will be less necessary. Nevertheless, even seasoned clinicians use comprehensive questioning in challenging cases when
hypothesis testing is ineffective.2
Beginning clinicians can generate a surprisingly relevant data base with
the comprehensive questioning approach. We will explore this in more depth
next and then briefly consider how the more advanced clinician integrates the
hypothesis-testing approach.
Obtaining and Describing Data Without Interpreting
It-For Beginning Clinicians

Both beginning and advanced clinicians should begin Step 6 with: A-expand
the description of symptoms already introduced by the patient, and Binquire about symptoms located in the same body system that have not yet
introduced.
A: Expand the Description of Symptoms Already Introduced by the Patient

Begin with the patient's most important problem and identify all symptoms
and secondary data starting from the onset of the concern. (Recall from
Chapter 4 that secondary data are any non-symptom information, such as,
tests the patient has had or medications s/he has taken.) Group the concerns
by common times of occurrence, translate each into a symptom, and then
refme each symptom using the "OPPQQRRST" descriptors (see Chapter 4).
Make use of repeated queries for temporal connections such as, "Then what?~
"What happened after that?~ or "And then?" The patient sometimes will not
introduce secondary data and so you must ask about prior treatment, procedures, diagnoses, and other secondary information (see Step 6D, below).
Alternatively, the patient may present a host of secondary data from which
you must sift out the symptoms. For example, a patient might say, "This chest
pain and shortness of breath occurred before my heart catheterization but
after they found my cholesterol and blood sugar were high; that was when I
was in the hospital last October for coughing up blood:' Here, the clinician
must recognize the primary data (chest pain, shortness of breath, and hemoptysis) and not confuse them with the secondary data (heart catheterization,
elevated cholesterol and blood sugar, hospitalization).
Seek to understand the temporal (time) course of all data, using calendar
dates and exact times when possible, and always for recent or acute problems.
More remote problems often can be marked by weeks, months, or even years.

Chapter 5

THE MIDDLE OF THE INTERVIEW: CLINICIAN-CENTERED INTERVIEWING

93

As you will see in the next vignette, the clinician uses closed-ended questions to elicit most information and offers periodic supportive remarks, maintaining a patient-centered atmosphere of warmth and understanding.
Continuation of Ms. Jones VIsit (From Chapter 3, p. 64)
Clinician: If it's OK then, !'a like to shift gears and ask you some different
types of questions about your headaches and colitis. I'll be asking a lot more questions about specifics.
Patient: Sure, that's what I came in for.
Clinician: I know the headache is the biggest problem now (chief concern).
[The clinician will now elicit the descriptors of the symptom,
recognizing that some were heard in Steps 3 and 4. If, however,
the clinician somehow had not yet heard about the headache
and other physical problems (because the patient expressed a
pressing personal concern in the beginning of the interview),
he would first obtain a detailed description in the patient's own
words.]
Patient: Yeah, it sure is.
Clinician: When exactly did it begin? [The interviewer wants to reaffirm the time frame of the headaches and uses a closed-ended
question.]
Patient: Oh, just a few weeks after I got here. That's about 4 months
ago now, so the headaches have been about 3 months. [Time of
onset]
Clinician: How long does each headache last, the shortest and the longest
they might last?
Patient: At least a couple hours. When they get bad, they'll last up to 12
hours or so. [Further characterizing the onset and chronology
by identifying the duration]
Clinician: What happens to the symptom when it's there?
Patient: Well, it's not so bad at first but it just keeps getting worse and
then the nausea comes. [Time course of symptom]
Clinician: How many do you have in a week or a month?
Patient: I can have 2 to 3 a week when they're bad. You know, every 2 to
3 days. [Symptom periodicity and frequency]
Clinician: How long have they been that often?
Patient: Since things got bad in the last month, especially the last couple
of weeks. Before that they were only once or twice a week. [Total
number can be calculated if important]
Clinician: You said the headache was in the right temple; can you point to it
for me? [Having gotten a good story ofthe onset and chronology,

94

SMITH'S PATIENT-CENTERED INTERVIEWING

the interviewer shifts to understanding the position (location),
referring to the patient's description of the headache location in
the beginning of the interview.]
Patient: (puts hand over much of right side of head) It's all over here,
sometimes larger than others. [Sounds more diffuse than specifically in one location]
Clinician: Is it always in the same spot? [The clinician asks a dosed-ended
question, focusing away from the personal dimension and on
the symptom itself, now getting the precise position.]
Patient: Yes.
Clinician: Does it move any place else? [Another of what will be many
closed-ended questions as the clinician asks about radiation,
another descriptor of the symptom. Note that the clinician is
introducing new topics and is also leading the conversation,
appropriate for the middle of the interview.]
Patient: No, it stays right there. [No radiation]
Clinician: Does it feel like it's inside your head or outside on the surface;
you know, does it hurt to comb your hair or touch it?
Patient: No, it doesn't hurt to touch it. It's down inside I think. [A deep
rather than superficial pain]
Clinician: Could you give me a description of what it feels like; such as
aching, burning, or however you'd describe it. [It's appropriate
to give examples, if necessary, but provide more than one, with
no particular emphasis, so as not to influence the patient.]
Patient: Oh, it's more throbbing or pounding, like you feel each pulse
beat. [Quality of the pain identified, and the patient offers no
bizarre description]
Clinician: How do they begin, gradually or all of a sudden~
Patient: Oh, pretty much out of the blue. [Onset is sudden]
Clinician: Now I want to get an idea of how severe these headaches are. On
a scale of 1 to 10, with 1 being no pain and 10 being the worst
pain you can imagine, like labor pains, what number would you
give these headaches?
Patient: Well, they're sometimes worse than having a baby! I'd give them
a 10, especially when they get bad. And I've missed work a few
days but not very often. [Quantifying the intensity and noting
some disability]
Clinician: They sound pretty bad. You've really had a lot of trouble with
this! [A respect statement. Empathic comments and behaviors
are used during the middle of the interview.]
Patient: You're telling me!

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Clinician: Do you know of anything that brings them on? [The clinician
asks about precipitating factors. He is not inquiring about the
setting because he already knows that from the beginning of the
interview.]
Patient: Well, just what I've told you, getting upset. Once or twice it
seemed like having some wine did it but I was stressed then too.
[Perhaps another precipitant]
Clinician: Anything that worsens them once they've begun?
Patient: No, they're bad enough already! Well, bright lights sure do,
now that I think about it. [A transforming (aggravating) factor
identified]
Clinician: They sure have been bad. What seems to help them once they
occur?
Patient: Just lying down in a dark room, and an ice bag on my head. Well,
the narcotic shot they gave me in the emergency room took it
away too. [Another transforming (relieving) factor elicited. Also,
secondary data, the narcotic and the emergency room visit, are
introduced by the patient.]
Clinician: What about the nausea? When did it start? [With a full description of the headache symptom, the clinician is moving now to
better define a related symptom, staying with primary data for
the moment. Notice that a non-pain symptom has fewer appropriate descriptors; for example, one usually does not try to identify location or radiation of nausea.]
Patient: I've had it for about 2 months now, just when the headaches are
bad.
Clinician: Help me understand better what the nausea is like. [A focused
open-ended request]
Patient: Like I'm sick to my stomach and could vomit if it got worse.
[Quality of nausea]
Clinician: And how does it begin? [A closed-ended question, as many of
the subsequent inquiries will be]
Patient: Oh, it just kind of gradually comes on after the pain has been
there awhile. [Gradual Onset]
Clinician: How bad is it, how severe?
Patient: It's minor compared to the pain. It's never really been the problem the pain is. [Not very severe or disabling]
Clinician: How often does the nausea occur?
Patient: Just when the pain gets bad. I've probably had it each time with
the headache in the last month; that's when the pain has been
worse. [Number of episodes identified]

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Clinician: You said this began about a month after the pain, so that means
the nausea has been there about 2 months? [Ms. Jones has previously indicated the time of Onset]
Patient: Yeah, but it's been worse in the last month.
Clinician: How long does the nausea last once it begins?
Patient: Oh, about a couple hours, when the headache finally goes away.
[Duration of nausea and Transforming (relieving) factor]
Clinician: Anything else that relieves id
Patient: Not that I know. I tried some antacid but it made me worse.
[Other Transforming (aggravating and relieving) factors
explored. Secondary data also introduced (antacid).]
Clinician: And what's the time between each episode?
Patient: Same as the headaches, you know, every couple of days.
[Intervals identified. Chronology of symptom and setting also
can be inferred from what Ms. Jones has said already since the
nausea is linked to headaches.]
Clinician: Ever throw up with them?
Patient: Just once. That's when I went to emergency. [Related symptom]
Clinician: How much did you vomit?
Patient: Oh, just enough to soak a hankie. [The clinician has obtained
pertinent descriptions of the nausea and now has discovered
another symptom, vomiting, which would now be similarly
explored. It can take considerable time to obtain appropriate
details of each symptom for complicated patients.]
Clinician/ [Not recounted here, the clinician and patient now develop
Patient: details of the patient's vomiting and cough. As you gain experience, you will recognize that the headache, nausea, and vomiting
go together. This allows you to develop the symptoms simultaneously and avoid repetition.]
Clinician: It sounds like you went to the emergency room once when it
was bad. What's been the time course of the headaches and nausea; you know, better, worse, or about the same?
Patient: They are getting worse. They last longer and are more often in the
last 2 weeks. [The overall course of the primary data is learned.]
Clinician: Have you seen anyone for them? [A good description of symptoms and their course to the present has been obtained. and the
clinician is beginning to move away from symptoms to associated secondary data.]
Patient: Nobody, except the emergency room a week ago. I thought the
aspirin would help.
Clinician: Have you taken anything else?

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Patient: Nothing except that one shot; a narcotic of some sort I think.
Clinician: Did they do any tests on you in the emergency room?
Patient: Yeah, they did a blood count and a urine test.
Clinician: Any scans or any X-rays ofyour head? [Recent inquiry is aimed

Patient:

at understanding pertinent secondary data. Notice the repeated
use of closed-ended questions to obtain a more precise description of the symptoms.]
No.

B: Inquire about Symptoms Located In the Same Body System(s) Not Yet
Introduced (and General Health Symptoms)

Until this point, the clinician has addressed symptoms (and related secondary
data) volunteered by the patient but there often are other symptoms ("related
symptoms" from Chapter 4) that have not been mentioned, which either by
their presence or absence are pertinent to making a diagnosis; the absence of
a symptom can be just as diagnostically important as its presence. The clinician thus needs to develop a more complete profile ofthe patient's problem(s).
You can often assume that symptoms in the same system are related to the
same underlying disease process. You know what the patient's major concerns
are and can therefore identify the body system likely involved if disease is
present. At this point, ask the questions from the ROS under the involved
system heading; for example, a patient with urinary hesitancy and increased
urinary frequency usually (but not always) has a disease in the urinary system
and so you would use closed-ended questions to inquire about the symptoms
under that heading in the ROS (dysuria, nocturia, urgency, hematuria, particulate matter in the urine, and so on until you comprehensively questioned
about all possible symptoms under the urinary system heading of the ROS).
At times, however, a symptom can suggest more than one system as a source
of disease; for example, shoulder pain can indicate disease in the musculoskeletal system (rotator cuff injury), gastrointestinal system (cholecystitis), or
the cardiopulmonary system (angina). In this case, you would inquire about
all possible musculoskeletal, cardiopulmonary, and gastrointestinal symptoms Qoint swelling, hemoptysis, orthopnea, vomiting, diarrhea, and so on).
Questioning in this way often uncovers symptoms the patient may have
forgotten or not thought important, and can at times provide crucial diagnostic information; for example, in the preceding patient with urinary concerns, discovering the periodic presence of particulate matter in the urine in
association with bloody urine suggests renal calculi. Frequently; however, the
patient will deny most symptoms on the list, this is also diagnostically important; for example, the absence of gross hematuria in this patient would weigh
against renal calculi as well as some bladder or renal diseases.

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Inquiring about symptoms under the General heading of the ROS fills out
the symptom profile. In most patients, ask about appetite, weight, general
feeling of well-being, pain, and fever, regardless of the system their symptoms reside in. Many diseases, especially more serious ones, exhibit one or
more of these general symptoms. In our vignette, the clinician relies predominantly on closed-ended questions, and continues to intersperse supportive remarks.
Continuation of Ms. Jones VIsit

Clinician: Any other symptoms you might have had? [A focused, openended request, phrased as a question.]
Patient: Well, nothing that I think of.
Clinician: Ever had problems with dizziness or lightheadedness? [Because
the patient's major symptom, headaches, is a neuropsychiatric
system symptom, the clinician is beginning to dosed-endedly
inquire about other possible neurological symptoms in the neuropsychiatric system as well as relevant neurological symptoms
listed primarily in head, neck, eyes, ears, nose, and throat.]
Patient: Not now. I used to get carsick as a kid and did a couple times
then.
Clinician: Ever had a fainting spell?
Patient: No.
Clinician: Stiff neck?
Patient: No.
Clinician: Any problems with your vision?
Patient: No. I don't even use glasses.
Clinician: Any double vision?
Patient: No.
Clinician: Difficulty hearing?
Patient: No.
Clinician: Ringing in your ears?
Patient: No.
Clinician: Any change in your sense of taste or smell?
Patient: No.
Clinician: Any face pain?
Patient: No. [The clinician would continue exploring all remaining
symptoms in the above systems of the ROS: facial paralysis;
difficulty swallowing or with speech; difficulty elevating the
shoulders; muscle weakness or movement difficulty; extremity
numbness, tingling, decreased sensation, or paralysis; the shakes
or tremor; difficulty with balance or walking; and seizures.]

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Clinician: Besides the nausea and vomiting once, have you had any other
problems in your stomach or digestion? [A focused, openended question starts a new area of inquiry. The clinician will
now obtain a complete profile of the patient's other major symptom, nausea.]
Patient: There haven't been any.
Clinician: [Even though the patient indicates none was present, the clinician would now use closed-ended questions to go through the
symptoms in the gastrointestinal system not already addressed:
appetite, weight, heartburn, abdominal pain, vomiting blood
(hematernesis), bloody or black stools, constipation or diarrhea,
dark urine or jaundice, and rectal pain or excessive gas. The
clinician then shifts to general symptoms.]
Clinician: You've told me a lot already about this, but how've you been
feeling in general? [A focused open-ended question introduces
a new area of inquiry, her general health. Information about
appetite and weight will already have been obtained during the
above inquiry about gastrointestinal symptoms.]
Patient: Great, except all these things.
Clinician: You've sure been through a lot. Any problem with fevers? Chills?
Night sweats? Change in appetite? [The clinician continues to
make empathic comments and asks some closed-ended questions about general health.]
Patient: No. [Therefore, there is no problem with general health symptoms of fever, chills, appetite, or weight. Not included here, the
clinician completes the general health questions from the ROS.]

With experience, you will base the extent of this ROS upon clinical acumen,
and it almost always can be considerably shortened; for example, an experienced clinician might be seriously considering a diagnosis of migraine and
inquire only about "Have you ever had a stroke? Head injury? Recent fevers?,
For beginning clinicians, however, systematically going through all the possibilities is the best way to learn them.
Interpreting Data while Obtaining It: Testing Hypotheses about
the Possible Disease Meaning of Symptoms-For More Advanced
Clinicians

From the gathering/describing technique described above, you now have a
complete profile and chronology of symptoms. But, you have not interpreted
or grouped them in a way that points to specific diseases that could cause them.
Just recounting symptoms usually does not identify a disease. Nor have you

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SMITH'S PATIENT-CENTERED INTERVIEWING

accounted for potentially significant symptoms in other systems. Inquiring
about all symptoms outside the involved system is not feasible, would take too
long, is intellectually unsound, and is boring. 2
After completing parts A and B of Step 6, more advanced clinicians should
therefore add two additional parts: C-ask about relevant symptoms outside
the body system involved in the HPI, and D-inquire about the presence or
absence of relevant non-symptom data (secondary data) not yet introduced
by the patient, before concluding with the third part, understand the patient's
perspective.
C: Ask about Relevant Symptoms Outside the Body S)stem Involved
In the HPI

Ask about symptoms outside the involved body system if they are pertinent
to a diagnosis you are considering. For example, in a patient with advanced
rheumatoid arthritis who is feeling fatigued, asking about gastrointestinal
bleeding symptoms ("any black stools?"), while outside the musculoskeletal
system, is still warranted if you suspect that gastrointestinal bleeding due to
nonsteroidal anti-inflammatory drug (NSAID) therapy is causing the fatigue.
In patients with more than one problem, you will need to inquire in multiple
systems during the HPI.
D: Inquire about the Presence or Absence of Relevant Non-Symptom Data
(Secondary Data) Not Yet Introduced by the Patient

It is important to know about any medications taken to relieve the symptom,
diagnoses given for the symptom in the past, prior treatments, and clinician
visits or hospital stays for the symptom. This is especially true for complementary and alternative medicine treatments. Research shows that patients,
as a rule, will not volunteer information about complementary and alternative treatments, therefore you must ask specifically and concretely about their
use and do so in a nonjudgmental way.6 Also, asking relevant questions about
possible etiological explanations for the diagnoses being entertained may
help narrow the differential diagnosis. For example, if pulmonary embolism
is a concern, ask about recent long car rides or air travel; if lung cancer is a
hypothesis, ask about cigarette smoking.
How do you test hypotheses during the interview? Based on unique
symptom(s) characteristics and secondary data suggesting one diagnosis
over the others, and based on knowledge of what diseases are most common, you rank-order disease possibilities in your mind starting from the
opening moments of the interview.z,s,7 Then, as noted earlier, seek additional
diagnostic data (primary and secondary) to support the current best choice,
almost always via extensive closed-ended questioning. If complete data have
already been obtained descriptively, the new data will be largely outside the

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1.01.

involved system. If not supported, another disease hypothesis becomes the
best choice ("next best choice") to explain the symptom(s) and you will similarly explore it. By following this process of testing multiple, ever-changing
best hypotheses, you will eventually arrive at the best diagnostic possibility,
the "current best hypothesis"-which is the best fit of our patient's primary
data (and secondary, if available) with a known disease.
It is common to start with one disease hypothesis (angina) and, based on
symptom descriptors and associated symptoms, end with a quite different one
(esophagitis). For example, because of substernal chest pain radiating into
the arms, the clinician's first hypothesis was angina. But, s/he knew esophagitis also was a possible cause of chest pain radiating to the arms and asked
about descriptors and other symptoms associated with this diagnosis and they
were present (precipitation of pain by coffee or recumbence, relief by belching and antacids, poor appetite) and other descriptors expected with angina
were not present (no relationship of pain to exertion, no dyspnea. or diaphoresis). When a hypothesis is well supported, it greatly enhances the probability
that the corresponding diagnosis is present. A diagnosis can often be inferred
from the history alone (e.g., angina) but sometimes additional data from the
physical examination (e.g., elevated jugular venous pressure for a diagnosis of
congestive heart failure) or the laboratory (e.g., low hemoglobin for a diagnosis of anemia) are needed before you can establish a diagnosis.2
The more knowledge and experience you gain the more facUe and efficient
you will become in formulating the diagnosis and knowing the proper questions to ask in real time rather than in a subsequent interview. Nevertheless,
virtually all beginning clinicians will find themselves fully synthesizing the
diagnosis only after completing the interview, reading about the problem,
talking again with the patient to clarify issues they overlooked, and discussing
the problem with faculty and more senior team members. Although this vast
topic of clinical diagnosis8 is outside the scope of this text, and you will study
this material extensively during your clinical years of training, the process of
clinical problem solving is illustrated in Table 5-2. The table shows how clinicians test hypotheses whUe obtaining the HPI.

Continuation of Ms. Jones VIsit
Clinician: Ever had problems with swelling or pains in your joints? [The

Patient:

clinician has the hypothesis that vasculitis might be causing
headache and knows that this diagnosis is sometimes associated with arthritis. He is thus using closed-ended questions to
inquire about specific primary data outside the system involved
to support this hypothesis.]
No.

• TABLE 5-2. An Example of Clinical Problem Solving
Clinicians proceed, much as Sherlock Holmes? by first obtaining a few bits of presenting data (e.g., nonradiating chest pain, fever, acute shortness of breath, and a swollen left leg in a 70-year-old man) with which
to generate the current best hypothesis (e.g., pulmonary embolus) and then ask specific questions (e.g.,
whether the patient has had hemoptysis) that would further support or detract from this hypothesis. 2 •7 •5 In
this example, the clinician asks about hemoptysis, previously unmentioned by the patient, because her or
his first hypothesis was pulmonary embolus and this symptom is pertinent to its diagnosis. Let us say that
hemoptysis was not present but the clinician pursued the hypothesis further by inquiring if the leg swelling
was recent or if there had been any long trips or immobility of the leg recently, common findings of some
diagnostic value in pulmonary embolism. We'll suppose that symptoms began following a 12-hour car ride
just 3 days ago and the clinician became more confident of pulmonary embolus as a possible diagnosis.
Even though the diagnosis may be likely, the clinician tests alternative hypotheses-other diseases likely to
be causing this patient's chest pain. For example, the advanced clinician also would consider questions
supporting myocardial infarction (substernal location of pain, crushing or squeezing pain, diaphoresis),
pneumonia (productive cough, chills), rib fracture (injury), pericarditis (pain relieved by sitting up and leaning
forward, and aggravated by lying supine), lung cancer (weight loss, cigarette, or asbestos exposure), and a
host of other possibilities as long as they reflected reasonable possible causes of the patient's chest pain
and other symptoms. Notice that none of these symptoms had been mentioned previously by the patient,
that the clinician introduced them with close-ended questions, that if left to a simple comprehensive questioning/descriptive approach and subsequent routine inquiry many would have been completely dissociated
from the HPI (a history of chest trauma is usually asked about in the PMH and cigarette use is asked about
in the SH), and that some may never have arisen without such hypothesis-driven inquiry (relief of pain by sitting up is not a routine question).
The clinician in this case would of course proceed to obtain a complete history and physical examination
and appropriate laboratory and imaging data to clarify her or his hypotheses and, hopefully, establish a
diagnosis.

Clinician: Ever had any dancing or bright, shimmering lights in your

vision for a few minutes before the headache starts? [The clinician has learned that this symptom (scintillating scotomata) is
of diagnostic value in migraine and is properly inquiring specifically about it to build support for the hypothesis of migraine
headaches.]
Patient: No.
Clinician: Because these could be what we call vascular headaches, you

know, like migraines, I want to ask you some specifics about
that. Do you use birth control pills or other hormones? [The
clinician is beginning to formulate diagnostic hypotheses about
what has caused the headaches. He suspects migraine from the
clinical story and his knowledge of headaches. Accordingly, it
is appropriate to obtain additional supporting diagnostic data
and, hence, the question about birth control pills, as these can

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1.03

cause migraine headaches in some women. In addition, because
head injuries also can cause headaches, the clinician will ask
about that as an alternative hypothesis. Indeed, any possible
causes that have been entertained could be further addressed in
this way; for example, if the clinician were suspicious of meningitis from the story, perhaps because of intermittent fever and
stiff neck, additional questions to support or refute that hypothesis would be in order: any rashes, sick contacts, or other exposure, and whatever else the clinician considered important in
supporting a diagnosis of meningitis.]
Patient: Yeah, I've been on them for the last 6 years. [The clinician
would pursue the type, doses, and experience with this later in
thePMH.]
Clinician: Any family history of migraine? [Because this clinician knows
that a positive family history supports the hypothesis of
migraine, he includes these questions here rather than in the
family history.]
Patient: One of my aunts had what they called sick headaches when she
was young but they all cleared up when she got a lot older.
Clinician: By the way, have you ever had any head injuries? [The clinician
is testing another non-migraine hypothesis for the headache.]
Patient: No.
Clinician: Have you ever been unconscious for any reason?
Patient: No.
Clinician: Any neck injuries or problems there? [Neck problems also can
cause headaches and the clinician is exploring this hypothesis.]
Patient: Nope.

Understand the Patient's Perspective
By this point, you have elicited a detailed description of the patient's
symptom(s), performed a targeted ROS and, if you are an intermediate or
advanced clinician, sought symptoms in relevant body systems and obtained
pertinent non-symptom (secondary) data. Nevertheless, the patient's history
of present illness is not complete until you have a good understanding of the
patient's perspective on his/her illness. This is key to making an accurate diagnosis and being of the most help to the patient. Much of this information
may have been elicited during Steps 3 and 4, particularly if you used indirect
emotion-seeking skills in Step 4. The patient may also have related some of
this data while answering your questions thus far in Step 6. Ask about each of
the remaining areas now.

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Impact (Meanl~ of Illness on Self/Othets

Ask, "How is this symptom affecting your life/work?'~ "How has it impacted
your family/spouse/coworkers?" [How an illness affects the patient and his
or her family is important psychosocial information and it can have practical
implications, for example, need for home services.]
Health Beliefs (See Also DocCom Module

J9)

Ask about the patient's "explanatory model" of illness, "What do you believe
is causing your (symptom)?" because it is critical to understanding how the
symptom is affecting the patient and what is important to her or him10; it
can also give you an opportunity to correct misconceptions and address
fears with an empathic response. It is useful to normalize this question by
saying something like, "Many patients already have ideas about what's causing their problems so I ask this question of everyone. It really helps me help
them." Occasionally, in eliciting a patient's belief or attribution s/he will say,
"You're the clinician, you tell me!" Don't get flustered by this response. Calmly
explain, "I find that it helps to share each of our perspectives so that we can
come up with the best treatment plan for you:' Ifthe patient persists in saying
that you're the clinician and it's your job, you can switch to a more cliniciancentered interviewing style, having learned about a strong patient preference
at the same time.
Trlggets for Seeking care

Another indirect emotion-seeking skill which, if not asked about in Step 4,
should be elicited here is to understand the reason(s) why the patient came at
this time: "What made you decide to see me today for this (symptom)?" This
often provides a window on the patient's personal life, important relationships, and health beliefs (e.g., a coworker with similar symptoms is recently
told of a serious diagnosis, or a worried spouse insists that the patient seek
care). Asking, "What else is going on in your life?" can uncover interpersonal
crises or other sources of distress that can cause or amplify symptoms. 11
In the case of Ms. Jones, we learned in Steps 3 and 4 that her headache is
related to her work and a bit about the impact on her relationship with her
husband. The clinician now asks several questions to learn more about her
perspective:
Continuation of Ms. Jones VIsit

Clinician: You mentioned that troubles with your boss might be causing
your headaches. How has all this affected you and your family's
lives? [Open-ended inquiry about the impact of the headaches
on her and others' lives. This question could have been asked in

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1.05

Step 4 (Chapter 3) as a way to "prime the pump" for personal
context and as an indirect emotion-seeking skill if the patient
had not spontaneously mentioned the personal context of her
symptom story. Clinician-centered skills allow the clinician to
take the lead like this to obtain necessary details about personal
data.]
Patient: It's been very disruptive. We were always quite happy and
enjoyed things together. Even our love life has suffered.
Clinician: Say more about that.
Patient: For the past 3 months I just haven't been in the mood much. We
used to make love a few times a week, now it seems like once
every few weeks, and now the kids seem to get on my nerves all
the time too. Things need to get settled down. The job; not just
the headaches. I'm not sure I'll stay in this job if things don't
change.
Clinician: It's been a difficult time. I do think we can help with the headaches, but I don't know about your boss. [Interspersing a
patient-centered intervention, here with naming and supporting statements, continues to be important. The clinician could
pursue her sexual issues here, but there is also the opportunity
to do so during the social history.]
Patient: He's supposed to retire in 6 months. If the headache comes
around, I can make it that long.
Clinician: I know you think the headaches are from your boss, but any
other ideas about why you might be getting them? [The clinician is leading and shifting away from her boss and probing for
any other beliefs about why she is ill.]
Patient: Well, I'm not really sure. At first, I thought it was just because of
my boss but they have lasted a long time now, are more frequent
and are getting worse.
Clinician: Go on.
Patient: I know it sounds silly but the past couple of days I've been worried that I might have a brain tumor or something.
Clinician: I can appreciate why that thought would worry you. Thanks for
sharing your concern. It really helps to know about it. We still
have a lot of data to gather before coming to any conclusion
but nothing you've told me so far makes me concerned about
a brain tumor. I will keep your concern in mind and keep you
as informed and up to date as possible. [The clinician offers
respect and support.]

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Patient: It's a relief to know and it somehow feels less scary.
Clinician: Good. Any other thoughts about what might be causing the
headaches?
Patient: Only punishment! I was raised with that always there.
[Depending on the amount oftime available, the clinician could
use patient-centered interviewing skills and explore this, allowing Ms. Jones' ideas to lead. On the other hand, it is not current
and she is exhibiting no distress so that it also can comfortably
be left until another time as the clinician does here. If it seemed
relevant, the clinician could pursue any triggers for making the
appointment now, but he seems to have gotten a good idea of
her perspective on this illness.]
Clinician: That's an important piece of information that I'll want to come
back to later or the next time I see you. Right now, I need to ask
you some other questions about your colitis, cough, and your
past health issues, if you feel finished talking about the headache. Anything else we need to cover, before we go on? [It continues to be important to note transitions, check if the patient is
finished, and see if she has anything further to add to the topic
at hand.]
Patient: That's fine. You've covered everything, I think. [This evaluation
shows how a novice clinician first obtains data in the involved
system to help develop hypotheses, then tests the hypotheses
with selective questions designed to support or refute them, and
wraps up with understanding her perspective. Not shown here
because of space constraints, the clinician now learns about the
patient's other active problems (OAP): her recent cough and her
colitis. The write-up in Appendix D presents this information.]
Procedural Issues

When the patient presents more than one concern, you will need to evaluate
each one in much the same way. For example, Ms. Jones also had colitis and
a recent cough. These now could be systematically explored. If these are not
currently active health problems, though, they can be explored instead as part
of the PMH (Step 7), in less depth. And when not contributing to current
problems, as in Ms. Jones' situation, they are included in the PMH portion of
the written report. When they are contributing to the patient's current problems, they are included as OAP at the end of the HPI.
This is a lot to assimilate, and it will require much practice before you feel
competent and confident interacting with patients. Review the demonstration

• TABLE 5-3. To Minimize Bias from Closed-Ended Questioning
1. Listen actively-When the patient responds, listen to what she or he says and how she or he says it,
rather than thinking about what question to ask next.
2. Proceed from general to specific-Start with an open-ended question in each major area and then "cone
down" with closed-ended questions. ("Other than this chest pain, how is your health? Do you have any
medical problems?", "How about high blood pressure?", "High cholesterol?", etc.)
3. Pursue details-For example, dosage of medications, how often they are meant to be taken, how often
the patient actually takes them, barriers to taking them, side effects.
4. Use single questions-Avoid "Have you ever had headaches, fainting, loss of vision, blurred vision, poor
memory, or a stroke?" Rather ask, "Have you ever had headaches?"
5. Orient the patient with transitional statements between sections-For example, "Now I'd like to shift and
ask you some questions about your family's health, because some diseases can run in families."
6. Avoid negatively worded questions: "You're not coughing up blood?"
7. Don't suggest a response by the way the question is framed-Avoid "Do you feel the pain in your left arm
when you get it in your chest?" or "You don't smoke, do you?"
8. Give equal weight to alternative answers-Ask "It sounds like there is some pain when you exert yourself,
but what about when you're not exerting?"
9. Don't interpret data while collecting it-Avoid "Must be hemorrhoids. Ever had any nausea or vomiting?"
10. Give balanced attention to all aspects-Advise, "We've talked a lot about your constipation, but not much
yet about the chest pain."
11. Don't confuse the patient with rapid shifts or technical languagejjargon-Avoid "Did they do an ERCP or
another endoscopy?" "Were any lesions found?", or "Have you had an Ml before?"
12. Encourage questions.
13. Check patient's understanding.
14. Summarize-At the end of section or end of interview.

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SMITH'S PATIENT-CENTERED INTERVIEWING

information into the conversation where necessary. This is especially helpful
in testing hypotheses; for example, in a patient with a chronic cough, it is perfectly appropriate to introduce these thoughts if the patient hasn't mentioned
them: "'Are you a cigarette smoker?': "'Have you lost weight?': or "'Have you
ever been tested for TB?"
The HPI/OAP concludes when you have addressed all the patient's presenting symptoms. At this point you will, after some experience, understand
the problem and have the best possible disease explanation in mind, if not the
actual diagnosis. This will determine what corroborating data to look for on
the physical exam and in the laboratory evaluation. You will also more fully
recognize the close interaction of symptoms and secondary data with the personal data obtained in the beginning of the interview.
At this time, you will make a statement about changing the conversation to
some topics "'we haven't yet talked about, such as your past health issues," as
the clinician did with Ms. Jones earlier, inquiring if she thought her story has
been completely discussed, summarizing, and asking if there was anything
further to add.
Addressing a Predominantly Psychological Problem

In patients with psychiatric diseases or other serious psychological problems,
the personal contextual data you obtained during the beginning of the interview usually are not sufficient for complete evaluation. Steps 1 to 5 are just
the beginning. In Step 6, you pin down details about the psychological problem, just as you would with a physical symptom. Elicit the patient's symptoms
and test hypotheses about the underlying diagnosis by selectively testing different diagnostic possibilities. For example, a patient's depression may have
become apparent during Steps 1 to 5, but it now is your task to explore its
possible disease causes, potential complications, and treatment options. Using
open-ended inquiry and "coning-down" to closed-ended questions you differentiate, for example, major depression, bipolar disorder, schizophrenia,
medication side-effects, and medical diseases as causes of depression. You
will gain much more experience with the medical interview questions needed
to diagnose both medical and psychiatric diseases during your clinical clerkships, but we use depression as an example here, because depressed mood can
be a normal emotion or a symptom of a psychiatric disorder. One psychiatric
diagnosis called major depressive disorder is prevalent, so we screen for it by
asking two questions 12:
Over the last 2 weeks, how often have you been bothered by:
1. Having little interest or pleasure in doing things?
2. Feeling down, depressed, or hopeless?

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1.09

If the patient answers, "more than half the days" or "nearly every day" to
one or both questions, the sensitivity to rule in the diagnosis of depression is
83% and the specificity is 90%. In this case you would follow-up with seven
more questions to confirm the diagnosis. The patient needs to answer "more
than half the days" or "nearly every day" to a total of at least five of the nine
questions (the two screening questions and the seven follow-up questions) to
meet diagnostic criteria for major depressive disorder. 13 These questions are:
Over the last 2 weeks, how often have you been bothered by:
Trouble falling or staying asleep, or sleeping too much?
Feeling tired or having little energy?
Poor appetite or overeating?
Feeling bad about yourself-or that you are a failure or let your family
down?
7. Trouble concentrating on things, such as reading the newspaper or watching television?
8. Moving or speaking so slowly that other people could have noticed, or the
opposite-being so fidgety or restless that you have been moving around a
lot more than usual?
9. Thoughts that you would be better off dead, or of hurting yourself in some
way?

3.
4.
5.
6.

Many medical patients are like Ms. Jones and have no apparent overriding
psychological problem or diagnosis. That may surprise you after everything
we have heard about Ms. Jones' job stresses and interpersonal conflicts. While
it is important for you to understand your patients at this level, life stresses
such as these are not necessarily symptoms of a psychiatric disease. Indeed,
these types of problems occur in everyone's personal lives and are not outside
the realm of normal. Simply feeling heard and understood by a caring person
is often enough to help. Indeed, some patients express, "I feel better just having come to see you!" You will gather additional personal details for patients
like Ms. Jones in the SH (Step 8).

General Comments about the Remainder of the Interview
You now have completed the most important part of the middle of the interview. Step 6 is where you will spend most of your time. The remaining steps
(Steps 7-10) are very straightforward, consisting of lists of questions on various topics you ask one by one. In many practice settings, patients complete a
questionnaire beforehand and the clinician uses it to efficiently guide this part
of the interview. While continuing to be on the lookout for clues to hypotheses, most hypothesis testing should have been completed.
You will note that the questions are extensive and to completely ask and
answer all of them could literally take several hours! We present all of this

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SMITH'S PATIENT-CENTERED INTERVIEWING

material in order to provide you with an idea of the magnitude of potentially important information about the patient and what may be necessary to
understand her/him fully. Note that the experienced clinician rarely obtains
all of this information, certainly not at one sitting; pertinent but nonurgent
information often is obtained over many visits. Information in Steps 7 to 10 is
gathered selectively according to the individual patient's needs. As you proceed
through these steps, consider which might be more important in, for example,
older patients, women, men, children, crisis situations, and high-risk patients.
As a beginning clinician, you should initially obtain complete information in
all areas as a way of learning the categories and beginning to appreciate the
rich diversity of your patients. When you have learned and memorized all the
categories you should become more selective also.
While much of the information in Steps 7 to 10 is quite routine, continue
to watch your patient's response, particularly fatigue and impatience with a
long process. Periodically ask how the patient is responding to the interview
itself. It can be tiring and you may need to ask if the patient needs a break or
if it would be appropriate to continue at a later time. At the other extreme,
while these may appear to be very standard questions, they often strike an
emotional chord in patients and you may need to return to patient-centered
inquiry, particularly empathy skills (NURS); for example, when asking a
spouse's age, the patient becomes sad because of a recent divorce. It is also
essential in this more routine part of the history to maintain the respectful,
patient-centered atmosphere you have previously established and not become
hurried. Finally, normalize the situation by telling patients that the questions
you are asking are indeed customary and asked of all patients; for example, a
patient might get insulted when asked about drug use or sexual practices if
you do not explain the reason for asking.
•

PAST MEDICAL HISTORY (STEP 7)

In the past medical history (PMH), you elicit information about significant
past medical events unrelated to HPI/OAP. Events occurring in the past that
are related to the HPI/OAP, however, are elicited as part of the HPI/OAP. For
instance, in a patient presenting with chest pain, the prior history of myocardial infarction usually is obtained in the HPI rather than the PMH; it would
also be reported there in the written and oral presentation of the history and
physical (Hand P). Similarly, because of the close association of diabetes and
coronary artery disease, if this patient also were a diabetic of 20-years duration, this fact would be elicited and recorded in the HPI. On the other hand,
if the same patient presented with diverticulitis or hip fracture, the cardiovascular history would be obtained and presented in the PMH as long as it was

• TABLE 5-4. Past Medical History (Step 7)
• Inquire about general state of health and past illnesses
o Childhood: measles, mumps, rubella, chicken pox, scarlet fever, and rheumatic fever
o Adult: hypertension, heart attack, stroke, heart murmur, other heart disease, diabetes, tuberculosis, sexually transmitted infections, cancer, major treatments in the past (blood transfusions, steroid treatments,
anticoagulation), and visits to healthcare providers during the last year
• Inquire about past injuries, accidents, psychological problems, unexplained problems, procedures, tests,
psychotherapy
• Elicit past hospitalizations (medical, surgical, obstetric, rehabilitation, and psychiatric)
• Review the patient's immunization history
o Childhood: measles, mumps, rubella, polio, hepatitis B, tetanus/pertussis/diphtheria, human papilloma
virus, influenza, meningococcal, varicella, Haemophilus influenzae type B, rotavirus
o Adult: diphtheria/tetanus/pertussis boosters, hepatitis A, hepatitis B, influenza, pneumococcal pneumonia, herpes zoster
• Inquire about status of age-appropriate preventive screening
• Obtain the female patient's women's health history
o Age of menarche, cycle length, length of menstrual flow, number of tampons/pads used per day
o Number of pregnancies, complications; number of live births, spontaneous vaginal deliveries;cesarean
section; number of spontaneous and therapeutic abortions
o Age of menopause
• List current medications, including dose and route
o Ask specifically about inhalers, over-the-counter medicines, alternative remedies, oral contraceptives,
vitamins, laxatives
• Review allergies
o Environmental, medications, foods
o Ensure that medication "allergies" are not actually expected side effects or nonallergic adverse reactions

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SMITH'S PATIENT-CENTERED INTERVIEWING

understanding of diagnoses or interpretations of treatments. Follow the
already described procedure: convert concerns to symptoms from the ROS
and refine them with the symptom descriptors, and then organize relevant
primary data (symptoms) and secondary data (doctor visits, hospitalizations,
tests) into chronologie sequence.
For PMH problems with little significance to present health (appendectomy or tonsillectomy many years ago), little detail is needed other than getting the patient's version of diagnosis, complications, and statement that there
have been no subsequent problems. Indeed, time constraints and patients' comfort discourage acquiring unnecessary data, such as the details of an uncomplicated appendectomy 30 years earlier.
As listed in Table 5-4, identify significant past problems by inquiring in the
following areas.
Screen for MaJor Diseases
Screen for problems that might not yet have been identified. Begin with childhood illnesses by asking "Tell me about any illness you had as a child." Then
inquire about specific childhood illnesses (e.g., measles, mumps, German
measles, chickenpox). Continue with adult illnesses by asking, "Other than
(chief concern), how is your health? What significant illnesses have you had?~
followed by specific inquiry about common adult illnesses (hypertension,
heart attack, stroke, heart murmur, other heart disease, diabetes, tuberculosis, sexually transmitted infections, cancer), blood transfusions, and visits to
healthcare providers during the last year. Similarly, ask about prior treatment,
such as cortisone, insulin, blood transfusions, and anticoagulants, that suggests serious problems.
Other Medical, Surgical, or Psychological Problems
Inquire about injuries, accidents, visits to the emergency room, illnesses
requiring several visits, unexplained problems, procedures, tests, psychological problems, and psychotherapy.
Hospitalizations
Hospitalizations may identify the most serious problems patients have experienced: surgical, medical, psychiatric, obstetric, rehabilitation, and any other
type. The more recent and the more serious a hospitalization, the more data
are required, sometimes more extensive than the HPI; for example, in a
patient who is admitted with a hip fracture as the primary problem but who
had a history of three heart attacks, you would need to elicit extensive details

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1.1.3

of all primary and secondary cardiovascular data in order to assess the safety
of planned hip surgery. Hospitalizations usually are presented in chronological order.
Immunizations

Ask about childhood (measles, mumps, rubella, polio, Haemophilus influenzae type b, hepatitis B, tetanus/pertussis/diphtheria, HPV, varicella, meningococcal, rotavirus) and adult (diphtheria booster, tetanus boosters, measles/
mumps/rubella boosters, hepatitis A, hepatitis B, influenza, pneumococcal,
herpes zoster, meningococcal) immunizations. The most recent Centers for
Disease Control and Prevention vaccination recommendations can be found
at https://www.cdc.gov/vaccines/schedules/index.html.
Screening

There are a number of recommended health-screening procedures (varying
by age, circumstance, and gender) that you will want to ensure are up to date.
These might include screening for tuberculosis, hyperlipidemia, hypertension, cervical cancer, breast cancer, colon cancer, etc. Screening recommendations change as new knowledge is discovered. You can find the latest US
Preventive Services Task Force health screening recommendations applicable
to your patient at http://www.ahrq.gov/clinic/pocketgd.htm.
Women's Health History

Essential information to obtain from women and girls about menses is age
at onset ("How old were you when you had your first period?,), cycle length
("How often do you get your period?"), duration ("How long does your
period last?"), discomfort or pain with menses, number of pads or tampons
daily. and age at menopause. Use of contraceptives, including birth control
pills or other hormonal preparations also is sometimes elicited here ("Do you
or your partner[s] use birth control? What type? How often?"). The sexual
history. sexually transmitted infection history. and intimate partner violence
questions found in the SH can be asked here in the PMH if you prefer.
The obstetric history includes number of pregnancies ("Have you ever been
pregnant?" How many times?"), deliveries of living children and their outcome, other deliveries and reason for adverse outcome, any complications of
pregnancy. spontaneous abortions ("Have you had any miscarriages?"), and
induced abortions. You can elicit breast-feeding history and problems here. The
women's health history often is elicited and reported as part of the HPI when
genitourinary problems are the focus. Many women's health questions are also

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SMITH'S PATIENT-CENTERED INTERVIEWING

found in the ROS because some clinicians ask about women's health history
there instead of in the PMH or SH. You will learn from your teachers which
section you are expected to record and report the women's health history in.

Medications and Other Treatments
List all prescribed and other medications with dose, duration of use, reason
for use, and any adverse reactions. Also obtain a listing of medications used
during the last year but which are not presently being taken. Specific inquiry
about agents sometimes not considered to be medications is necessary as well:
inhalers, eye drops, laxatives, tonics, hormones, birth control pills, patches,
and vitamins. Inquire about agents obtained over-the-counter, from alternative healers, or from other sources such as a friend. In order to identify all the
patient's medicines, you may need to contact the pharmacy or ask the patient
to bring in the actual medications so that they can be definitively identified,
particularly when all the patient knows is that "I'm taking a brown pill for my
circulation:' Sometimes it helps to consult an online resource such as Pillbox
from the National Library of Medicine (http://pillbox.nlm.nih.gov/), which

allows for rapid identification ofpills based on color, shape, and size.
Ask about non-pharmacologic forms of treatment, whether administered by
self or others, including physical therapy, massage, biofeedback, relaxation techniques, yoga, acupuncture, psychotherapy of any type (e.g., individual, group),
diet, and exercise. Specifically inquire about complementary and alternative
treatment (e.g., homeopathy, herbal medicine, chiropractic) since these often are
not mentioned out of embarrassment or fear of disapproval by the clinician.14

Allergies and Drug Reactions

If not already ascertained, ask about asthma, hay fever, hives, and atopic
eczema because they are common allergic disorders and these patients also
may be more sensitive to certain medications (e.g., aspirin in asthmatics).
Drug reactions can be allergic/immunological (rash due to penicillin) or
non-immunological (candida vaginitis due to an antibiotic). Patients seldom
make this distinction but you must because true allergic reactions usually
preclude subsequent use of the medication while alterations in dosage and
frequency can sometimes allow continued use following a nonallergic drug
reaction. List all allergic or other drug reactions, dose and duration of use of
the agent, specific symptoms (e.g., hives, anaphylaxis, rash) and secondary
data (e.g., desensitization, skin tests, cortisone), recurrence, history of reexposure, and final outcome.
We now pick up again with Ms. Jones.

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1.:1.5

Continuation of Ms. Jones VIsit
Clinician: Other than the headaches and colitis, how is your health? [A
good way to start the PMH with an open-ended question.]
Patient: Fine.
Clinician: I'm going to ask you about some specific diseases now and
just tell me if you've ever had them. By the way, these are routine questions; I'm not asking because I suspect something.
[Instructions and a normalizing statement]
Clinician/ Rheumatic fever (no), scarlet fever (no), diabetes (no), TB (no),
Patient: cancer (no), stroke (no), heart attack (no), or any other diseases
(no). [The clinician begins the PMH by screening for major
diseases. In a series of questions like this is, ask each one individually and give the patient sufficient time for an answer; the
patient should not feel pressured nor should a string of questions be asked at once. It is important throughout to be sensitive
to the patient's response to all inquiry and to respond to questions. In particular, it almost always helps to reassure the patient
that items being inquired about are routine and that you have
not noticed something to make her or him suspicious.]
Clinician/ Besides the cortisone for your colitis, I'm going to ask you a
Patient: lot more specifics now about major treatments you might ever
have had: blood transfusions (no), insulin (no), or anticoagulants (no). [This is an additional way of screening for any major
problems not yet mentioned.]
Clinician: Any visits to your doctor during the last year or so for anything
we haven't covered?
Patient: Well, I did have a bladder infection once and got some medicine
for it.
Clinician: How was it diagnosed? [The clinician is not taking her word for
the diagnosis (secondary data) and wants to know more.]
Patient: Oh, my doctor did a urine test and gave me an antibiotic. With
the medicine it was gone in about 2 days, but I took the medicine for a week.
Clinician: Any tests done, like X-rays or cultures of the urine?
Patient: No.
Clinician: Ever had this before?
Patient: Nope, it didn't amount to much. [The clinician has established
the chronology of what sounds like an uncomplicated lower
urinary tract infection. This is a very simple and straightforward problem, but the clinician would evaluate each PMH

1.:1.8

SMITH'S PATIENT-CENTERED INTERVIEWING

problem that might be significant to the patient's present health
in a similar fashion.]
Clinician: Any other problems you've seen your doctor or anyone else
for?
Patient: No.
Clinician: Tell me about any hospitalizations you've had, you know,
other than that time for the colitis. [Although not recounted
in the HPI/OAP or PMH, for space considerations, the clinician already has addressed Ms. Jones' cough and colitis; the
results of this inquiry are given in the write-up of the history in
Appendix D.]
Patient: I had my tonsils out as a kid.
Clinician: Any other hospitalizations? [The clinician might have asked
about any complications or subsequent problems.]
Patient: Well, I did break my arm once in high school and they had to set
it.
Clinician: How's that been since? Any problem? [It would be important to
know how it was broken.]
Patient: No, it's just fme. I play tennis and have no trouble.
Clinician/ Other hospitalizations (no), injuries (no), accidents (no),
Patient: or sickness (no)? [These questions are asked and answered
individually.]
Clinician: Didn't you mention having kids?
Patient: Oh, yeah. I forgot! They're six and eight. But I had no trouble
delivering [This sounds uncomplicated at this point, and the
clinician will get the details of the menstrual and obstetric history at the end of the PMH although it could just as easily be
done now.]
Clinician: OK. If there's nothing else, I'd like to shift and find out about any
medications you take, and some other things. [A good openended and orienting start into this new area. Because of space
constraints, we'll simply summarize the clinician's findings
about Ms. Jones: Except for the birth control pill and aspirin
with the headaches (detailed doses and other data obtained),
she is taking no medications or other treatments from either
prescribed or other sources. Her history of prednisone use is
reviewed. She has no allergic diseases and there is no history of
adverse reactions to any drugs or other substances. She had her
"baby shots" years ago and had a tetanus shot 2 years ago when
she punctured her hand with a nail. Her women's health history
reveals that she has Pap smears every 3 years and performs breast

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1.1.7

self-examination about a week after each menstrual period. She
has not had any sexually transmitted infections such as gonorrhea, syphilis, HIY, chlamydia, abnormal Pap smears (caused
by human papilloma virus-HPV), genital warts, or hepatitis.
The remainder of her women's health history is recounted in the
write-up in Appendix D.]
•

SOCIAL HISTORY (STEP 8)

Also called the psychosocial history, the psychosocial ROS, or the patient profile, the social history (SH) is where you learn about the patient's behaviors
and other personal factors that may impact disease risk, severity, and outcome; it also helps you to get to know the patient better. The routine information obtained here compliments, and should not be confused with, the rich
psychosocial data that you obtain in Steps 3 and 4. As with other parts of
the history, you may uncover aspects of the SH during different parts of the
encounter. Regardless of where in the history you obtain the data, when you
do an oral or written case presentation, you will place those parts of the SH
not involved in diagnosing the chief concern under the heading social history,
to help organize the information.
Start with a transition statement ("Now l(:llike to ask you some questions
about your life and things you do to stay healthy") and initiate each major
SH area in Table 5-5 with a focused open-ended request or question ("Can
you tell me about your work?"), then follow-up with enough closed-ended
questions to get the necessary details. Because the SH addresses many sensitive areas, be especially careful to be patient, courteous, nonjudgmental,
and understanding as a way of ensuring continuation of the patient-centered
atmosphere. Patients often are reassured when you state that the questions
are routine and asked of everyone. Address tension-laden areas delicately
with considerable use of open-ended and empathy skills; you may need to use

patient-centered interviewing skills if significant issues or emotions develop, or if
a previously reticent patient begins to open up. It is not uncommon to go back
and forth between patient-centered and clinician-centered skills many times.
The interviewing strategy for obtaining very sensitive information, such as
sexual or drug use history, is expanded upon in Chapter 7.
The list of potential topics of inquiry in the SH is extensive and may not
seem relevant to the reason the patient is seeking healthcare. However, understanding these aspects of the patient's life can aid you in diagnosing the chief
concern, helping the patient recuperate after hospital discharge, and keeping the patient healthy by addressing harmful behaviors. As you gain experience, you will learn which questions are most important to ask for a particular

•

TABLE

5-5. Social History (Step 8) 8

Occupation
Workplace
Level of responsibility
Daily routine and schedule
Health hazards
Occupational exposures
Work stress
Financial stress
Satisfaction
Health promotion
Diet
Physical actlvltyjexerclse history
Functional status
Dressing
Bathing
Feeding
Transferring
Walking
Shopping
Using the toilet
Using the telephone
Cooking
Cleaning
Driving
Taking medication
Managing finance
Cognitive function
Extent of interference with normal life
Safety
Seat belt use
Safety helmet use
Smoke detectors in home
Toxins at work and home
Safe gun storage
Health screening
Cervical cancer
Breast cancer
Prostate cancer
Colon cancer
Lipids
Hypertension
Diabetes
HIV
Sexually transmitted infections
Tuberculosis
Glaucoma
Dental
Self-examination

Exposures
Pets
Travel
Illness at home, in the workplace
Sexually transmitted infections
Substance use
Caffeine
Tobacco
Forms
Pack-years
Alcohol
Type and amount consumed at 1 time/daily/weekly
"CAGE" questions
Drugs
"Recreational" or "street" drugs
Illicit use of prescription drugs
Personal
Living arrangement (with whom, how are things
at home?)
Personal relationships and support systems (Who
do you count on? How have people responded
to your Illness?)
Sexuality
Orientation
Practices
Difficulty
Intimate partner violence/abuse
Life stress
Mood
Spirituality/religion
Faith
Importance
Community
Address
Health literacy
Hobbies, recreation
Important life experiences
Upbringing and family relationships
Schooling
Major losses/adversity
Military service
Financial situation
Aging
Retirement
Life satisfaction
End-of-life planning
Cultural/ethnic background
Legal Issues
Living will or advance directives
Power of attorney
Emergency contact

"Items in bold should be asked about in most new patient encounters: they have high yield for risk factor modification, assist in building the doctor-patient relationship, and/or are important to patients but rarely brought up by them. Ask about other items as time
allows and as indicated by the patient's symptom(s).

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1.1.9

patient encounter. The bold items in Table 5-5 should be addressed in most
encounters; these topics will identify targets for risk factor modification and
assist in building the clinician-patient relationship. These issues, although
rarely brought up by patients, should be discussed openly and in a nonjudgrnental fashion to both garner trust and obtain accurate information. You may
need to obtain this type of information over multiple encounters with the
patient.
Ask about the unbolded items in Table 5-5 if time allows or when directed
by the patient's illness. For example, you would ask about travel and pets if the
patient presented with acute fever.
We recommend that you begin with less sensitive topics first. generally
following the order listed in Table 5-5. Make a transition statement between
topics and assure the patient that you ask these questions of all your patients.
Recommended questions for some important topics are listed in the following sections, followed by the rationale [in brackets].

Occupation
Ask, "Do you work outside the horne? Tell me about your work. How long
have you done this work? What other jobs have you had? Have you ever been
exposed to fumes, dust, radiation, or loud noise at work? Do you think your
work or environment is affecting your symptoms now?" If so, ask, "Do your
symptoms improve away from work?" and "Are others at work having similar
symptoms? Tell me about stress at work." Ifthe patient does not work outside
the horne, ask what a typical day is like.
[A patient's occupation can affect health through toxic exposures, injuries,
and stress. 15 For example, auto body workers can develop asthma, woodworkers have an increased incidence of nasopharyngeal carcinomas, and clinicians
can be exposed to tuberculosis, HIV, and viral hepatitis.]

Health Promotion
Diet (See Also DocCom Module 2518)

Ask for a 24-hour dietary recall, "Tell me what you've eaten in the past 24
hours, starting with just before you came here and working backward." Avoid
asking, "Tell me about your diet," because for some patients a "diet" is something one goes on to lose weight. A 24-hour dietary recall (assuming the day
is typical) gives you a more accurate understanding of actual dietary practices
than asking about what the patient eats on an average day.
Screen for bulimia by asking, "Are you satisfied with your eating habits?" If the patient answers no, then follow-up with, "Do you ever eat in
secret?"17

1.20

SMITH'S PATIENT-CENTERED INTERVIEWING

Depending on the clinical scenario, you may need to explore some additional areas:
• Sodium: Reducing sodium can decrease blood pressure as much as starting a medication, and it can relieve heart failure symptoms, so ask about
salt use in patients with hypertension and congestive heart failure. Does
the patient add salt during cooking and/or at the table? Ask about hidden
sodium, found in prepared foods such as cold cuts, bacon, ham, canned
soups and vegetables, and in restaurant meals.
• Fat: Dietary animal and hydrogenated fat intake can significantly affect
heart disease risk Inquire about intake of dairy products, eggs, red meat,
and organ meats.
• Caffeine: Can cause nervousness, tremor, palpitations, eyelid twitching,
and insomnia. Ask about intake of caffeinated beverages (e.g., coffee, tea,
cola, Mountain Dew, energy drinks) and caffeine pills (e.g., No-Doz).
• Fiber: Low-fiber diet can lead to constipation, hemorrhoids, and diverticulosis.
• Dairy products: For patients who might have lactose intolerance.
• Wheat: For patients who might have celiac disease.
[Understanding your patient's dietary choices and relationship to food is
important because of the increasing incidence of obesity and eating disorders. Diet also plays an important role in many common diseases such as
hypertension, diabetes, and hyperlipidemia. Symptoms can also be caused by
foods, such as diarrhea and bloating in patients with lactose intolerance after
consuming dairy products, and in patients with celiac disease who eat wheat.
Malnutrition can exist even if the patient is obese.]
Exercise (See Also DocCom Module 2518)
Ask, "Tell me what you do for physical activity or exercise:'

[A sedentary lifestyle contributes to many illnesses including obesity, type
2 diabetes, and heart disease. The US Department of Health and Human
Services in its 2008 Physical Activity Guidelines for Americans (www.health.
gov/paguidelines) recommends that adults get at least 2 1;2 hours per week of
moderate intensity, or 1 hour and 15 minutes a week of vigorous-intensity
aerobic physical activity, or an equivalent combination of moderate- and
vigorous-intensity aerobic activity. It also recommends that adults should
do muscle-strengthening activities that are moderate or high intensity and
involve all major muscle groups on 2 or more days a week. Understanding the
details of a patient's exercise and physical activity can allow you to counsel the
patient appropriately.]

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:12:1

Safety

Say, "Now I want to ask you about some personal safety issues. Do you wear
seat belts? How often? Do you use a bicycle helmet? How often? Do you ride
a motorcycle? (If so) Do you wear a helmet? How often? Do you have smoke
detectors in your home? How often do you change the batteries? Can children
get at medications or toxic substances like cleaning products? Is there a gun
in your home? (If so) How is it stored?"
[Asking patients about their day-to-day safety practices provides an opportunity for counseling that may be lifesaving. 18' 19 For example, in recent years
about 60% of the approximately 30,000 annual fatal motor vehicle accidents
have been due to failure to use seat belts. The National Highway Traffic Safety
Administration estimates that seat belt use saves about 13,000 lives a year.
Accidents are the leading cause of death of young adults. If a clinician can convince a healthy young patient to use a seat belt, it is possible to have more impact
on that patient's lifespan than any other medical intervention. It may be advantageous to reinforce the fact that seat belt use saves thousands of lives every
year. Bicycle helmets reduce the risk of head injury by 85%; motorcycle helmet
use reduces the risk of fatal head injury by 27%. 19 Ensuring that firearms in the
home are safely handled and stored may reduce the risk of homicide or suicide:
homicide risk has an odds ratio of2.7, and suicide risk has an odds ratio of4.8 in
households with handguns compared to households without a handgun.18,2°-23
Smoke detectors reduce the risk of death from residential fires by 80%.18]
Substance Use (See Also DocCom Modules .24,24 .29,25 and 3()26)

Ask about tobacco use, including forms of tobacco (e.g., pipe, snuff, chewing
tobacco) and number of pack-years for cigarette use (packs smoked per day
multiplied by number of years of smoking, e.g., smoked 2 packages of cigarettes daily for 8 years= 16 pack-years).
Determine whether the patient consumes alcohol and whether it may be
a health problem. Ask "'Do you drink alcohol, including beer, wine, and hard
liquor? How much alcohol do you drink? Has alcohol ever been a problem
in your life? When was your last drink?" A response of "'less than 24 hours
ago, to this last question has a positive predictive value of 68% and a negative
predictive value of98% for alcohol abuse.27 Then, you can follow-up with the
"'CAGE" questions28.29:
"'Have you ever:
•
•
•
•

felt the need to Cut down on your drinking?
felt Annoyed by criticism of your drinking?
had Guilty feelings about your drinking?
taken a morning Eye opener?"

1.22

SMITH'S PATIENT-CENTERED INTERVIEWING

An affirmative answer to two or more has a sensitivity and specificity of
>90% for alcohol dependence.27
Determine whether the patient uses or abuses either "'street'' drugs or prescription drugs, and quantify the amount. Also determine if the patient shares
drug equipment, such as needles and straws. Prescription drug abuse is now
the most common form of drug abuse. 30- 33
Patients often minimize their use of drugs or alcohoL in an attempt to
delude themselves rather than hide the truth from you. Maintain a respectful
and nonjudgmental approach in order to win the patient's trust. You might ask
if the patient has had problems from using addicting substances (divorce, job
loss, delirium tremens with alcohol withdrawal, emphysema from cigarettes),
attempted to quit or decrease the habit; whether s/he was successful in stopping before and if not, why not; and if s/he is interested in getting help to quit.
As welL ask about problems with the legal system, and with other substance
abuse problems in the patient's life. Finally, particularly with drug and alcohol
abuse, be alert for psychiatric issues that commonly co-exist with these problems, such as anxiety and depression. You will often find that, when alcohol
or drug abuse exists, it often relates to the major problem the patient has and
almost always has a significant impact on the patient's health. In such cases,
you will present this information in the HPI, even if you obtain it as part of
the SH. Examples include a patient who presents with chest pain suggesting
angina and also a history suggesting alcoholism, or a patient who presents with
progressive shortness ofbreath who also has a 40 pack-year smoking history.

Personal
Living Attangement and Personal Relationships

A good way to inquire about home life is to ask, "How are things at horne?
Does anyone else live at home with you? Tell me about him or her~ "Tell me
about your support systems in your life. Who do you count on?"
[Most beginning clinicians are uncomfortable inquiring about patients'
personal lives. It can feel intrusive or voyeuristic to ask intimate questions
about a stranger's private life. This is understandable. It is helpful to keep in
mind some of the reasons you are asking these questions. As a clinician, you
are interested in public health issues such as the spread of communicable diseases; you are also interested in patient safety, including falls and intimate
partner violence; risky behaviors such as unprotected sex; inherited and
inheritable genetic diseases; etc.
As a beginning clinician, you may not feel that you can do anything helpful
with the information you have gotten. Once you are on clinical rotations, you
will be a key member of the team caring for the patient and the history you
obtain may be the most important and complete one the patient will undergo.

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:123

For example, knowing a patient's personal relationships allows the team to
know who to contact and when it is time to discharge the patient, the team
will know the potential support systems (or lack thereof)-this may mean the
difference between sending the patient home, arranging for visiting nurse,
or sending the patient to a rehabilitation center. Regardless of your clinical
level, be honest with patients that you are learning about medical interviewing; most patients will be very willing to help you learn by answering all your
questions. In fact, your encounter with the patient may be the high point of
the patient's otherwise boring day.]
Sexuality (See Also DocCom Module Uf4)

A transition statement such as, "In order to provide healthcare that is right for
you, it is helpful for me to understand your lifestyle" may provide a comfortable segue into asking about sexuality.35 Also, stating that "these are questions
I ask all of my adult patients" may be helpful. After the transition, the following questions can then be asked:
•
•
•
•

•
•

•
•

"Is there someone special in your life? Are you and this person having sex?"
"Are there any other sexual relationships that I should know about?"
"Do you have sex with men, women, or both?"
"Do you have sex with people who might be at risk for having sexually
transmitted diseases or HIV (intravenous drug users, cocaine users, prostitutes, unknown partners or gay or bisexual men)?
(For persons having sex with men) "Are you using condoms to prevent
disease? What percent of the time?''
(For women) "Do you have a need to discuss birth control?, Have you ever
had a Pap smear? When was your last one? What were the results? Have
you ever had an abnormal Pap smear? Have you ever had a biopsy or other
procedure on your cervix because of an abnormal Pap smear?"
"Have you ever had gonorrhea? Syphilis? HIV? Chlamydia? Herpes? HPV?
Genital warts? Hepatitis?"
"Do you have any other questions or concerns about sex? I'm happy to
discuss any concerns you have."

To detect sexual problems, ask:
• "Have you noticed any recent changes or problems with your sexual
functioning?"
• Men: "Do you have any problems having or maintaining an erection? Any
trouble having an orgasm?"
• Women: "Do you have pain during intercourse? Any problems with lubrication or becoming aroused? Do you have difficulty having an orgasm?"
• "Has your illness affected your sexual functioning?"

1.24

SMITH'S PATIENT-CENTERED INTERVIEWING

[Do not make assumptions about a patient's sexual orientation or practices
and do not assume that orientation determines practices. For example, some
men who have sex with men do not consider themselves to be gay or bisexual.
Avoid questions such as "'Are you married or single?'' or (to a woman), "Do you
have a boyfriend?" Gender-neutral language (e.g., "partner") communicates
to gay, lesbian, bisexual, and transgender patients that it is safe for them to be
themselves with you. 36 Seek to understand both a patient's sexual orientation
and the sexual activities slhe engages in. This will allow you to screen appropriately for sexually transmitted infections, give relevant health education,
and provide personalized healthcare. For example, gay and lesbian patients
receive less preventive care than heterosexual patients, primarily because of
dissatisfaction with the clinician-patient relationship.37 Also, gay and lesbian
teens are six times more likely to attempt or commit suicide than the national
average.38 A trusting relationship with the clinician may help establish safety
and uncover and respond to extreme distress and suicidal thoughts.
It can be helpful to explore issues of gender identity with a screening question, such as, "'Because so many people are impacted by gender issues, I have
begun to ask everyone if they have any concerns about their gender. Anything
you say about gender issues will be kept confidential. Ifthis topic isn't relevant
to you, tell me and I'll move on:'39
As with the rest of the medical interview, tailor questions to the particular
encounter. For example, it would not be appropriate to take a detailed sexual
history from a person in acute congestive heart failure in a crowded emergency department. Once the patient is stabilized and in a more private setting,
you could return to these questions as indicated.]
Intimate Partner VIolence/Abuse (See Also DocCom Module 2~ 0)

One in three women and one in four men have been physically abused by an
intimate partner; one in five women and one in seven men have been severely
physically abused by an intimate partner.41 Although it may feel uncomfortable, you must learn to sensitively inquire about intimate partner violence,
since patients are unlikely to broach this important issue themselves.42 One
suggested approach43 is "Have you ever been hit, slapped, kicked, or otherwise
physically hurt by someone?~ "Has anyone ever forced you to have sexual
activities?" If the patient answers yes to either question, learn more about
the situation, using open-ended questions. You can then follow-up with the
"SAFE" questions44:
• Stress/Safety: "What stress do you experience in your relationships? Do
you feel safe in your relationships/marriage? Should I be concerned for
your safety?"

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:125

• Afraid/Abused: "Are there situations in your relationships where you have
felt afraid?" "Has your partner ever threatened or abused you or your children?" "'Have you been physically hurt or threatened by your partner?"
"'Are you in a relationship like that now?" "Has your partner forced you to
engage in sexual activity that you did not want?" "People in relationships/
marriages often fight; what happens when you and your partner disagree?,
• Friends/Family: "Are your.friends, parents, or siblings aware that you have
been hurt?" "'Do you think you could tell them, and do you think they
would be able to give you support?" (Assess the degree of social isolation.)
• Emergency plan: "Do you have a safe place to go and the resources you
(and your children) need in an emergency?" "If you are in danger now,
would you like help in locating a shelter?" "Would you like to talk with a
social worker/counselor/me to develop an emergency plan?"
Stress

Stress is ubiquitous in life. Unmanaged, it can negatively affect mental and
physical health through chronic activation of the hypothalamic-pituitaryadrenal axis and suppression of the immune system.45 If not disclosed earlier
in the interview, ask, "Can you tell me about the kinds of stress you're under?':
"Have you had any recent changes or losses at home? At work?"
Mood (See Also DocCom Module 2rt8)
You might get clues to a mood disorder in the beginning of the interview and
you could choose to pursue your hypothesis while you are completing the
HPI in Step 7. Alternatively, you can inquire about the patient's mood here,
or as part of the ROS (Step 10). Begin by asking, "How has your mood been?"
or "'How are your spirits?" To screen for depression, the most common mood
disorder, ask, "Over the past 2 weeks, have you been bothered by little interest
or pleasure in doing things? Feeling down, depressed, and hopeless?" If the
patient answers yes to either question, there are more in-depth questionnaires
such as the PHQ-9 to confirm the diagnosis and its severity.13
SplrltualltyfRellJllon (See Also DocCom Module W

1
)

One suggested mnemonic for asking about spiritual and religious beliefs is
FICA48:
Faith and belief: "'Do you consider yourself to be a spiritual or religious
person?" "What is your faith or belief?" "What gives your life meaning?"
Importance and influence: "What importance does faith have in your life?"
"Have your beliefs influenced the way you take care ofyourself and your
illness?" "What role do your beliefs play in regaining your health or coping with illness?"

1.28

SMITH'S PATIENT-CENTERED INTERVIEWING

Community: "Are you a part of a spiritual or religious community?" "Does
the community support you? Ifso, how?" "Is there a group ofpeople you
really love or who are important to you?"
Address in care: "Would you like me to address these issues in your healthcare?"
[Spirituality and religious beliefs are important to many patients, especially
in times of illness. Beliefs can be a source of comfort and support. Some studies
show an association between spiritual beliefs and improved health.49•50 Religious
belief can also result in poorer health outcomes through avoidance of care.51
Additionally, belief that illness is a punishment from God can lead to increased
mortality.52 Depending on the severity of the illness and time available, seek to
understand what is ultimately meaningful for patients, how this relates to their
suffering, what their belief and faith are, who and what they love, their meditation or prayer practices, their orientation to giving and forgiving, and the patient's
actual worship practices; that is, the integration of mind, body, and spirit.53
While most patients welcome their clinicians knowing about their religious
beliefs, the number is highest in cases of serious illness and lowest for routine
office visits, so, as always, be sensitive to patient preferences.] 54
Health Literacy (See Also DocCom Module ~)

Health literacy is defined as the capacity of a person to obtain, process, and
understand health information to make decisions regarding illness prevention or treatment. 55 Ask the screening question "How confident are you filling
out forms by yourself?" to identify patients with low health literacy. 56
[Examples of behaviors where health literacy is required include reading
the instructions on a medication bottle, understanding an appointment slip,
filling out health forms, participating in an informed decision discussion
before an operation, managing a chronic health condition, and enrolling in a
health insurance plan. Patients with low health literacy have worse health outcomes and incur higher costs than patients with adequate health literacy. Low
health literacy is more prevalent among older people, those with less educational attainment, those with limited English proficiency, those in minority groups, and the medically underservecl It is estimated that one-third of
patients in the United States have low health literacy. Patients may try to hide
their low literacy by avoiding reading ("I forgot my glasses."); they may have
few questions and may not be able to explain how to take their medications.]
Other Issues

Ask about the following areas as time permits and as indicated by the clinical
situation.

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Advance Directives (See Also DocCom Module

:127

3r

7
)

With patients who are severely ill, disabled, or elderly, inquire about advance
directives (e.g., "do not attempt resuscitation" wishes, living will, use of a ventilator to sustain life), power of attorney, and whom to contact in the event
of serious health problems. An advance directive makes the patient's end-oflife wishes known in the event of incapacitation. Experts in bioethics recommend advance directives, but they are not being used nearly often enough,
leaving patients biased toward choosing cardiopulmonary resuscitation when
they don't understand its ramifications. Research data show that addressing advance directives improves elderly patients' satisfaction, 58 which can be
enhanced by using patient-centered skills when necessary.59
Functional Status (See Also DocCom Module 23'1")

Especially in the elderly and those with disabling problems, it is important to
know what their functional status is; for example, how well they can dress and
bathe themselves, use the toilet, transfer from bed to chair, walk, shop, cook.
clean, drive, take medications, and keep track of their bank account. Indeed,
the American College of Physicians has asked that patient histories be standardized to include routine functional status and well-being assessments.61
In addition, make an assessment of how much a disability interferes with the
patient's life and wishes; for example, one may no longer be able to climb stairs
but this does not interfere with what the patient wants to do or, alternatively,
the same disability results in great hardship by preventing the patient from
attending baseball games.
Continuation of Ms. Jones VIsit

Clinician: Let me ask you now some other questions about your life and
what you do to stay healthy. [A good transition into the SH.]
Patient: Seems like I've told you everything.
Clinician: I need to get a few more details so that I can be of best help to
you. First, though, how are you doing with all this questioning?
[Always attending primarily to the patient's needs, the clinician
takes time to inquire about the process of the interview itself.]
Patient: No problem. I like how thorough you are. [She is doing well and
makes a positive comment about the clinician, indicating that a
good relationship exists.]
Clinician: Thanks. I imagine it can feel like pressure to get so many questions coming at you. I appreciate your patience. Now, I do need
to get some more information. How old are you? [The clinician
is beginning to get some basic demographic data. Age is sometimes asked much earlier for basic orientation.]
Patient: 38 and just had a birthday.

1.28

SMITH'S PATIENT-CENTERED INTERVIEWING

Clinician: Well, happy birthday! And your family has been here for how
long? [The clinician is not clear how long she has actually been
in the city.]
Patient: About 4 months.
[Because of space constraints, we will again simply summarize
the findings about Ms. Jones, some of which required return to
a patient-centered process of inquiry. We know about her work
but also learn that she worries about being "workaholic:' The
clinician explores more about her work stress and support, since
it seems to be a very important contributor to her symptoms.]
Clinician: If it's ok to change topics a bit, ICl like to ask you something
else (she nods approval). You mentioned your husband earlier.
Anybody else around that you can talk with?
Patient: There's another new person at work with the same problem and
we commiserate all the time. He's taking over in another area
but has the same boss. We get along great and seem to help each
other. And, a couple other guys there know what's going on and
have been very helpful-and had some good advice: stay away
from him. [As with the rest of this dialogue, nothing urgent is
arising so the clinician, recalling the need to be timely, simply
obtains the information and doesn't pursue these issues in any
depth.]
Clinician: It's great that you have some trusted colleagues at work. Is it
possible to avoid your boss? [An empathic respect statement,
followed by a closed-ended question addressing a very practical personal issue that has therapeutic implications, once again
showing how inextricable is the link of disease and the personal
dimension.]
Patient: Actually, it is. I have to do a lot of traveling and can schedule it
around him and things are much better then. I figured it out and
I can miss him for at least half the time in the next 6 months!
[If it weren't possible to avoid him and treat the headaches, the
clinician and Ms. Jones would have a bigger problem on their
hands. In that event, this could be further addressed now or,
more likely, at a subsequent visit that might be set up specifically for developing a strategy.]
Clinician: You've sure had a lot of stress. Are financial issues a problem,
you know like medical insurance or anything? [Changing the
subject to another important potential problem that must be
raised by closed-ended means.]

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Patient:

:129

No! That was one of the benefits here. They cover everything
with their insurance plan. I only pay a few dollars for everything, even medicines.
Clinician: Let me now ask you how your mood has been.
Patient: Other than feeling stressed about my boss, I guess it's fine.
Clinician/ Have you been feeling down over the past 2 months? (no).
Patient: Depressed? (no). Hopeless? (no).
Clinician: Have you been bothered by a loss ofinterest or pleasure in doing
things?
Patient: No. Painting is my true love. It really helps get my mind off of
things, especially these days. I would like to do it every day,
come rain or shine, but work has been so busy lately I've only
been getting to it on weekends. [Current outside interests or
hobbies rule out anhedonia, a frequent symptom of depression.]
Clinician: That must be hard for you; I get a sense of how important your
painting is to you for stress management.
Patient: It sure is. I think I need to fit it back into my life.
Clinician: Sounds like a good idea. [The clinician would generally postpone helping the patient strategize how to put regular painting
back into her life until the end of the interview, see Chapter 6.]
[Summarizing the remainder of the social history, she eats a
low-fat/salt diet and exercises three times weekly in a 45-minute aerobics class, maintaining her weight around 120 pounds.
She wants to do more about relaxing but isn't sure what to do.
She is trying to be a good model for her "lax husband" and
always uses her seat belt. Except for an occasional cup of coffee
and glass of wine, she has never used addicting substances. She
and her husband socialize frequently and she views him as her
main source of emotional support. Her husband has had some
erectile dysfunction; she has no reason to suspect her husband
has other sexual partners. She thinks her decreased libido "will
take care of itself" when her job problems are resolved. She's not
interested in talking any further about it at this point. She has
no sexual partners outside of her marriage and had two other
sexual partners prior to marriage. There's no history of sexually transmitted infection or intimate partner violence (or other
types of abuse now or in the past), and she and her husband are
heterosexual. She feels that, if not for her work stress, her mood
would be fme and she does not endorse symptoms of depression
or anxiety. She acknowledges the role of stress in her symptoms.

1.30

SMITH'S PATIENT-CENTERED INTERVIEWING

Her church attendance has decreased since moving here due to
her busy schedule, but she still prays regularly and fmds it a
comfort. The clinician learns that Ms. Jones has no functional
limitations, has done nothing about an advance directive but
thinks it's a good idea. Ms. Jones' situation is admittedly very
straightforward, and she is a bright, resourceful patient. The circumstances and details, however, don't always fall together so
easily and this inquiry can take much longer. Because of space
constraints, we won't recount the remainder of the SH but,
rather, indicate that the clinician inquired about each remaining item in Table 5-5 that had not already been covered. This
information can be found in the written report of Ms. Jones in
Appendix D.]
•

FAMILY HISTORY (STEP 9)

The family history (FH) is another rich source for completing the personal
database, as well as for understanding familial health risks, both genetic62
and environmental. The FH can provide information about contagious
(pinworms, tuberculosis, varicella), toxic (carbon monoxide, lead), familial
(breast cancer, coronary artery disease, alcoholism, depression), and heritable
(hemophilia, sickle cell anemia) diseases. Also ask if anyone in the family has
similar physical problems to the patient's, or if anyone at home has been ill
lately with similar concerns.
With families, the complexities of multiple interpersonal interactions
come to the forefront.63 You most want to know who is who, who is available
to the patient and in what way. In general, obtain information for at least two
generations preceding the patient, as well as for any subsequent generations,
and include parents, siblings, and children for each generation. Although not
significant for genetic disorders, this includes spouses, adoptees, and other
significant members of the family outside the bloodline, because shared environmental factors may contribute to illness, and these relationships can have
importance for the patient's health that transcend genetics.
Once again, use open-to-closed coning inquiry to obtain the information in Table 5-6. After announcing the transition and explaining your rationale ("Now Ia like to ask about the health of your family members, because
sometimes diseases can run in families"), begin with a screening open-ended
question ("Tell me about any illnesses or other problems that run in your family''). Then ask open-ended questions about the age and health of the patient's
immediate family as well as the causes ofdeath and ages offirst-degree relatives

• TABLE 5-6. Family History (Step 9)
1. General inquiry
2. Inquire about age and health (or cause of death) of grandparents, parents,
siblings, and children
3. Ask specifically about family history of
. Diabetes
· Tuberculosis
· Cancer
· Hypertension
· Stroke
· Heart disease
· Hyperlipidemia or high cholesterol
· Bleeding problems
·Anemias
· Kidney disease
·Asthma
· Tobacco use
· Drug use
· Alcoholism
· Weight problems
· Mental illness
o Depression
o Suicide
o Schizophrenia
o Multiple somatic concerns
· Symptoms similar to those the patient is experiencing
4. Develop a genogram
a. Two generations preceding the patient and all subsequently; involves
parents, siblings, children, and significant members outside the bloodline
for each generation
b. Age, sex, mental and physical health, and current status are noted for each;
note age at death and cause
c. Note interactions among family members for psychological and physical/
disease problems
5. Psychological
a. Dominant members and style (e.g., love, anger, alcoholism)
b. Major interaction patterns (e.g., competition, abuse, open, distant, caring,
manipulation, codependent)
c. Family gestalt (e.g., happy, successful, losers)
6. Physical/disease
a. Patterns of disease (e.g., dominant, recessive, sex linked, no pattern)
b. Patterns of physical symptoms without disease (e.g., bowel trouble,
uncoordinated, headaches)
c. Inquire about others with similar symptoms (e.g., infection, toxic, anxiety,
anniversary reaction)

1.32

SMITH'S PATIENT-CENTERED INTERVIEWING

("How is your father's health?" "Your mother's health?~ etc.). Patients with
recent losses may exhibit emotion, which you should address with "NURS."
Then list specific diseases, for example, tuberculosis, diabetes, colon cancer,
breast cancer, prostate cancer, heart disease, bleeding problems, kidney failure
or dialysis, alcoholism, drug and tobacco use, weight problems, asthma, and
mental illness (depression, schizophrenia, multiple somatic concerns, suicide,
violence) ("Thinking now about all of your relatives, does anyone have diabetes? Tuberculosis?~ etc.). In the case of genetic diseases, determine if the
affected family member is a blood relative; obviously this doesn't apply for
infectious or environmental diseases.
Some clinicians construct a genogram to organize these data.63- 65
Genograms can identify conditions that might be amenable to genetic testing,
and help identify dysfunctional family patterns and high medical utilization.
As demonstrated by Ms. Jones' genogram in Appendix D, this graphic form
depicts myriad features in the family. Ages, gender, state of mental and physical health, and current status are obtained for each; when deceased, the age
and cause of death are noted. Depending upon time, data can profitably be
extended to include education, work, psychological style, and a host of other
features for each member.
Given time and need, learn also about dominant and nondominant family
members, and their specific styles, for example, controlling, passive, caring.
In addition to individual psychological proftles, the interactions among family members (e.g., direct, indirect, conflicted, close) are equally important.
You can also ascertain the gestalt of the family and its unique persona, for
example, the patient came from a happy family or a fighting family.
Many patients link diseases in the family and their disorder ("my father
had a heart attack and I've got a murmur" likely refers to different problems).
Finally. especially following the death of a relative, patients worry about being
at increased risk because of familial connections. To illustrate, a healthy
21-year-old woman presents with chest pain and worries about having a heart
attack 10 days after her grandfather died suddenly of a myocardial infarction. Most of these symptoms relate to the patient's understandable grief and
worry. While not the intent of the FH, if emotional material arises you must
be supportive and address it; for example, in discussing the dates of death
of her grandfather, the patient becomes sad and tearful. As before, patientcentered interviewing skills may be called upon.
With the large amount of potential data, the FH focuses on family data
relevant to current problems. Beginning clinicians, however, again are urged
to obtain all FH data during initial interviews in order to learn the categories
themselves and the richness and variability ofthe FH in different people. Busy
clinicians often must acquire these data over many visits, often aided by questionnaires that patients can complete beforehand.

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:133

Continuation of Ms. Jones VIsit
Clinician: Well, that's a lot of information. You've sure had a lot going on
(referring to the SH). We've still got a little more information
to gather and need to switch now to your family because some
illnesses can run in families. [The clinician continues to weave
a patient-centered, respectful atmosphere into orienting comments to Ms. Jones, and is making yet another transition, now
into the FH.]
Patient: That's fine.
Clinician: Are there any medical problems in your family, you know illnesses or any problems? [Focused, open-ended beginning]
Patient: Nothing really. You made me think earlier about that one aunt
who had some kind of headaches.
Clinician: Besides headaches, is there anything running in the family. [The
clinician makes sure Ms. Jones knows that any familial problem
is being inquired about.]
Patient: Well, my grandmother had diabetes; is that what you mean?
Clinician/ Yeah, that's it. Any other diabetes in the family (no)? Tell me
Patient: if anyone in the family has any of these diseases when I mention it: tuberculosis (no), cancer (no), high blood pressure (no),
stroke (no), kidney failure (no), bleeding problems (no), heart
attacks (no), alcoholism (no), high cholesterol (no), tobacco
use (no), drug use (no), or mental problems (no) [This helps
the patient understand what is being requested; the clinician
screens for a number of diseases ofpossible familial origin, each
asked individually.]
Clinician: I need now to get some information on your immediate family,
and then we'll go to your parents' and grandparents' families. Can
you start by giving me the ages of your kids and your husband?
[The clinician has begun getting a listing of each family member
of this and the preceding two generations. This will include their
ages, sex, mental and physical health, and age and year of death,
as applicable. We will not recount the interview here because
of space constraints but Ms. Jones' genogram is presented in
Appendix D. Note the interactions among many members.]
Clinician: Well, we're just about done. Before we go on, though, how are
you doing?
Patient: A little weary but I'm fine.
Clinician: I know this is a lot of questions to be asking. You've been very
helpful. Anything I can do for you before we go on? [Once
again, the clinician uses patient-centered skills and attends to
the patient's needs.]

1.34

SMITH'S PATIENT-CENTERED INTERVIEWING

•

REVIEW OF SYSTEMS (STEP 10)

The review of systems (ROS) is less important than other parts of the histor~.67; we already have discussed the ROSin Chapter 4 as a resource that
lists most symptoms; Table 4-1 has a detailed list. Indeed, by this point, the
interviewer ordinarily knows everything of significance. The ROS is not used
for obtaining pertinent HPI/OAP, SH, or PMH data, rather, it serves only as a
final screening tool. Recall that the HPI and OAP are elicited after repeated
inquiries of "What other concerns do you have?" and "Is there something
else?" during agenda-setting (Step 2)-which means that little if any new,
important, or active information should arise here. Nonetheless, relevant data
are sometimes acquired; you must then fit them into the appropriate section
(HPI/OAP, SH, or PMH) during the write-up or oral presentation.
The ROS concerns primary and secondary data from systems not yet
considered. Here you return to the ROS and inquire about still unaddressed
symptoms and any secondary data, including specific diseases such as psoriasis or cataracts.
Some patients may attempt to list each cold and upper respiratory illness
they have had over the last 20 years when you are asking about nasal symptoms. Rather than obtaining details, you want to know only if the problem
has caused any disability, represents a significant issue, or has not completely
cleared. Refocusing patients helps, with comments such as "I don't need all the
details, but I do want to know if there have been any major problems." Do not
probe for, or encourage, symptoms except in pediatrics (see Chapter 7). Most
frustrating is the patient who answers positively to most questions, exhibiting
a "positive system review:' If this persists following clarification, it suggests
still unrecognized diseases or, more likely, a psychological disorder such as
somatization in which patients present with multiple physical concerns that
have no disease explanation. This represents the patient's expression of psychological distress through physical symptoms.
The ROS proceeds almost entirely by rapidly paced, brief closed-ended
questioning after an initial, orienting question such as "I need to ask you now
about any other important or current problems or symptoms you might have
had, so we don't miss something. Say yes only if the symptom has been significant problem." For example, if the gastrointestinal system had not yet been
addressed, the interviewer might begin open-endedly with "Any trouble with
your digestion or bowels?" and then inquire "Have you ever had trouble with
your appetite" (No); "Weight loss?" (No); "Weight gain?" (No); "Difficulty
swallowing?" (No); "Nausea?" (No); and so on until all of this system has been
explored. Questions of course are asked and answered individually. When
the more advanced clinician has memorized all symptoms on the ROS list,
s/he is urged to obtain the ROS when performing the physical examination-as

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:135

a time-saving device. For example, while examining the nose, ask questions
about nasal symptoms, while examining the eyes, ask questions about eye
symptoms, and so on. Always remain attentive to the patient's responses and
needs, and tells her or him that questions are "routine" and that you have not
noticed something to make you suspicious.
When the ROS is concluded, summarize briefly, ask if the patient has any
questions, and indicate that the physical examination will follow. Continue a
patient-centered atmosphere of courtesy, respect, and support throughout the
encounter.
Continuation of Ms. Jones VIsit
Clinician: I need to ask you now about some symptoms we haven't yet
talked about, you know, to be sure we haven't missed something
so far. Just let me know if you've had significant issues with any
of the areas I mentioned. [An effective open-ended introduction to the ROS]
Patient: Fine, but I don't think there's much more.
Clinician: We haven't talked yet about any skin problems; any problems
there? [An open-ended introduction to the integument system]
Patient: I thought I had some infection in my elbow once in 2000, but it
turned out used too strong a soap. It's cleared long ago.
Clinician/ Any problems since (no) or other skin problems like sores (no),
Patient: itching (no), rashes (no), changes in moles (no), abnormal hair
growth (no), or nail problems (no)? [The clinician is getting an
idea of how significant this is to Ms. Jones' current health and
then completes the ROS for the integument-related system.]
Clinician: [The clinician would now proceed to other systems not yet
addressed and inquire about all possible symptoms in each, as
outlined in Table 4-1 of Chapter 4; for example, hematopoietic,
endocrine, breasts, genital. At its conclusion, he would conclude
the middle of the interview as noted next.]
Clinician: Well, you've done a nice job telling me a lot about the problems
with headaches and your boss, and about the colitis. I think I
have a very good picture of what's going on. Is there anything
else you'd like to add? [A brief summary, understanding, support for her performance, and a patient-centered invitation for
any final words.]
Patient: No, I don't think so.
Clinician: In that case, we'll move on to the physical examination. I'll step
out now so you can get completely undressed. Please put this
gown on with the opening in the back, have a seat on the exam
table and drape this sheet over your legs. I'll be back in a few

ra

SKILLS EXERCISES
(Likely spread over several sessions)
Note: All the following exercises are preceded
by 3 to 5 minutes of patient-<:entered interviewing using Steps 1 to 5 with a smooth transition
into Step 6. This emphasizes the integration of
patient-<:entered and clinician-<:entered skills,
which are not used in isolation from each other.
1. Conduct Step 6 in role play multiple times,
taking from 5 to 15 minutes. Initially, use
very straightforward disease problems, much
as with Ms. Jones, over 5 minutes or so. As
you become comfortable with developing the
chronological description of symptoms (Step
6), the role play "patient" can begin to have
more complicated problems, such as angina
pectoris of 3 years duration but worsening
over 3 weeks in conjunction with cigarette

smoking and a family history of high cholesterol. See the vignette of Ms. Jones and the
video demonstration for examples.
2. When comfortable in role play, begin doing the
same exercise with real or simulated patients.
3. Try to do some hypothesis-testing with each
exercise. When doing role plays, have the
"patient" tell you in advance what problem
they will depict so you can read up on it beforehand and, therefore, have some hypotheses and relevant questions in mind to ask
about.
4. Each learner performs a complete history
on a family member or fellow Ieamer. Ask all
questions in each substep of Steps 6 to 10.
It is recommended that you use the book or a
checklist as a reminder of the many questions.

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:137

• SUMMARY
Begin the clinician-centered HPUOAP by converting the patient's concerns to
symptoms from the ROS and then refining them with the symptom descriptors. Then organize primary and secondary data into chronological sequence,
progressively learning to test disease hypotheses as you proceed. Use the
PMH to elicit important but not current problems. The SH and FH complete
the personal and, to a lesser extent, the primary and secondary data base.
Finish by screening for still undetected primary and secondary data using the
ROS. (This order-with minor variation-is used by clinicians throughout
the world to present [in writing and verbally] the patient's history. Obtaining
it in the same order will help you organize your presentations.)
By the repeated coning-down process of brief open-ended screening
followed by closed-ended acquisition of necessary details, you will better
understand previous personal and symptom data from the beginning of the
interview and, in addition, acquire other essential parts of the data base to
complete the interview. Although not now as prominent, intermittently use
patient-centered interviewing skills by making supportive comments and
inquiring about how the patient is doing with the process of the interview,
more extensively using these skills when the patient becomes emotional or
presents important, new personal data, in order to draw out the story, seek out
the emotion, and respond empathically (NURS).
This completes the middle of the interview. You can now make a complete
biopsychosocial description of the patient using integrated patient-centered
and clinician-centered interviewing skills. By fully appreciating the patient's
disease problems and the personal/emotional illness context in which they
occur, you are using a scientific approach, which will benefit the patient. After
obtaining further information from the physical examination, you will be
ready to end the interview, as we will discuss in the next chapter.
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393-397.

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Step 11: The End
of the Interview
The doctor of the future will give no medicine but will instruct his patient in
the care of the human frame, in diet and in the cause and prevention of disease.
Thomas Edison, 1902
In the beginning and middle of the interview you gathered information from
the patient and established a relationship with him/her. At some point in the
interaction, usually after an appropriate physical exam and/or review of laboratory data, you need to share your impressions and engage in a conversation
about the next steps of diagnosis and/or treatment. You may be tempted to
educate and/ or motivate patients earlier in the interview, but this vital activity
is usually best done after data gathering is completed. A successful end of the
interview leads to better health outcomes, because patients are more likely to
understand and agree with plans and carry them out. Patients take the pills we
prescribe, go for x-rays and tests, and keep their appointments. We do not do
it for them. Therefore, the end of the interview is a key element in successful
health outcomes. 1- 6 See also DocCom Modules 10 to 12?-9
The structure of the end of the interview depends on the needs of the
patient. Consider these patients during a single clinic morning. The first
patient, new to your care and similar to Ms. Jones, requires information on
your findings from the history and physical examination, answers to questions, and diagnostic and treatment plans for the future. The second is a patient
making a follow-up visit to discuss the results of a recent test. Unfortunately,
you have discovered a life-threatening disease and you need to deliver bad
news to this patient. In this case, you devote a large part of the interaction,
following the interview and physical examination, to delivering the bad news
and making subsequent plans. The third patient asks for no information but
you want to discuss a topic that the patient does not ask about-the patient's

143

• TABLE 6-1. End of the Interview-General Guide

1. Share information
a. Orient patient to the end of the interview and ask for permission to begin
discussion
b. Frame the discussion (diagnosis, treatment, prognosis) according to the
patient's perspective-ideally already elicited
c. Iteratively provide information using "ART loops"
d. Use plain language
2. Assess understanding
a. Ask patient to teach-back, using ART
b. Provide written plans/instructions
3. Invite the patient to participate in shared decision making
4. Close the visit
a. Clarify next steps, as necessary
i. What you will do
ii. What the patient will do
iii. What the time of the next communication will be
b. Encourage questions
c. Acknowledge and support
Speak as plainly as possible, avoid jargon, and give information in small chunks.
Answer patient's questions, elicit and/or address patient's emotional reactions
throughout the encounter.

use of tobacco. You devote the end of this interview to motivating the patient
to consider quitting smoking.
The end of the interview thus involves issues stemming from either the
beginning or middle of the current interview, or from a previous interview; and
requires effective skills in delivering information, motivating, and sharing decisions with patients. 10•11 The end of the interview guide that follows, outlined in
Table 6-1, provides a pathway for ending most clinical interviews. Sections entitled "End of the Interview-Giving Difficult News" and "End of the InterviewMotivating Patients for Behavioral Change" describe steps for those tasks.

•

END OF THE INTERVIEW-A GENERAL GUIDE

Share Information
Orient the Patient to the End of the Interview and Ask for Permission
to Begin Discussion

This can be done with a simple statement, such as, "We have about 5 minutes

left; I'd like to share my thoughts about what may be causing your symptoms and
then discuss where to go from here. Is that all right with you? Seeking permission before sharing information increases the patient's receptivity to it.6

Chapter 6

STEP 11: THE END OF THE INTERVIEW

1.45

Ftame the Discussion (DI~osls, Treatment, Prognosis) According
to the Patient's Perspective-Ideally Already Elicited

Sharing information with patients can be a difficult task as they often do not
understand the information provided and forget up to 40% of it.12 Equally
problematic, most clinicians underestimate their patients' desire for information, especially when the patients are shy, reticent, or inarticulate. As a result,
they spend very little time explaining their findings to patients.4,5•13- 15
Seeking permission before sharing information increases the patient's
receptivitf: "Would it be OK if I shared my thoughts about what's causing
your symptoms?" Sharing information effectively does not mean you have to
turn the patient into a "mini expert" on the topic under discussion. 10 Rather,
provide enough information until the patient has a conceptual understanding
or "gets it:'10
By this time, you should have an understanding of your patient's perspective regarding the chief concern, for example, fear that a headache could be
due to a brain tumor. It can be helpful to incorporate this perspective in your
discussion. Depending on their expectations, health beliefs, previous experiences, or general disposition, some patients can perceive as "bad news" diagnostic data that you consider routine. 16, 17 One way to mitigate this is to deliver
good prognostic information before you declare the diagnosis,18 for example,
"After reviewing all the information I feel confident that we have an excellent
chance of controlling your headaches. I believe you have migraine headaches,
not a brain tumor, as you feared."
Clinicians have a tendency at this point to provide a "data download:' which
can overwhelm patients, even those with high health literacy. Derived from
the motivational interviewing literature, the Academy of Communication
and Healthcare has developed some better, systematic ways for providing
information at the end of the interview. 19 After sharing the diagnosis and
before presenting details or plans, use the mnemonic ART to Ask, Respond,
and Teach.
Ask the patient what he/she knows about the diagnosis in order to establish
the patient's baseline knowledge and help you tailor your message for maximum benefit, for example, "Have you heard of migraine headaches? What do
you know about them?" See also DocCom Module 10?
Once you have heard the patient's answer, Respond, with empathy if needed,
for example, "Sounds like you know a lot about this!" or, "Wow, your cousin
really had a difficult time with her headaches. I can imagine that could be
concerning for you" -that is, use your NURS skills.
Having a sense for the patient's a priori knowledge, Tell him/her what s/he
needs to know to correct misunderstandings or fill in knowledge gaps. WhUe
giving information, speak as plainly as you can, avoiding medical jargon, for

1.48

SMITH'S PATIENT-CENTERED INTERVIEWING

example, saying "pain killer" instead of "analgesic" and "cancer" instead of
"carcinoma." Use clear, short statements with simple words about just one bit
of data at a time. Encourage and answer questions until the patient understands the information.
Present each major piece of data about diagnosis, therapy, or prognosis
with ART. These "ART loops" can turn the "data download" monologue into
a dialogue, encouraging the patient's questions and helping to ensure that the
patient understands the information.
Use the steps outlined in the section entitled "End ofthe Interview-Giving
Bad News" and Table 6-2 in the cases where you anticipate strong negative
reactions to the news you are about to deliver.

Assess Understanding
Use ART to ask the patient to "teach-back" information,20 for example, Ask,
"Just to be sure we are on the same page, can you tell me what you understand
so far?" or, "When you get home your spouse is going to ask, 'What did the
doctor say?' What will you tell him?" Respond to the patient, for example,
"You really recalled the details!" and Tell what is needed to correct any misunderstanding or repeat the most important messages if the patient does not
mention them. "Closing the loop" in this way enhances patient understanding and adherence.20 Remember to assess and address the patient's emotional
reaction(s) to the information given.
Invite the Patient to Participate In Shared Decision Making

Clinicians are increasingly expected to involve patients in decisions about
their care. 1 For example, the 2010 Affordable Care Act includes provisions
that foster shared decision making in clinical practice. A clinician may order
the right tests and prescribe the best treatments, but these will do no good if a
patient is not able or willing to follow the clinician's recommendations. Many
patients are not aware that they can or should participate in decision making;
so, explicitly invite patients to participate11 by saying, for example, "I'd like us
to make this decision together; or "I want to make sure whatever we decide
works for you; so, I want you to be sure to let me know your preferences and
concerns about where to go from here:'
Some clinical decisions, such as whether or not to order a routine blood
test, only require a clear statement of what you would like to do and why, for
example, "I think we should check your iron level to see how much blood you
have lost. Does that seem reasonable to you?" Typically, these basic decisions
have clear, singular outcomes. ART can be used for other decisions, like starting a new medication, which have moderately uncertain outcomes but are

°

• TABLE 6-2. Giving Difficult News
1. Prepare yourself to give difficult news
a. Prepare emotionally
b. Confirm the medical facts
c. Prepare your delivery (consider patient
personality, health literacy)
d. Arrange proper place and adequate time
e. Determine who the patient would like to be
present
2. Establish what the patient (and family) already
knows
a. Set the stage if not already done
b. Ensure a safe, comfortable, private setting
c. Ensure patient's readiness to hear the news
d. Set the agenda
e. Address/negotiate another time for patient's
unrelated concerns
f. Assess patient's ability to comprehend the news
3. Determine how much the patient wants to know
a. Recognize, support various patient preferences
i. Decline voluntarily to receive information
ii. Designate someone to communicate on her
or his behalf
b. People handle information differently
i. Race, ethnicity, culture, religion, socioeconomic status, age, and developmental level
4. Deliver the news
a. Start with a warning shot
b. Give the news, then stop
Be comfortable with silence; do not rush patient
c. Give information in small chunks (categories)
with appropriate transitions
d. Speak as plainly as possible
e. Allow patient to determine pace and flow
f. Encourage/answer questions directly

5. Use relationship-building skills to express empathy
a. Monitor/address patient's emotional reaction
throughout interaction
b. Use emotion-seeking and empathy skills
(NURS)
c. Recognize that your presence alone can be
therapeutic
d. Convey hope while avoiding false reassurances
e. Reassure patient of your support; that you will
not abandon
f. Explore beliefs about implications of the news
6. Iteratively explain and negotiate next steps
a. Provide details as requested by the patient
b. Develop a plan for the future
i. May include further testing, treatment,
consultations
ii. Schedule next follow-up telephone and/or in
patient contact(s)
c. Assess/address patient safetyjsuicidality
d. Ensure support system is available, including
spiritual resources. If necessary, help patient
to access support
e. Ask patient to summarize main points and next
steps
f. Correct misunderstandings.
g. Provide (written or taped) summary of
discussion

Based on information in Buckman R. How to Break Bad News: A Guide for Health Care Professionals. Baltimore, MD: Johns Hopkins
University Press; 1992:65-97.

not controversial. These decisions usually require discussion of alternatives
with their pros and cons; for example, "We need to control your blood pressure better. We could increase the dose of your water pill or add a medication
called a beta blocker. The higher dose of the water pill might make you urinate a lot but the beta blocker might make you fatigued. Are you clear about
the pros and cons of these choices? What would you like to do?" 11

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SMITH'S PATIENT-CENTERED INTERVIEWING

Decisions that are controversial require explanation of the associated
uncertainties; again, ART can be a helpful structure.
Clinician: Ask "We should talk about your desire for a prostate-specific
antigen (PSA) test What do you know about the test?"
Patient: "It catches prostate cancer early and I'm worried about prostate
cancer."
Clinician: Respond and Teach "Many men are worried about prostate cancer; thanks for letting me know. Yes, the test can detect early cancers, but it
can also be abnormal ifyou have large prostate with no cancer. Unfortunately.
finding prostate cancer early is unlikely to help you live any longer, and we do
know that there can be serious side effects from testing and treatment such as
not being able to get an erection and leaking of urine. However, different men
have different preferences, so I would like to hear your views. What questions
do you have about the test?" 11 Regardless of the complexity of the clinical
decision, be sure patient understands pertinent information and decisions by
asking him/her to "teach [them] back."20
Decisions that require patients to significantly change their behaviors often
require more active engagement from the clinician than just explaining and
inviting patient participation. The section entitled "End of the InterviewMotivating Patients for Behavioral Change" describes a method that has been
effective for motivating behavioral change in some of the most challenging
patient encounters in clinical practice.21- 23 See also DocCom Module 31.24
Close the VIsit

In the final moments of the encounter, ensure that the patient is dear about
the next steps, has a fmal chance to ask questions, and that you part ways with
warmth and courtesy.
Clarify Next Steps, as Necessary

Summarize the conversation and be prepared to provide a handout if necessary; be sure the patient can read and understand the written information.
"We have decided that you will take one pill every morning and every evening
until the bottle is empty. that will be 7 days. We also agreed that you would
come back in ... Here is a handout of the exercises we talked about ... Do you
have any problem reading it?" If necessary. have patient "teach-back"19 the
discussion one last time.
A three-step process can ensure clarity: state what you will do, what the
patient should do, and when the next communication will be. "I will step out
to call the radiologist. When you are dressed, please go to the receptionist to
pick up the instruction sheet and schedule your next appointment. I will call
you as soon as the x-ray results are back."

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1.49

Questions

Give the patient a chance to ask remaining questions. It can be tempting, at
the end of the encounter, to subtly discourage questions, by saying, "Do you
understand?" or "Do you have any questions?" Instead be more encouraging
by asking, "What questions do you have?"
Acknowledge and Support the Patient before Saying Goodbye

Warm partings, like warm greetings, lead to strong and trusting relationships. "It's been a pleasure to be involved in your care," "It was good to see you
again;' "Please call if you think of any other questions before our next visit:'
"Take care of yourself and say hello to your spouse for me:'
Conclusion of Ms. Jones VIsit

Clinician: We have about 5 minutes left. If it's okay, I<l like us to talk about
where to go from here. [Clinician orients patient to end of interview and asks for permission to begin discussion.]
Patient: Please go ahead.
Clinician: Well, based on your history and physical examination, I'm
pretty confident that I know what is going on.
Patient: Oh good.
Clinician: I know that these headaches really were interfering with your
work and that you<l become worried that they could be due to
a brain tumor [incorporating the patient's perspective]. After
talking with you and examining you, the good news is that I
don't believe you have a life-threatening disease like a tumor or
stroke. I think you have migraine headaches. Tension headache
is also possible, but less likely. Do you know anything about
migraines? [notice how clinician begins with good news before
sharing the diagnosis. Before explaining further, the clinician
tries to establish patient's prior knowledge (Ask in ART)]
Patient: Not much, but one of my coworkers mentioned it when I was
telling her about my headaches. Boy I'm glad to hear that I don't
have stroke or a tumor.
Clinician: I can certainly understand that. I'm glad to be able to address
that concern. [Here, the clinician Responds to the patient
and expresses empathy with an understanding and support
statement.]
Patient: Me too.
Clinician: Okay, let's talk about what causes migraines; and then we can
talk about what to do about it. The exact cause isn't known, but
there is probably a problem with how blood vessels on your

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brain react to stress and other factors. Sometimes what you eat,
changes in weather, or hormones in your body can "trigger" a
migraine. We will have to figure out what your other triggers
are, but it certainly sounds like stress is one of them. [Clinician
first indicates the topics to be discussed, and then Teaches, using
plain language.]
Patient: [Nodding] How can we find out if! have any other triggers?
Clinician: The best way is to keep a diary of your headaches. I can give
you a handout: every time you get a headache, you will write
down what you ate or drank, events prior to the headache,
things like that. Bring the diary to your next appointment and
you and I can look to see if we can figure out what brings on the
headaches. Do you think you can do that? [Clinician follows
the patient's guide in iterative discussion by answering patient's
questions and responding to emotions and feelings.]
Patient: I can certainly try.
Clinician: Okay, once we figure out what your triggers are, we can talk
about how to avoid them. In the meantime, I have some suggestions about what to do to help the headaches. Is it okay if I talk
about them now?
Patient: Yes, please, that's what I need.
Clinician: First let me say that I want to make sure we decide what's best
for you; so, please let me know if you have any preferences or
concerns about anything we discuss.
Patient: Okay.
Clinician: Sometimes just managing stress and knowing that you do not
have a life-threatening disease can really help the headaches;
so, it is reasonable to just wait and see, but I'd like to prescribe a
medication that can help with the headaches if they become too
frequent or unbearable.
Patient: Oh, that would be great. ICl definitely like to avoid taking pills if
possible, but I like the idea of having something on hand in case
I need it.
Clinician: Okay. You don't have to remember all this, because it will be
written out on the pill bottle, but for the pills to work best,
you will need to take one at the frrst sign of a headache. If the
headache is not significantly improved, take another one after
2hours.
Patient: I'm glad it will all be written down.
Clinician: Absolutely. In fact, I can send prescriptions electronically to
the pharmacy right now so that they will be ready when you

Chapter 6

STEP 11: THE END OF THE INTERVIEW

:15:1

get there. Which pharmacy would you like me to send it to?
(Clinician sends prescription electronically to pharmacy after
explaining dosage and instructions to patient.)
Patient: Thank you.
Clinician: So, if you go home and your husband asks you what we talked
about, what will you tell him? [Clinician is closing loop by inviting patient to "'teach-hack."]
Patient: I have migraine headaches. They are caused by a problem with
the blood vessels in my brain, but stress can make it worse ...
I have to figure out what else can bring them on by keeping a
diary of my headaches, activities, and what I eat. In the meantime, if my headaches become unbearable, you want me to take
this medicine whenever I get a headache; hut you don't want me
to take more than two pills for any one headache. Is that right?
Clinician: Perfect. Now, it is important for us to see each other again in
about a month to see how you are doing and go over your diary.
Will you be able to come for a follow-up appointment in about
a month?
Patient: Yes, that will he all right.
Clinician: Before you leave I'll give you a sheet that summarizes everything that we have talked about. It explains what a migraine is
and some of the things that trigger it. It also has a headache
diary for you to keep and gives some suggestions about how to
relax when you are in the middle of a stressful situation. like
you to read it when you get home and we can talk some more
about it at your next appointment.
Patient: Okay. What about my colitis?
Clinician: Thanks for bringing that up.
like you to sign this form to
allow us to get your records from Dr. Jergens. In the meantime,
our referral clerk will call you next week. after we get approval
by your insurance company. to schedule an appointment with
the specialist.
Patient: Okay, thank you.
Clinician: What other questions can I answer before we fmish?
Patient: What are the side effects of the medicine I will he taking?
Clinician: Excellent question. A rare but significant side effect is chest
pain, and you should call right away if you experience this. It is
also possible to have an allergic reaction to it. This side effect is
also pretty rare, hut you can call me if you have any problems
with it, and we can try something else.
Patient: Okay that sounds good.

ra

ra

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SMITH'S PATIENT-CENTERED INTERVIEWING

Clinician: What other question I can answer for you?
Patient: No. You've explained everything very well.
Clinician: Wonderful. Just to make sure we are on the same page, can you
tell me what we have agreed to do from here? [The clinician
uses ART to ask the patient to "teach-back" periodically and at
the end of the conversation to enhance patient recall of important information.]
Patient: Well, I'll pick up my prescription from the pharmacy and take
it at the first sign of a headache. I will keep a diary and bring it
to the next appointment in about a month so that we can figure out what I can do to prevent these headaches. I'll read this
handout on stress management for some ideas on how to better
deal with my stress. Is that right?
Clinician: Yes, very good. The only other thing is that our referral clerk
will call you next week to schedule an appointment with the
specialist for your colitis. [The clinician responds to what the
patient said before teaching to correct misconceptions or to
reinforce information.]
Patient: Oh yeah, that's right.
Clinician: Okay, I will go out and get the headache information sheet and
Please bring this paperwork to the receptionist so that she can
schedule your appointment and give you a token for the parking lot. I look forward to seeing you in a month. [The clinician
closes the visit by stating what the clinician will do now, what
the patient should do now, and when the next communication
will be.]
Patient: Okay, I'll do that. Thank you very much.
Clinician: Thank you. Have a wonderful day.
Patient: You too.

• END OF THE INTERVIEW-GIVING DIFFICULT NEWS
As noted above, some patients may react negatively to routine information
about their health, and you may inadvertently find yourself in the middle of
a "bad news" situation.2>-27 Certain situations, such as sharing a new diagnosis of cancer, will negatively affect most patients. While we do not expect
or recommend that students share difficult news with patients on their own
without a more senior clinician being present for support, anyone who has
mastered the skills already discussed in this book can learn to effectively
deliver this news by following the steps outlined in Table 6-2. 25 See also
DocCom Module 33.28

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:153

Prepare to Give the Difficult News
First prepare yourself to be fully present with the patient. Consider how you
feel about the news you are about to deliver. Clinicians who fail to attend
to their own responses often are ineffective in delivering such news.29
Unrecognized emotions like guilt. sorrow, identification, or fear can cause
you to falsely reassure a patient, ignore her or his emotions, or avoid giving
the news altogether. 30•31
Next, determine who needs to be informed of the difficult news. In rare
cases, giving this news might be medically or psychologically dangerous, for
example, if the news would increase the risk of a depressed patient committing suicide. Nevertheless, we advise against long delays in giving difficult
news. Sometimes families ask that information be withheld from the patient,
often to "protect" them; sometimes cultural issues are involved (e.g., in some
Asian cultures, family members make health decisions with or without the
patient, and the patient sometimes defers all information and decisions to the
family). The clinician may accommodate a brief delay, for example, to bring a
close relative home, but a postponement should not be prolonged unless the
patient declines to receive the information. Patients have the right to information about themselves and they can also decline to receive it (see Step 3).
Determine who else, if anyone, needs to be informed and if this person should
be at the initial meeting. When the patient is young or of limited competence, a responsible person must be present. Similarly, a psychologically fragile patient or one in denial needs a responsible and supportive person present.
Indeed, many benefit from the presence of a supportive person. On the other
hand, if the patient does not want anyone present. accept this initially.
Review all relevant laboratory and other diagnostic tests prior to the meeting to make sure you have accurate data and that you fully understand them.
Most patients will ask questions about further testing, therapeutic choices, and/
or prognosis.32 Be prepared with the answers to these questions as well as questions about logistics such as which consultants to see and where/when to obtain
testing. Most patients remember very little after being given bad news, so be
prepared to keep answers short. simple, and tailored to patients' needs. Before
the difficult discussion, determine the important points you plan to make; you
can even rehearse the key statements aloud. Incorporate information about
the patient's personality style, spiritual life, beliefs, and support system in your
preparation. Be prepared to offer the patient some written information that
summarizes the major points of the conversation. This will help the patient
later remember the information and follow your recommendations.
Be sure to arrange a proper place and time to ensure privacy and allow
enough uninterrupted time to deliver the news, address the patient's emotions, and answer questions. A private office or room often suffices. Avoid

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SMITH'S PATIENT-CENTERED INTERVIEWING

discussions in hallways, coffee shops, or any other place where privacy and
comfort are unlikely. When bad news can be anticipated, negotiate in advance
who should be present at the follow-up meeting. If advance arrangements
have not been made, you can personally make them; but avoid giving bad
news on the phone; say instead, "Some of your lab tests are back. They're
too complicated to talk about on the phone so,
like you and your wife to
come in later today, to discuss them:' This sort of "message framing" sounds
innocuous but may still worry the patient, so try to arrange the meeting as
soon as possible and provide sufficient time.

ra

Establish What the Patient Already Knows

Use patient-centered skills to uncover and address immediate concerns and
eliminate potential barriers to communication. As with every patient-centered
encounter, first set the stage by properly greeting the patient and companions
and making sure the patient is ready for the conversation.
Next, set the agenda for the encounter. Indicate how much time is available and your need to discuss the health problem, and invite the patient to
give his/her agenda items; for example, "We have about 20 minutes together.
I want to discuss the results of your tests. Before that, though, ICllike to know
whether there is something else you wanted to talk about." Setting the agenda
allows you to learn about whatever else might be going on in the patient's life
at the time that might be more important and/or more stressful than the news
you are about to deliver.33 If the patient brings up an item that is not easUy
addressed during the allotted time, negotiate a deferral. As you set the agenda.
inquire about the patient's expectations and specific needs for the interaction; for example, "What do you understand about your illness?" "'How would
you describe what is going on with your health right now?" "What did other
doctors tell you about your condition or any procedures that you might have
had?" "When you first developed your symptom, what did you think it might
be?" Try to engage the patient in a conversation about what s/he understands
about his/her condition. Determine if absent famUy members that the patient
relies on can be brought in; reschedule if needed.
Look especially for emotions; you may discover, for example, that the
patient fears anticipated bad news or has exaggerated anxiety about its implications. Alternatively, you may learn that the patient has some misinformation that needs to be corrected.
Determine How Much the Patient Wants to Know

Having established what the patient already knows about his/her condition,
it is important to determine how and if the patient wants to learn about any

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bad news. Many clinicians misinterpret the biomedical ethical principle of
autonomy as meaning that every patient must know all relevant information
about their condition, that is, become a "mini expert." 10 Autonomy means
that patients can decide how much, if any, information they want to hear.
Patients have various preferences regarding the amount of information they
want/need, and this step, whUe it seems counterintuitive, allows you to determine and respect those preferences. One patient may want all the detaUs,
while another may decline to receive information, designating someone else
to make decisions on his/her behalf. You can begin this discussion by asking,
for example, "If this condition turns out to be serious, do you want to know~"
or "Would you like to know the full details of your condition~ If not, is there
somebody else you want me to talk to?" or "Some people like detaUed information, some people only want 'broad brush strokes; and some people don't
want to know what is happening with them, but would rather their families be
told. What do you prefer?~
The steps of this pathway up until now are best completed before diagnostic tests are ordered, but often in the hospital setting this is not possible
and you will need to perform these steps while keeping the knowledge of the
difficult news to yourself. This can be emotionally challenging, especially for
clinicians early in their training. We urge you to seek out support from more
experienced clinicians. It is often helpful to watch an expert share such news
with a patient first, and then get support and coaching when you do so.
Deliver the Dlfflcult News (See Also Section Entitled
"Share Information")

Based on what you learned from the prior steps, you are now able to share the
news in a way that the patient prefers. It is important to prepare patients to
receive difficult news, as sudden delivery may heighten the shock and prevent
the patient from processing the information.34 Preface by indicating that a
problem exists; for example, "I'm afraid I have some difficult news for you;'
"This is more serious than we thought," "I'm afraid the news is not good:' This
"warning shot" allows the patient to brace him-/herself for what is to come
and lessens the shock of the news. Proceed by sharing the news, "The growth
turned out to be cancer." As always, use plain language, avoiding euphemisms
and jargon, and then stop to allow the news to sink in.
Giving difficult news is often anxiety-provoking for the beginning clinical student. Many clinicians in high-anxiety situations find that silence adds
to their distress and they respond by talking, in the case of difficult news by
launching into a "data download" and listing treatment options and citing
survival statistics. We urge you to resist the temptation and put yourself in the

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SMITH'S PATIENT-CENTERED INTERVIEWING

patient's shoes at the moment they have been given what may be life-altering
news. You and your patients will benefit from the use of engaged silence, what
some label being a "non-anxious presence." Patients' responses vary widely,
but they will usually give you adequate verbal and nonverbal clues as to what
to do next.35
Use Relationship-Building Skills to Express Empathy

While relationship-building skills are always important in interactions with
patients, they are especially important in the setting of delivering difficult
news. After hearing this news, many patients express emotions either verbally
or nonverbally. Respond with empathy often using NURS. If emotion is not
forthcoming, ask for it with emotion-seeking skills and then respond to it
using NURS. As the interaction evolves, reinforce the patient's other supports,
strengths, and prior abilities in dealing with adversity. Assess the impact of
the news on the patient's life and the lives of others. Reassure patients that
they will not be abandoned, a common and weighty fear. Silence and a quiet
presence are powerful. Your own genuine emotions are appropriate and often
consoling. Alleviation of suffering can be most successful when you abandon
efforts to reassure and recognize there may be nothing to do but be available and provide support. You will be most effective if you can establish and
develop this relationship over many encounters, as might occur in a primary
care setting.
When giving the news, avoid false reassurance but still convey hope (hope
for the best; prepare for the worst). For example, in sharing a new diagnosis of cancer with a patient, you might say, "I know it looks bad but treatment is working better all the time, and there's still some chance for a cure."
Sometimes, though, you and your empathy provide the only immediate hope.
Your presence and support (both verbally and nonverbally such as placing
your arm around the patient's shoulder or holding the patient's hand) are
often the first link in eventually restoring meaning and hope to the patient,
'1 will be here with you and for you."
Iteratively Explain and Negotiate Next Steps (See Also Sections
Entitled "Share Information" and "Close the VIsit")

After attending to the patient's emotions and allowing the initial shock to
pass, the patient will often have questions. Indeed, difficult news interactions
usually involve multiple topics (such as the patient has cancer; s/he blames
him-/herselffor the diagnosis; the patient needs further testing but is worried
about how to pay for it; the best treatment is surgery, but the patient is afraid
of surgery because sister had a complicated post-op course). 16 Give only one

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bit of the most important information at a time and make clear transitions
between topics.
Remember to speak as simply and plainly as possible. Many patients do
not understand common medical terms like "mass, or know the location of
organs. Diagrams and pictures can be very helpful tools in explaining problems and diagnoses to patients. Try to avoid words Uke "positive; "negative:'
and "progressing" that inappropriately alarm or reassure patients because
they have different connotations in nonmedical settings.
Follow the patient's lead in deciding how far and how fast to proceed,
accepting questions and listening for emotions. Patients will usually ask
for more information. Give clear answers and explanations, and clarify any
misperceptions or overreactions; for example, "Yes, surgery will be needed
but they usually remove just the lump and not the entire breast anymore."
Gauge how well the patient is handling the information and try not to overwhelm him/her. Keep it short and simple. Most patients remember very little
after being given bad news. You will find that it is often more efficient and
effective to discuss details (e.g., of referrals and treatments) in a subsequent
visit. Additional meetings are often necessary to allow sufficient assimilation
of all information.
When the patient is ready, develop a plan for the future. Next steps may
include further testing, referral, and/or treatment. Ensure that the patient has
satisfactory support. This includes medical and psychological professionals as well as family, friends, church, support groups, and others. With some
patients, you may need to assist in obtaining support, either because there is
little of it or the patient is too overwhelmed or defeated to seek it out.
It is important to determine if the patient is suicidal. This can only be done
through direct inquiry; for example, "This is a lot to throw at you and I know
you're quite down. Do thoughts of hurting yourself arise, you know, taking
your life?" Ifyou detect suicidal intent, hear more about it and ask for immediate outside help. DocCom Module 2736 has more information on communicating with depressed patients.
In emotion-laden situations many people do not assimilate information
well and can develop an erroneous understanding, often one that is dramatically better or worse than the actual situation. For example, a patient might
erroneously expect to get better from a diagnostic test. Just asking the patient
whether s/he understands what you have talked about may not uncover gaps
in understanding. Instead, use ART to get a «teach-back,,20 described in section entitled "Assess Understanding:' Have the patient state his/her understanding of the main points and the next steps; correct misunderstandings
and reinforce key points. Even if a patient provides an accurate summary,
s/he may later not recall important information and/or instructions. To offset

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SMITH'S PATIENT-CENTERED INTERVIEWING

this, it can help to audio or video record the interaction and give the recording
to the patient, or provide written material as you normally would for the end
of the interview.37•38
Arrange a specific follow-up visit in the very near future both to provide
support and to monitor the patient for any further psychological impact of the
news. Follow-up can be in person or via telephone. In the inpatient setting,
you can ask if the patient would like a visit from the chaplain; you can get a sitter for the patient who is suicidal or visit the distressed patient again later that
day. Psychological or medical interventions may be necessary. Prescribing
specific tasks helps the overwhelmed patient; for example, listing who and
how to tell the news, writing down questions, and talking to others with similar problems.

•

END OF THE INTERVIEW-MOTIVATING PATIENTS
FOR BEHAVIORAL CHANGE

In addition to giving information, clinicians often have to ask patients to
adopt or change behaviors in order to improve their health. This can lead to
a conflicted end of the interview and jeopardize the clinician-patient relationship. Shared decision making in the clinical encounter is a prerequisite
for successful behavioral change.39 The transtheoretical model of change
shows that behavioral modification depends on the readiness of the patient to
change.2 Patients in early stages of preparation need the most help in arriving
at the decision to change. The clinician helps raise the issue to full awareness,
encourages insight, helps patients set realistic goals that are consistent with
their values, and negotiates specific plans with the patient. The skills that are
outlined in sections entitled "Share Information" and "Invite the Patient to
Participate in Shared Decision Making" are necessary, although not always
sufficient, for motivating patients to change. The patient who has already
made the decision to adopt a behavior requires support to make and maintain
the change. These principles have been used to help patients adopt healthy
diet and exercise programs (see DocCom Modules 16 and 2540.41) and quit
smoking (see DocCom Module 2442), drinking (see DocCom Module 2943 ),
and abusing drugs (see DocCom Module 3044).
We present here an evidence-based model of motivating patients that
has its foundation in the patient-centered skills you learned in Chapters 2
and 33.2 1•45 and in the principles of motivational interviewing. 19•4M 7 For the
patient who is not ready to commit to change, work to maintain the relationship and keep the door open for later educational activities. You can assume
that you are working with emotionally charged material. Use relationshipbuilding skills throughout, particularly at points of resistance. You will need

• TABLE 6-3. End of Interview-Motivating Patients
1. Education
a. Determine knowledge base, the patient's specific situation, and readiness
for change
b. Clearly inform about adverse potential of health habit needing change
c. Make brief, explicit recommendation for change
d. Highlight patient's capacity for change
e. Emphasize that help is available
f. Indicate that past failures do not bode poorly
g. Check understanding and desire for change
2. Commitment
a. Declare need for commitment
b. Assess patient's readiness to commit
c. Reaffirm commitment
d. Manage decisions against advice
e. Reinforce victories great and small
f. NURS liberally
3. Goals
a. Set realistic long-term goals
b. Set short-term goals to operationalize long-term goals
c. Should be specific, behaviorally defined, limited
4. Negotiation
a. Medical interventions
b. Behavioral change
c. Consultations and referrals
d. Follow-up

a sound clinical base to effectively educate the patient. Because the specific
approach to each adverse health habit is unique and varied, we have presented
a general guide only. As you learn clinical medicine, you can easily fit specific clinical information into the template outlined in Table 6-3 (1). (See also
DocCom Module 31.) 24 Use the mnemonic ECGN to help you remember the
following steps.
Educate the Patient

Use ART loops to explain the issue and options (including doing nothing) to
the patient. Assess the patient's knowledge base and readiness to change; for
example, "What do you know about the health impact of cigarette smoking?
Where are you in thinking about quitting?" In order for a person to change a
behavior, the pros for the change must outweigh the cons. 39 Help the patient
arrive at a realistic and meaningful understanding of the risks and benefits of
the different options.

1.80

SMITH'S PATIENT-CENTERED INTERVIEWING

Make a clear statement of your recommendation for the desirable behavior;
for example, "Your smoking is putting you at considerable risk n:J.like to see
you quit." Use your knowledge of the patient's personality type (see Chapter 8
section entitled "'Dimensions of the Patient that Affect the Relationship-The
Patient's Personality Style") to maximize impact and to enhance the relationship. For example, cite statistics to a patient with obsessive-compulsive personality trait, for example, "'research shows that smoking increases your risk
of lung cancer by 10-fold, even more for cardiovascular disease; it reduces
your life expectancy by 6 to 7 years. Ifyou quit smoking now, your health will
improve immediately; if you continue to be smoke-free for a year, your risk
for heart attacks and strokes will be almost as though you'd never smoked; the
same is true for emphysema after 2 years and cancer after 10 years"; emphasize cosmetic benefits to a patient with histrionic personality trait, ".. . if you
quit smoking your skin will be brighter, your teeth will look much whiter, and
your breath will be fresher ... I will work hard with you to prevent weight
gain." Similarly, appealing to a patient with a self-defeating style that continued smoking could prevent his/her ongoing care of an ailing family member may be compelling. Emphasize interests that the habit could interfere
with such as seeing grandchildren grow up, and the patient's capabilities for
change, for example, "You've really done a lot at your church and are known
as a doer. You could add this to your list of achievements, set a good example
for many, and gain the benefit of saving a lot of money." Gauging from the
patient's personality style and response to suggested interventions, you may
need to be by turns a cheerleader, politician, diplomat, and/or confidant.
Use the skills outlined in sections entitled "Share Information'' and "Invite
the Patient to Participate in Shared Decision Making" to foster shared decision making as you educate the patient. If you use undue pressure without
attending to the patient's needs and preferences, slhe is likely to resist. Keep a
hopeful and positive tone; for example, "There are smokers' support groups
and medications that are helpful. Weve had some great results." To further
encourage the patient, you can say that having failed before at changing a bad
habit bodes well for future success because most successful patients have had
many unsuccessful previous attempts.

Obtain a Commitment
Behavior change requires commitment from both the patient and the clinician. Signal your own commitment, for example, "I'll be working with you
weekly on this ifyou decide to go ahead ..." and explicitly ask for commitment
from the patient, "'Quitting is not easy and it will require effort from both of
us-are you ready to start working on this?" Trying to obtain a commitment

Chapter 6

STEP 11: THE END OF THE INTERVIEW

1.61.

may be the most awkward part of the interaction; tension can lead you to be
vague, indirect, or provide a loophole for escape. To someone who appears to
be on the fence about changing, you might begin to obtain commitment by
saying, "Are you really committed to walking ... On a scale of 1-10 (Where 1
is not at all and 10 is total commitment) where would you put yourself? Why
did you choose that number and not a lower one? What would it take to help
you get closer to 10?"
If the patient does commit to change, support the plan and reaffirm your
availability and that of other help. Praise and reinforce the decision to make
a change; for example, "I'm impressed that you're willing to work on such a
big change. I know it will be hard work but I know you can do it." Failure to
do an agreed upon task is common and predictable. Patients may consent to
a task because it is socially acceptable but fail to follow through because of
unexpressed ambivalence that results in weak commitment. They may have
difficulty disclosing the ambivalence or be unaware of it until after the visit.
Maintain an empathic stance and express curiosity, for example, "We were
both optimistic that you would set a quit date by the end of last month. Tell
me what prevented you from doing so." Focusing on a patient's positive qualities when progress is fleeting or absent can be difficult, but it is essential to
helping the patient to eventually succeed.
Shared decision making allows and accommodates the option that
the patient may choose not to follow your advice or recommendations.
Nonjudgmentally inquire about the patient's refusal, being careful that the
patient does not feel pressured or criticized, and clarify any possible misunderstandings. You can ask, "What would it take for you to change your
mind?"48 Our cigarette smoker, for example, might answer with, "Well, a heart
attack or cancer, I guess:' The answer itself sometimes helps the patient realize
how really dangerous the habit is and encourages behavior change.
Let the patient know that you accept and respect his/her decision. Defuse
differences or tension that might interfere with subsequent care. Reassure the
patient that you will neither pressure nor abandon him/her-but that you will
continue to gently explore the patient's readiness to change. One empathic technique is to express understanding of a dilemma; for example, "I can see you are
caught in a bind On the one hand, you're tired ofthese chest colds and want to
stop smoking. On the other hand, you enjoy smoking and find it releases stress
at work. So you want both to quit and not to. That's a real predicament!"
Help Patient Set Realistic Goals

A key component of effective behavior change is goal setting. Many chronic
diseases like diabetes, cardiovascular disease, and medically unexplained

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SMITH'S PATIENT-CENTERED INTERVIEWING

symptoms (MUS) are not curable; patients who suffer with them need to
establish realistic long-term goals to keep functioning or improve functioning
after setbacks. Healthy people may want to prevent disease and maintain their
well-being. Dialogue about goal-setting may include statements like, "What
are some of the things you would be doing if you weren't feeling so badly?"
Long-term goals are realized by achieving specific, measurable short-term
goals. Ask the patient, "What two or three things could you commit to doing
over the next 1 to 2 weeks?" If a patient indicates that she or he would like to
start exercising, ask him/her, "What exactly do you plan to do ... How many
times a week will you walk ... for how long?" Review these short-term goals
during subsequent visits and revise them together as needed, for example,
"You thought that stretching every morning would be possible for you. What
got in the way?" Write down all long- and short-term goals to help keep both
you and the patient accountable.
Negotiate a Speciftc Plan

After goals have been set and commitment is made, you need to negotiate
specific plans with the patient and understand the details of the behavior to
be changed so that an effective plan can be agreed upon. In our example of
the patient who smokes cigarette, you want the details of when the patient
smokes, the most important times for smoking (e.g., while drinking coffee),
what stresses prompt smoking (e.g., work), who else in the patient's environment smokes (e.g., best friend), and what situations might make the patient
resume smoking once stopped (e.g., "having a beer with the boys"). Strategies
for change must address these issues and, at the same time, be compatible
with the patient's daily life.
As usual, involve the patient actively in identifying problem areas and the
solutions. For example, if a cigarette smoker identifies drinking beer with his
friends as a situation that leads to smoking, you can ask the patient to identify
ways to either avoid or manage this potential trigger. Similarly, if a patient
says that s/he wants to light up every time s/he drinks coffee, you might ask
the patient what else s/he could drink or do instead of having coffee. Only the
patient can find those solutions that are unique to his/her life circumstance.
With some habits, use a "step at a time" approach; for example, in initiating
a low-cholesterol diet, negotiate decisions about which foods to reduce (e.g.,
red meats), the amount of reduction (e.g., one serving daily instead of three),
and the meal from which they are reduced (e.g., breakfast). Only if the cholesterol level does not fall would further negotiation be required (e.g., further
reduce red meat intake to twice weekly, and omit butter).
When applicable, negotiate medical interventions as well. For example,
you may use medications for elevated cholesterol only after dietary measures

KNOWLEDGE EXERCISES
1. At what point in the interaction does patient education usually occur?
During which visit?
2. List several circumstances where providing routine data is involved; list
several circumstances where you might need to give bad news; list several circumstances where you may want to not only inform the patient
but also motivate them to action.
3. In which patient education category will an extra focus upon the clinician-patient relationship be most important? In addition to using NURS,
what other factor(s) enhance the relationship in motivating the patient
to change?

SKILLS EXERCISES
1. In role play, inform a patient of the necessary details of his/her program
for several medications taken at different times of day; for example, an
antibiotic, decongestant, vaporizer, and oxygen for a patient with mild
("walking") pneumonia.
2. In role play, give a patient bad news; for example, that they have AIDS, an
abnormal mammogram, an abnormal amniocentesis, an elevated blood
sugar, or a cancerous-appearing lump in a chest x-ray.
3. In role play, inform and motivate a patient to stop or change a deleterious habit; for example, to stop smoking cigarettes, to change to a low-fat
diet, to begin a program of progressively increasing exercise.
4. When facile in role play, conduct all exercises with real or simulated
patients.

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Adapting the
Interview to Different
Situations and Other
Practical Issues
The interview vignette with Ms. Jones that we have presented thus far in this
textbook is just one example of how the patient-centered interaction between
a clinician and a patient can unfold. If you have viewed the AccessMedicine
companion videos or the DocCom modules, you know that the patientcentered interview can be adapted to different clinical settings and all patient
encounters. In this chapter, we will provide you with more instruction and
details on working with patients and situations that differ from the routine
medical visit and present challenges. We will discuss how you can adjust the
interview to different clinical situations. Perhaps you worry about interviewing a patient who cannot seem to stop talking, or one who it feels hard to pull
information from. The skills required in these situations are used primarily
in the beginning of the interview (Steps 1-5). This chapter focuses only on
how you can tailor the process of the interview in various medical encounters
with a variety of patients and does not consider the content that needs to
be addressed in specific clinical situations. Clinical textbooks will help you
obtain the details that must be incorporated into many of the encounters discussed here. 1
To aid you, we have developed several companion videos available at
AccessMedicine (www.accessmedicine.com/SmithsPCI). Rather than have
experts demonstrate the clinician's role, we have used resident trainees to
make the videos more realistic and applicable for readers who are themselves
new to interviewing. The demonstrations show what is possible after training.
•

BALANCING PATIENT-CENTERED AND CLINICIAN-CENTERED
INTERVIEWING SKILLS

There is no ftxed rule on how to distribute the time you have for an interview
between the beginning of the interview, the middle, and the end. Based on the
169

1.70

SMITH'S PATIENT-CENTERED INTERVIEWING

patient's needs, you will determine the initial balance during Steps 1 to 5. You
might average 10% of your time in the beginning of the interview for most
patients, but this allocation of time can vary from 2% for, say, a patient who
needs a medication refill and has no personal issues to more than 50% with,
for example, a patient with severe marital problems. The balance will depend
on the severity and urgency of the patient's personal issues. It may also be
necessary to return repeatedly to using patient-centered interviewing skills
even late in the interview.
In the beginning ofthe interview, the main block ofcontrollable time lies in
Step 4, continuing the HPI. Steps 1 to 3 and Step 5 usually take little time and
are similar from patient to patient. Consider the following examples where we
first describe patient-centered medical encounters in a variety of clinical situations and then with patients who possess various styles and characteristics.
•

ADDRESSING VARIOUS MEDICAL ENCOUNTERS
AND CHALLENGES

New Inpatient or Outpatient without Urgent or Complex
Personal Problems

First consider a typical new patient, like Ms. Jones, who comes to the clinician without urgent medical concerns (where immediate action is required)
or complex personal problems. Physical symptom complaints often predominate and we usually devote about 10% of our time to the initial patientcentered process of the interview. This will be your experience with most new
patients in a medical setting, whether inpatient or outpatient. Such patients,
like Ms. Jones, have defmite personal issues, yet they are not urgent or overwhelming; for example, a patient with known cancer is admitted to the hospital for chemotherapy but is more worried about his wife being home alone
with the flu; an outpatient presents with a weight loss of 5 pounds and is
somewhat concerned about possible cancer and wants "to be sure." The companion AccessMedicine video "New Inpatient Interview" demonstrates a
typical first patient encounter in the hospital setting. In this setting, the same
five steps are used. The AccessMedicine video, "'Evidence-based Interviewing:
Patient-Centered Interviewing" is much longer and depicts the entire patientcentered interview with extensive labeling; it involves a new outpatient and is
conducted by an expert.
New Patient with Urgent or Complex Personal/Behavioral
Health Problems

Some new inpatients and outpatients present with more urgent and complex
personal problems; for example, acute marital discord led to sleeplessness,

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ADAPTING THE INTERVIEW TO DIFFERENT SITUATIONS

1.71.

depression, headaches, and diarrhea for an outpatient who requested a
"'checkup"; or a recent unexpected business setback immediately preceded
the admission to the hospital of a now very angry man with chest pain; or a
patient admitted for pneumonia who is overwhelmed and crying after being
informed that his HIV test came back positive. In these instances, you will
give more time to exploring personal and emotional issues by increasing
time in Step 4 and, very likely, you also will spend time during the middle
of the interview (especially in Steps 6 and 7) to better understand details of
what could be a serious psychological problem (see Chapter 5). The companion AccessMedicine video, "'Patient with a Mental Health Disorder''
depicts Ms. Johnson, who comes to see her physician with vague complaints
of fatigue. After development of the personal and emotional stories and
through the use ofNURS, her clinician learns that Ms. Johnson suffers from
depression.
Follow-up Inpatient or Outpatient without Urgent or Complex
Personal Problems

Just as with new patients, most follow-up (return visit) patients do not have
urgent or complex personal problems but these encounters differ because they
are much briefer. Consider a 5- to 15-minute follow-up visit, either in- or outpatient, for predominantly physical concerns. You progress through Steps 1 to 4
but Step 4 will be rather brief, since the patient offers no pressing personal
issues or emotional burdens. You will then make a transition (Step 5) to the
middle of the interview (Step 6) where you will fill in the HPI of the patient's
physical symptoms; for example, any worsening or new symptoms after treating the patient's strep throat 1 week ago or any change from the preceding day
in this inpatient's chest pain. In both instances, you must listen for new personal contextual information ("'want to get back to work," "want to go home")
and respond empathically, yet most personal data already will be known and
the patient's symptoms will be your primary focus. The personal issues of follow-up patients frequently concern treatment and disposition; these are often
addressed in the end of the interview, as we saw in Chapter 6. The companion
AccessMedicine video "Follow-up Inpatient Interview" with Ms. Jones (a different Ms. Jones than the one we have gotten to know throughout this book)
demonstrates using the five steps for a follow-up visit as does the vignette with
a clinical student and Mr. Gomez below.
~nette of Mr. Gomez
(Ward rounds by a clinical student on a patient with primarily physical symptoms on his second day of hospitalization with no more than 15 minutes
available.)

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SMITH'S PATIENT-CENTERED INTERVIEWING

Student:

Patient:
Student:
Patient:
Student:
Patient:
Student:
Patient:
Student:

Patient:
Student:

Patient:
Student:

(Observes patient for comfort, helps with pillow, and sits down)
Hi Mr. Gomez, it's Nancy Brown. I'd like to examine you this
morning (pointing to stethoscope), but before I do that, let's get a
list of the concerns you want to talk about. [The student sets the
stage by attending to the patient's comfort, gives her own agenda
(stethoscope), and asks about the patient's agenda so that both
Step 1 and Step 2 are addressed in no more than a few seconds.)
Nothing new.
How are you doing with the pain? [An open-ended question to
start Step 3]
The pain is better. Can I leave now? [The patient gives both
symptom and personal data]
Leave?
Yeah, to go to my job. Remember, we talked about it?
We did talk about that, anything new?
No, but they still need me at work, and my wife's in a fix being
alone at home with the kids.
Well, I sure understand you're concerned about your job and
that's a tough situation for your wife to be in, but there's a little
more. Our (gesturing to the patient and herself) biggest concern now is to be certain you are OK and don't have an appendicitis and we aren't sure yet. [Note that, in a brief visit, the
student addresses the personal issue to start Step 4, but does
not reexplore what she already knows except to ascertain no
change. The student also incorporates naming, understanding,
respect, and support into her response. The response was supportive both verbally and nonverbally. involving the patient by
pointing and using the terms "our" and "'we:']
You still think tomorrow?
Well, if the blood count and CT scan tum out OK and the pain
clears up, it's possible. But we just don't know for certain yet.
Our focus now is your health and getting you back to your
job in good shape. Sounds difficult for you, though. [The student continues addressing personal issues in Step 4 by staying
focused on the question raised by the patient and again makes
a supportive statement about wanting most to help the patient,
and a respect statement about how difficult this situation is.]
Yeah, thanks [The patient seems satisfied.]
Let me shift now and ask you to tell me more about the pain.
[This is Step 5, the transition, and a beginning of Step 6 of the
middle of the interview still using open -ended requests. Note

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ADAPTING THE INTERVIEW TO DIFFERENT SITUATIONS

1.73

that the student effectively conducted the patient-centered process in about 1 minute and now will address the patient's symptom in Step 6.]
Patient: Well, the pain yesterday was more around the belly button but
now it's down here on the right (right lower quadrant). It hurts
to push on it but isn't bad otherwise.
Student: Have you had bowel movement yet? ... [The student will spend
the next several minutes determining symptom descriptors,
if symptoms are changed from yesterday, and search out and
defme any new symptoms. She will then examine the patient,
review the laboratory data, and make further plans, in conjunction with the resident and supervising physician. Steps 7 to 10
of the clinician-centered process will be unnecessary because
the student obtained these data when the patient was admitted
to the hospital the previous day. The student also will inform
the patient that she will be back when the results of the lab tests
and computed tomography (CT) scan are available. Note again
how closely the patient's personal issues revolve around the
symptom.]
This vignette demonstrates that a predominantly clinician-centered
follow-up interaction also can address personal issues.

Follow-up Patient with Urgent or Complex Personal Problems
You may have a follow-up patient with urgent or complex personal issues,
often but not always with no physical complaints. You will quickly determine
this during Steps 1 to 4, and then take more time in Step 4 to better develop
the personal issues, uncover emotion, and respond with NURS, resulting
in a predominantly patient-centered interview. Even with no physical concern expressed by the patient, you will still make a transition to the middle
of the interview and use clinician-centered skills to, for example, ask more
about symptoms of depression (see Chapter 5, section entitled "Addressing a
Predominantly Psychological Problem" and the companion AccessMedicine
video with Ms. Johnson titled "Patient with a Mental Health Disorder"), and/
or briefly inquire about the patient's physical health; for example, "Any more
problems with the heartburn? The constipation?~ that is, always integrating
the personal and symptom data.
~nette

of Ms. Wong

(An outpatient previously seen for other problems now presents with a predominantly personal problem in a 15-minute appointment slot.)

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Clinician: Hi, Ms. Wong. I haven't seen you for a while. Aie you comfortable sitting there? (She nods.) Anything you need before we get
started? [Step 1]
Patient: No, unless you can fix my son. He's getting a divorce. And that
means the grandchildren will have to leave town. And then ...
[The patient is introducing tension-laden personal material
already.]
Clinician: That sounds very important. I want to hear more about it in a
moment, but before we get started, I want to be sure to get a list
of what you would like to talk about today; so I can be sure to
address all your concerns, OK? [The clinician determines that
it is appropriate, as is usually the case, to interrupt briefly and
respectfully to get the agenda (Step 2).]
Patient: Well, I came because of my back. It's a little worse, and you did
all those tests a year ago that were 0 K. I think it's the stress with
my son.
Clinician: OK, the back and the stress. Is there something else? [The clinician is being certain that the entire agenda is elicited.]
Patient: No, that's enough!
Clinician: OK. So, tell me more about this stress. Sounds like a tough time
for you [When the patient has already begun with strongly felt
personal data, it is appropriate to return directly to the material
raised to start Step 3.]
Patient: Well, my son has been married for nearly 15 years and everything always seemed OK. I think they thought so, too. And now
this. My daughter-in-law is furious at him.
Clinician: (Silence) [The clinician is in the nonfocusing Step 3 and simply
letting the patient lead.]
Patient: He's always been a bit of a ladies' man and, well, that's caused
problems before, too.
Clinician: This sounds like it's been a tough time for you. How're you
doing with all this? [Beginning to grasp the problem and recalling the need to be timely; the clinician introduces Step 4 by
changing the focus to her emotions. While following the steps
in sequence, one does not always need to address all substeps
such as, in this example, addressing physical symptoms before
proceeding to emotion. The details of the son's problem are less
important also and can be developed later if necessary.]
Patient: (Starting to cry) I'm mad at him for being so stupid. And I can't
stand having to be away from the grandkids. She'll get them and
they'll move back to her home. (More crying)

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[This story would now be developed by using, active openended, emotion-seeking, and empathy skills over and over in
a cyclic way. Using these skills allowed Ms. Wong to admit that
she'd been feeling depressed and had stopped going to her card
games; she expressed worry because this is how she felt following her husband's death. We will now pick it back up to show the
transition to the middle of the interview.]
Clinician: You've sure been through a lot and I'm glad you've told me
about it. Do you feel OK to change gears now so I can ask a few
more questions about your back? [The clinician is in Step 5 and
checking to see if the patient is finished talking about this difficult problem.]
Patient: Sure, and thanks again for listening. I feel better.
Clinician: [In Step 4, the patient related that she had lost interest in a previously enjoyable activity-her card games (anhedonia) and
felt depressed. She offered positive answers for depression,
without having been specifically asked the depression screening questions (see Chapter 5, the section entitled "Addressing
a Predominantly Psychological Problem" and the companion
AccessMedicine video titled "Patient with a Mental Health
Disorder"). Now, in the middle of the interview, the clinician
will ask more questions to complete the diagnostic criteria for
depression.] I wanted to ask about your sleep. How's that going?
Patient: Not very good.
Clinician: Tell me about it.
Patient: I just stare at the ceiling and worry! [In addition to sleep disturbances, the clinician will learn that Ms. Wong has other
symptoms of depression: a poor appetite, low energy, and difficulty concentrating, further supporting the diagnosis of major
depression, an urgent problem that will require treatment. The
clinician then ascertains, continuing to use predominantly
closed-ended inquiry, that Ms. Wong is not suicidal. We now
pick up the conversation where the clinician is addressing the
back pain that brought the patient in.]
Clinician: Well, that's sure been a hard time for you. Could you now
say more about the backache? [One still addresses physical
symptoms-however insignificant they may seem or however
much the patient downplays them. Note again how closely the
symptoms and personal problems often are related.]
Patient: It's the same place. And it never did go down the leg after that
one time 4 years ago. I don't think it's anything ... [During the

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next few minutes the clinician reviews the symptom descriptors
and then examines her. When the patient has dressed, the clinician will make recommendations about the depression and the
back pain.]
When a patient relates personal issues that cannot be "fixed; it is easy
to feel overwhelmed and unhelpful, but remember that communication is
therapeutic. The key to successfully managing the encounter is to recognize
the power of simply connecting with the patient through careful listening
(which begins in Step 3), drawing out the emotional context of the personal issue, and responding empathically, using NURS (Step 4). Most often
patients merely want to express their problems and receive empathic witnessing, rather than being told what to do to flx the problem. Of course, as
in this case when a diagnosis such as depression is made, specific treatments
can be offered such as antidepressant medications, psychotherapy, counseling, and other mental health treatments. Some mental health treatments
share the quality of professional and patient emotional connection seen with
patient-centered interviewing, yet they are different, more complex treatments with different processes and outcomes, and do not substitute for one
another.
Dlseas&-Preventlon VIsit

Patients often come without a focused, specific problem to address, yet they
might want preventive screenings, frequently referred to as an "annual physical." In this case, you will proceed in the same stepwise fashion that has been
outlined. In Step 2, the patient may often want to discuss several issues, for
example, flu shot, exercise program, diet, mammogram, and Pap smear.
Because the patient has no particular concern and may have many agenda
items, it is essential to keep asking, "What else?" or "What other concerns do
you have?" until all the concerns have been elicited. 2-4 It is often fruitful to ask
why the patient has come in at this particular time. You might learn that some
health problems have occurred in a family member or friends, or that the
patient has noted some alteration in body function and wants to be sure there
is nothing wrong such as cancer, high cholesterol, or diabetes. Upon eliciting
this story in an open-ended manner, use the emotion-seeking skills to explore
the attendant worry and anxiety. Then, you can use naming, understanding,
respecting, and supporting (NURS), offer especially a respect statement praising the patient for corning in and working to achieve maximum health status.
On the other hand, many patients simply come in for routine visits without
a specillc reason. In that instance, the beginning of the interview may be no

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more than 1 to 2 minutes oflargely agenda-setting and praising the patient for
coming in. In all disease-prevention visits, much time is spent in the middle
and end of the interview, using clinician-centered skills in the middle to pin
down details of the patient's health-related activities; for example (a) present
exercise pattern, how many minutes, how vigorous, or any related injuries;
and (b) specific daily diet, understanding of caloric and fat content, interest in
making major changes, and prior attempts to diet. Chapter 6 addressed how to
educate and motivate patients to change harmful behaviors such as smoking.
In addition, even though the patient may not have it as an agenda item, you
will want to determine his/her interest in pursuing routine age-appropriate
health-prevention recommendations, such as colon cancer screening, immunizations, and mammograms. During such visits, address all pertinent (to
the patient's age, gender, and status) aspects of social history (Chapter 5):
ethical-social-spiritual practices, functional status, health-promoting and
health-maintenance activities, and health hazards.
Of course, there is a spectrum of patients between the urgent and less
urgent personal categories, and there is no way to predict how many physical
symptoms will be present in either category. 5 In the difficult situation where
both personal and symptom data are plentiful, urgent, and complex, careful
agenda-setting (Step 2) will define what seems most important to both you
and to the patient. Even so, some issues may have to be deferred to a later
appointment.
Acute, Ufe-Threatenlng Medical Illness VIsit

During an acute, possibly life-threatening illness visit as seen in the
AccessMedicine companion video titled "Acutely ill Patient" the clinician
remains patient-centered as she addresses Mr. Green's medical issues, concerns, and fears. Patient-centered communication includes the use of touch
and reassurance-no need to use all five steps during these visits. Patients
require immediate medical/physical attention as they receive empathic
words regarding their physical state and the state of loved ones. As seen in
Mr. Green's emergency room encounter, the physician introduces herself,
clarifies her role, orients the patient, provides education regarding injuries
and subsequent plan, attends to comfort, and asks about his immediate
emotional needs. Generally, emergency patients require care that respects,
honors, and addresses patients' and families' needs, wishes, preferences, and
participation in decision making. Patient-centered communication geared
toward care, comfort, information and education, privacy and expectation
management facilitates the patients' understanding and capacity to aid in
their recovery.6

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•

ADDRESSING COMMON PATIENT COMMUNICATION
STYLES AND CHALLENGES

Even after you learn how to distribute time between the beginning, middle,
and end of the interview, there are still patient communication styles and clinical situations that influence interviewing and affect how time will be spent.
Patients interact with clinicians in diverse ways-some assertive, some passive, some informed. some less so, and some with communication challenges.
For example, as can be seen in AccessMedicine video titled "How to Interrupt"
and the section below "The Art of Interrupting," a loquacious patient can
require more time, more interruption, and less encouragement to talk than a
reticent patient telling the same story. Closing the encounter can feel awkward
until the art of interrupting and skillfully controlling the encounter becomes
learned through deliberate practice and learned techniques. Different interactional styles are influenced by many factors, including age, gender, education level, personality style (see Chapter 8, section entitled "Dimensions of
the Patient that Affect the Relationship-the Patient's Personality Style"), and
cultural upbringing (see section below entitled "Cultural Competence"). We
now consider some of these unique considerations, noting that most decisions about the available time are made during Steps 1 to 5.

The Less Talkative, Reticent, Embarrassed, or Fearful Patient
It is important to get reticent patients talking, about anything, whatever it
takes. Typically, the agenda items (Step 2) are limited and focused on physical
symptoms, and there is little response on the patient's part to initial openended inquiry (Step 3). The nonfocusing open-ended skills (silence, continuers, nonverbal encouragement) often are ineffective and, in Step 4, you
must rely on the focusing open-ended skills (echoing, requests, summary)
and emotion-seeking skills (direct, indirect). Among the latter, self-disclosure
may be particularly effective; for example, "I once had back pain and was very
frustrated, how about you?" Even though the patient may express no emotion,
you can direct empathy skills toward what you do know about the patient, for
example, "It sounds like some difficult problems you've had; you were right
to come in so we can help (naming, respecting, supporting):' Or "I bet you
have feelings about that tough situation." The reticent patient will often share
additional information in response.
To get the conversation going, you might need to be very explicit about
what you are asking for. For example, to begin Step 3 you might normally say,
"It sounds like the back pain is the most important thing for you today-tell
me about it." If the patient responds, "It hurts;' you will need to provide more
detailed instructions: "Please tell me all about your back pain, from the time

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it started until today, in as much detail as you can remember. This will help
me to help you." This cueing will often get a reticent patient started. The key
is to not give up on your open-ended skills too quickly. Rather, rely on more
actively using the focusing open-ended skills than you might in another interview. Often patients need time and experience to learn that you are interested
in the symptom story. If you try all the open-ended skills repeatedly and you
still cannot get much of a symptom story from the patient, then, in Step 4 ask
about the patient's symptoms using closed-ended questions, such as, "Where
exactly is the back pain located~': "Does it go down your leg~~ ·1\ny leg weakness?" Remember though to elicit the personal context of the symptom, looking for any thread of personal data to facilitate; for example, ifthe patient says,
"I can't walk the dog anymore;' focus on it to get some personal conversation
going and attempt to elicit the emotional context in order to respond empathically. Specifically, ask about, for example, the kind of dog and age of the dog,
rather than medical symptoms.
Ordinarily, reticent patients will talk and satisfactory stories can be elicited,
albeit briefer and less complete than with other patients. Symptom data are
easier to obtain during the middle of the interview because you have more
control of the conversation, and sometimes reticent patients offer personal
data during the middle or end of the interview, seemingly warmed-up by what
has preceded. For example, while giving the family history (FH) or deciding
on starting an exercise program, the patient begins to talk about personal
issues. Of course, you would then alter your style to become patient-centered
and further develop this personal information.
Thus far, we have assumed that the personal information obtained during the beginning of the interview is the most important personal information. Indeed, that is almost always so, but such data aren't always complete,
especially around topics where patients feel embarrassed or fear others will
perceive them to be abnormal; common examples include sexual practices,
substance use, suicidal intent, and intimate partner violence.
Proceeding through Steps 1 to 5, you may first suspect a hidden problem, such as a story of severe depression, which causes you to wonder about
suicidal intent or a story of frequent fractures, which raises the question of
falls due to alcoholism or elder abuse. In fact, sometimes awareness does not
become apparent until later (e.g., you observe unusual bruises during the
physical exam leading you to consider intimate partner violence).
Clinician-centered interviewing skills allow you to obtain the necessary
information, usually early in the middle of the interview (Step 6) although
sometimes later, for example, in the past medical history (PMH) or social
history (SH). Begin with a transition statement ("I want to focus now on your
use of alcohol") and follow-up with progressively more closed-ended inquiry

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until all significant information is obtained. Following this format orients the
patient to the interview and what is asked of him/her. The social history section of Chapter 5 (Step 8) shows the key data you should elicit about areas
such as intimate partner violence or substance abuse.
Perform this inquiry sensitively, nonjudgmentally, and respectfully. Tell
the patient how important this information is for you to be able to help, and
reassure confidentiality. Often, the patient has some strong feelings that you
must elicit with emotion-seeking skills and address using empathy skills.
We recommend using clinician-centered interviewing skills in this way
whenever pertinent personal information is not obtained in the beginning
of the interview. For example, if the patient does not seem to be following
your treatment recommendations, you might start the middle of the interview open-endedly with a question or statement such as, "Let's talk about how
you're taking each of your medicines each day," and follow-up with more narrowly focused inquiry until clarity is achieved; for example, "Let's count how
many pills you have left in the container to be sure you're taking them like I
think you are:' Thus, clinician-centered skills that are predominantly dosedended often are required to supplement the personal database.
Clinicians usually find it difficult to address issues that patients are avoiding and have strong feelings about. It is normal to experience fear, concern,
abhorrence, or voyeuristic curiosity. Ifyou are personally aware, you can keep
these responses from interfering with your patient interaction, as we discuss
in more detail in Chapter 8.
The OVerly-Talkative Patient

Loquacious patients make clinicians feel overwhelmed. It is important to
establish a personal and emotional focus efficiently, while redirecting the
patient if conversation is either too detailed or too tangential. Talkative
patients may begin without you saying anything. Developing the agenda
(Step 2) typically is difficult. Nevertheless, you must develop a list of concerns, often by respectfully interrupting and refocusing frequently. Further, in
Step 3 you might not even need an open-ended beginning question or statement because the patient is already giving much information. Indeed, silence
alone often suffices as the patient talks on. After no more than 1 minute with
a new patient (sooner with follow-up patients), you will need to get actively
involved, lest you become a nonparticipator.
Some patients feel the need to recount every detail of their symptoms
and concerns. This sort of over-inclusive talk can interfere with your getting
personal and emotional data. You must respectfully and tactfully interrupt,
refocus, and redirect, sometimes repeatedly. Summarizing what has been

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said up to that point can assist a patient to move on. ("Excuse me. So, you
were hurrying, slipped, and fell on the ice, and still had to go to work where
you were uncomfortable sitting all day, right? Tell me more about .. ,") Other
patients discuss issues that do not relate to themselves directly, for example,
other people's care, politics. Still others focus on remote past events with no
apparent relevance to their present situation. In all instances, you will need
to actively refocus the patient (Step 4) to the here and now ("The President's
health policy affects us all; can you tell me how it applies to you personally?")
and, in particular, their emotional reactions, using the emotion-seeking skills
("Those are important details, but how did that affect you, emotionally?").
Also, you can use NURS to redirect the patient; for example, "That's been a
long spell for you. I can sure understand how upsetting it might be. Thanks
for giving me that background. Let's move on now to what happened yesterday." On the other hand, if patients are talking about themselves in the present
and giving emotional data, you will want to stay with and facilitate this focus.
Once such a focus is established, your task is to complete Step 4 in a timely
manner. A firm, clear transition statement effectively changes focus to the
middle of the interview; for example, after summarizing and using NURS,
"We need to change gears now so I can ask you some questions to learn more
about your constipation if that's OK."
Talkative patients produce plentiful personal data and you may easily obtain
a long story. Because of time constraints, avoid a prolonged return to personal
information if the patient reintroduces it later in the middle of the interview.
The most important data usually will already have arisen. Nonetheless, if the
patient expresses emotion, you must address it. Briefly listening and using
empathy skills usually will suffice.
Talkative patients can seem "easy" to the student inclined to passivity and
"irritating to one who likes to take control-either way your task is to remain
patient-centered as you gather relevant information. Awareness of your own
personality characteristics will maximize effectiveness. In Chapter 8, we discuss further strategies for addressing your personal responses and for managing these patients.
Let's take a moment to discuss the art of interrupting in greater detail.
The Alt of Interrupting

Even though you may have been warned, "never interrupt;' interrupting is a
key patient-centered skill if it refocuses the patient on something they already
have mentioned.7 But, during the patient-centered portion of the interaction, you should not interrupt to change the subject raised by the patient
to something not yet mentioned by him/her. As described in Chapter 2, in
the patient-centered portion of the interview, the clinician only talks about

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what the patient has "put on the table" for discussion-and does not bring
up new topics. For example, if a patient mentions chest pain but not dyspnea
(shortness of breath) or mentions his own worry but not his wife's, it would
be inappropriate to interrupt to ask. "is there any shortness of breath?'' or "is
your wife worried?": On the other hand, it is very patient-centered to interrupt to focus (more accurately, refocus) on something already mentioned by
the patient. In the example above, it is perfecdy appropriate to interrupt your
patient who has perhaps meandered away from describing the symptom story,
the personal context, or the emotional context to say, "you're getting ahead of
me, sorry to interrupt but I'd like to get back the chest pain you mentioned,"
or "excuse me, that's important, but let's first get back to what you mean when
you say you are worried." These are patient-centered interruptions because
they simply refocus the patient on something already mentioned, typically
something the interviewer believes needs further elucidation. As depicted on
the AccessMedicine video "How to Interrupt;' interrupting may be necessary,
especially with the talkative patient, during agenda-setting, during the body
of the interview when the patient gets away from something the interviewer
thinks is important (often emotional material), or at the end of the interview
when the interviewer needs to interrupt a talkative patient in order to end the
encounter.
The sequential model (five steps) ofpatient-centered interviewing oudined
in this text organizes the medical appointment to give the patient time and
encouragement to discuss concerns as well as providing respect and understanding in an efficient manner. Patients want to be heard and you can learn
ways to listen and still guide the conversation.8- 10 Here are examples of appropriate interruptions that successfully refocus the patient in a respectful way.

• Agenda-setting-"Just a minute, could we go back to our Ust of concerns
today? I want to make sure I get them all down so we cover everything you
want to talk about"; "Excuse me, we'll get back to that, but I want to make
sure we get a list of all of your concerns today."
• During Step 4 and other times- "Can I ask you about something you said
a minute ago? It sounded important;" "We'll get back to your medications,
but you mentioned being angry, can you first say more about that." Going
back to a previously stated topic or word helps the patient to join you in the
conversation, and not feel interrupted.
• Ending the interview-"I'm saddened to hear that your daughter's babysitting job (patient raised a new topic) has been hard for you (respecting).
Before we end our visit today (telegraphing the interaction is about to
end), could you tell me which pharmacy to send your prescriptions to?"

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(changing the topic). "I know, you mentioned that earlier (concern about
what an x-ray technician said) and I can understand your concern, I'll
check on it for you. So, it's time for us to stop today, I'll see you for your
next appointment in a month."
Patients "feel interrupted" when the clinician changes topics, does not recognize that an interruption took place, or gives only a perfunctory response
to a concern and then moves ahead. This is foremost with inappropriate,
clinician-centered interrupting during agenda-setting. Research demonstrated that clinicians interrupt patients an average of 18 seconds after asking the patient what concerns they had, meaning that the clinician took the
lead away from the patient before they got their first sentence out. Beckman
and Frankel8 also found that when cut off early, patients often later raised
the concerns-at the end of the visit. This means now needing to address the
problem that should have arisen during agenda-setting, one that now must be
addressed after the interview should be over.
The Stole/Unemotional Patient

We now focus on a difficult and fortunately less common problem: when
the patient seems unable to discuss the personal context of the symptoms
or the emotions connected with them and persists in describing symptoms
and reciting secondary data, such as results of tests slhe has had. This patient
differs from "The Less Talkative, Reticent, Embarrassed or Fearful Patient"
discussed above in that, the patient is not able to focus on and describe
emotions-they lack words to describe feelings/emotions.
In these cases, open-ended skills may not be enough to encourage the
patient to share the personal and emotional context of the situation, and you
may have to actively direct the patient with emotion-seeking skills. The symptoms may be prominent, and these patients may be secretly fearful. Uncovering
and empathically addressing the emotion can be therapeutic. First, summarize the symptom information and then follow immediately with emotionseeking skills. Direct emotion-seeking (e.g., "How does that make you feel?")
is often ineffective, and indirect emotion-seeking must be used. Asking about
impact ("How does this affect your life?") can be particularly effective in getting a focus on the personal context. Then you can ask about emotion directly.
Respectful interrupting often facilitates the transition as well. As with the reticent patient, the personal stories often are more truncated and less complex.
These patients can be frustrating because the interview is difficult and
because they are hard to get to know personally. Simply recognizing this frustration will help you provide them the best care they will allow you to.

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Vl~ette

of Mt. Swenson

Patient:

(In Steps 3 and 4, the patient has given limited descriptions of
arm pain, headache, loose stools, and nausea from medication,
but without expression of concern, emotion, or anything more
personal. The patient also mentions a negative CT scan and
Dr. Johnson's diagnosis of arteritis) [The clinician knows that
s/he is going to have to work harder than usual to draw out the
broader personal context of these symptoms.]
Clinician: (first summarizes the physical problems and immediatdy
follows with this entry) Boy, you've sure had a lot of things
going on. How does that make you feel, you know, emotionally? [Clinician makes a respect statement followed by a direct
emotion-seeking question.]
Patient: I don't know. This pain keeps going right over here. And
I've also been coughing. That started last ... (clinician interrupts) [Patient is staying with symptoms and not responding
with hoped-for information about the personal impact of the
symptoms; clinician interrupts quickly to try again to establish a more personal focus, otherwise the symptom focus will
continue.]
Clinician: I'm sorry to interrupt, but what I'm asking about are other
things, like what you think is going on. Why's all this happening? [Indirect emotion-seeking probing patient's beliefs is tried
instead of repeating the direct inquiry about feelings]
Patient: Dr. Johnson says it's arteritis. It's a blood vessel disease ... (clinician interrupts) [Clinician continues to look for personal clues
but none yet-will keep trying]
Clinician: But why you, why do you think you got it? [Probes for beliefs;
most patients usually have some opinion about this, which will
lead to personal data.]
Patient: I don't know. [The patient isn't saying much; clinician needs
to use other indirect inquiry or return to direct inquiry about
fedings.]
Clinician: With so much going on, how's it affected your life? [This may be
a more productive indirect emotion-seeking inquiry because it
forces some personal data; the patient can hardly say he doesn't
know.]
Patient: Not much. I retired and wasn't doing anything anyway, until all
this stuff came. That pain is right in ... (clinician interrupts) [At
last, some personal data is "on the table''; the interviewer will
now actively focus on this.]

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Clinician: Tell me more about that, retiring and not doing much.

Patient:

[Combined open-ended summary and request; now that personal data have appeared, focusing open-ended skills will be
used repeatedly to maintain the focus and develop the personal
story, as already described. Earlier, rather than indirect inquiry
about beliefs and personal impact, the clinician could also have
used triggers, self-disclosure, or asked about the impact of illness on others' lives; if the patient lapses back into symptom
data, these would be used now.]
Well, since I retired I don't have a regular schedule. I just sort
of sit around all day watching TV-not sure what to do. Then
I stay up late thinking that I will sleep in but my internal clock
wakes me up at the usual 6:00 am that I am used to, but now
I have nowhere to go and nothing to do. [This personal data
gives clues to the adjustment difficulties the patient has encountered since retiring-biopsychosocial data. Use NURS to both
demonstrate empathy and elicit more information to rule out
depressive disorder vs. adjustment disorder vs. alexithymia.]

In many ofthe common interviewing challenges, learners can become frustrated and disappointed, either because the patient is reticent or because the
patient's story lacks personal and emotional information. Learners sometimes
lament they "didn't get much." Nevertheless, the patient still feels understood
and a good clinician-patient rdationship devdops. The amount of personal
information obtained, especially emotional, is not a marker of a successful interview. Rather than measuring a good interview by getting the patient to cry or
express anger, we look for successful use of the patient-centered steps, and ultimately a good clinician-patient relationship.

• ADDRESSING COMMON CHALLENGING COMMUNICATION
SITUATIONS
Developing a patient-centered focus requires special attention when communication problems exist. A clinician may focus so much on how to communicate with a deaf, blind, or dysarthric patient that s/he can be distracted from
a patient-centered approach. In these cases, it hdps to pay special attention
to the relationship. Nonverbal communication like touching, a well-timed
smile or friendly gesture, or an accepting demeanor can be especially effective. The following section presents additional measures that can enhance
data-gathering and the relationship, often focusing on setting the stage for a
successful interview and attending to comfort (Step 1).

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Patients Who Are Deaf or Hard of Hearing
Most common in older patients, hearing loss can cause great difficulty, and is
associated with higher than normal mortality due to lower health status 11 and
is a barrier to mental healthcare. 12 A person who is hard of hearing can still
get linguistically useful information from speech, whereas a person who is
deaf cannot. Certain skills can help improve communication with the patient
who is hard of hearing. 13 Ask the patient how you can best communicate, with
an attitude of mutual decision making. Minimize background noise as much
as you can. Sit so that your face is well lit. Be sure that the patient is looking at
you before you speak. If the patient has a hearing aid, encourage the patient
to use it. Use repetition, then rephrasing if the patient does not understand
you. Check-in with the patient from time to time, "Am I doing a good job
communicating with you? How might I be more effective?" Summarize periodically to be certain that you and the patient are getting the information
right. Portable speech amplifiers, available at some clinical sites, can help you
interview a patient who is hard of hearing.
People who become deaf later in life and orally educated deaf people may
communicate orally by speech reading. However, physicians often overestimate
the amount of words that can be lip-read (only 30%). 14 The same guidelines
for communicating with patients who are hard of hearing apply. Additionally.
be sure that your mouth is not covered while speaking. Because the patient has
learned to speech-read normally speaking people, do not slow down, shout, or
over articulate your speech. Speak at a moderate rate. pitch, and volume; pause
at the end of sentences; use complete sentences; and inform patients of changes
in topics being discussed Because the speech of a deaf person who communicates orally may be difficult to understand, you may need to ask the patient to
repeat, rephrase, or write to ensure that you understand
Interviewing a deaf patient who communicates with sign language requires
a sign language interpreter. Use the preceding guidelines for communicating with limited English proficiency (LEP) patients and orally communicating deaf patients, with a few modifications. 14 The patient and interpreter will
determine the best seating arrangement, usually with the interpreter sitting
next to and a bit behind the clinician. The interpreter will interpret simultaneously, in contrast to the sequential interpretation of an interpreter for LEP
patients. Writing notes is not a substitute with deaf patients who do not orally
communicate because American Sign Language (ASL) is its own language,
with a different vocabulary and grammar than English; many deaf people
who are deaf from birth or an early age may not learn English fluently.
Deaf people, particularly those who use ASL, comprise a cultural group
that has its own norms and values. You are not expected to be an expert in
the details of every cultural group that you encounter; instead, expressing

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respectful curiosity will allow you to better understand how your patient selfidentifies and how to successfully interact with him/her. You might learn that
"hearing impaired" is felt to be offensive because of the term "impaired"; that
people who are involved in the Deaf community and share their culture (especially the use of ASL) prefer the term "Deaf"; that lower case "deaf" refers to
the audiological condition; that the term "hard of hearing" is used for others
who may or may not be part the Deaf community and may have some residual hearing (i.e., individuals that have some hearing loss or those that have
had oral schooling or may not know ASL). Such understanding can help to
create rewarding bonds between clinician and patient, regardless of cultural
differences.

Patients Who Are Blind
Persons who are blind, while communicating verbally in normal ways, use
auditory cues to understand others' mood, style, friendliness, and other features rather than depending on sight clues. Therefore, it is helpful to check-in
with their perceptions; for example, you might ask, "I believe I am understanding, so far, yet I want to check with you how I'm coming across and how
our interaction is going." Barriers often include communication, including
difficultly interacting with physicians and other medical staff, physical barriers in the office, and information barriers such as receiving written material
in inaccessible formats. 15
It is useful to inquire if the blind patient has special ways of proceeding,
if s/he needs assistance, if s/he has any requests relating to her/his blindness, and not to offer unwanted help, yet this does not replace medical staff
education to ensure patient-centered experience. Patients with low vision or
blindness may use assistance, such as service dogs, canes, and others assisting
them. Allowing the patient to take the lead and know that you are available
and open to his/her needs demonstrates respect for self-sufficiency. Introduce
yourself and professionals in the room, and orient the patient to furniture and
doors along with your movement during the history and physical examination. Your speech quality, intensity, and pace should remain normal and not
be "adjusted" for the patient who is blind, although patient education materials may offer a challenge (e.g., need for Braille or large print labels, voicerecorded instructions, etc. V5
Patients Who Are Cognitively Impaired
Persons who are cognitively impaired have challenges processing auditory or
visual information. Therefore, the information they give you may be less reliable and meaningful, especially when the cognitive loss is severe.

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Cognitive dysfunction is a vast topic you will learn about during clinical
rotations in medicine, pediatrics, surgery, psychiatry, and neurology. Such
dysfunction is common, can be acute or chronic, and may have many causes,
such as congenital, head injury, dementia, brain tumor, alcohol withdrawal,
drug abuse, meningitis, medications, anemia, uremia, sepsis, hypoxia, poisoning, and postoperative state. In addition, psychiatric disorders of mood,
altered thinking, and abnormal mental experiences can have cognitive changes
as part of their presentation, for example, schizophrenia and depression. 16
Until now, we have assumed that the patient was a reliable authority for
primary and secondary data. Cognitively impaired patients can vary considerably in symptom reporting with each telling and the chronology is typically
unreliable. Similarly, emotions and other personal issues often are quite variable and nonreproducible. In these cases, you need to obtain external corroboration, often from family, caregivers, and others, while still attending to
the patient's needs and the relationship. Use patient-centered interviewing
skills with the family member, including empathy for the challenges caregivers often face.
Begin the interview in the usual way. With severe cognitive dysfunction,
you will easily recognize the problem during Steps 1 and 2: the patient may
not know where he is, that he is in a medical setting, or who is with him. He
may make little sense and his story may be inconsistent. There may be additional psychiatric symptoms such as hallucinations if the cognitive changes
are part of a psychiatric problem.
Mildly affected patients who remain aware that they are losing their cognitive capacities often compensate by keeping detailed notes of events and
appointments to assist their failing memory, and carefully guard against
showing evidence of cognitive dysfunction. Nevertheless, such loss of thinking capacity can be suspected during Steps 1 to 5 by vagaries, inconsistendes, an undue focus on familiar areas, and deft circumventing of areas where
memory has failed. The patient may use humor to mask confusion and failing
memory. Unlike in the case of severe cognitive impairment, you usually need
to perform a systematic mental status evaluation to be certain.
The formal mental status evaluation (MSE) is summarized in Table 7-1.
The MSE and the screening Mini-Cog17 MSE are presented in Appendix E.
Perform the MSE as part of the middle of the interview, starting as usual with
a general open-ended statement and the pinning down details using closedended inquiry; for example, "Tell me about your memory" (No problems),
"Good, I need to ask you some specific questions so we can get the details";
then ask specific questions in the Mini-Cog or the formal MSE, shown in
Appendix E. A score of less than 3 or 4 on the Mini-Cog should prompt a
formal MSE (Appendix E and summarized in Table 7-1).

• TABLE 7-1. Formal Mental Status Evaluation (See Appendix E
for Details)
1. Appearance: age, physical stigmata, dress, depression, general health,
cleanliness, neatness
2. Attitude: cooperative, angry, guarded, suspicious, attentive, seductive, playful,
obsequious
3. Activity: increased (hyperactivity, agitation), decreased, catatonic, abnormal
movements (tics, tremors), visual-motor integrity
4. Mood (sustained objective emotional feeling): sad, happy, anxious, angry,
depressed, detached, irritable
5. Affect (transitory, immediate emotional expression): full, flat, blunted,
inappropriate, anhedonic, labile
6. Speech: normal, slowed, reduced, increased, pressured, mute, dysarthria,
punning, rhyming
7. Language: bizarre, distracting, colorful, word salad, circumstantial, tangential,
loosening of associations, neologisms
8. Thought content: logical, incoherent, derailment, poverty of content,
obsessive, delusional, paranoid
9. Perceptions: illusions, hallucinations (visual, auditory, olfactory, tactile),
depersonalization, derealization
10. Judgment and insight: realistic, unrealistic, Ia belle indifference
11. Neuropsychiatric evaluation
a. Level of consciousness: comatose, stuporous, drowsy, alert, hyper-alert
b. Attention and concentration: repeating digits, serial 7's, spelling
backwards, immediate memory
c. Language function: fluency, comprehension, naming, repetition, reading,
writing
d. Memory: recent (orientation to time, place, and person; recall three
unrelated objects); remote (past events); amnesia (retrograde,
anterograde)
e. Other higher functions: abstraction (proverbs), calculation, intelligence
Data from Andreason NC, Black DW. Introductory Textbook of Psychiatry. Washington, DC: American
Psychiatric Press, Inc.; 1991:37-40.

We suggest that you complete the full MSE in all new patient evaluations during your early clinical rotations as a way of learning the content
and becoming familiar with how cognitively intact and impaired patients
respond. Written reports of the patient should include comments on the
MSE in conjunction with the physical examination of the neurological system. Although mostly obtained during an earlier phase of your interaction,
the MSE is part of the "physical examination'' of the brain and its functional
integrity. Interpreting the MSE requires knowledge of the various psychiatric,
neurologic, and medical conditions that cause abnormalities of mental status.
These details can be found in standard clinical textbooks. 16•18

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•

PEDIATRIC PATIENTS (SEE ALSO DOCCOM
MODULES 2119 AND 2220)

Integrating patient-centered and clinician-centered interviewing skills applies
with children and adolescents as well as adults.21 You still want to establish a trusting, therapeutic relationship and obtain adequate personal and
symptom data, but with an emphasis on growth, development, and famUy
interactions.22.23 The younger the child. the more age-related communication
issues are involved: decreased ability to communicate, shorter attention span,
less cognitive development, and increased dependency on parents.
For pediatric and some adolescent patients, Steps 1 to 5 are modified.
Children often lack the psychological maturity to participate fully in the beginning of the interview, and you may need to rely more on clinician-centered
interviewing skills.24 Nevertheless, always elicit their concerns and involve
them in treatment discussions and decisions.21 Children become increasingly
autonomous as they grow older and patient-centered interviewing skills will
become more effective; however, even as young children they have a right
to express their perspective of their bodies and healthcare needs.25 Patientcentered interviewing skills should be used in interacting with the parent,
with a focus on the child's problems, but also empathizing with the impact of
the child's illness on the parent.
Attend to the various steps of the interview, modifying your approach
for the age and initiative of the pediatric patient. In Step 1, age-appropriate
opportunities and facilities can be made available; toys, games, and small
chairs can improve interactions with younger children while teens frequently
do not want to sit with chUdren or in chUdlike circumstances.2 2,23 Older chUdren and adolescents can often provide their own agenda in Step 2 but parents
usually formulate the issues for younger chUdren.
The age of the child determines how Steps 3 and 4 are best carried out.
Involve the parent more when the patient is a younger child. Even then,
address the child first in an open-ended style and keep the child the focus of
the inquiry? 1.23 Directly interview children who can speak. irrespective of age,
but keep in mind their unfamiliarity with many medical and other words. 25
The younger the patient, the more concrete, simple, and brief your questions
should be. Always try an open-ended approach; it can be productive even in
the very young. In fact, clinicians often underestimate how much information
they can get from little chUdren-"Mommy says Daddy needs to get a better
job." Nevertheless, it frequently helps to initiate conversation by giving ageappropriate "menus" of topics to choose from such as inquiring about recent
birthdays, school, siblings, friends, athletic events, social events, and the like
in an open-ended manner?2 Get the child to talk about whatever interests

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:19:1

him/her. In addition, you will want to see how the child interacts with the
parent and others, perhaps observing the child in the waiting room. 23 Try to
interact with the child, even if briefly, without the parent present. Observe the
child's behavior as well as his/her communication.
In Step 6 (completion of HPI) obtain information from child, parent, or
both as already described in Chapter 5. Step 7 (PMH) and Step 8 (SH) are specialized in pediatric interviews. Because growth and development are critical,
the younger the child the more detail is required about the mother's pregnancy
and delivery, and the child's birth and infancy, and subsequent developmental
landmarks (e.g., feeding, growth, walking, talking, toilet training, progress in
school, social development). Immunization status, usual childhood illnesses,
hospitalizations, poisonings, accidents, and injuries merit special attention.
The SH contains information about the pertinent social aspects of the family
(e.g., father's job) as well as the patient (e.g., less fighting at school and improved
reading). Inquire about salient family interactions as well (e.g., ignoring a new
brother, parents getting along better since mother got a new job). It might also
be helpful to speak with a child's teacher to best understand the SH, especially
if the child is having problems. Ensure that parents store toxic substances and
medications out of reach, check that hot water temperature is no more than
125°F to prevent scalding, and use protective devices like car seats, seat belts,
and bicycle helmets.26 As the child ages, the interview more closely resembles
that of the adult PMH and SH.
Step 9 (FH) also has a unique emphasis in the pediatric interview. The
FH and genogram include the health histories of grandparents, parents, and
siblings. Because genetic disorders and precursors of adult diseases frequently
begin in childhood, it is important to obtain a careful genetic pedigree. The
mother's health is especially important. Inquire about menses, contraception,
marriages, pregnancies, and outcomes, subsequent progress of children, and
plans for more pregnancies. Ascertain her feelings about her pregnancy with
the patient, and learn about her physical and psychological health. Her own
rearing (punishment practices, abuse) and expectations of what being and
raising a child are like are germane. Assess preparedness for motherhood and
look for areas where an intervention or support may be helpful; for example,
she may need support to build her confidence as a mother. Similarly, inadequate father involvement is associated with poorer child health outcomes and
higher infant mortality.27 All parents, whether living in the child's horne or
not, need to be included in the child's healthcare.28 With many dual-income
homes, employment and the parenting relationship are important health considerations. Whether or not both parents live in the child's horne, most want
to be included and not marginalized.

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Step 10 (review of systems [ROS]) is more important with children than
adults.22 Because children have much shorter histories and because it can be
more difficult to obtain pertinent symptoms during the HPI, make detailed
inquiry in all systems prior to the physical examination and pay more attention to transient or "minor, complaints; for example, increased urinary frequency off and on can signify severe disease, such a congenital genitourinary
malformation.
Adolescence can be a physically and psychologically tumultuous period.
Some adolescents will be perfectly comfortable with the patient-centered
approach you would use with an adult, while others can be made uncomfortable and anxious by it and prefer a more structured approach, that is,
transitioning to the middle of the interview sooner than you would with an
adult Prominent issues and themes that can emerge include dependency on
parents, being forced to come to the clinician, conflict with parents and others, confidentiality, desire to see an "adult clinician; obliviousness of health
risks, hypochondriasis, mood changes, confusion about sexual orientation,
and rebelliousness.22 It may be more important to provide support and comfort rather than obtaining open-ended information, particularly at the beginning of the relationship. Seeing the adolescent alone for at least part of the
visit is often more effective and can lead to a better relationship. Being aware
of various ages of consent and under which conditions parental consent/
involvement necessitates a conversation with the adolescent. For instance, in
some states a pregnant teenage girl can give consent for her child, but not for
herself. It is important that you provide patient-centered care with the legal
guidelines in mind.

•

ELDERLY PATIENTS (SEE ALSO DOCCOM MODULE 2329)

As with pediatric patients, geriatric patients have unique issues,30 particularly difficult to address because older patients often have been overlooked
in research.31 Research provides critical information. For example, older age
is a strong predictor of long-term benzodiazepine use, which predisposes
older patients to falling. 32 Older patients often have multiple medical problems combined with greater functional, social, psychological, and economic
impairments. To understand and integrate this multiplicity ofbiopsychosocial
problems, you will often seek the help of other professionals such as nurses,
social workers, and therapists.
Setting the stage and ensuring comfort in Step 1 requires special attention.
Consider your patient's comfort and pride (dentures available, hearing aids in
and on, full dress), their ease of hearing and seeing, and show proper respect
(use the patient's surname). During the interview, the patient may tire if the

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:193

pace is too fast and s/he does not have time to formulate responses. Your rate
of speech will likely be faster than the patient is accustomed to-mindfulness
of this factor can help you slow down. Check with the patient frequently to
see how you are doing. In addition, the presence of friends and relatives may
make the patient more comfortable and also provide information; confidentiality issues of course must be clarified.
The longer one lives, the longer one's medical history typically is. Agendasetting in Step 2 can be difficult if there are many problems. The time available, the number of concerns, and the patient's fatigue may necessitate that
you defer less pressing problems to a later visit; obtaining a full history may
sometimes take two or three visits. Completion of a pre-visit history questionnaire form (and sometimes other forms assessing functional status, mental
status, and psychosocial status) can be useful adjuncts that provide necessary
information without overly taxing the patient.30
Steps 3 and 4 usually are conducted as already described. The following
can sometimes greatly facilitate the interaction: touching the patient sensitively and caringly, showing interest and patience, and addressing the older
patient's priority concerns.30 It can sometimes be difficult to get older patients
to talk spontaneously, rather than responding to questions. It may be hard to
move them from symptoms to talking about personal or emotional concerns.
Nevertheless, most respond to and benefit from a patient-centered approach
if you gently persist.
Some older patients tend to recite long stories about the past, posing difficulty for the interviewer. Patients often tell "'old war stories" to communicate to the clinician that they were, and therefore still are, people of value
and dignity.30 To shift the conversation to current concerns, you must first
acknowledge what the patient is trying to tell you. For example, to a patient
relating his successes with a job in 1949, you might say, "That's quite an
accomplishment; you sure did a lot. Thanks for telling me. We'll get back to
that ifwe can, but let me shift gears because I am very interested in how things
are going for you now:'
The history of present illness/other active problems (HPI/OAP) will be longer in most elderly patients because they usually have more than one problem,
their multiple problems interact, and many problems are chronic with long
histories. Focus primarily on currently active problems. Falls, painful feet,
incontinence, sexual dysfunction, waning memory, depression, insomnia, and
decreased hearing and vision are common. Similarly, functional difficulties
are increasingly common as people age: dressing, bathing, feeding, using the
toilet, transferring, using a telephone, shopping, cooking, cleaning, driving,
taking medications, and managing finances. Multiple losses (of function,
spouses, siblings, and friends) and loneliness are prominent. There also may

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be more concerns about death and disability as well as about living circumstances and remaining independent.
The past medical history (PMH -Step 7) also is apt to be extensive. Once
again, focus on problems relevant to the patient's health. The social history
(SH-Step 8) elicits the patient's social situation and her/his support structure. As patients age, they may lose capacity in what was previously routine,
such as bathing and cooking. It is essential to learn specifically what their
support structure is and how it is affecting their health (e.g., senior citizens'
center, church groups, meals on wheels).
Ask if the home has been assessed for fall hazards, such as throw rugs and
uneven floors. This assessment can be done during a house call or by the local
visiting nurse agency.
Many elderly patients have active sexual interests and are willing and interested to talk about them. 33 They also have high rates of alcohol abuse. 34 Health
maintenance activities are especially important but frequently ignored; it is
particularly important to make a nutritional assessment for caloric excesses
and deficiencies. Make sure the patient has the opportunity to discuss advance
directives and end-of-life issues.
The family history (FH-Step 9) can become quite complex, and it is
essential that only information that is still important to the patient's health is
obtained; for example, a family history of elevated blood pressure or diabetes
in an 80-year-old is of little value, but who is available to help the patient is a
critical question. Similarly, the ROS (Step 10) is focused only on issues salient
to the patient's health.
When More than One Person Is Present

Although the family interview5 is beyond the scope of this text (see DocCom
Module 20), there are other situations where the clinician involves more than
one person in the interview (e.g., it is estimated that the mean rate of family
accompaniment to routine older adult physician visits was about 46%). 36 The
interviewer might decide (with the patient's consent) to consult a patient's
relative or friend hoping to obtain unique information (e.g., a father giving
information about his child, what happened while the patient was unconscious, information the patient has forgotten or denied). A properly conducted
interview involving a relative or other third person provides information otherwise unavailable, including how the patient interacts in this relationship,
for example, domineeringly, passively, distantly, angrily, or lovingly; many
hours of interviewing the individual patient would be needed to provide as
much "hard data" about the patient's interactional style. Perhaps the patient
relates a story of great independence and achievement only to behave in a
very dependent way when his/her spouse arrives. Or a person who appeared

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:195

very sensitive and considerate during the interview becomes hostile and sharp
with a family member.
During Step 1, it is useful to first introduce yourself to the patient and then
ask the patient who the other parties are and their relationship to the patient;
then determine if both the patient and the other parties want the other parties present. Sit closest to the patient, asking others to move as needed. Next,
ensure the other parties that you value their input, that you would like to begin
by interviewing the patient, and that you will ask them for their information
afterward. Conduct the patient interview as usual. Monitor how the third
party is doing, how slhe interacts with the patient, and what effect s/he has on
your learning about the patient. Weigh whether more or less information is
being obtained because of the third party's presence. Although older patients
are known to contribute less information when accompanied to a visit, family members often contribute missing information.34 Problems can arise if the
third party interrupts or nonproductively lengthens the interaction. Often,
this possibility has led clinicians mistakenly to reflexively dismiss all third
parties rather than productively structure the dialog placing limits on thirdparty input when necessary. If they are interfering, which is unusual, it is best
to focus on them, obtain the information they might have, and then respectfully excuse and thank them. On the other hand, relatives and friends typically
remain quiet. Involve them for points requiring clarification or at the end of
the interview to see how they view the problem and how they are responding
emotionally (e.g., a spouse may see the patient as at great risk for cancer while
the patient denies this or ask practical questions the patient did not raise or
may be far more upset than the patient). You can do this by asking if they have
anything they would like to add, how they are doing with the patient's problem.
Ensuring privacy while discussing sensitive issues and during physical
examination are other reasons for excusing some third parties. You should
always try to have some time alone with the adult patient, especially if the
patient is a woman and the accompanying person is a man. Some partners in
abusive relationships can be very controlling, answering for the patient, and
not wanting the patient to be alone with the clinician. Also, in some cultures,
the man traditionally is more controlling. Regardless of the reason, you cannot tell whether there is abuse or not unless you have the chance to ask the
patient in private. The transition to the physical examination is often a good
time to say, "I must ask you to wait outside now while I do the physical examination. I will invite you back in when we are through:" A patient's partner may
feel more comfortable leaving if a female staffer is present as a chaperone,
often required policy in clinics and hospitals. Once the partner has left, you
can explore issues such as intimate partner violence and sensitive information
such as sexual practices and illegal drug use.

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The pressure of a group, often with an acutely ill or dying patient, is another
complex and challenging interaction. If it is possible to conduct an interview
with the patient, the earlier guidelines pertain. The less responsive the patient,
the more important are the relatives, and the more important to identify who
knows the most about the patient. Once you have attended to the patient's
needs, consider your obligation to the relatives who also need to feel heard and
understood. Listen to their concerns and emotions, use empathy skills, answer
questions, and help find solutions. We often forget that spouses and significant
others are impacted as much or more than patients themselves. Indeed, they
sometimes require more empathic/NURS support than the patient.
Involving third parties usually takes little time and produces information
that otherwise would not be available (on average 5 minutes36). Nevertheless,
the additional time required, the need to incorporate data from new sources,
and having to focus on the needs of third parties do increase the demands on
the clinician. Understanding your own feelings (e.g., frustration, loss of control, aggravating an already inefficient approach, strict time orientation) can
help you avoid adverse, often reflexive responses such as impatience, dismissing third parties, or avoiding relatives.
Working with an Interpreter

Limited English proficient (LEP) patients report more problems and less satisfaction with their healthcare. 37•38 Poor clinician-patient communication is
often to blame, including the fact that clinicians often are less patient-centered when interacting with LEP patients.38 LEP patients prefer a clinician
who is fluent in the same language, especially for complicated or long-term
care. However, it is possible to have an effective, satisfying, and therapeutic
clinician-LEP patient relationship by using interpreters. Indeed, Title VI of
the Civil Rights Act of 1964 requires providers who participate in Medicaid,
Medicare, or any other federally funded program to provide oral language
assistance. Professional interpreters in healthcare are held to high standards of
accuracy; confidentiality, impartiality, respect, cultural awareness, role boundaries, and professionalism established by the National Council on Interpreting
in Health Care (NCIHC).39 If in-person medical interpreters are not available, video or telephone interpreters are usually accessible, even at remote
sites,40 and are much preferable to ad hoc interpretation by a family member
or untrained staffer. Ifyou must use a family member as an interpreter, realize
that confidentiality will be an issue that may limit the patient's willingness to
answer questions. All ad hoc interpreters should be advised of the requirements of their task, for example, "I'm going to speak to your mother and she
to me. I need you to translate exactly what I say and exactly what she says back.

• TABLE 7-2. Guidelines on Using Interpreters
Recognize that, by definition, the visit will take (at least) twice as long
Use trained interpreters whenever possible
Ask for exact translation
Place interpreter out of the sight-line
Speak directly to the patient and watch her or him when interpreter is speaking
Write down key points, instructions, and ask interpreter to transcribe for patient
Check for comprehension by asking patient to summarize

I know you'll be tempted to add or subtract information because of what you
know already but, for now, I need a precise translation only. Can you do that
for me? When we are done I will be sure to ask your thoughts and answer your
questions:' Table 7-2 summarizes guidelines for using interpreters.
The interpreter should sit slightly behind and next to the patient, so you
speak to the patient one sentence at a time, making good eye contact with the
patient. Conduct the interview as you normally would; avoiding jargon, technical terms, abstractions, highly idiomatic speech, complicated sentences,
sentence fragments, and changing your ideas in the middle of a sentence.
Multiple questions at one time can be confusing for both the interpreter and
the patient. Speak in shorter, simpler sentences so that the interpreter can
communicate accurately. A professional interpreter can give you information
on the patient's nonverbal reactions, their understanding, cultural interpretation, and tips on how to make the interview flow smoothly. Even with such an
effort, the experience can be less fluid for patient and clinician alike. Indeed,
it is helpful to acknowledge this; for example, "It may be harder for us to get to
know each other, but I want you to know I'm going to work on if' Recognize
that, since everything is said twice, the interview will take at least twice as long
as a language concordant one. Allow for adequate time. Interviewing through
an interpreter will take twice the usual time since every utterance will need to
be repeated. Note that professional interpreters translate every word spoken
in the examination room, even if you are speaking to the medical assistant or
a colleague. 39 When possible, have bilingual family members complete the
patient's medical history in writing on standard intake forms.
Cultural Competence (See Also DocCom Module 1541)

You may think that cultural competence is important only when working
with patients who speak a different language or who come from a different
country, but every interaction between clinicians and patients is an intercultural encounter. 37 Even if you and your patient have similar backgrounds, the

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SMITH'S PATIENT-CENTERED INTERVIEWING

patient is from the culture ofpatient and you are from the culture of clinician.
How does your patient want to be treated? The golden rule ("'Do unto others
as you would have them do unto you") is unlikely to give you an answer. The
"platinum rule" is more helpful: "Do unto others as they would have you do
unto them." Cultural competence requires cultural humility-the willingness
to learn from patients how they would like you to interact with them.37
While the patient-centered interviewing skills discussed in this book can
be useful in any medical encounter, additional knowledge, skills, and attitudes
can benefit clinicians who care for patients from different cultures. Culture
can be defined as, "Ideas, beliefs, values and assumptions about life, created
by people and transmitted across generations, that are widely shared among a
group of people and guide behavior.'>42
The first step in improving interactions with others is to understand your
own culture. One's own values are cultural blind spots until understood.43 For
example, many clinicians value punctuality and, as "time people," they may get
irritated with "event people:' for whom what is happening now is more important than artificial time constraints. Another example is the value placed by
dominant American culture on individuality and self-actualization. Clinicians
can become frustrated when caring for a patient from one of the many cultures that value reliance on family overreliance on self, because our dominant
biomedical ethical principle, autonomy, may not be dominant for the patient.
After understanding your own culture and culture-bound values better, we
urge you to learn about the cultures frequently encountered in your hospital
or clinic, specifically the members' values, beliefs about health and illness,
and folk illnesses.44 In addition to asking local cultural representatives, you
can access resources with cultural information.45-47 A danger of relying solely
on lists of cultural values and beliefs is generalizing them to all members of a
cultural group. Cultures can consist of subgroups (e.g., Latinos include Puerto
Ricans, Mexicans, Dominicans, Cubans, and others) with widely different
beliefs. Cultural beliefs are also, in part, affected by socioeconomic status,
education, level of acculturation, and English language proficiency.
Respectful curiosity and sensitive inquiry can help determine a patient's
culturally mediated health beliefs. Kleinman48 recommends specific questions (Table 7-3). This knowledge can be critical to negotiating a treatment
plan that the patient will adhere to. In follow-up visits, specifically inquire
about medication side effects, concerns, and the patient's belief about medication effectiveness. For example, in some cultures the shape or color of pills is
believed to indicate their potency. Failing to understand this belief can lead to
poor adherence and outcomes.
Health disparities exist among different races, ethnicities, gender identities, and sexual orientations and those with limited English proficiency.

• TABLE 7-3. Determining Patients' Explanatory Model
What do you call this problem?
What do you believe is the cause of this problem?
What course do you expect it to take? How serious is it?
What do you think this problem does inside your body?
How does it affect your body and your mind?
What do you most fear about this condition?
What do you most fear about the treatment?
Based on information in Kleinman A. The Illness Narratives: Suffering, Healing, and the Human Condition. New York, NY: Basic Books; 1988.

"Race or ethnicity, sex, sexual identity, age, disability, socioeconomic status,
and geographic location all contribute to an individual's ability to achieve
good health:' 49' 50 Because all of us operate on various assumptions within
our careers and personal lives, you may want to learn more about your own
implicit assumptions by taking an Implicit Assumption test at http:/ /project
implicit.net/index.html.49

•

UNIQUE ISSUES FOR THE NEW LEARNER

How Much Time Does the Interview Take?

Learners in the first clinical year (e.g., third year of medical school) are usually required to obtain complete histories from new patients, often inpatients.
Beginning clinical learners can ignore the need for efficiency. As experience
accumulates, efficiency follows. Initially, the beginning of the encounter
(Steps 1-5) takes at least 15 minutes; the middle of the interview (Steps 6-10)
can take up to 30 minutes; physical examination will take another 30 minutes
or more at the outset; learners must carefully attend to the patient's comfort
and sometimes may have to return at a later time to complete the evaluation
if the patient tires. The learner then reads, discusses, synthesizes data, obtains
data from other sources, plans and analyzes diagnostic interventions, participates in treatment decisions-and may again interview the patient to focus
the differential diagnosis.
By graduation or certification, you should be able to conduct a full interview in less than 60 minutes and by completion of residency and with experience, in 20 minutes or so. New patients typically receive 40- to 60-minute
appointments in residents' and advanced students' clinics. Follow-up visits
with both inpatients (ward rounds) and outpatients (clinic visits) typically
involve patients you know and should range from 10 to 30 minutes.

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SMITH'S PATIENT-CENTERED INTERVIEWING

Taking Notes
During the beginning of the interview (Steps 1-5), you can unobtrusively jot
down a few pertinent words or dates. This helps when the patient is giving
the chronology of his/her chief concern. Nevertheless, avoid any excessive
break in eye contact, so as not to disrupt the flow of information. You will be
surprised how much of the patient's story you can remember, because you
heard it as a story.
During the middle of the interview, the patients tends to respond with isolated facts, rather than a narrative, and so most physicians take notes, sometimes
quite extensive, but still keep the primary focus on the patient. In Chapter 10
we discuss how to use electronic health records during the encounter.

Recording of Interviews
You may have been introduced to using and critiquing audio or video
recording during initial instruction in patient-centered interviewing skills
(Steps 1-5). Because the interview is a core skill, it is important to continue
recording interviews on your own, much as musicians or athletes hone their
most important skills daily. Self-critique and input from your peers or supervisors lead to continuing improvement.
Inexpensive audio recorders or your cell phone can be used with minimal
inconvenience and great benefit. Inform patients that recording is confidential
and that it will be erased when its use is completed; you should of course inform
patients if others will be listening to the recording and who they are. In getting
permission to record, you benefit from patients' usual willingness to help; for
example, "Before we get started talking, ni like to ask your help. I'm interested
in improving my communication skills and would like to record our interaction. I (and my instructor-or my group) will listen to it afterward to see how
I could have communicated better. Nobody else will hear it. Then we'll erase
it. Your medical care will not be affected whether you agree to the interview
or not. This is purely for my training. If during the interview, you change your
mind I will erase the recording immediately." Patients rarely refuse. Recording
Steps 1 to 5 is especially important-to critique your patient-centered interviewing skills and transition into the middle of the interview.

Clinical Conduct
Many of our students and residents have debated which behaviors and attitudes are appropriate in the clinical encounter and, in many discussions, generated the guidelines presented here. These suggestions are not intended to be
comprehensive, however.
There is consensus that the behaviors listed in Table 7-4 are the most
important.

• TABLE 7-5. Harmful Clinician Behaviors
Drinking any beverage or eating
Chewing gum or a toothpick
Swearing
Behaving seductively or making sexual remarks or jokes
Poor personal hygiene
Uncomfortable joking or teasing
Expressing personal opinions about others
Going beyond appropriate self-<lisclosure to discuss one's own problems
Making judgments that imply good or bad about the patient or others

Our students and residents believe the behaviors listed in Table 7-5 are seldom if ever appropriate when with the patient.
Our discussions with learners addressed other difficult issues. While certainly wanting to avoid seductive behavior, what is the role of touching the
patient outside the physical examination? The students and residents generally agreed that this was appropriate but only if it felt comfortable to the student or resident, was motivated out of genuine personal concern, and would
appear professional. Although hugging or putting one's arm around a wellknown patient can be appropriate and professional, they preferred more limited touching, for example, a pat on the back or arm.

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SMITH'S PATIENT-CENTERED INTERVIEWING

What sort of conversation should one conduct during the physical examination, especially during the more tension-laden portions, for example, pelvic, breast, genital, or rectal examination? All agreed that calm, confident
discussion of what one is doing and why is appropriate, whUe attending to
the patient's experience and comfort. Inquiry about symptoms and problems
in the areas being examined also defuses tension. The clinician can explain
self-examination and other preventive techniques, for example, during breast
examination, instructing a woman in self-examination.

•

EFFECTIVE CLINICIAN-PATIENT RELATIONSHIP
AS TREATMENT

As noted already, this book is not intended to outline specific treatments for

medical conditions. Nevertheless, it merits comment that you now have two
powerful therapeutic tools at your command. Expressing empathy (NURS)

and being present with the patient in times of difficulty, whether physical or
psychological, are highly therapeutic in and of themselves. In this way, the clinician is the medicine. These skills are key determinants of the clinician-patient
relationship.51
Clinicians may believe that they have nothing to offer patients who are
beyond hope medically and/or surgically (e.g., terminal cancer) or who have
no disease explanation for their physical symptoms (medically unexplained
symptoms), but we know that being with patients in a supportive way and
using empathy (NURS) are highly effective, from a humanistic and scientific
perspective. Even for the many patients whose diseases respond to biomedical treatments, there is good evidence that the relationship contributes significantly to their health outcomes and satisfaction. We invite you to read an
in-depth explanation of this effect in Appendix B. We have come full circle:
these are the benefits that accrue from being patient centered-and you now
know how to achieve them!

• SUMMARY
In the clinic or at the bedside, the advanced clinician makes key practical decisions during Steps 1 to 5. These decisions fme tune the interview
as required for a particular patient: for patients who are reticent, talkative,
focused on biomedical material, or in for a routine exam; when the personal
context is not offered in the beginning of the interview; when more than one
person is present; for patients with communication problems (hard of hearing, deaf, blind, cognitively impaired); and for pediatric and geriatric patients.
Interviewing issues unique to the clinical student include taking sufficient

SKILLS EXERCISES
1. To get the feel for short patient~entered
interactions, practice (in role play) using all
five steps in 2 to 3 minutes. Touch all five
steps but don't worry about each substep,
except in Step 4 be sure to always start with
eliciting the symptom story, switch to the
personal context, and end up with the emotional context and NURS.
2. When you are comfortable with question
#1, try omitting some of the substeps; for
example:
a. Ignore physical symptoms in an emotionladen situation; ignore personal data in
same situation; in each case proceed
directly to NURS and rely upon that as
your sole patient~entered activity;
b. In a low-key emotional situation but with
many serious medical problems, use just

NURS even though the patient has little
or no emotion.
3. When you have mastered questions #2 and
#3 in role play, do the same with real or
simulated patients.
4. Perform an in-depth patient~entered interview, lasting 15 to 20 minutes, with a
patient who has significant personal issues.
The key here is in Step 4 where you keep
using the cycle of skills to develop chapter
after chapter of the patient's story.
5. In role play or with patients, practice Steps
1 to 5 in the following circumstances: reticent patient, talkative patient, deaf patient,
using an interpreter, blind patient, pediatric
patient, geriatric patient, patient with a terminal disease, with a relative present, with a
demented patient.

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SMITH'S PATIENT-CENTERED INTERVIEWING

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Universities Press, Inc.; 1957:395.

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The Clinician-Patient
Relationship

(.)

Human behaviorflows 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.3- 5 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 slhe
says it, how comfortable slhe is emotionally, and his/her ability to interact and

207

208

SMITH'S PATIENT-CENTERED INTERVIEWING

negotiate. For example, a comfortable, safe, and otherwise healthy clinicianpatient 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 18 and 41 discuss sexual
issues and professional boundaries, respectively8.9). You must understand
both the patient's communication style and personality and your own. This
understanding allows you to adjust your behavior to better mesh with your

patient.
• YOUR PREVIOUSLY UNRECOGNIZED RESPONSES AFFECT
YOUR RELATIONSHIP WITH THE PATIENT
Clinician interviewers frequently exhibit personal responses that are counterproductive10; changing them improves the clinician-patient relationship. Most
problems occur during Steps 1 to 5 (beginning of the interview) because the
relationship is just beginning, and because it is here that the patient expresses
most of the personal information that can be stressful to hear. Nevertheless,
your personal responses affect the clinician-patient relationship throughout
the encounter.
We define a "personal response" as one's internal feelings and their emotional and/or behavioral expression. For example, a beginning student became
afraid of an authoritarian patient who reminded her of her father. This led
her, in turn, to become verbally and nonverbally passive during the interview,
allowing the patient to dominate, even though the student knew better. A clinician became anxious and felt out of control when a patient began talking about
death. This led him to take excessive verbal control ofthe interview by switching

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209

prematurely to the middle of the interview. In each instance, the interviewer's
feelings (fear, anxiety) led to a nonproductive interviewing behavior.
Negative thoughts, feelings, and emotions can be triggered by any aspect
of a patient, for example, personality, job, illness, family, or even odor. Some
clinicians have negative feelings about people with certain communicable diseases, perhaps because of fears of contracting the disease themselves. 10 Others
experience negative feelings about people who abuse alcohol or drugs, because
of their seeming unwillingness to take responsibility for their actions; and
some respond ineffectively to patients with no definable disease to explain
their symptoms, often from frustration at their inability to make a disease
diagnosis. Negative feelings produce negative behaviors such as avoidance,
criticism, or superficiality.
Dysfunctional responses also can initially feel positive, as in sexual attraction to a patient. Similarly, "liking" a patient because that patient reminds the
clinician of a positive person in his/her life can be harmful ifthe feeling results
in treating the patient as though s/he was that other person. Such behavior
ignores the patient's real self and needs. For example, a clinician might avoid
a discussion of cancer in an elderly woman who reminds the clinician of his/
her own much-loved grandmother.

The Problem
Research involving medical students, residents, and fellows demonstrates
that clinicians' negative responses to patients are very common. Thirteen of
15 sophomore medical students 11 and 16 of19 residents and fellows 12 exhibited
potentially harmful responses when each was observed in a single interview.
Table 8-1 lists the potentially dysfunctional outcomes and the feelings that
underlie them. Commonly felt fears of losing control, of addressing psychological issues, or of appearing unpleasant resulted in interviewing behaviors
that were, respectively, overly controlling, avoiding of psychological material,
and superficial. You can imagine their harmful potential. Consider, for example, the life-threatening impact of not asking about suicidal ideation, nonadherence to treatments, and specific symptoms-as well as the effect of these
behaviors on data-gathering and the relationship itself.
In another study, board-certified physicians with an average age of 50 years
exhibited potentially dysfunctional responses to patients, particularly when
they felt that their integrity or self-esteem was threatened. 13 While these seasoned practitioners reacted adversely to fewer patient encounters than did
students, residents, and fellows, their reactions did not diminish with age
or experience. Once established, patterns remain intact. This suggests that
experience alone will not change potentially harmful behaviors unless one is
exposed to specific educational interventions.

• TABLE 8-1. Unrecognized Feelings and Resulting Behaviors in Medical
Students, Residents, and Fellows During One Interview"
1. Unrecognized feelings elicited immediately after a patient interview
Common
1. Fears of losing control, addressing psychological material, appearing
unpleasant, harming the patient
2. Unique personal issues, e.g., reminds one of own difficult divorce, fear of
cancer in self
3. Performance anxiety
Uncommon

1. Sexual feelings, attitude favoring biomedical data, anger, fear of
involvement, intimidation by patient, inadequacy, disdain
2. Identification with the patient
Not found
Severe anxiety, depression
2. Unrecognized behaviors observed during a patient Interview
Common
1. Overcontrol of the patient and interview, e.g., inappropriate interrupting or
changing subject
2. Avoidance of psychological material, e.g., death, loneliness, disability
3. Superficial behavior, e.g., overly reassuring, overly social, cocktail party
atmosphere
4. Passivity, e.g., no control or direction, inactive, detachment
Uncommon
1. Seductiveness
2. Critical, intimidating, passive-aggressive
3. Lack of respect and sensitivity
4. Withdrawal, distancing
5. Awkward interactions
"These data were obtained during and following training interviews. 12 •43 The author personally
observed the learner-patient interview and noted untoward behaviors that were potentially unrecognized behaviors. The teaching critique followed immediately and always was begun with open·
ended inquiry. This produced data about the learner's affective response to the patient and also
provided the data showing whether the interviewer was fully aware of the behaviors observed by
the author. When the interviewer previously was fully aware of the emotions or behaviors observed
by the author, they were not included, that is, only incompletely recognized emotions and behaviors
are recorded here.

We studied internal medicine residents who were learning patientcentered interviewing and associated psychosocial skills. 14 Of 53, 50 had negative reactions that interfered with learning interviewing and were harmful to
patients. Happily, with instruction, 44 of 50 were able to change these negative
reactions and to improve their communication and relationship skills.

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THE CLINICIAN-PAT! ENT RELATIONSHIP

2:1:1

Because these personal responses are part of the human condition, we
consider them normal. 11 '12' 14 Nonetheless, unrecognized thoughts, feelings, and
emotions have harmful potential and should be addressed. Why? Unlike most
disciplines, where the relationship is not as central, the clinician-patient relationship is key to effective medical care and these very human reactions can
interfere with learning as well as care. Troublesome unrecognized responses
often override or interfere with new learning. Patient-centered interviewing
skills require clinicians to relinquish some control and address patients' emotions but because of ineffective personal responses, many clinicians attempt to
seize control of the interview and avoid exploring patients' emotional worlds.

What You Can Do about Unrecognized Personal Responses
(See Also DocCom Module 2 15)
Effective coaching by a teacher16 will best help you become aware of previously unrecognized responses, but you can nevertheless make significant
progress working alone or with colleagues.
Diagnosing the Problem

To diagnose difficulties with your personal responses you must make your
reactions more conscious and recognizable. You can reexperience emotions
by recalling negative or otherwise difficult experiences with patients, clinical
situations, peers, and family. By thinking individually or talking freely with
peers, you can become more aware and begin to understand your personal
responses. First identify the thought or feeling. Then link it to a specific emotion or behavioral outcome; for example, one clinician was angry about a
slight and shunned the provocateur. In considering many difficult situations,
the clinician identified a common pattern: perceived slights caused him to
feel anger and the result was to withdraw from nurses, friends, spouse, and a
teacher.
Another exercise to better recognize your interfering thoughts and feelings
relates specifically to the interview. Following any interaction, a good first
question to ask yourself is, "What was my emotional reaction to the patient,
and how did it affect my interviewing behavior?" Look for one positive and
one negative reaction to each patient, and identify the behavioral responses
involved. Consider imagined as well as actual behaviors, for example, wanting
to shake a patient abusing alcohol, "for being so stupid." Reviewing a video or
audio recording of the interaction will allow you to reexperience your feelings
and to more carefully observe any untoward responses, such as unnecessarily changing the direction of the interview or avoiding certain topics. Early
learners who are not yet seeing patients can increase their affective awareness
by considering other medical encounters: working on cadavers, operating on

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animals, having blood drawn, drawing blood, watching an uncomfortable
procedure, reading about awful diseases, experiencing difficult interactions
with teachers or peers, and the general educational atmosphere.
In addition to negative responses and emotions, it is also useful to track
your positive experiences. Having a breakthrough in a patient interview,
resolving a difficult situation with a colleague, spouse, or friend, and doing
well in a presentation that involved a lot of preparation are all examples of
positive responses to environmental as well as internal cues. Understanding
the full range of your responses helps prepare you for your role as a working
professional, able to recognize and adapt to a variety of situations.
There are other routes to increase awareness of emotions, such as reading stories of patients' courage in the face of severe pain and/or suffering.
Additional strategies include keeping a journal, reading emotion-laden biographies and fiction, watching movies with high emotion, recalling personal
experiences, enjoying music and art, working with actors who can mimic
emotional moments, or considering likely emotional events in the future (such
as births or deaths). It is useful to seek positive as well as negative emotions.
Self-help or centering measures can be valuable for hardworking students
and clinicians. Regular exercise, relaxation, 17 meditation, 18- 21 taking personal
time, nonintellectual pursuits, hobbies, creative endeavors, meeting different
people, altruistic activities, and spiritual practices are all useful methods for
increasing affective awareness and the mindful practice of medicine.
Addressing the Previously Unrecognized Affect and Emotion

Repeatedly acknowledging a problem with thoughts, feelings, and emotions
sometimes leads to improvement; for example, a clinician recollects before
each interview that "discussing death and other painful issues is difficult and
I need to be on the lookout for how this could change the course and direction of the interview:' Selecting a specific healthier behavior to work on is frequently useful. Progressing one step at a time, for example, learning to make
just a few comments, is a good start for someone who has trouble talking in
the presence of a professor or attending physician. Rehearse the desired new
behavior in your mind and then in role play with a peer, taking your own
and then the other person's (or patient's) role in the problematic situation.
Then re-perform both roles using the planned new behavior. This provides
important insight about the old pattern and promotes satisfactory change in
the new one.
Changing affective responses is more difficult. Sometimes self-supportive
statements help; for example, "He simply reminds me of my father. I have
important things I want to begin saying." Using empathy skills with oneself helps. Consciously recognize that the work is uncomfortable, that you

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are working hard and trying new behaviors, and that progress, while slow, is
occurring. Reinforce your self-esteem with positive self-talk and recall that
this work will make you a better clinician. In other words, be kind and patient
with yourself.
Whether new learners or seasoned professionals, clinicians can make
remarkable changes as they get to know themselves better, take some risks,
and stretch personally. Clinicians' innate capacity for adult growth and maturation uncovers unexpected strengths and capabilities that can lead to more
effective relationships with patients-and others.22.23
Doing this work with a few colleagues produces the best results. You can
provide each other support using open, honest feedback, and insightful suggestions for new behaviors. Table 8-2lists useful guidelines for teachers and
clinicians within such groups (or pairs24). (See also DocCom Module 40.25)
This process works even better if you carefully analyze your thoughts,
feelings, and emotional responses by keeping a journal.26- 28 Synthesize selfawareness work and identify specific issues and behaviors to address in the
future. Some useful guidelines for joumaling include writing about a memorable but not necessarily dramatic event; most important learning experiences
in which you applied new knowledge, emotions (and resulting behaviors);
how behaviors have changed; how feelings and emotions have changed; specific new learning goals including immediate next step(s), successes as well as
problems; and whether the personal and group work are meeting your expectations and why or why not.
A little anxiety and tension can help you with this process, but if you
experience depression, marked anxiety, disruption of work or relationships,
or other evidence of psychological disturbance you should seek help from a
mental health professional. It is worth noting that self-awareness work does
not "cause" problems but, sometimes, facilitates their identification.
Finally, as noted in Step 3 (Chapter 3), awareness of your thoughts, feelings, and emotions during the interview is an important part of a self-aware
practice. Feelings engendered in the clinician by the patient are called countertransference. These can be due to a "personal countertransference" or a
"diagnostic response."29 In a personal countertransference, your feelings when
interacting with a patient have their origin in an issue elsewhere in your life.
For example, feeling sadness when interviewing a patient because she reminds
you of your grandmother who died when you were young is countertransference. Recognizing this response as coming from outside the clinician-patient
relationship will help you manage your response and provide the best possible
care for your patient.
In a diagnostic response, the feelings you experience are actually coming from the patient and can help you make a diagnosis. For example, if you

• TABLE 8-2. Guidelines for Personal Awareness Group Work
1.
2.
3.
4.

5.
6.
7.
8.
9.
10.

11.
12.
13.
14.
15.
16.
17.
18.

Meet regularly for the sole purpose of personal awareness work/improvement.
Observe strict confidentiality.
Members speak only for themselves, and participate only when ready and to the extent comfortable.
Give feedback that focuses on behaviors rather than the person; be sure the feedback is descriptive
and nonevaluative, contains a balance of reinforcing and corrective information, and provides only a
manageable amount of information for the next step. 24
Focus on feelings, emotions, and "here and now" events; intellectual discussions are appropriate but
should not dominate.
Ask members not only to work with their own problems but also to try to be supportive and empathic to
colleagues.
A nonjudgmental attitude and unconditional positive regard for each member keeps the setting safe and
comfortable for the sharing that makes the process work.
Members use predominantly open-ended questioning and remain person centered.
Members and teachers facilitate problem-solving and provide support. These are more valuable than
advice, analysis, trying to fix or change others, and "the hard truth."
Foster patience, understanding, and recognizing that each person's behavior is what works best for her
or him right now; this offsets frustration with slow or apparent lack of progress. Many people do not
understand or even recognize aspects of themselves that are very obvious to others. Even after being
addressed, the same issue often surfaces repeatedly and requires additional exploration.
Self-disclosure and responding to one's own feelings encourage others to do the same.
Recognize that respectfully and supportively discussing personal issues cannot harm another, and that
others can take care of themselves; this assists in working with "painful" issues.
Address feelings about other members of the group, especially when conflict occurs.
Recognize the link between issues in personal and professional life.
Expect to find that healthy, positive feelings often are among the most guarded and suppressed.
Realize that support leads to hope.
Appropriate touch helps, to the level of each member's comfort.
A facilitator can sometimes enhance the group's work. Seek help if problems or conflicts arise that interfere with the group work.

begin to feel down or sad while interviewing a patient, it may indicate that
the patient is depressed. We urge you to hone your ability to become aware
of your affective responses to patients in real time and determine if they are
coming from another part of your life or from the patient.
•

DIMENSIONS OF THE PATIENT THAT AFFECT THE
RELATIONSHIP-THE PATIENT'S PERSONALITY STYLE

Most of us will have several features of the basic personality styles noted next;
you are encouraged to look for these in yourself. For example, many clinicians
have been described as having predominantly obsessive and authoritarian
styles. These are very useful for ensuring professional success, but, in excess,

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they also can have some adverse consequences personally and in clinicianpatient relationships.30
The patient's personality is far more difficult to change than yours, and it is
not your job to try to change theirs. Nevertheless, ifyou understand the patient's
personality style, you can improve the clinician-patient relationship by adjusting your behavior to the patient's unique style. Personality style is defined as that
group of enduring personal characteristics that describe how a person thinks,
feels, behaves, and interacts in relationships with others and the environment.31
Personality partially determines how people respond to the various stressors in
life, including illness. It determines how a patient recognizes and presents her
or his illness, relates to the clinician, responds to treatments and procedures,
deals with discomfort and disability, and manages chronic and disabling conditions. Knowledge of a patient's personality style can alert you to likely stressful
circumstances that can perhaps be avoided or ameliorated. As noted earlier,
personality styles apply to clinicians as well as patients. We can identify and
name these styles but we must be careful not to use the terms pejoratively. There
is growing evidence that patients who share the same personality styles and
characteristics as their physicians are more satisfied with the care they receive.32

Most personalities are within the range of normal, and readers will recognize parts of themselves in most styles described. Many styles are blends, for
example, many people have both dramatic and organized styles. Personality
characteristics form the bedrock of psychological structure and are the basis
of success as people make their way in the world: a dramatic flair can be essential for a good performer or politician while an organized style is essential for
an effective professional or a good homemaker.
A personality style is abnormal only when it is maladaptive and interferes with successful functioning, then it is called a personality disorder 1;
for example, a histrionic patient's over concern about his appearance leads
to mutilating surgical procedures (multiple plastic surgeries), a person with
obsessive-compulsive personality disorder may count ceiling tiles and wash
her hands throughout the entire day. Importantly, maladaptive patterns can
be precipitated or exacerbated by illness or stress. These patterns then may
puzzle and obstruct clinicians, leading them to label the patient as a "problem," "hateful," or "difficult:'
This section describes how to enhance the relationship by using knowledge
of the patient's personality style, derived from a constellation of features rather
than any one or two of them. You can assess a patient's personality style during
Steps 1 to 3 and can use appropriate skills during this time based on your assessment. Further diagnose the style in Step 4 by focusing on corroborating features
and considering whether the style is adaptive or maladaptive. The sooner the
patient's style is accommodated, the smoother the interaction will be.

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After identifying a personality style, meet the needs of its predominant feature to maximize the relationship. With normal, well-adapted patients this
process is simply woven into each visit. Normal patients present no unique
problems in the medical setting. Establishing the initial relationship with
maladaptive patients, however, is just the start. Maladaptive patients usually
require ongoing care by a mental health professionat with a goal of developing more adaptive traits and gradually weaning patients from their maladaptive behaviors, a topic beyond the scope of this text that will be addressed in
further training such as your psychiatry clerkship. Note that each personality style has unique features that require from you different, and sometimes
opposing behaviors.
We will only present summaries of some major personalities and how they
affect the clinician-patient relationship.31.33 For illustrative purposes, we will

emphasize the maladaptive patterns (personality disorders), but remember that
normal patients exhibit some characteristics ofthese, as we will also summarize.
Further, while this review presents each type singly. you will want to consider
how different patterns might be combined. Most of us exhibit features of several different personality styles.
Dependent Style

Basic need: The basic need of a person with a dependent style is to assuage
fears of abandonment, starvation, and/or helplessness which were learned
very early in childhood. The maladaptive dependent patient wishes for
boundless interest, attention, and care.
Clinical presentation: You will observe the following in better-adapted
patients with dependent styles: normal and greater degrees of requests for
advice, need for detailed directions, checking of plans in order to do things
"right," a history of "super-independence"-overcompensation for dependence wherein the patient single-handedly performs many activities and
seldom wants help, living in the parental home as an adult (when financial
circumstances do not demand it), deferring to a spouse for answers and decisions, using the collective "we" to indicate another's close involvement in their
activities ("We took the medicine and then we did the physical therapy"),
repeated stories of how others help and support them, and problematic oral
habits like overeating, smoking, excessive drinking, and other addictions.
Maladaptive dependent patients may reach out quickly and impulsively
to clinicians. They often demand urgent, special attention, and may appear
selfish. The simplest instructions often require repetition and assistance,
for example, how to get to the lab for a test. Losses and separations from
loved ones are particularly stressful to these patients and can lead to illness

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21.7

and psychological deterioration. Because illness leads to increased caretaking, relinquishing its nurturing aspects when health is regained may be
difficult.
Maladaptive dependent patients can pose difficult problems in medical settings, becoming angry and frustrated when their needs are not met.
Incessant demands may make the clinician feel emotionally exhausted or
"sucked drY. Many clinicians who are mothers have likened the situation to
having a child constantly tugging at their breast. Passivity, helplessness, and
a sense of entitlement often preclude following directions, paying bills, and
performing other responsible acts.
How to respond: You can meet dependency needs during your initial contacts by incorporating much support into your conversation and actions; by
evincing a positive outlook and showing interest in patients aside from their
disease; by giving guidance, advice, more detailed instructions, and special
favors; and by arranging for more frequent visits. Supporting and giving praise
for independent behavior as you provide empathy can sometimes decrease a
patient's dependent behavior. Because the patient desires closeness and only
know how to solicit closeness through dependence, sometimes offering frequent support and praise for independent behavior while not abandoning the
patient can decrease dependence.
Problems for clinician: The authoritarian clinician typically interacts
nicely at the outset with dependent patients; that is, these clinicians like to
take charge and these patients like to be taken care of. Unfortunately, this
approach results in a cycle of the dependent patient trying to get increased
attention from clinicians who derive satisfaction from helping ... until a pattern is established. At this point, the clinician faces two possible relationship
problems. First, she or he may try to meet the endless dependency needs and
the relationship may become over-involved, enmeshed, terribly time consuming, and nonproductive. The clinician becomes frustrated from trying hard
and failing, and the patient becomes frustrated in not getting enough. Second,
the clinician may reject and distance him/herself from the patient so that the
relationship dies.
Obsessive-Compulsive Style

Basic need: The basic need of a person with obsessive-compulsive style is to
maintain control, especially of emotional expression. Control assuages unconscious fears of emotion, dirtiness, disorderliness, impulsive aggression, and
pleasurable indulgences-often the result of excessive childhood punishment.
Clinical presentation: You may observe the following in better-adapted
obsessive-compulsive patients: normal and greater degrees of orderliness,

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precise speech, detailed information, self-discipline, tidiness, punctuality,
conscientiousness, a well-organized approach, responsibility, conservatism,
and concern with right and wrong.
Maladaptive patients use knowledge as a tool for controlling their fears.
Thinking substitutes for feeling and emotion. For the unaware clinician who
may also share obsessive-compulsive personality traits, there is the danger
that emotion will be entirely absent from the encounter-the medical visit
transforms into a medical discourse. Maladaptive patients characteristically
use ritualistic behaviors and obsessive thinking that replace action, and elaborate rationalizations follow. Far from being useful, patients may bring extensive written notes for reference and give detailed, boring accounts of routine
body functions and symptoms to assuage their anxiety. Although asking many
questions, they do not listen and obsessively focus on selected details as a way
to control emotion (rather than for intellectual need). Because illness means
a loss of control, they typically try to take control of medical interactions and
often succeed. Obsessive patients guard against emotions. When asked how
they feel or what their emotional reaction is, they characteristically respond
with what they think.
Maladaptive obsessive-compulsive patients in medical settings can demand
a great deal of time, having many questions and presenting detailed expositions of symptoms. Anger, depression, and anxiety may supervene when
control falters. Self-doubt, indecisiveness, and vacillation can pose problems
when medical decisions (especially urgent ones) have to be made.
How to respond: Meeting an obsessive patient's needs means giving information in appropriate detail, which can include written material, and often
includes specific plans for diagnosis and treatment. Repeated requests for
information, however, indicate an underlying anxiety that must be explored
rather than responded to by simply supplying information. It helps to involve
the patient actively, giving her or him a sense of control in decision making
(e.g., which consultant to see), and in deciding the details of daily conduct
(e.g., when blood is drawn, how bath will be given). Putting the patient in
charge helps, as long as it is comfortable and consistent with good care. Also,
it may help to compliment such patients on their knowledge, reasoning, selfsufficiency, and high standards.
Problems for clinician: The authoritarian clinician can have trouble interacting with obsessive-compulsive patients if a battle for control emerges. The
result is often an unengaged relationship in which patients may become unhappy
and go elsewhere. If an authoritarian clinician yields appropriate control and
gives information, the patient will be impressed by the clinician's remaining
obsessive features such as thoroughness, precision, and clear reasoning.

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21.9

Histrionic Style
Basic need: The basic need of a person with histrionic style is to merge emotionally with others, especially of the opposite sex. Interacting in an emotionally intense way gratifies, irrespective of the pain and discomfort it produces
for them or others.
Clinical presentation: In better-adapted histrionic patients you may
observe: normal and greater degrees of charm, colorfulness, liveliness, attractiveness, sexual appeal, gregariousness, romanticism, sentimentality, artistic
interest, and creativity. Many people with this personality style exhibit a zest
for life and pleasure, have a rich fantasy life, and arouse the envy and admiration of others for these qualities.
Maladaptive histrionic patients communicate through emotions, feeling,
and performing rather than thinking and doing. They are overly dramatic,
flamboyant, teasing, inviting, flighty, and impulsive. Concern about appearance and bodily integrity is paramount. Although histrionic patients can be
quite personable, engaging, and entertaining at the outset, you may soon note
a pervasive superficiality and lack of depth. Patients often are seductive in
dress, style, and language. Women may present as defenseless, vulnerable,
or as sexually provocative. Histrionic men emphasize their manliness and
courage, and may make "macho" remarks. Alternatively, men may present
as effeminate and fragile. In the intellectual domain, maladaptive histrionic
patients impress the clinician as vague, imprecise, inconsistent, circumstantial, contradictory, and exaggerating. Such patients may have a short attention
span, decreased ability to concentrate, and handle factual data erratically.
Maladaptive histrionic patients in medical settings can become angry,
depressed, and jealous if they are not noticed as attractive and outstanding.
Dissatisfaction in the clinician-patient relationship can lead them, as it does
in their personal lives, to precipitously leave for another caretaker. Their
impulsivity and inexperience with sound reasoning can lead to difficulties
with drugs, medications, ill-advised surgery, and other decisions about care.
Minor problems, especially perceived bodily defects, create ongoing anxiety. When deforming disease (breast surgery, facial laceration) occurs, these
patients can be particularly vulnerable.
How to respond: Meeting a histrionic patient's needs includes brief compliments on the patient's appearance made in a useful, tasteful, and non-suggestive way. It is essential, however, to show and express interest in such a
patient as a person rather than just as an object of attention. Respond calmly
and firmly when patients behave seductively. Allow patients to ventUate their
fears and concerns, but do not foment or encourage them. Reassurance works
better than intellectual explanations. Try to involve these patients in decision

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making, but you may have to assist them by providing guidance, advice, and
support.
Problems for clinician: To the extent that you are susceptible to seduction
or are seductive yourself, these patients can prove disastrous. Sexual encounters between clinicians and patients are a harmful outcome of such interactions. Similarly, fears of such involvement can lead to the opposite extreme-a
distancing interaction. Most clinicians working with histrionic patients are
troubled less by sexual issues than by the patients' lack of sound cognitive
skills that can be a source of frustration to a more cerebral caregiver. This is
perhaps a factor in the observation that clinicians seem to discount the reality
of histrionic patients' problems. For example, with the same clinical presentation of coronary artery disease depicted on videotape, physicians pursued
further investigation in only about half as many histrionic patients as they did
in obsessive patients.34
Self-Defeating (Masochistic) Style

Basic need: The underlying need of persons with self-defeating style, a
category whose existence as an entity has been questioned, 31•35 is to sufferresulting from severely repressive upbringing (physical, sexual, and psychological abuse) that, nonetheless, symbolized love and attention. The child
felt loved only when suffering or when the parent showed remorse following
punishment.
Clinical presentation: Better-adapted self-defeating patients may demonstrate normal and greater degrees of guilt and need to atone for misdeeds,
complaining about their troubles, self-effacement and submission, expecting
adverse outcomes, feeling unworthy of success, seeing themselves as victims
without recourse, and meeting others' needs without concern for their own
needs.
Maladaptive self-defeating patients repeatedly fail. Expressions of much
suffering and bad luck, many disappointments, and general hard times typify
them. They present as the helpless victim, believing that they don't deserve
success, and that if success occurs, something bad will follow to offset it.
Such patients may precipitate their own misfortune and are often incapable
of learning from prior mistakes, even when made aware of their repetitious
patterns; for example, the spouse of an alcoholic who repeatedly returns to the
marriage or, once having left, partners with another alcoholic.
In the medical setting, maladaptive self-defeating patients can complain
bitterly about many problems. Moreover, when one problem is resolved, they
are not happy but, instead, present more difficulties. Reassurance typically
leads to more complaints. There is resistance to encouragement, denial of

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improvement, accentuation of yet unimproved aspects ofhealth, and a spurning of efforts to help. These patients feel helpless and futile, generating the
same feelings in caregivers. They frequently reject advice that would improve
their situation, for example, to quit riding a motorcycle that has caused five
injuries. They often request painful procedures or surgery and sometimes
seek them out against medical advice.
How to respond: In meeting these patients' needs, avoid reassurance, suggestions of improvement, or promises of cure. Instead, simply acknowledge
and respect their plight. Empathy skills work nicely for this. Tests or treatment can be framed as yet another burden for the patient to endure. When
patients exhibit a prominent martyr component, frame interventions in terms
of how it will help someone close to them ("Your husband needs you to be
healthy so that you can continue to care for him.")
Problems for the clinician: Self-defeating patients create a situation with
great potential for unwitting, but nevertheless harmful, interactions. They
elicit much sympathy, and you may respond by wanting to help, reassure, and
cure. These responses are, however, counterproductive with self-defeating
patients, create dissonance, and eventually lead to loss of the relationship and
the patient. Instead, you should restrain your usual more positive approach,
acknowledge the patient's plight, and use a less hopeful, more austere style.
Narcissistic Style

Basic need: The basic need of people with narcissistic style is to overcome
low self-esteem and lack of confidence in maintaining personal identity. To
be intimate or accept anything from others means merging with them and
losing one's individuality. Narcissistic people overcompensate by attempts to
be superior and unique.
Clinical presentation: Working with better-adapted narcissistic patients,
you may observe normal and greater degrees of expressing opinions and feelings. The distinction between well-adapted and less well-adapted patients is
whether this pattern represents a healthy self-respect while respecting others'
needs and opinions rather than representing an attempt to maintain one's own
self-esteem.
Maladaptive narcissistic patients present as all powerful and all important
with exaggerated self-confidence, often appearing smug, vain, arrogant, supercilious, possessing mysterious knowledge, disdainful of others' opinions, and
grandiose. With others, they may be patronizingly superior, overbearing, callous, or aloof. Not surprisingly, they do not have close relationships, have difficulty establishing new ones, and are not described as friendly or warm. They
often irritate clinicians, particularly by engaging in prolonged monologues.

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In the medical setting, maladaptive narcissistic responses increase with illness, and this is characteristically manifested by an attitude of superiority to
clinicians, always trying to "one-up" them, being content only with the "'best"
clinician (typically the chief of service), and being disdainful or patronizing
of other clinicians. In their incessant search for weakness in their caretakers,
patients lose confidence as they dwell on the clinician's faults, thereby exacerbating their stress and narcissistic behaviors.
How to respond: You should meet the patient's needs by acknowledging
the patient as a person of unique achievement; but, at the same time, being
careful also to show expertise in a nonthreatening fashion, lest the patient lose
confidence. It may help to engage the patient at a medical level by discussing recent journal articles and sharing ideas as one might with a colleague.
Narcissistic patients respond most to an attitude ofrespect and concern rather
than one of warmth and caring.
Problems for the clinician: Narcissistic patients often challenge or threaten
authoritarian and other clinician styles with their superior behaviors, lack of
trust, self-referral to other consultants, and ignoring advice. You may enjoy
working with such patients more if you can develop patience and not feel
threatened.
Paranoid Style

Basic need: The basic need of persons with a paranoid personality style is to
assuage their fear oftheir own faults, weaknesses, impulses (often retaliatory),
and of infringement by others. Often severely criticized as children, they distrust others but allay their unwanted impulses by projecting them onto other
people, for example, they see their own aggressive impulses in others. Their
suspiciousness is rigid and intense, and characterized by a hyperalertness to
anything out of the ordinary.
Clinical presentation: Better-adapted paranoid patients may demonstrate
normal and greater degrees of suspiciousness, critical evaluation, alertness
to things being out of order, cynicism, complaining, planning ahead to avoid
dangerous circumstances, self-righteous statements, rigid limit-setting, ruminating on negative problems, and anticipating problems.
Maladaptive paranoid patients are guarded, vigilant, quarrelsome, suspicious, and fearful. They complain bitterly of mistreatment and neglect and
blame others for their problems. Oversensitivity to slights and alertness to
the negative feelings of others are typical. They often feel persecuted and can
respond with self-righteous counterattacks out of proportion to the magnitude of the perceived criticism.
In medical settings, a maladaptive paranoid patient's querulous approach
for more attention, better food, less noise, faster nurses, and better clinic

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personnel is disrupting and time consuming. Such patients, by threatening
legal action and blaming others, frighten and irritate clinicians. Anger and
aggressive control of personnel engender an unhappy milieu. Depression and
anxiety bespeak deterioration.
How to respond: Meeting patients' needs requires giving full information about plans and treatment, expecting to be more detailed than usual and
subjected to greater scrutiny. Avoid inadvertent slights, including those by
other staff. A friendly. courteous approach that avoids closeness works best.
Attempts at more usual, closer relationships are met with great suspicion for
what is perceived as an infringement. Do not reinforce, dispute, or ignore
patients' paranoid assertions. Rather, create a sense of safety and acknowledge
how difficult the problems are for a sensitive person like the patient to have
to tolerate during an illness; you can also praise the patient's grasp of facts,
self-control, and sense of autonomy, using empathy skills. Acknowledge the
patient's feelings without either disputing or reinforcing them, and the patient
is then ready for an appeal for more tolerance.
Problems for the clinician: A paranoid patient creates considerable difficulty for authoritarian and other clinicians if they battle or ignore the patient.
Even when these understandable tendencies are controlled, management is
difficult and received without gratitude.
Schizoid Style

Basic need: The basic need of the person with schizoid style is to protect
against certain disappointment when relating to others. These patients may
have experienced repeated early emotional deprivation and the absence of
long-term ties (absent caregiver, erratic caretaking, multiple foster homes,
institutional rearing)-or the influence of schizoid or other distant parentsthat later in life make them feel uninvolved, detached, and remote. They never
learned how to love or be loved. Aloofness is a protective denial of the many
painful relationships gone awry.
Clinical presentation: You may observe the following in better-adapted
schizoid style patients: normal and greater degrees of distance in relationships and comfort in being alone. Healthy people have relationships of varying degrees of closeness and involvement.
Maladaptive schizoid patients isolate themselves. They are unsociable, out
of touch, relate poorly. and have solitary interests. Although they may appear
independent and not easily impressed, they often are oversensitive, fragile,
and lacking in resilience. Because this personality style and its isolation are
not compatible with joining most workplaces where interactions are required,
these patients frequently are oflow socioeconomic status and using public support. Although usually uninterested, some patients with schizoid style have

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eccentric ideas and behaviors around foods, health measures, religious movements, social betterment schemes, and dress.
Illness threatens the reclusiveness of maladaptive schizoid patients, and
can trigger severe denial and minimization. Patients with schizoid style
may appear surprisingly undisturbed despite very significant problems.
Typically, these patients are brought to the attention of medical professionals
by well-meaning relatives or neighbors. Solitary drinking as a means of selfmedicating is common but may go unrecognized. Schizoid patients can fail
to follow up on recommendations, especially at the beginning of treatment.
Intermediate and long-term adherence can also be poor.
How to respond: Meeting schizoid patients' needs means accepting their
unsociability and not threatening them with closeness or demands for relating. But do not permit withdrawal. This requires maintaining a considerate
interest that is quiet and reassuring, and that does not demand reciprocation.
Try to engage such patients to a degree they can tolerate although the relationships may frequently remain distant and refractory to your best efforts.
Problems for the clinician: Many clinicians find these patients unappealing because of their inability to relate, yet their eccentric ideas and beliefs may
arouse interest. Recalling these patients' long-term deprivation may help you
maintain steady but reserved interest.
Summary and Implications

Conduct the beginning of the interview (Steps 1-5) according to the guidelines outlined in earlier chapters. In addition, during Steps 1 to 5, identify the
personality style of the patient and then meet the unique needs by matching
your approach to the dominant patient style identified. Matching enhances
the clinician-patient relationship by meeting psychological (personality)
needs of the patient. This process works with better-adapted patients; maladaptive patients will require much more work in consultation with a psychotherapist to develop healthier patterns.
•

NONVERBAL DIMENSIONS OF THE RELATIONSHIP
(SEE DOCCOM MODULE 147 )

Nearly everything we have discussed so far concerns verbal aspects of interviewing. Nonverbal communication is equally-if not more-important in
its effect on the clinician-patient relationship.36.37 Nonverbal communication
has been shown to influence patient satisfaction, adherence to medical advice,
and even clinical response to treatments. 37•38 This may be especially important
for female clinicians.39 Prior to language acquisition, we all responded solely
by nonverbal means; we cry to express hunger or pain, and smile to express

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225

contentment.40 With language, we acquire a new way of expressing feelings
("I don't like you, Mommy").40 However, the original capacity to experience
feelings and express emotions at a nonverbal level remains. Although normal growth and development requires that we integrate verbal and nonverbal
expressions, much nonverbal behavior remains unintegrated41 and nonverbal
expressions may remain incompletely recognized. This dissociation leads to
the classic mixed message,36 for example, a patient answers "yes" to a request
to stop smoking while shaking her or his head "no." The savvy clinician knows
this represents ambivalence and that the nonverbal channel expresses the
truer message.7
Nonverbal responses give you a picture "beyond words; for example,
seductive, angry, or depressed. By integrating nonverbal and verbal information during the interview, you will get a better picture of the whole person
and a fuller understanding of the patient and her or his suffering, and in the
process, make the most meaningful connection possible.
There are four categories of nonverbal communication: kinesics (movement), proxemics (the space between the clinician and patient), paralanguage
(pitch, tone, and volume of speech), and autonomic (physiologic changes
caused by the autonomic nervous system).7
Kinesics refers to movement, such as facial expression, gaze, body tension,
gestures, fidgeting, touch, and body position. These nonverbal behaviors are
under some degree of voluntary control. 7
Proxemics refers the space between clinician and patient, including differences in vertical height, interpersonal distance, angles of facing, and physical
barriers created by crossed arms and legs, charts, computers, and desks.7 For
example, to minimize feelings about power and control, you should not sit or
stand higher than the patient. If the patient is lying in bed you can reduce the
disparity by sitting or squatting at the bedside. The same applies to interacting
with a child. You strive to empower rather than overpower.
Paralanguage pertains to the vocal qualities of tonality, rate, rhythm,
volume, and emphasis. If your voice is warm and inviting, your patient will
feel more comfortable and will open up more?
Autonomic changes refer to alterations in a person's internal state such as
flushing or blanching of the face or sweating of the face or palms. Breathing
and pupil size can reflect strong feelings in the patient.7

Observe the Patient's Nonverbal Communication
To observe the patient's nonverbal expressions, it may help to briefly tune out
the words, as though watching a movie without the sound. The four categories of nonverbal communication, as outlined earlier, interact to characterize
many of the emotions found in Appendix C. As an exercise, consider what

228

SMITH'S PATIENT-CENTERED INTERVIEWING

nonverbal cues characterize each emotion listed; that is, what unique somatic
or nonverbal features typify anxiety, grief, despair, joy, love, devotion, and
determination? From the other direction, what are the possible emotional
meanings of the following commonly observed nonverbal responses: leaning
away from the clinician; frequent patting or stroking of the clinician's hand.
arm, or knee; quivering lower lip; arms tightly crossed over chest; frown;
slumped shoulders; furrowed brow; standing to talk; glistening of eyes (tearing); or smiling? As reviewed in Chapter 3, in Step 3 you will also want to
integrate other nonverbal data about physical characteristics (emaciated),
autonomic changes (sweaty palms), accouterments (tattered clothing), and
environment (no greeting cards in the hospital room of a patient in the third
week of hospitalization).
As early as the initial moments of Step 1, you will begin to consciously
observe the patient's emotional responses. This will give you an idea of the
patient's associated nonverbal response pattern and let you recognize them
more easily later on.
Up until now, we have discussed observing and interpreting nonverbal
behaviors, but done little about them. Below, we will describe how to respond.
Matching

Matching is a neurolinguistic programming concept wherein the clinician
subtly mirrors a patient's nonverbal expressions to establish rapport.42,43
This is done slowly to avoid distracting or alarming the patient; for example,
observing that a patient had her or his head tipped to one side, the clinician would slowly adopt a similar position. For example, with a patient who
gestured a lot with her or his hands, the clinician would slowly begin similar
hand gestures; talking to a patient who frequently pursed her or his lips, the
clinician might emulate this unobtrusively. Matching applies to a vast range
of behaviors, especially those in the kinesics and paralanguage categories discussed earlier. Matching need not be complex and can be as simple as mirroring the way the patient crosses her or his legs, folds her or his arms, or rubs
her or his chin. It is very effective at establishing rapport and can be viewed as
the nonverbal equivalent of NURS.

Leading
People in nonverbal synchrony might want to remain that way, but there is also
the possibility of using nonverbal behavior to shift from one state to another.
A leading behavior by one member induces a reciprocal act by the other, as
long as it is introduced slowly and subtly.42•43 This provides two opportunities for the clinician40: (1) if the patient follows a lead. it confirms nonverbal

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227

connectedness; (2) to lead the patient away from nonproductive behaviors;
for example, after matching a patient's persistent frown, the clinician might
gradually introduce a slight smile, hoping that the patient will follow the gesture and indeed feel better.
You may worry that matching and leading seem manipulative and deceptive in some way. The intent is for you to become conscious of leading and
matching activities and skills that are entirely natural but usually done unconsciously. In the same way that learning patient-centered interviewing skills
helps you serve your patients more effectively, building and maintaining rapport by attention to nonverbal communication allows you to engage your
patients more effectively.'

Addressing Nonverbal Behaviors
As with verbally expressed feelings, address overt nonverbal expressions of
emotion with empathy skills (NURS); for example, to a crying patient, "That's
really sad for you and I can understand ..." With less overt nonverbal messages, you need to use emotion-seeking and focused open-ended queries to
better understand the nonverbal behavior; for example, "You look a little
down, tell me what's going on ..." or "You seem kind of tense." Once the emotion is clear, respond empathically (NURS), deepening the clinician-patient
relationship. Sometimes you will just note the nonverbal behavior if you suspect that addressing it would be poorly timed or offensive; for example, you
might choose not to immediately address the fact that the patient's arms are
tightly folded across the chest in a defensive way.
Mixed messages, where the verbal and nonverbal messages are incongruent, represent conflict, perhaps conflict with the clinician, and a lack of
safety for its direct expression. 7 The following can be helpfu140: (1) Indirectly
acknowledge the disparity; for example, to a patient saying everything at work
is fme who at the same time is shaking her or his head negatively, "I hear your
words but I still get the feeling that things aren't going too well at work." If
this prompts appropriate, congruent discussion, no more is necessary. If not,
a brief apology for misunderstanding is sometimes useful. You also might
frame the incongruity in terms of a paradox; for example, "I know some
people who say everything is fine at work at the same time they were concerned about their jobs." (2) Sometimes, directly addressing the incongruity is
best, "I notice you saying 'all is well' but shaking your head as if you are saying
'no: What about that?~ although you usually have to know the patient well
enough to be comfortable that it will not be perceived as mocking. Clinicians
themselves often send mixed messages, for example, saying, "'Ia like to hear
more about that" while standing up to leave or looking at the chart or the

KNOWLEDGE EXERCISES
Clinician-Patient Relationship

1. Define the clinician-patient relationship
and its dyadic components. What are nondyadic influences on the clinician-patient
relationship?
2. Why and how does one monitor the
clinician-patient relationship? What
characterizes a good clinician-patient
relationship?
3. Discuss the obsessive-compulsive features of many clinicians, 27 why they occur,
what is useful about them, what is potentially harmful, and what might be done
to decrease their negative impact on the
patient.
4. What is an unrecognized response? Are
students and clinicians with unrecognized

responses abnormal? Why is the clinician
the best focus for improving the clinicianpatient relationship?
5. Distinguish between the clinician's
unrecognized feelings and her or his
unrecognized behaviors. Do these unrecognized responses feel good or bad to the
clinician?
6. What problems can unrecognized
responses cause? How common are unrecognized responses toward patients? Do
clinicians outgrow these responses as they
gain experience? List the common unrecognized feelings and unrecognized behaviors.
7. List several ways clinicians can conduct
"self-analysis" to increase personal awareness of affect.
(continued)

KNOWLEDGE EXERCISES {continued)
8. Why can't clinicians easily recognize these
potentially harmful problems about themselves and, once recognized, easily change
them? Is it possible for clinicians to prevent
their feelings from becoming manifest?
9. Why is it valuable to develop selfawareness of unrecognized personal
responses concerning other people as well
as patients?
10. If one chooses to change, is the focus
the behavior or the emotion or both? List
several techniques the clinician can use to
assist change.
11. What principles characterize working on
self-awareness with colleagues?
Personality
1. Define personality style, and contrast it to
personality disorder. Why is the patient's
personality important to the clinician?
When and how does the clinician "read"
the patient's personality?
2. For each personality style described
(dependent, obsessive-compulsive, histrionic, self-defeating, narcissistic, paranoid,
and schizoid}, answer the following: why
does the personality occur, what are its
general features in maladaptive and betteradapted patients, how do maladaptive
and better-adapted patients present in the
medical setting and what unique problems
do they pose, what unique therapeutic
measures are employed with each to
enhance the clinician-patient relationship,
and what problems might these patients
pose for authoritarian and other type clinicians. Also, describe how control, intellectuality, emotionality, and ability to engage in
a relationship vary from one personality to
another.
3. To enhance the clinician-patient relationship, is it possible to change the patient or
their behavior? If so, how?

4. In responding to the patient's personality, what does "going with the flow" of the
predominant personality feature mean?
5. Given your own personality, what are your
likely interactions with patients having maladaptive as well as adaptive personalities
of each type-would the interaction "feel"
good or bad to you?
Nonverbal Behaviors
1. Why are nonverbal behaviors important?
Are they more or less important than verbal
behaviors to understanding the patient?
What is meant by a "mixed message" or a
mind-body split when verbal and nonverbal
behaviors are compared?
2. What can the clinician do to ensure that
her or his own nonverbal behaviors do not
create an adverse reaction?
3. Give the different categories of nonverbal
behaviors, as shown in section "Nonverbal
Dimensions of the Relationship," and list
the different bodily or somatic (nonverbal)
manifestations of at least 10 emotions;
see Appendix C. What are likely meanings of the following nonverbal behaviors:
leaning away from the clinician; frequent
patting or stroking of the clinician's hand,
arm, or knee; quivering lower lip; arms
tightly crossed over chest; frown; slumped
shoulders; furrowed brow; standing to talk;
glistening of eyes (tearing); or smiling. How
are nonverbal behaviors similar or different
in animals?
4. Define pacing and describe with an example how to perform it.
5. Define leading and describe with an example how to perform it. Why does it work and
what is its potential utility?
6. How does the clinician address nonverbal behaviors when emotion is overtly
expressed, near the surface, or when there
is a mixed message?

SKILLS EXERCISES
Clinician-Patient Relationship
1. In addition to your usual critique, identify
one positive and one negative feeling toward
a patient that you have experienced, for
example, like them, not like them, warm
interaction, distant interaction.
2. Over time, working with colleagues and
teachers, identify one or more personal
responses to patients or others that
could be harmful, for example, overly
controlling, overly "nice," avoid psychosocial
issues, and fear in discussing a specific
issue such as death. Also, identify those
responses that could be helpful, for example, caring, respect, empathy, and desire
to help.
3. If you decide to change a previously unrecognized, potentially harmful response,
develop a new one that is more conducive
to a healthy clinician-patient relationship.
Role play the old response and the new
response.
4. Maintain an active journal of personal awareness experiences.
Personality
1. Role play the various personalities. The clinician practices Steps 1 to 5 with the additional assignment of identifying the patient's
simulated personality. The simulation
works best using the maladaptive patterns
because the changes are easier to portray
and recognize. Have the person simulating the personality do it as an unknown so

everyone can make a diagnosis following the
interview.
2. Role play meeting the patient's predominant
personality need ("going with the flow").

Nonverbal Behaviors
1. Watch a video of a clinician's interview with
the sound turned off and identify nonverbal behaviors in both clinician and patient,
what they signify about the interaction, and
whether clinician and patient are synchronized or not.
2. Role play different emotions using only nonverbal communication.
3. Watch any video in a foreign language and
identify paralanguage (non-content aspects)
communication and what it means, for
example, voice pitch and rapidity.
4. Role play the positive and negative impact
of various common nonverbal behaviors, for
example, too close, too far, excessive eye
contact, no eye contact, arms folded, supportive touching, appropriate smiling, and
eye level interaction.
5. Role play appropriate and inappropriate nonverbal pacing.
6. Role play appropriate and inappropriate nonverbal leading.
7. Role play how the clinician would address
nonverbal behavior when emotion is overt
(with empathy skills), when it is not (with
emotion-seeking or focused open-ended
skills), and when there is a mixed message
(with focused open-ended skills).

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and standardized patient satisfaction. J Gen Intern Med. 2003;18(3):170-174.
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40. Stern DN. Diary of a Baby. New York, NY: Basic Books; 1990.
41. Carson CA. Nonverbal communication in the clinical setting. Cortlandt Consultant.
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42. Bandler R, Grinder J. Frogs into Princes: Neuro Linguistic Programming. Moab, UT: Real
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c:::

Summarizing
and Presenting
the Patient's Story

UJ

1-

a..

<

:::I:
(.)

The deepest truth is found by means of a simple story.
Anthony de Mello
Up until now you have worked to create an effective clinician-patient relationship, elicited information about the patient's symptoms and their personal
and emotional context, and translated this information into a biopsychosocial
story about a person and her or his illness. Now how do you summarize and
transmit this information to others?

• SUMMARIZING THE PATIENT'S STORY
You have gathered a great deal of information and synthesized it sensibly, but
there remains the task of meaningfully summarizing to reflect the essence
of the patient, that is, the biopsychosocial story, which includes disease
diagnoses. 1 While you may not always include these details in your oral or
written presentation, you should integrate mind (psychosocial) and body
(biomedical) components to describe for yourself the whole person and his/
her dynamically interacting parts in order to provide the best care.
Relationship Story

Your experience during the entire encounter with the patient allows you to
synthesize a story of the clinician-patient relationship. 2.3
Clinician Responses

Your first task is to sort out and be conscious of your own personal feelings
and resulting behaviors toward the patient or the patient's circumstance. For
example, fear of doing harm could lead to avoiding a discussion of death, fear

235

238

SMITH'S PATIENT-CENTERED INTERVIEWING

of contracting a disease might lead to avoidance of touching the patient, or
sexual feelings toward a patient could result in excessive attention or avoidance. These feelings and responses are not necessarily expressed in a written
report or verbal presentation; only information that you are comfortable having many others know should be divulged. Reserve more personal feelings
and responses for discussion with your preceptor(s), as this can be very useful
in developing your personal awareness.4
Patient's Personality

Because personality manifests itself in relationships, it is part of the relationship
story. Make your observations throughout the interview and identify the patient's
dominant personality style as dependent, histrionic, obsessive, self-defeating,
narcissistic, paranoid, or schizoid (or other types), as outlined in Chapter 8. For
most people, this designation depicts their style of interacting with others and is
not abnormal. When personality style interferes with normal functioning, it is
called a personality disorder and is so identified in the summary.5
Clinician-Patient Interaction

Finally, consider the interactional process itself and note any difficulties.
Does the interview feel strained? Is there a give and take to the conversation?
Is there a lack or overuse of eye contact? Is the interview formal, collegial,
parent-chUd, or charged?
Personal Story

Synthesize the multiple bits of personal data, gathered throughout the
interview, into a psychosocial story or theme. This ordinarily is quite straightforward. Identify the major issues and summarize them in two or three sentences. While every patient is unique, you will fmd that the following themes
occur frequentlf"" 8: (1) fear of death, mutilation, and disability; (2) dislike,
distrust, and disbeliefofthe medical system; (3) concern about loss of function
(physical and sexual), wholeness, role, status, and independence; (4) denial of
problems; (5) separation, grief, and losses of many types; (6) leaving home
and becoming independent; (7) concerns about retirement; (8) marital or job
problems; (9) economic, housing, safety issues; (10) other unique personal
problems of the patient; and ( 11) administrative issues relating to disease
diagnosis (e.g., requesting disability).
Disease Story

Similar to the personal story, synthesize multiple bits of primary and secondary data to make disease diagnoses or, at least, high-level probabilistic

Chapter 9

SUMMARIZING AND PRESENTING THE PATIENT'S STORY

237

hypotheses about the disease problem(s). A list of problems or diagnoses represents the disease story. Such a list usually numbers three or four but there
can be as many as 15 or 20 problems/diagnoses in complex patients. Data for
problems and diagnoses derive from the personal description of symptoms
during the beginning of the interview and their further clarification during
the middle and during the physical examination. Of course, the more knowledge of disease patterns you gain the easier it will be for you to make diagnoses such as angina or infectious hepatitis. Beginning clinicians, however,
are not expected to make diagnoses; you should simply describe and list the
problems identified and characterize them as fully as possible; for example,
substernal chest pain occurring with exercise and relieved by rest, vomiting
and jaundice of recent onset where one other family member has the same
problem.
Even after thorough clinical and laboratory evaluation, clinicians often
do not have a satisfactory disease explanation for their patients' symptoms. Sometimes symptoms resolve and we never know what caused them.
Occasionally, symptoms persist and patients are later found to have a disease.
Many patients are labeled as having medically unexplained symptoms-the
expression of emotional distress through physical symptoms for which we
find no disease explanation.9- 12
You cannot put the patient's story to rest as a fixed event or unchanging
"'reality." Patient stories are dynamic. The story changes as diagnoses are
resolved, treatment is implemented, new personal responses occur, and the
clinician-patient relationship deepens. Indeed, the very telling of the story
will lead you to new thoughts and emotions about yourself and, in turn, to
new actions and attitudes so that a new, a different story will evolve as part of
the narration process. 13- 15
•

THE MEDICAL RECORD-THE 1'WRITE-UP" OF THE
PATIENT'S STORY

The written description of the patient's story is usually called the "write-up"
or "Hand P" (for History and Physical). The Hand P follow the outline in
Table 9-1. Appendix D contains a full write-up of Ms. Jones' initial evaluation.
See Chapter 5 for general guidelines about length.
As with most scientific endeavors, a well-organized, tighdy knit written
summary does not describe the discovery process itself. In fact, write-ups
synthesize personal, primary, and secondary data from different parts of the
interview. The order in which you discover data often has little bearing on just
where these data will be presented in the written version.

• TABLE 9-1. Recording the New Patient Evaluation-The Write-up
A. Identifying data: age, gender, job, race, intimate
relationship status, address, telephone number
of nearest relative in case of emergency, referral
source (if any)
B. Source and reliability of information: patient,
relative or translator (specify), outside records
(indicate completeness), judgment of reliability of
information from all sources
C. Chief concern and agenda: the patient's most
bothersome concern and a summary (list) of all
presenting concern(s)
D. History of present illness (HPI) and other active
problems (OAP)
1. Overview of symptoms and time of onset
2. Complete description of the dimensions of
each symptom; i.e., onset and chronology,
position and radiation, quality, quantification,
related symptoms, setting, and transforming
factors
3. Pertinent negative symptoms
4. Relevant positive and negative secondary data
5. The personal contextual dimension of
the above; e.g., story content, emotions,
patient's beliefs and explanations, impact of
illness on daily life, triggers for seeking care,
relationships, support systems, and role of
stress
E. Past medical history
1. General state of health and presence or
absence of past illnesses: childhood illnesses
(measles, mumps, rubella, chicken pox,
scarlet fever, and rheumatic fever); adult
illnesses (hypertension, heart attack, stroke,
heart murmur, other heart disease, diabetes,
tuberculosis, sexually transmitted infections,
cancer); major treatments in the past (steroid
treatment, blood transfusions, insulin,
anticoagulants); visits to clinicians during the
last year; injuries; accidents; unexplained
problems; procedures; tests; psychotherapy;
other
2. Hospitalizations: medical, surgical, psychiatric,
obstetric, rehabilitation, other
3. Immunization history

4. Status of age-appropriate preventive screening
5. Women's health history: age of menarche,
cycle length, duration of menstrual flow,
number of tampons/pads used per day;
number of pregnancies, complications; number
of live births, spontaneous vaginal deliveries/
cesarean section; number of spontaneous and
therapeutic abortions; age of menopause
6. Medications and other treatments: prescribed,
inhalers, over-the-counter, alternative remedies,
oral contraceptives, vitamins, laxatives
7. Allergies and drug reactions: allergic diseases
(e.g., asthma, hay fever), medications
(describe reaction), foods, environmental
F. Social history
1. Occupation, workplace, level of responsibility,
daily routine and schedule, occupational
hazards and exposures, work stress, financial
stress, satisfaction
2. Health-promoting and health-maintenance
activities
a. Diet
b. Physical activity/exercise history
c. Functional status: dressing, bathing,
feeding, transferring, walking, shopping,
using the toilet, using the telephone,
cooking, cleaning, driving, taking
medications, managing finances, and
cognitive function; extent of interference
with normal life
d. Safety: seat belts; helmet use when riding
a bicycle or motorcycle; smoke detectors;
protection of self and others from poisonous substances (including medications),
firearms, and dangerous circumstances at
home and at work
e. Health screening (if not listed under PMH):
cervical cancer, breast cancer, prostate
cancer, colon cancer, lipids, hypertension,
diabetes, HIV. sexually transmitted infections, tuberculosis, glaucoma, dental, selfexamination
3. Exposures: pets; travel; illness at home, in the
workplace; sexually transmitted infections

• TABLE 9-1. Recording the New Patient Evaluation-The Write-up (continued)
4. Substance use: caffeine, tobacco, alcohol,
street drugs, prescription medications
5. Personal
a. Living arrangement
b. Personal relationships and support system
c. Sexuality
Orientation
Practices
Difficulty
d. Intimate partner violence/abuse
e. Life stress
f. Mood
g. Spirituality/religion
h. Health literacy
i. Hobbies, recreation
j. Important life experiences
Upbringing and family relationships
Schooling
Major losses/adversity
Military service
Financial situation
Aging
Retirement
Life satisfaction
Cultural/ethnic background
6. Legal issues
a. Living will or advance directives
b. Power of attorney
c. Emergency contact
G. The family history (FH)
1. Age and health (or cause of death) of
grandparents, parents, siblings, and children
2. Presence of family history of tuberculosis,
diabetes, cancer, stroke, hypertension, high
cholesterol, heart disease, bleeding problems,
anemias, kidney failure or dialysis, drug use,
alcoholism, tobacco use, weight problems,
asthma, and mental illness (depression,
schizophrenia, multiple somatic complaints),
symptoms similar to those the patient is
experiencing
3. Genogram
a. Two generations preceding the patient and
all subsequently; involves parents, siblings,

children, and significant members outside
the bloodline for each generation
b. Age, sex, mental and physical health, and
current status are noted for each; note age
at death and cause
c. Note interactions among family members
for psychological and physical problems
1. Psychological
a. Dominant members and their style
(e.g., loving, angry)
b. Major interaction patterns (e.g.,
competition, abuse, open, distant,
caring, manipulation, co-dependent)
c. Family gestalt (e.g., happy, successful, losers)
2. Physical/disease:
a. Patterns of disease (e.g., dominant,
recessive, sex linked, no pattern)
b. Patterns of physical symptoms
without organic disease (e.g., bowel
trouble, uncoordinated, headaches)
c. Inquire about others with similar
symptoms (e.g., infection, toxic, anxiety, anniversary reaction)
H. System review items not already consideredreview of systems (ROS)"
1. General
a. Usual state of health
b. Fever
c. Chills
d. Night sweats
e. Appetite
f. Weight change
g. Weakness
h. Fatigue
i. Pain
2. Skin
a. Sores/skin ulcers
b. Rashes
c. Itching (pruritis)
d. Hives
e. Easy bruising
f. Change in size or color of moles
g. Lumps
continued

• TABLE 9-1. Recording the New Patient Evaluation-The Write-up (continued)

3.

4.

5.

6.

7.

8.

9.

h. Loss of pigment
i. Change in hair pattern
j. Change in nails
Hematopoietic
a. Enlarged lymph nodes (lymphadenopathy)
b. Urge to eat dirt (pica) or ice
c. Abnormal bleeding or excessive bruising
d. Frequent or unusual infections
Head
a. Dizziness
b. Headaches
c. Fainting or loss of consciousness
d. Head injuries
Eyes
a. Use of glasses
b. Change in vision
c. Double vision (diplopia)
d. Pain
e. Redness
f. Discharge
g. History of glaucoma
h. Cataracts
i. Dryness
Ears
a. Hearing loss
b. Use of hearing aid
c. Discharge
d. Pain
e. Ringing (tinnitus)
Nose
a. Nosebleeds (epistaxis)
b. Discharge
c. Loss of smell (anosmia)
Mouth and throat
a. Bleeding gums
b. Sore throat
c. Painful swallowing (odynophagia)
d. Difficulty swallowing (dysphagia)
e. Hoarseness
f. Tongue burning (glossodynia)
g. Tooth pain
Neck
a. Lumps
b. Goiter

c. Stiffness
10. Breasts
a. Lumps
b. Milky discharge (galactorrhea)
c. Bleeding from the nipple
d. Pain
11. Cardiac and pulmonary
a. Cough
b. Shortness of breath (dyspnea)
c. Shortness of breath with activity (exertional
dyspnea)
d. Shortness of breath when lying down and
need to sit to breathe (orthopnea)
e. Awaking at night with shortness of breath
(paroxysmal nocturnal dyspnea)
f. Sputum production
g. Coughing blood (hemoptysis)
h. Wheezing
i. Chest pain
j. Pounding or fluttering sensation in the
chest (palpitations)
k. Shortness of breath on exertion
I. Swelling of feet or other regions (edema)
12. Vascular
a. Pain in legs, calves, thighs, hips, or buttocks when walking (claudication)
b. Leg swelling
c. Blood clots (thrombophlebitis)
d. Leg ulcers
13. Gastrointestinal
a. Loss of appetite
b. Weight change
c. Nausea
d. Vomiting (emesis)
e. Vomiting blood (hematemesis)
f. Difficulty swallowing (dysphagia)
g. Painful swallowing (odynophagia)
h. Heartburn (dyspepsia)
i. Abdominal pain
j. Difficult or infrequent bowel movements
(constipation)
k. Loose, frequent bowel movements (diarrhea)
I. Passing mucus

• TABLE 9-1. Recording the New Patient Evaluation-The Write-up (continued)
m.
n.
o.
p.
q.
r.
s.
t.

Change in stool color/caliber
Black, tarry stools (melena)
Rectal bleeding (hematochezia)
Hemorrhoids
Rectal pain (proctalgia)
Rectal discharge
Rectal itching (pruritus ani)
Yellow discoloration of sclerae and skin
oaundice)
u. Dark urine-the color of tea or cola drink
v. Excessive upper (belching or eructation) or
lower (flatus) bowel gas
w. Lump in groin or scrotum
14. Urinary
a. Frequent urination (polyuria)
b. Awakening at night to urinate (nocturia)
c. Infrequent urination
d. Abrupt urge to urinate (urinary urgency)
e. Difficulty starting stream (urinary hesitancy)
f. Loss of control of urination (incontinence)
g. Blood in urine (hematuria)
h. Pain or burning on urination (dysuria)
i. Particulate matter in urine (urinary gravel)
15. Female genital
a. Lesions/discharge/itching
b. Age at menarche
c. Interval between menses
d. Duration of menses
e. Amount of flow
f. Last menses
g. Painful menses (dysmenorrheal)
h. Absence of menses (amenorrhea)
i. Irregular, heavy menses (menometrorrhagia)
j. Bleeding between periods
k. Pregnancies
I. Abortions/miscarriages
m. Libido
n. Painful intercourse (dyspareunia)
o. Orgasm function
p. Age at menopause
q. Menopausal symptoms
r. Postmenopausal bleeding
16. Male genital
a. Lesions/discharge

b. Erectile function
c. Orgasm function
d. Bloody ejaculation (hematospermia)
e. Testis swelling/pain
f. Libido
g. Hernia
17. Neuropsychiatric (see headings Head, Eyes,
Ears, Nose, Throat for cranial nerves) (see
heading Musculoskeletal for motor function)
a. Fainting
b. Paralysis
c. Tingling (paresthesia)
d. Decreased sensation (hypesthesia)
e. Absent sensation (anesthesia)
f. Tremors
g. Loss of memory
h. Depression
i. Mania
j. Apathy or loss of interest
k. Loss of enjoyment of life (anhedonia)
I. Suicidal thoughts
m. Sleep
n. Anxiety/nervousness
o. Speech disorders
p. Dizziness or vertigo
q. Poor balance (ataxia)
r. Inability to get to sleep or stay asleep
(insomnia)
s. Excessive sleep (hypersomnolence) nightmares
t. Symptoms without an explanation (somatization)
u. Bizarre or unrealistic thoughts (intrusive
thoughts)
v. Bizarre or unrealistic perceptions (hallucinations)
w. Seizures
18. Musculoskeletal
a. Weakness
b. Muscle pain
c. Stiffness
19. Endocrine
a. Excessive thirst
b. Frequent urination
continued

• TABLE 9-1. Recording the New Patient Evaluation--The Write-up (continued)
c. Numbness or tingling of hands/feet
d. Weight gain or loss
e. Episodes of confusion, sweating, lightheadedness (hypoglycemic reaction)
f. Blurred vision
g. Date of last eye exam
h. Swelling in neck
i. Weight gain or loss
j. Palpitations or racing heart
k. Tremulousness

I.

J.
K.
L.

I. Hair loss (alopecia)
m. Dry skin
n. Heat or cold intolerance
o. Loss of skin pigment (vitiligo)
p. Constipation or diarrhea
Physical examinationb
Initial diagnostic formulations and treatment interventions (if any)b
Assessment
Investigative and treatment planb

"Many of these symptoms can occur in systems other than where listed.
"Not addressed in this book.

The following format is commonly used for recording the history (items
A through H), physical examination, initial diagnostic formulations, and
treatment interventions, assessment, and treatment/investigative plans. All
but the history are outside the scope of this book; we include the others to
illustrate the integration of the interview with the other basic components of
a formal patient evaluation. These components will be extensively addressed
during clinical rotations.
Identifying Data

Obtain identifying data (see Table 9-1) from admitting records and other data
that accompany the patient and by simple observation and inquiry.
Source and Reliability of Information

The source of data and its reliability reflect the quality of data obtained. Note
any concerns regarding reliability.
Chief Concern and Agenda

The chief concern and patient's agenda clarify the patient's visit, arising mostly
from Step 2. Recalling that the patient may not have presented it as the first
item during agenda setting, the chief concern, or most bothersome symptom,
serves as a powerful tool to direct the focus of the written story. When possible, cite the chief concern in the patient's own words. Then the full agenda
list should be summarized.

Chapter 9

SUMMARIZING AND PRESENTING THE PATIENT ' S STORY

243

History of Present Illness (HPI) and Other Active Problems (OAP)
Noted in Table 9-1, there are five specific aspects of the HPI (or OAP):
1. An overview ofpertinent symptoms (those that fit together to best describe
the underlying disease process) and their time of onset,
2. Specific symptom descriptors,
3. The absence of pertinent symptoms (called "pertinent negatives"),
4. Relevant secondary data, and
5. The personal context of these data.
Using these five aspects of the history, you can convey a dynamic understanding of the patient's situation and thus prepare the reader to understand
the full biopsychosocial description of the patient that is to be provided later
(in assessment). For beginning clinicians, it can be helpful to put each category
in a separate paragraph, as outlined here; as you gain experience, these categories will frequently be condensed and interwoven considerably.
Paragraph # 1. Provide an overview of all relevant symptoms, reflecting the
chief concern and other current problems, identifying when each began. You
will most likely have obtained this information during Steps 3 to 4, or sometimes at the very beginning of Step 6 (if the patient's personal or emotional
concern prevented you from hearing about the symptom during the beginning of the interview).
Paragraph #2. Record all symptoms (primary data) relevant to the prob-

lem and expand upon each with a full recording of the symptom descriptors
(OPPQQRRST: onset and chronology; position, precipitating factors, quality,
quantification, radiation, related symptoms, setting, and transforming factors [aggravating/alleviating]). The descriptors can be recorded in this order,
as shown for Ms. Jones in Appendix D, and must be clearly anchored in the
chronology and timing dimension. Rather than including all descriptors, experienced clinicians will often record only those of diagnostic significance, sometimes referred to as "pertinent positives." Beginning clinicians are advised,
however, to remain comprehensive until their skills more fully develop. As
your skills and understanding of diseases increase, you will recognize more
and more symptoms that belong in this paragraph; that is, the "related symptoms" category of the descriptors increases. You will have gotten most information in this paragraph during Step 6 of the interview.
Paragraph #3. Next record the absence ofpertinent symptoms, called "pertinent negatives." You will have obtained most ofthis information in Step 6. This
paragraph includes the absence of symptoms from the same system involved
in the chief concern. As you become more facile with hypothesis-testing and
develop a better understanding of disease, you will also include the absence of
other pertinent symptoms, especially those of causal (etiological) importance

244

SMITH'S PATIENT-CENTERED INTERVIEWING

and those outside the body system known to be involved. For example, in
a patient with chest pain, beginning clinicians might record the absence of
hemoptysis and dyspnea in this paragraph while more advanced clinicians
would also indicate the absence of joint pains and skin rash if systemic lupus
erythematosus was a diagnostic consideration (these are sometimes useful
diagnostic symptoms). Data for this paragraph usually come from Step 6.
Paragraph #4. Pertinent positive and negative non-symptom (secondary)
data are included in this paragraph. This includes data about pertinent visits to clinicians and healthcare facilities, diagnostic tests and results, treatments and results, specific habits, occupation, and other non-symptom data
that are important to understanding the patient's disease problem-especially
the etiology (cause) and pathogenesis (mechanism); for example, a history
of smoking in a patient with cough and shortness of breath, a recent hospital
stay with normal coronary angiogram in a patient with chest pain, the use of
birth control pills in a woman with headaches, or a famUy history of sickle cell
anemia in an Mrican American boy with acutely painful legs. This information will often have arisen in Step 6 but less experienced clinicians may have
uncovered it in Steps 7 to 10.
Paragraph #5. Although usually obtained in the beginning of the interview
(primarily in Step 4), personal data often are recorded last to enhance our
understanding of how personal factors interact with the symptom. Here you
will explicitly join symptom, personal, and emotional/psychological dimensions, establishing the mind-body link. Although obvious in Ms. Jones' situation, we do not always find a clear causal relationship between personal
factors and the disease problem. In all patients, however, we can describe a
personal and/or emotional context of the presenting problem.
The HPI, the most important part of the history, synthesizes the patient's
personal and symptom dimensions. Beginning clinicians simply record the
chronology of primary data (including symptom descriptors), secondary
data, and their personal dimensions. As you learn more about disease patterns
later in training, you will begin to record the patient's data in a way that leads
another clinician to the same diagnostic conclusion (given in the assessment).
You will begin to selectively highlight portions of the story, still utilizing the
five dimensions, to provide data for and against the diagnosis (hypothesis) you
have arrived at. The diagnosis and reasonable alternative diagnoses are painstakingly recounted so that another professional (often a preceptor) can make
an informed decision about their accuracy. Ms. Jones' HPI in Appendix D
illustrates this diagnostic process.
Only primary and secondary data are included in the HPI. Discussion and
interpretation of the patient's problem come in the assessment. Interpretative
comments can be made, however, when the clarity of data is in question; for

Chapter 9

SUMMARIZING AND PRESENTING THE PATIENT'S STORY

245

example, "The patient states that she underwent some type of heart surgery
when hospitalized in 2003 but doesn't know what it was and we have no
records of it yet:'
The OAP is where you will record problems that are unrelated to the HPI
but are nonetheless active and related to the patient's present health. Each of
these areas requires a five-part approach simUar to the HPI, although usually
less extensive. Each typically has its own symptom with cardinal features and
its own personal and emotional contexts.
While the HPI is recorded in narrative form, the remainder of the write-up
can be recorded in narrative form, outline form, or both; the latter is shown in
Ms. Jones' write-up in Appendix D.
Past Medical History

The past medical history (PMH) is recorded as noted in Table 9-1, often in
the order suggested in the table. It is detaUed where necessary to provide an
understanding of the patient's health, but abbreviated for past events of little
relevance. For example, in a patient admitted for a hernia repair, you would
record in the PMH data about the patient's coronary artery stenting 1 year earlier; if the patient was presenting with chest pain, you record coronary artery
stenting in the HPI. Although usually recorded in outline form, pertinent
details are essential for all major problems, for example, symptoms, secondary
data, dates, treatments, doses of medications, types and outcome of adverse
reactions to medications, and detaUs of any complicated obstetric problem.
Social History

The social history (SH), as noted in Table 9-1, is often recorded using a combination of outline and narrative form. Only background and routine data are
recorded under the SH heading; when detaUs pertinent to patient's current
problem(s) have been elicited during the SH part of the interview, they are
recorded in the HPI portion of the written record. For example, when evaluating a patient with shortness of breath, cigarette smoking habits are recorded
in the HPI. Similarly, some SH data may have already been recorded, where
relevant, as part of the OAP or identifying data. Following the guidelines in
Chapter 5 will allow you to record all relevant data, for example, dates, relevant people, when a Pap smear was last performed, daUy number of cigarettes
smoked, number of pack-years, and efforts to stop.
Family History

In the family history (FH), record the information detaUed in Table 9-1,
including a genogram diagram, as shown for Ms. Jones in Appendix D. Most

248

SMITH'S PATIENT-CENTERED INTERVIEWING

important is to know who is available to the patient in a support role; and
which family member(s) have or had anything like what the patient is suffering from or fears about what they might have. As already noted, some of these
data may need to be included in the HPI/OAP when pertinent to the patient's
diagnosis.
Review of Systems

Here you simply record symptoms discovered in the review of systems (ROS)
that you have not already mentioned during the HPI/OAP or PMH. Beginning
clinicians often record a lot of information here, grouping the positives and
negatives together in each system. lbis detail is necessary for learning purposes. More advanced clinicians record only pertinent positives, eventually
noting only those that are significant.
Physical Examination

Documentation of the physical examination, 16 outside the province of this
text, includes routine vital signs (temperature, pulse rate, respiratory rate,
blood pressure, height, weight) and the details of the examination in each
system (such as heart murmur heard on auscultation of the chest, an enlarged
uterus on pelvic examination, or cerumen found on examining the ears).
Initial Diagnostic Formulations and Treatment Interventions (If Any)

Also recorded here are initial diagnostic or therapeutic interventions by you
or others, which occur largely in acute situations. These might include a complete blood count and a CT scan of the abdomen in a patient with one day
of right lower quadrant abdominal pain. These data should not be confused
with secondary data obtained before the patient came under your care and are
already recorded in the HPI or PMH.
Assessment: The Biopsychosocial Description--The Patient's Story

Sometimes, additional observation or diagnostic investigation are required
before a full biopsychosocial description can be made. When descriptions
are defmitive enough to allow identification of a disease, the disease itself
is recorded in the appropriate category. When descriptions are not sufficient

to permit a disease diagnosis, a succinct description of the problem is recorded
and caUed a ''problem" in contrast to a diagnosis. Patients have from four to six
problems/diagnoses on average in adult ambulatory practices. 17

Further Investigative and Treatment Plan
Further investigative and treatment plans (not addressed in this text) follow
logically from the assessment and could include, for example, pain medication and exploratory surgery for a patient with probable appendicitis .
•

PRESENTING THE PATIENT'S STORY (SEE ALSO DocCom
MODULE 3718 )

Beginning and advanced clinicians frequently tell patients' stories to other
professionals. These verbal presentations are valuable for learning and teaching, and they are the medium for communication among professionals.
Although you may find presentations difficult at the outset, you will quickly
master them. Presentations demonstrate your ability to elicit and synthesize
large amounts of data, your skills in communicating with others, and the way
you see and understand the patient as a person. The oral presentation can
range from a brief summary on rounds to a more formal presentation in a
conference setting. 19
There are some general guidelines for a presentation (Table 9-2): (1) It is
essential to know beforehand what your goals are (what the listener expects),
and how long you will have to present. (2) Know the patient thoroughly.
(3) Begin your preparation of the presentation with the problem list/diagnoses you have identified (clarify it if uncertain), know what the differential
diagnostic issues may be, and know what needs to be done to clarify diagnoses in the future. Your entire presentation will be focused on providing evidence, pros and cons, for your definition of the problem (although sometimes
• TABLE 9-2. Guidelines for Making a Presentation
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Goals (what the listener expects) and time available
Know the patient
Focus on the problem list/diagnoses
Present only relevant data, saving interpretation for the assessment
Use a standard format: CC/HPI, physical exam, and diagnostic investigations
Summarize and invite questions
Be engaging and interesting
Use note cards only for reminders of factual data
Practice and get feedback from colleagues
Observe other good presentations and emulate those
Avoid logistic and other problems
Avoid personalizing and recounting specific conversations

248

SMITH'S PATIENT-CENTERED INTERVIEWING

presentations may focus upon difficult treatment issues for a known diagnosis). (4) Present only relevant data, usually focused upon the problem
list. Present this much in the fashion of a lawyer presenting a case to a judge
and jury. You are trying to convince the listener of your problem list items/
diagnoses, providing all relevant information on both sides of any controversial or unclear issues. In other words, you will be presenting the patient's story.
(5) Stick to the standard format: start with the CC/HPI, interweaving only relevant data from other parts of the interview, and then proceed to the physical
exam and, finally. to any diagnostic investigations performed. If the patient
has had prior examinations and laboratory data (from before this illness episode), these are included in the HPI; you use only data from the present event
when presenting physical examination or laboratory fmdings. (6) Summarize
the presentation and invite questions. (7) Be engaging and interesting so your
listeners become and remain interested. (8) Use note cards only for reminders
of factual data and avoid reading a presentation. (9) Practice and get feedback from colleagues. (10) Observe other good presentations and emulate
those. (11) Avoid logistic and other problems you may have devoted much
time to but which are irrelevant to your diagnostic/problem list; for example,
"Radiology was out of contrast media for a certain study and this delayed
obtaining it,, "It took several hours to find a relative to obtain permission for a
lumbar puncture., (12) Avoid personalizing and recounting specific conversations that occurred.
There are three types of presentations: very brief, standard, and long. Very
brief presentations last no more than a minute or so and orient another professional to key problems in nonurgent situations; for example, "I'll be in the
clinic all afternoon. Mr. Johnson in Room 345 has pneumonia but is doing
OK on azithromycin. Check his blood cultures when they're out at 4:00 p.m.
His wife should be in about then; let her know all is OK and I'll be back to talk
with her around supper time. Thanks:'
The standard, 3- to 10-minute presentation conveys full, pertinent information to a listener unfamiliar with the patient. Such presentations are useful
teaching exercises as well as being relied upon to transmit critical information
to other clinicians. Students and junior residents make these presentations
to preceptors or senior residents at morning report, on rounds, and in the
clinic. The beginning clinician synthesizes personal, primary. and secondary
data into a logical diagnosis, and then presents it cogently and interestingly.
Presentations follow the same format as the write-up, including the logic of
clinical reasoning, but are much more condensed and contain only the most
essential data.
The following is an example of a standard presentation-using Ms. Jones
as our subject. (This is a transcript of the clinician's presentation of Ms. Jones'

Chapter 9

SUMMARIZING AND PRESENTING THE PATIENT'S STORY

249

initial evaluation to his preceptor in the clinic. Although some preceptors
may want more detail, most prefer a succinct, pertinent presentation. Always
ask your preceptors to be certain of their preference.)
Identifying Data, Source and Reliability of Data, Chief Complaint,
and Other Major Agenda Items

The clinician gives these in one or two sentences, and conveys the broad
strokes of the situation:
Joanne Jones is a 38-year-old woman who is a lawyer and lives with
her husband. She is a reliable historian, and self-referred for headaches of 3 months duration and to get establlshed with a primary care
provider. She also is concerned about stress at work, a past history of
ulcerative colitis, and a recent cold.
History of the Present Illness

If you can organize the HPI chronologically, the listener will better understand the subsequent diagnosis or problem identification you came to. This
does not mean that a preceptor will agree with the analysis, but it allows her
or him to judge the data and rationale you used. Avoid bias and emphasize
pros and cons of diagnostic data. To continue with Ms. Jones' presentation,
the clinician presents the following:
Throbbing, nonradiating right temporal headaches associated with
nausea and photophobia began suddenly 3 months ago. These have
progressively worsened, especially in the last month, so that they
now occur 2-3 times weekly, lasting as little as 2 hours and as long
as 12 hours, during which time they progressively increase in severity. They are quite severe ("worse than having a baby") and make her
miss work. An ice bag and dark room seem to help some.
She has been well between headaches and there are no other symptoms, particularly scintillating scotomata or those suggesting neurological disease, meningitis, or head injury. I get no history of arthritis
or anything suggesting a collagen-vascular disease.
An aunt likely had migraine and the patient has used birth control
pills for 6 years. She had to go to the emergency department a week
ago, received a narcotic injection, and only a blood and urine study
were done; we don't have these results yet.
Headaches clearly relate to anger at her boss, who criticizes and
disdains her often, and don't occur when he's not around. She is gradually replacing him as the lead attorney in GHI Corporation here,

250

SMITH'S PATIENT-CENTERED INTERVIEWING

and he is resisting this more than her Board had said he would. She's
mad at them, too. She also had headaches as a child when her mother
criticized her unfairly and repeatedly. Talking about these problems
brought on the headache during our interview. Although her support
system is fairly good, she's getting worse and, if there's no help with
this, she may quit her job. She's not depressed and has had no similar
problems getting along in the past.
Notice that the clinician has covered the five components of the HPI we
discussed as part of the write-up: a chronological overview of the story, the
dimensions of each symptom, pertinent positives and negatives, the course of
the problem and relevant secondary data, and the personal contextual aspects.
The clinician next reports only pertinent OAP, PMH, SH, FH, and ROS data.
Except for chronic stress on the job and being a self-described "workaholic:' she takes good care of herself from a health maintenance
standpoint: seat belts, aerobic exercise almost daily, low fat and low
salt diet, no addicting substances, and no risky habits. She is up to
date with her health maintenance, including Pap smears.
Her past medical history is significant for mild ulcerative colitis in 2010 when she was hospitalized at the University Hospital in
her home town. Shea had bloody diarrhea off and on for 3 months
then and responded to 3 months of prednisone and about a year of
sulfasalazine after her work-up was completed. It sounds like both
colonoscopy and barium enema were done as well as several other
tests and I'm sending for the records. She was followed regularly
by a Dr. Jergens and was asymptomatic until November 2015 when
nonbloody diarrhea recurred and colonoscopy and barium enema
showed minimal changes in what she calls the "distal sigmoid colon."
No surgery has ever been advised and she continues without symptoms, having responded almost immediately to another course of sulfasalazine which she took for 6 months. A colonoscopy 6 months ago
was said to be normal.
She's had two uncomplicated spontaneous vaginal deliveries. Except
for a mild but now cleared respiratory infection recently. and a single
urinary tract infection in July. 2017, she has been in good health.
Aspirin, 6-8 daily, is the only other medication. There are no drug
sensitivities or allergies.
The SH is significant only in that this job was a big step forward
professionally. She does not use tobacco or drugs and drinks less than
one glass of wine per week. The FH is not further contributory. ROS

reveals nothing more.

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SUMMARIZING AND PRESENTING THE PATIENT'S STORY

251.

Physical Examination

Only pertinent data are given, both normal and abnormal, focusing at the
outset on a vivid general description of the patient and relevant vital signs
(because physical examination is outside the province of this text, only a brief
report of the exam is presented; most preceptors will prefer that it be more
complete and specific):
Physical examination shows a normotensive, friendly, and healthy
appearing woman. Head and neck are normal and without bruises
or tenderness. Pupils are equal, round and reactive to light and accommodation. Discs are sharp and vessels are normal. Neurological
evaluation shows normal cranial nerves, reflexes, cerebellar function,
extrapyramidal function, and motor/sensory function. She does have
a midsystolic dick along the left sternal border but there is no murmur or other abnormality.
Initial Diagnostic and Treatment Interventions (If Any)

As in the write-up, these usually emergency actions have been obtained under
the clinician's and his/her team's direction:
No diagnostic or treatment interventions have been made and we do
not yet have the lab data from a week ago.
Assessment: Blopsychosoclal Description-The Patient's Story

Assessment is equally cogent, as shown in Ms. Jones' story:
1. Ms. Jones is under severe stress from the conflict with her boss on a new job.
2. In turn, this has precipitated migraine headaches, with a typical clinical
picture of intermittent throbbing and photophobia and a family history.
The birth control pills could be a factor as well. Less likely is a stress tension
headache: I wouldn't expect this to be so intermittent, severe, or throbbing.
Meningitis, subdural hematoma, and a vasculitis all are extremely unlikely.
3. She has ulcerative colitis, needing further assessment.
4. Recent cold symptoms, resolved.
5. Probable mitral valve prolapse, asymptomatic.
Investigative and Treatment Plan

This is equally brief and to the point, as shown with Ms. Jones. In complicated
cases, this and the assessment are much more extensive.

Ia suggest we start her on either ibuprofen or sumatriptan tablets
for the acute headaches. Prophylactic treatment, with a beta blocker

KNOWLEDGE EXERCISES
1. In the write-up of the patient's HPI,
what is the content for each of the five
paragraphs?
2. List several guidelines for an effective case
presentation.
3. Define the types of case presentation.

4. In a patient presenting with chest pain,
where in your presentation or write-up
would you include a family history of
diabetes? Could there be more than one
location, depending upon the nature of the
pain? Explain.

SKILLS EXERCISES
1. Perform a complete new-patient history on
a colleague, a simulated patient, or a real
patient-and then write up your findings.

2. Present the same case in 30 minutes,
5 to 7 minutes, 1 to 2 minutes.

REFERENCES
1. Barrows HS, Pickell GC. Developing Clinical Problem-Solving Skills: A Guide to More
Effective Diagnosis and Treatment. New York, NY: Norton Medical Books; 1991:226.
2. Inui TS. What are the sciences of relationship-centered primary care. J Pam Pract.
1996;42{2):171-177.
3. Tresolini CP; Pew-Fetzer Task Force. Health Professions Education and RelationshipCentered Care. San Francisco, CA: Pew Health Professions Commission; 1994:72.
4. Smith RC, Dwamena FC, Fortin AH VI. Teaching personal awareness. JGen Intern Med.
2005;20:201-207.
5. APA. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC:
American Psychiatric Association; 2013.
6. Kravitz RL, Callahan EJ. Patients' perceptions of omitted examinations and tests-a
qualitative analysis. J Gen Int Med. 2000;15:38-45.
7. Marple RL, Kroenke K, Lucey CR, Wilder J, Lucas CA. Concerns and expectations in
patients presenting with physical complaints-frequency, physician perceptions and
actions, and 2-week outcome. Arch Intern Med. 1997;157:1482-1488.
8. Smith RC, Hoppe RB. The patient's story: integrating the patient- and physician-centered
approaches to interviewing. Ann Intern Med. 1991;115:470-477.
9. Smith RC, Lein C, Collins C, et al. Treating patients with medically unexplained symptoms in primary care. J Gen Intern Med. 2003;18:478-489.
10. Smith RC, Lyles JS, Gardiner JC, et al. Primary care clinicians treat patients with
medically unexplained symptoms-a randomized controlled trial. J Gen Intern Med.
2006;21:671-677.
11. Smith RC, Dwamena FC. Classification and diagnosis of patients with medically unexplained symptoms. J Gen Intern Med. 2007;22(5):685-691.
12. Smith RC, Gardiner JC, Luo Z, SchooleyS, Lamerato L, Rost K. Primary care physicians
treat somatization. J Gen Int Med. 2009;24:829-832.
13. Chatwin J. Patient narratives: a micro-interactional analysis. Commun Med.
2006;3{2):113-123.
14. Eggly S. Physician-patient co-construction of illness narratives in the medical interview.
Health Commun. 2002;14{3):339-360.
15. Haidet P, Kroll TL, Sharf BF. The complexity of patient participation: lessons learned
from patients' illness narratives. Patient Educ Couns. 2006;62{3):323-329.

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16. LeBlond R, Brown D, DeGowin R. DeGowin's Diagnostic Examination. 9th ed. New York,
NY: McGraw-Hill; 2009.
17. Williams BC, Philbrick Tf, Becker DM, McDermott A, Davis RC, Buncher PC. A patientbased system for describing ambulatory medicine practices using diagnosis clusters.
J Gen lnt Med. 1991;6:57-63.
18. Monroe A. Module 37: The Oral Presentation. In: Novack D, Daetwyler C, Saizow R,
Lewis B, Hewson M, Levy J, eds. DocCom - an Online Communication Skills Curriculum
[Internet]. Lexington, KY: Academy of Communication in Healthcare and Drexel University College of Medicine; 2018. Available from: www.DocCom.org
19. Tierney LM Jr. The case presentation. In: Henderson MC, Tierney LM, Smetana GW,
eds. The Patient History. 2nd ed. New York, NY: McGraw-Hill; 2012:675-676.

Remaining
Patient-Centered
in the Digital Age
•

BACKGROUND: A BRIEF HISTORY OF MEDICAL
RECORD KEEPING

The modern era of medical record keeping began in the late 19th and early
20th century. Medical records ofthat time period were largely unsystematic, as
was medical education, which was unregulated and taught in privately owned
medical schools. Written records were treated as no more than "notes to self:'
of use and interest to individual practitioners only. In 1911, Richard Cabot, a
Boston physician, published a book entitled, Differential Diagnosis: Presented
Through an Analysis of 383 Cases, 1 in which he demonstrated how individual
records could be used to classify groups of patients according to the symptoms and signs they presented with, an early form of population medicine.
The next major innovation in written record keeping came in the late 1960s
from Lawrence Weed, a physician and medical educator who was interested
in ways of evaluating medical students' clinical thinking skills. 2 The ProblemOriented Medical Record (POMR) was organized around the SOAP note
(Subjective, Objective, Assessment, and Plan), a standardized method that
could be used to assess students' and, as it turned out, practicing physicians'
thought-processes and actions. Weed's innovation also paved the way for
third parties (teachers, peers, and later insurance companies and the federal
government) to use the written record to judge the accuracy, completeness,
and quality of care delivered.
Another important shift in record keeping came in the early 1990s on the
heels of the "digital revolution:' One major limitation of paper-based records
was their physical storage and portability. Records were typically limited to
a single location and facility. had to be retrieved by hand, and were placed
in a holder on the exam room door (most of the time) by a medical assistant. Computers changed all that and allowed records to be accessed, shared,

2&5

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and archived instantaneously by individuals, institutions, researchers, and
regulators without the traditional limitations of paper. By the early 1990s
the Institute of Medicine recommended that all physicians should be using
computers in their practice by the year 2000.3 By January of 2015, 83% of
office-based physicians in the United States had adopted an electronic health
record (EHR) in their offices (http://dashboard.healthit.gov/quickstats/pages/
physician-ehr-adoption-trends.php ).
One final chapter in contemporary medical record keeping is the migration
of computer-enabled health records from the back office, where they were used
for coding and billing in addition to entering clinical notes and test results, to the
exam room where they are used to document elements of the visit as it occurs.
It is in the intersection ofcaring for patients (maintaining patient-centeredness)
and documentation in the EHR (for coding, billing, and legal purposes) that is
causing distraction and conflicts in clinician attention. Unfortunately, there are
no national standards for where a computer and monitor should be placed for
optimal patient-centered care, nor is there much guidance in how to handle
the complexities introduced into the clinician-patient relationship by having an
EHR as an active "third presence" in the exam room.
In the following sections, we will explore these challenges and provide a
guide to current best practices from the research literature for using the exam
room EHR in the clinical encounter.

• EXPLORING THE CLINICIAN/PATIENT/COMPUTER
RELATIONSHIP
Researchers and educators have identified three discrete points in time where
the EHR can cause stress and negatively affect the quality of care and resilience of the clinician. These are: (1) preparing for the visit; (2) enacting the
visit; and (3) entering additional information into the EHR after the visit has
concluded. Sources of stress may be individual and/or organizational and
when they occur over time, which is typical, the result is a chronic decrement in processes and outcomes of care. Table 10-1 summarizes the sources
of stress and the levels at which they occur.
Preparing for the VIsit

As pressures on clinicians to be more efficient have mounted, and documentation tasks have multiplied, traditional norms of care have been challenged.
One in particular is clinicians' review of patients' records prior to entering the
exam room. In the era of hand written records, the physical chart was placed
in a holder on the exam room door and the clinician could simply remove
and quickly review it before entering the exam room entering the exam room.

• TABLE 10-1. Sources of Stress Related to EHR Documentation Challenges
Preparing for the visit

Enacting the visit

Post-visit documentation

Sources of stress
Individual:
o Some clinicians are naturally
slower than others in their visits
routinely creating challenges to
being on time and prepared for
upcoming visits
Mlcrosystem:
o Work flow may be inefficient
and informal norms of staff,
e.g., interruptions may limit
time to prepare for upcoming
visits
Organizational:
o Scheduling practices such as
double and triple booking may
limit clinician time to prepare

Sources of stress
Individual:
o Limited typing skills may make
documentation during the visit
difficult
o Physical placement of the
computer may make it
difficult to maintain patientcenteredness during the visit
o Interpersonal communication
skills may not be well-adapted
to being patient centered and
exam room computer use at
the point of care
Organizational:
o Formal or informal
expectations for efficiency may
create a chronically stressful
environment for the visit

Sources of stress
Individual:
o After-hours time spent in
EMR documentation may
compete with family time
at home
o Accuracy of notes may be
compromised over time
o Time for self-care activities
such as hobbies and
physical fitness may
be lost to after-hours
documentation
Organizational:
o Completion requirements,
e.g., within 24-48 hours
may place additional stress
on clinicians

With EHRs one must be in a location where there is a computer available
(typically the back office, which may be some distance from the exam room),
log in (which can take 2-3 minutes), find the patient's record and click
through separate fields to find the problem list, medications, tests ordered,
results, and the plan of care. All of this takes time that is limited by scheduling and documentation requirements. The result, more often than not, is to
skip the preparation phase in the back room and do it in the exam room,
in the patient's presence. In other industries, such as aviation for example,
doing a preflight checklist (which is the equivalent of the preparation phase
in patient care) once airborne would be highly unusual and result in reprimand or even dismissal, while in medicine it is rapidly becoming an informal
workplace norm. Foregoing preparation prior to entering the room has several associated costs as the following actual case study suggests (names have
been changed to ensure anonymity).
Case #l

Paul Antonov is a third-year medical resident seeing his fourth clinic patient
of the day, Albert Simms, who is a 71-year-old retired machinist with multiple
medical problems including hypertension (HTN), diabetes mellitus (DM),
and chronic obstructive pulmonary disease (COPD). His social history is

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unremarkable except for the fact that Mr. Simms' wife died 4 months ago
after a long illness. This is a follow-up visit to check his blood pressure since
Dr. Antonov increased his dosage of hydrochlorothiazide at the last visit. The
care plan also calls for checking Mr. Simms blood sugar level since it was
higher than usual at the last visit, and refilling his prescription for albuterol.
Dr. Antonov is already running 20 minutes late and has not had a chance to
review Mr. Simms EHR. The visit opens with the following exchange:
Doctor:
Patient:
Doctor:
Doctor:
Patient:

Doctor:

Doctor:
Patient:
Doctor:
Patient:

Doctor:
Patient:

Hi Mr. Simms, how are you doing today?
Okay
I'm just going to log into your chart here and have a look
((7 minutes of silence ensues))
So, what brings you in today?
Well, you asked me to come back to check my blood pressure
but then I had an asthma attack three nights ago and wound up
in the ER.
Oh, I didn't see that in reviewing your chart. Let me go back in
and check
((3 minutes of silence ensues))
I see it now. So, what else beside the blood pressure and your
asthma?
Well, I've been feeling pretty blue lately.
Why is that?
Well, you remember at our last visit I shared with you that my
wife of 49 years had passed away shortly before our 50th wedding anniversary.
Oh yes, I remember now. I was sorry to hear it. What else?
That's about it I guess ...

The "costs" of not having reviewed Mr. Simms' EHR prior to entering the
room can be summarized in terms of time, relationship, and "face:'4 In terms
of time, 7 minutes were taken as Dr. Antonov silently reviewed the EHR in
Mr. Simms presence, trying to "catch up," and another 3 minutes to access
the information after being informed about his emergency department visit
for an asthma exacerbation. At a minimum, 10 minutes out of a 30-minute
visit were taken up by Dr. Antonov's interactions with the computer screen
as he tried to establish who the patient was, the reason for the visit, and the
problems he was following him for. All of this with Mr. Simms sitting in front
of him, reminding him of their history together when, with preparation, that
time that could have been used to discuss more meaningful topics like depression and coping with a significant loss.

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259

In terms of relationship, the fact that Dr. Antonov had to be reminded
by Mr. Simms that he requested the visit and that he had previously been
informed about the loss of Mr. Simms' wife is a threat to their relationship.
In this case, having to rely on the EHR in real visit time to recall details of
Mr. Simms' medical care that Dr. Antonov likely would have had in hand,
had he had the chance to review his notes before entering the exam room,
communicates both lack of preparation and potentially a lack of caring. To
quote George EngeL the father of the biopsychosodal/patient-centered care
model (see Appendix A), "'To know and understand obviously is a dimension
of being scientific, to be known and understood is a dimension of caring and
being cared for." 5 Preparation for the visit clearly establishes the importance of
knowing and understanding the shared mutual biography created over time
in the patient-clinician relationship and the impact it has on the patient's
experience of care.
Perhaps more challenging still is the loss of face and embarrassment
Dr. Antonov experienced in failing to recall a critical fact and connect it to
Mr. Simms' concern about feeling blue. Almost certainly, no clinician wants
to find her- or himself in the position of having forgotten key information in
the care of his/her patient, and embarrassment and shame often follow when
they do. Clinicians often rely on patients to provide historical information
such as their recollection of recommendations made in previous visits. This
is one way of testing for comprehension and it can also enhance partnershipbuilding. You may not recall all the details of your patient's care but as long
as you know the major ones you can rely on the patient to fill in minor gaps.
When reliance on the patient for pertinent information happens routinely
and/or when very significant facts such as the death of a spouse are forgotten
or overlooked partnership takes a back seat and questions of trust and respect
come into play. Lack oftrust and respect, in turn, have been related to reasons
that patients and families sue for medical malpractice in the face of an adverse
outcome.6
Some of what Dr. Antonov experienced in this scenario cannot be
changed. The fact that his visits are scheduled every 30 minutes with little
time in between may be an administrative fact of life over which he has
little control. Similarly, the time needed to travel to the back office between
patients, log in, and review progress notes is unlikely to change any time
soon. Finally, the EHR itself has some significant limitations including multiple reminders, alerts and codes, not to mention having to click on multiple
screens to retrieve information that was literally at one's finger tips in the
era of paper records. These barriers notwithstanding, lack of visit preparation made an already difficult task much more complex and interpersonally
challenging.

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Enacting the Visit
One of the essential qualities of the clinician is interest in humanity, for
the secret of the care of the patient is in caring for the patient. 7
Francis Peabody

The quality of caring in medical visits can be defined in terms of how clinicians and patients share time, space, and language together. This includes, but
is not limited to, verbal and nonverbal behavior, prox.emics (shared space),
and the activity or action systems, like interviewing, doing a physical exam, or
giving an injection, in which they occur. With the additional burden of EHR
documentation during the visit, the tension between (interpersonal) caring
and (instrumental) documentation comes down to a competition for the clinician's attention to the patient or the exam room computer. When it works
well, shared attention communicates a sense of engagement on the part of
the clinician; when it doesn't work well, it creates a sense of distraction that
can become a source of distress, patient disengagement, and loss of clinician
resilience.
Distracted care in clinical practice has been shown to have negative effects
on both ends of the stethoscope. 8 For example, one study found that time
spent interacting with the computer screen varied by physician from 20% to
80%, with those interacting with the computer screen at higher rates having
scores consistent with low patient experience.9 In the exam room and hospital room, maintaining healing relationships while entering data into the
EHR will continue to be a challenge. Although research in this area is still
in its infancy, some studies suggest possible tradeoffs and solutions to the
problem. For example, one review of 43 studies of EHR adoption in office
settings found that actively engaging patients as partners in co-constructing
the record of care was important in successful implementation. 10 Studies have
also found that physicians with excellent overall communication skills often
used exam room computers effectively in their visits. 11 A recent systematic
review of 52 articles identified several behavioral and communication best
practices for exam room computing. 12 A similar set of practices are summarized below in the mnemonic, POISED: Prepare, Orient, Information gathering, Share, Educate, and Debrief. 13
Prepare-As already described, preparation for the visit is key to efficient
and effective patient-centered care. Preparation favors active listening and
responding to patient concerns and emotion, builds trust and connection,
and reinforces the primacy ofthe patient, not the computer, as the appropriate
focus for the visit.

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261.

Orient-Creating a welcoming atmosphere at the beginning of the visit is
an important step in creating trust, especially where the exam room computer
is involved. Taking time to welcome the patient and face him/her directly,
without hands on the keyboard or eyes on the computer monitor, communicates that s/he is the most important focus of the visit. Especially important
for new visits is orienting the patient and accompanying persons to the computer, ensuring confidentiality, and describing its role in the visit. This can
usually be accomplished in 15 to 30 seconds. Using partnership statements
such as, 'Tm going to be using the computer from time to time to help me
keep track of things. It's the best way I know of to create an accurate account
of what we discuss" will alert the patient of your intent and rationale for using
the computer. Most patients are grateful to know how technology, including the EHR, will be used in the exam room. In a study of physicians, half
of whom had been sued for medical malpractice and half had not, orientation statements, as in the above, were a protective factor and were statistically
more likely to characterize physicians who had not been sued. 14 Orientation
statements are useful not only in introducing the EHR and its use in the visit
but, more generally, in guiding patients in what to expect from the encounter.
Information-gathering-Several chapters in this book suggest that some
parts of the encounter should be patient-centered and others cliniciancentered. Being explicit about this distinction and the role of the computer
will help patients understand points in time when you may spend more time
interacting with the computer screen as opposed to engaging directly with
the patient. For example, at the beginning of Step 10, you can say, "I'm going
to ask you a lot of yes/no questions that we call a review of systems and I
will be entering your answers in the computer as we speak. Of course, if you
have any questions during this part of our conversation I am happy to hear
them:' During periods of time when information-gathering requires attention
to the computer screen it is a good practice to look at the patient from time
to time. In a study of male and female physicians' exam room EHR use, it was
noted that female physicians would punctuate long periods of screen time by
glancing at the patient every 30 seconds or so. By contrast, male physicians
tended to remain fixed on the computer screen and did not glance toward
their patients with any frequency. 8 Frequent eye contact communicates and
reinforces the importance of connectedness and relationship in the context of
other tasks such as documentation.
Share-The computer can be an important source of information and education. It also creates partnerships and brings patients directly into the care
process. Many stationary exam room computers are located in a comer of
the room where the clinician's back is to the patient as s/he types information

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SMITH'S PATIENT-CENTERED INTERVIEWING

FIGURE 10-1. Computer use excludes patient.

into the EHR. This is unfortunate as it creates a dyadic relationship between
the clinician and the computer, one that excludes the patient (Fig. 10-1).
A mobile mount or an extendable arm so that patients can see the screen invites
partnership and collaboration (Fig. 10-2). This approach has the double benefit of partnership and having two sets of eyes on the screen to check on the
accuracy and completeness of information that is being recorded in the EHR.
Educate- The computer screen is an excellent teaching aid. With the click
of a mouse, for example, a patient's weight, blood pressure, blood sugar, etc.
can be shown as a histogram on the computer monitor and also becomes the
basis for a conversation either reinforcing good health habits or talking about
ways to improve. Using the computer screen may be especially effective in
educating patients with low health literacy as written health education materials may be difficult for them to follow. 15 At the same time, too much clinician screen time outside of patient education has been shown to negatively
affect outcomes in patients with low health literacy. 16
Debrief-It is estimated that patients retain about 50% of the information
they receive in an ambulatory consultation. 17•18 Since they will act largely
upon what they remember of the visit, it is especially important to ensure that
they recall and understand what they are being encouraged/instructed to do.
One method that has shown promise is the use of a "teach-back," in which the
clinician asks the patient to repeat back the instructions that s/he has given
during the course of the encounter (see Chapter 6). This method is helpful

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263

FIGURE 10-2. Computer use includes patient.

in identifying gaps in recall and interpretation of actions suggested by the
clinician. 19 Using the visual effects of the computer screen can help reinforce
health-related behaviors, recommendations about lifestyle changes, medication adherence, and important decisions that patients may have to make
about treatment.
Being POISED in enacting the visit need not cost additional visit time.
Used well, just the opposite is true.
Post-visit Documentation

In a recent national study, Sinsky and colleagues20 estimated that the average amount of time American physicians spend after clinic hours working
on administrative tasks, mostly documenting in the EHR, is 1 to 2 hours per
night. In terms of time devoted to work, the additional effort spent on documentation could be the equivalent of an extra day and half in clinic or adding
more than 2 months of work per year. After-hours documentation is a source
of chronic stress on the clinician and also on the family as the following actual
case illustrates (details and names changed to ensure anonymity).

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case #2

Mary Decker is a 36-year-old physician assistant who has been providing care
in a women's clinic at Midwest Hospital System for the past 5 years. She has
a 4-year-old son and recently gave birth to her second child, a daughter. Her
husband is a small business owner and shares many of the responsibilities
of parenting but often travels and during those times is unable to provide
parental care for the children. Over the past several months, Ms. Decker's
productivity has slipped somewhat and in consultation with her chief they
have identified documentation in the EHR as the main source ofher problem.
They both agreed that coaching might be a helpful approach to improving her
documentation skills and efficiency.
In their first meeting, the coach, a communication scholar with expertise in
exam room computing, asked Mary to describe a typical clinic day. She replied
that she started her days feeling exhausted and quickly found herself behind in
seeing her patients. After that it was "'catch up" all the way to the end of clinic
and an hour or so after the clinic closed to do as much as she was able on her
documentation. When asked about what she did when she got home, she got
teary-eyed and said that she would prepare meals for the children, bathe them,
and put them to bed around 8:00 PM, after which she would spend 2 to 3 hours
per night finishing as many of her charts as she was able. Most nights, she said,
she fell asleep sitting at the computer doing chart documentation. The next day
would be just like the last, "'like being on a hamster wheel," she said tearfully.
Although Ms. Decker's story is a little extreme, it is not unusual to hear
clinicians decry the burden of documentation on themselves and their family life. As part of the coaching she received, Ms. Decker gave permission for
an observer to join her for a half day in clinic and for him to record how
she incorporated the computer into her visits. It was immediately apparent
in reviewing the recordings that for each patient visit Ms. Decker was creating "interim notes:' in full sentences, that she would later discard and replace
with new sentences in her fmal version of the medical record. In addition, the
final notes included a great deal of information, only a portion of which were
pertinent to the care she was delivering. Ms. Decker was surprised by these
observations and over the course of several sessions, the coach showed her
more efficient ways of entering and "shorthanding" notes that made her more
efficient in the exam room, at the end of the clinic day and at horne.
In addition to direct observation and feedback it also turned out that there
were several "'super users" at her facility, clinicians who were able to complete
high-quality notes during their encounters, and who also had high patient
satisfaction and resilience scores. These clinicians had developed a number of
shortcuts and efficiencies in using the EHR that they were more than willing
to teach Ms. Decker. Although most computer users develop functional ways

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265

of managing the technology, it is rare that they get together to compare notes
and strategies. In Ms. Decker's case, sharing tips and strategies worked so well
that the practice group created a monthly forum in which new shortcuts and
efficiencies in using the EHR were discussed. Finally, the coach worked with
Ms. Decker to learn relaxation and mindful practice techniques so that she
could feel fully present at horne and enjoy her children and husband without
always feeling guilty about needing to complete her charts. Over a period of
6 months, Ms. Decker's productivity increased as did her energy level job and
satisfaction. She still brought horne charts to complete but as she said, "I no
longer feel like I'm chained to my charts at the bottom of the sea."
Obviously, not all medical systems offer coaching in efficiently using the
EHR to document visits. However, there are a number of things that can be
done to improve one's approach; also see AccessMedicine video titled "Using
the Electronic Health Record" (www.accessmedicine.com/SrnithsPCI). These
include:
1.

2.
3.
4.
5.

Keep a log of when, where, and for how long you document after the visit
completes. Use the results to identify bottlenecks and patterns that are potentially modifiable.
Invite others to observe your style of documentation and offer feedback.
Identify clinicians who are highly efficient and patient-centered in realtime documentation and observe and learn from them.
Gather together with colleagues to share tips and strategies for successful
documentation.
Be mindful of the importance of resilience, self-care, and maintaining
healthy boundaries in balancing the responsibilities of home and work.

• CONCLUSION
Like it or not, exam room computing is here to stay and attempts to ignore it or
hopes that we will return to the way things were in the era of paper records are
likely in vain. It has been said that technology is neither good nor bad, rather it is
how it is used that determines its effect(s) on individuals, communities, and society. In the early 19th century the invention ofthe stethoscope heralded a new era
in medical science, introduced new technology into the exam room, and created
new norms of use. Today, the stethoscope is used routinely and is an accepted
ritual in practice. Electronic health records are a relatively new innovation in
exam room design and use. As such, there is a currently great deal of variability in their physical placement and use during patient encounters. Research and
best practices are beginning to emerge as are systematic reviews and curricula
to teach students, residents, and practicing clinicians.21.22 Table 10-2 provides a
checklist of such practices to use in different phases of the interview.

• TABLE 10-2. Checklist of Patient-Centered Behaviors to Optimize EHR Use
1. Preparing for the visit
Review patient's chart
o Check problem list, telephone messages, staff messages, and progress notes from last visit to
familiarize yourself with patient's current conditions and recommendations made
o Check for updated laboratory results
o Check medication list for any changes or additions to medications planned
o Make brief written notes of pertinent data and overall plan to take into the visit with you if necessary
2. Enacting the visit
o Greet patient sitting face to face with the without hands on the keyboard or looking at the monitor
o Engage briefly in social talk
o For new visits, orient the patient to the computer, how it will be used, e.g., "There are times when I will be
asking you a lot of yes; no questions, called a review of systems, and will be recording your answers into
the EHR"
o Where possible, physically orient the computer screen so that it creates a triangle between you, the
patient, and the computer screen. (This may necessitate physically rearranging furniture in the room to
accomplish)
o Address any confidentiality concerns
o Elicit concern(s) with minimal data-entry, looking directly at the patient
o Use transition statements from face-to-face interview to data entry, e.g., "I'm going to enter some of what
you've just told me into the EHR"
o During long periods of data recording, look up from the computer monitor/keyboard and make eye contact
with the patient
o Use the EHR to educate patients about progress over time, e.g., graphs of weight loss, diabetes control,
lab results, imaging
o Invite patients to review tests ordered, prescriptions, and history to ensure accurate and complete data
entry
3. Post-visit documentation
o Avoid cutting and pasting pertinent information
o Where necessary, develop shorthand notations made during the visit to be used in post-visit
documentation
o Limit interruptions and distractions when doing post-visit documentation, especially at home or in other
nonclinic locations
o Pay particular attention to documenting psychosocial issues as these may be more difficult than
biomedical issues to enter into the EHR
o Review notes for accuracy and completeness

The task of medicine to heal the sick and minister to their suffering has not
fundamentally changed in 2000 years. New discoveries and technologies have
made possible today what was unthinkable as late as the mid-20th century.
Nonetheless, the themes of being present and alleviating human suffering
persist in the face-to-face conversations that clinicians and patients, with the
aid of technology, continue to have every day.

Chapter 10

REMAINING PATIENT-CENTERED IN THE DIGITAL AGE

267

REFERENCES
1. Cabot RC. Difforential Diagnosis as Presented Through an Analysis of383 Cases. Philadelphia, PA: W. B. Saunders; 1911.
2. Weed LL. Medical records that guide and teach. N Engl J Med. 1968;278:593-600.

3. Dick RS, Steen EB. The Computer-Based Patient Record: An Essential Technology for
Health Care. Washington, DC: Institute of Medicine National Academies Press; 1991.
4. Goffinan E. The Presentation ofSelf in Everyday Life. New York, NY: Doubleday; 1959.
5. Engel GL. How much longer must medicine's science be bounded by a seventeenth century world view? In: White KL, ed. The Task ofMedicine: Dialogue at Wickenburg. Menlo
Park, CA: The Henry Kaiser Family Foundation; 1988:113-136.
6. Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. 1994;154:
1365-1370.
7. Peabody F. The care of the patient. JAMA. 1927;88:877-882.
8. Frankel RM. When it comes to the physician-patient-computer relationship, the "eyeS'
have it. In: Papadok.os P, Bertman S, eds. Distracted Doctoring: Returning to PatientCentered Care in the Digital Age. New York, NY: Springer; 2017.
9. Frankel RM. The effects of exam room computing on the doctor patient relationship:
a human factors approach to electronic health records and physician-patient communication. In: Agrawal A, ed. Safety of Health IT: Clinical Case Studies. New York, NY:
Springer; 2016:129-141.
10. Lau F, Price M, Boyd J, Partridge C, Bell H, Raworth R. Impact of electronic medical
record on physician practice in office settings: a systematic review. BMC Med Inform
Decis Mak. 2012;12:10.
11. Frankel R, Altschuler A, George S, et al Effects of exam-room computing on
clinician-patient communication: a longitudinal qualitative study. J Gen Intern Med.
2005;20:677-682.
12. Patel MR, Vichich J, Lang I, Lin J, Zheng K. Developing an evidence base of best practices for integrating computerized systems into the exam room: a systematic review.
JAmMed Inform Assoc. 2017;24(e1):e207-e215.
13. Frankel RM. Computers in the examination room. JAMA Intern Med. 2016;176: 128-129.
14. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and
surgeons. JAMA. 1997;277:553-559.
15. Schillinger D, Barton LR, Karter AJ, Wang F, Adler N. Does literacy mediate the relationship between education and health outcomes? A study of a low-income population with
diabetes. Public Health Rep. 2006;121:245-254.
16. Ratanawongsa N, Barton JL, Lyles CR, et al. Association between clinician computer use and communication with patients in safety-net clinics. JAMA Intern Med.
2016;176:125-128.
17. Rost K, Rater D. Predictors of recall of medication regimens and recommendations for
lifestyle change in elderly patients. Gerontologist. 1987;27:510-515.
18. Kessels RP. Patients' memory for medical information. J R Soc Med. 2003;96:219-222.

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19. Agency for Healthcare Research and Quality. AHRQ Implementation Quick Start Guide:

Teach-Back. The Guide to Improving Patient Safety in Primary Care Settings by Engaging
Patients and Families. Washington, DC: Agency for Healthcare Research and Quality;
2016:7.
20. Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T.
In search of joy in practice: a report of 23 high-functioning primary care practices. Ann
Fam Med. 2013;11:272-278.
21. Alkureishi MA, Lee WW, Lyons M, et al. Impact of electronic medical record use on the
patient-doctor relationship and communication: a systematic review. J Gen Intern Med.
2016;31:548-560.

22. Alkureishi MA, Lee WW. Frankel RM. Patient-centered technology use: best practices
and curricular strategies. In: Shachak A, Borycki EM, Reis SP, eds. Health Professionals'

Education in the Age of Clinical Information Systems, Mobile Computing and Social Networks. London, England: Elsevier; 2017:201-232.

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Foreword to the
First Edition -George L. Engel, MD

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-------

Being Scientific in the Human Domain: From Biomedical to Biopsychosocial
We include as biology not only the data obtained by observing other individuals and things but also those that we reach through [our own inner experiences
of living]. The biologist is himself of the same material of which are composed
the living things that he studies.
H.S. Jennings, 1933
Biologist Herbert Spencer Jennings' early insistence that "inner experiences"
are proper data for biology was my first encounter with the idea that the use
of subjective data need not violate the conventional requirement for scientific
respectability. Quite by chance, in 1937 as a college student, I had stumbled on
Jennings' Behavior of the Lower Organisms. 1 As a biologist, Jennings deemed
his inner experience as a living organism no less integral for understanding
living systems than his outward observations that were customarily relied on
for information about the physical (nonliving) universe. However, some 20
years would pass before the complementarity of outer observation and inner
experiencing fully took hold for me as a physician and helped me defme the
requirements for being scientific in the human domain.2-9
As a profession and an institution, medicine owes its origin to three distinctively human attributes. First, we humans are aware of death and its inevitability and we realize that feeling and/or looking bad ("sicl(') may be its portent.
Second, we suffer when our interpersonal bonds are sundered and we feel solace when they are reestablished. Third, we are capable of examining our own
inner life and experience and of communicating them to others via a spoken
and written language. Critical for all three and for the work of the physician is
the distinctively human capability of using words to communicate both what is

269

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being observed in the outer world, as well as what is being experienced within
the inner world. For each of us the distinction between sick and well is preeminently manifest as inner experience, which must be communicated verbally in
characteristic ways to become known. Surely, as scientists dedicated to organiz-

ing our experiences and formulating observations, we should be careful to define
science in such a way as to be able to include verbal reporting as legitimate data.
From biomedical to biopsychosocial refers to an historical transition in scientific thinking that has been taking place over the past century and a half.6
Particularly pertinent for medicine is its explicit attention to humanness. That
alone identifies biopsychosocial as a more complete and inclusive conceptual framework for guiding clinicians in their everyday work with patients.
Physicians have always depended on what patients have been able to tell them
about the experiences that led them to seek medical attention. This is testimony that the importance of verbal exchange between patient and physician
is the primary source of the data required for the clinician's task. Scientists
studying sick, diseased, or even dying animals or plants do not have a comparable resource; they are limited to what can be observed, as are all scientists
dealing with physical or infrahuman systems.

That we humans are able to participate actively in our own study by looking
inward and by contributing information that is otherwise not available should
be a great scientific advantage. Yet, paradoxically, biomedical thinking, a 20thcentury derivative of 17th-century natural science, categorically excludes
from science what patients have to tell us on the grounds that it is nonmaterial
in form and not measurable or subjective and not objective. On those grounds
alone even posing such a question is axiomatically disallowed. Instead, the
human domain as a whole is seen as the art of medicine, subject neither to
systematic inquiry nor to the possibility of teaching.
However, the history of medicine as far back as the papyri of Egypt of 5
millennia ago documents that information provided by patients was deemed
sufficiently valuable to justify writing ways that doctors might improve their
skills in eliciting such. 10 Paradoxically, its exclusion from medicine by medicine's science notwithstanding, few clinicians would seriously argue that what
patients tell us can therefore simply be disregarded. Rather, the issue hinges
on what has become a cultural imperative of western society, namely, that the
canons of science as defined in the 17th century continue to apply. The possibility that the premise itself is a fallacy is simply ignored. This is what we
now examine.

What we observe is not nature itself but nature exposed to our method ofquestioning.
W. Heisenberg11

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271

Physicist Heisenberg's dictum exemplifies a fundamental distinction
between 17th- and 20th-century scientific thinking, the latter of which is
derived from such conceptual developments as evolution, relativity, quantum
mechanics, general systems theory, far-from-equilibrium thermodynamics, and. more recendy, chaos and complexity theory. Loosely speaking, we
are applying biomedical and biopsychosodal as labels to contrast the two
positions.8
Actually. what Heisenberg enunciates is what clinicians have known from
time immemorial-namely, that the answers you get from a patient depend
on the questions you pose and how you do so. More broadly, it exposes
the fallacy of the 17th-century natural science position that what scientists
discover exists entirely external to and independent of themselves. In fact,
rather than simply examining or observing something "out there;' scientists
devise mental constructs of their experiences with the observed as a means
of characterizing their understanding of its properties and behavior. This
change in perspective began in physics with relativity theory, which required
acknowledgment that the location of the observer cannot be ignored relative
to what is being observed. The rediscovery of the obvious occurred in that
transformation-namely. that science itself is a human activity. The lesson is
that humanness and human phenomena cannot be excluded from science.
Medicine's long history of successful utilization of what patients have to say
about their experience of illness itself surely suffices to justify reviving earlier
efforts at developing more systematic (i.e., scientific) approaches to so doing.

It is important to ask questions ofpatients because with the help of these questions one will know more exactly some of the things that concern disease and
one will treat the disease better.
Rufus of Ephesus, 1000 A.D. 10
The first formal document solely about the value of the information
patients can provide is credited to Rufus of Ephesus. Surely, his words "will
know more exacdy" eloquendy reveal his advocacy of an approach more scientific than those solely dependent on chance, fate, magic, or mysticism that
were so commonplace in those days and that are still evident today in some
instances of so-called alternative medicine. Rufus thereby revealed his intuitive awareness that the very universality of sickness and death as human experiences rendered the patient a logical source of primary data.
The sick person's appeals for help and the helping responses evoked thereby
already reflect a biologic social interdependency with a long evolutionary history, which, in humans, was evident early in the response to the crying of an
infant. In that biologic constellation are already suggested the origins not just

272

SMITH'S PATIENT-CENTERED INTERVIEWING

of sick role behavior but also of the profession's and institution's responses
thereto. What originated in infancy as nonspecific cries of distress are eventually differentiated to include personal and social awareness of being sick as
a distinctive category of distress. Similarly, what may have begun merely as
helping responses comes to oblige the helper to differentiate sickness from
other types of distress. The mother's inquiry of her child as "What's wrong?"
or "Are you feeling all right?" can hardly result from anything other than
learning by living and experiencing; she has already gone through the same
steps in growing up, as have most of us.
Intuitively, doctors tend to take such lay opinions seriously if for no other
reason than that they often do prove to be correct. But such judgments by physicians are still mainly extensions of natural reactions with which we all have
grown up. They are not yet scientifically based. Biopsychosocial thinking aims
to provide a conceptual framework suitable for developing a scientific approach
to what patients have to tell us about their illness experiences. But to accommodate the human domain, science and being scientific must be redefmed.
The object of science is to render as reliable as possible whatever claims to
knowledge we make ... [and is achieved] by reasoned efforts that ultimately
depend on evidence that can be consensually validated.
Charles E. Odegaard, 198612

Historian Odegaard's succinct statement may be viewed as an effort to provide a more generic definition of science and being scientific, one that is independent of domain or method. With respect to the patient's verbal report of
an illness experience and the doctor's version thereof, both constitute claims
to knowledge about what each believes he or she knows about what has happened and about what the patient's experiences were like. These constitute
the data on which the doctor depends for further study and decision making.
Doing so scientifically requires the discipline to enhance the reliability of the
very process of data acquisition itself.
To explore scientific acquisition of verbal data, we can exploit the fact that
every reader has surely experienced falling ill. I propose that readers pause
and mentally reconstruct a recent occurrence of not feeling well, no matter
how trivial, just as one might in anticipation of seeing her or his physician.
I will do the same; but please do not look at my account until you are satisfied that what you have put together really represents what you think you
would want to share with your own doctor. Our respective offerings may then
be examined to see how useful Odegaard's generic definition may be for the
scientific handling of what patients tell us about feeling ill. You might fmd it
worthwhile to put your thoughts in writing as I do now.

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273

I had another of those unpleasant episodes last night. I awakened
early, about 5 A.M., feeling vaguely uncomfortable. Then gradually I
became aware of a steady, annoying sensation in my throat, a familiar recurring experience awakening me from sleep. The sensation is
hard to describe-it is clearly located at the level of the suprasternal
notch, I can indicate it with my fingers, as a "full, feeling, as though
somehow being stretched; slightly achy, steady; a little lump, a little
sore in the throat.
I wanted very much to sleep longer and hence tried to ignore it, but
it was in vain. Then I realized I had slipped down from the semiupright position and was lying flat, my head raised but slightly against
a pillow. From past episodes I had learned the mitigating effects of
sleeping semiupright. I immediately sat up, swung around and, leaning forward slightly, lowered my legs to the floor. In a minute or so,
I belched with prompt relief. I lay back against the pillows, propped
up at about a 70-degree angle, hoping I might now be able to sleep.
But the unpleasant sensation soon returned. Determined to get more
sleep, I did the next thing that usually helps; I got up and, while standing and moving about, drank a few swallows of hot water. Soon came
the first of three belches and again prompt relief.
Confident that I would enjoy another couple of hours of sleep, I
returned to bed, again propped up. I awakened symptom free, but
feeling a little sad, remembering how in the past when my wife had
noticed I had slid down, she would try to help me get repositioned
before symptoms developed. She has been in a nursing home for
more than a year.
From this representative sample of human (patient-derived) data, however
idiosyncratic, how may its acquisition and processing be rendered as scientific
as possible?
[The scientist] devises mental constructs of his experiences with [nature]
as a means of characterizing his understanding of its properties and behavior ... [They, in turn,] are predominantly communicated by language, it being
difficult to communicate them in any other way than by speaking about
them.
M. Delbruck, 1986 13
The whole ofscience is nothing more than a refinement ofeveryday thinking.
A. Einstein, 1950 14

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SMITH'S PATIENT-CENTERED INTERVIEWING

The raw data patients proffer are in the form of speech, gesture, and posture and not much else; that is, they are bits of distinctively human behavior, verbal and nonverbal. Physicists Delbruck and Einstein remind us of two
things: that 20th-century conceptual transformations render self-evident the
dependence of science and being scientific on a spoken and written language
and that the efforts of the person feeling sick to figure out what is happening
call on the same mental operations humans ordinarily employ whenever confronted with threats to their sense of well-being. But in contrast to the distress
evoked by threatening external events or circumstances, feeling sick and falling ill more often begin as private experiences that are not necessarily apparent to anyone else. Hence, the truly scientific physician not only must access
that private world but also must be reasonably assured that the information
(data) can be relied on. Critical is the recognition that the patient is both an
initiator and a collaborator in the process, not merely an object of study. The
physician in tum is a participant observer who in the process of attending
to the patient's reporting of inner-world data taps into his or her own personal inner-viewing system for comparison and clarification. The medium
is dialog, which at various levels includes communing (sharing experiences),
as well as communicating (exchanging information). Hence, observation
(outer viewing), introspection (inner viewing), and dialog (interviewing) are
the basic methodologic triad for clinical study and for rendering patient data
scientific.9
My written account of illness provides an opportunity to examine a patient's
inner viewing that has not yet been influenced either by the physical presence
of or by dialog with the doctor. It derives both from what I literally strove to
remember and to reconstruct from what I had experienced a couple of hours
earlier, as well as from much else that carne into my mind in the course of so
doing. The actual written material available to the reader, however, is already
limited by the fact that I am obliged to convey that information not only in
words but also in writing and in a textbook to boot. Moreover, you have no
means to ascertain on what basis my final words were selected from the myriad of associations with which I was bombarded in the process of writing it.
Clearly, this process is very different from what would have gone on in my
head were I seated in the doctor's waiting room rehearsing what I would want
to tell her or him.
Such a state of affairs at once identifies long-known barriers to being scientific in the handling of human (patient-derived) clinical data. Painfully
evident is the fact that what can be communicated of such data to others is
limited both by the frailty of human memory and by the constraints imposed
by the requirement to convey in words actual experiences for which suitable
words may not exist. Gaps are inevitable between what patients experience

Appendix A

FOREWORD TO THE FIRST EDITION

275

and what they can effectively communicate to the doctor; between the words
of the patient and what the doctor remembers and may select as relevant; and
ultimately between the preceding and what the doctor reports orally or writes
in the record, which is the public data available for clinical reasoning.
Yet, the fact remains that, notwithstanding such formidable obstacles,
experienced clinicians using observation, introspection, and dialog can be
remarkably successful in documenting the existence of explicit pathologic
bodily processes and of associated nondisease issues as first inferred simply from what the patient had to say. Thus, a clinician knowledgeable about
physiology surely would quickly consider problems with the esophagus as
one plausible explanation for the attacks I described and would accordingly
pursue appropriate inquiries to test such a hypothesis. 15 Moreover, the experienced clinician would recognize the interrelationship of my disease process
and my personal life. Consider, for example, how my sadness about my wife's
incapacity might affect my esophageal symptoms, for example, they might be
worse since she went to the nursing home.
Biomedical education has an a priori assumption that such patient-derived
data and the means of their acquisition are neither teachable nor subject to
systematic study, which needs to be examined. To do so let us consider two
dimensions of such data by again using my case protocol.

[The] relationship between doctor and patient partakes of a peculiar intimacy
presuppos[ing} on the part of the physician, not only knowledge of his fellow
man, but sympathy... [D]esignated as the art [of medicine] ... [intimacy],
should most properly be called [its] essence.
W.T. Longcope, 1932 16

[The] widened, vicarious experience [provided by] narrative is memorable
precisely because it is necessarily enmeshed with past and future, cause and
consequence.
{Patients'] life stories cultivate ... interest in their oddities and their ordinariness and a tolerance of both.
The narrative in each case belongs to a human being who is an object of scientific study and to that person's world of lived experience and belief ... [it]
remains central to knowledge in medicine [precisely] because the patient is the
focus.
K.M. Hunter, 1991 17
Odegaard proposed defming science as independent of domain. 12 But a
universal requirement for being scientific is that we understand and respect

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SMITH'S PATIENT-CENTERED INTERVIEWING

the natural state of whatever domain we are concerned with. Thus, just as
marine biologists must master functioning underwater to study marine life
scientifically, so too must clinicians accommodate to what is distinctive about
the human condition and the environment of patients. And what is more distinctive about being human than how we communicate and interact?
In effect, Longcope's "'intimacy" refers to a unique quality of the doctor's
relationship with the patient, one that he felt was so indispensable that medicine "would cease to be" medicine without it. Where in my protoco~ if anywhere, does intimacy reveal itself? I, in my anticipation of meeting with my
doctor, deliberately included one item that, on the face of it, would seem to
contribute little or nothing to his understanding of the symptom complex that
I was struggling to make clear to him. (Actually, it did contribute something,
as I already mentioned.) It was my reference to my wife's residence in a nursing home. His response to that intensely personal and poignant item would,
I anticipated, give a clue as to where we stood with each other, whether my
confidence in our intimacy was shared by him.
By the same token, while imagining myself telling my doctor what I had
just gone through, my recollections quite naturally took on a narrative form,
as my story. That is, after all, how we humans ordinarily communicate our
experiences to others, especially to those to whom we would turn for help. As
Hunter reminds us, narrative style facilitates vicarious participation of the listener in whatever the patient was or is experiencing. That, in itself, implies an
element of intimacy between the two participants and helps direct attention
to what is distinctive about the individual whose story is unfolding.
Readers need only review their own experiences with doctors taking their
histories to appreciate the difference between encouraging narration and
requiring reporting. The latter approach is deliberately interrogative with
the doctor assuming the initiative and agenda and the patient as an object of
study rather than an active participant in his own study. Eighteen seconds has
been reported as the mean length of time that elapses before doctors interrupt
the patient's first response. 18 Small wonder that patients complain that doctors do not listen. Interrogation generates defensiveness; narration encourages intimacy.
Do the words intimacy and narration refer to phenomena about which
consensual agreement with regard to criteria can be achieved? The answer to
that question is key to whether the concepts that the words express fall within
the scope of science. The history of science is a record of repeatedly rendering
the tacit manifest, the difficult easy, and the impossible possible. We all agree
the answer to our question is difficult for many reasons that have already been
cited. Others insist that the very consideration of such questions in medical matters is impossible. But surprise is also characteristic of science-the

Appendix A

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277

unexpected. sudden discovery, or technologic development in one field that
fosters a corresponding progress in another.

... [R]ejoice in the discovery of a great and final instrument of drama [one],
which all the other arts have had since time immemorial, which the oldest art,
the theatre, lacked until today; ... [an] instrument that gives it precision and
scientific serenity.
R. Boleslavsky, 1933 19
What discovery could be so important to a noted stage director and
teacher of acting to inspire him to announce it as fmally providing the theater "precision and scientific serenity?" Astonishingly, Boleslavsky awarded
that high honor to the newly introduced "talkie" motion pictures, which at
that very moment were being ridiculed by traditional theatre as an outrageous degradation ofthe stage and its art for purely commercial purposes. For
Boleslavsky films finally made possible the preservation of the art of the actor
and of the theatre. "Do you realize; he passionately exclaimed, "that with the
invention of spontaneous recording of the image, movement, and voice, and
consequently of the personality and soul of an actor, the theatre is no more a
passing affair but an eternal record?"
Written more than 60 years ago, Boleslavsky reveals an impressive grasp
of one of the essentials of being scientific-namely, to have publicly available and lasting records of natural phenomena that are otherwise evanescent
or not accessible to direct human perception. The introduction of talkies, an
early stage of audiovisual (AV) technology, marked the first time in history
that humans could observe the behavior not only of another but also of one's
self and could do so repeatedly and in public! Although I have made use of AV
technology for teaching and research for almost 50 years, appreciation of that
momentous change for humankind came to me only on reading Boleslavsky's

Acting. The First Six Lessons.*
The conclusion seems inescapable. However powerful the cultural imperative was that was engendered by the 17th-century scientific revolution, medicine's resistance or, more accurately, blindness to the need to address the issue
ofbeing scientific with human data stems not just from the inherent difficulty
of so doing but also from a lack of any dependable means to do so, an altogether common occurrence in the history of science. For the human domain,

*When I first came upon Boleslavsky's little adialog" with the fictional "CreatureH as an inexperienced,
stage-struck young ingenue in 1992, it seemed to me that both he and I had been struggling with the
same problem: his concern-how to teach actors-mine and my colleagues-how to teach medical students-was the common domain of human phenomena not subject to reexamirultion.20

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SMITH'S PATIENT-CENTERED INTERVIEWING

AV technology fills that gap just as did telescopy for astronomy and microscopy for biology.
A successful dialogue between patient and physician is at the heart of working
scientifically with patients.
G.L. Engel, 199520

Those words epitomized my final tribute to John Romano (1908-1994);
they also epitomize this book. What they recall is the impact of my seeing
Romano in 1941 sit down with a patient on medical rounds and engage with
him as though in the privacy of his office. That single experience was to inaugurate an association between us that culminated in Romano's concept of
human biologf1 and in my move beyond the biomedical to the biopsychosocial and finding synthesis and subsistence in the Rochester medical curriculum as an integrating, driving reality. Bob Smith's book represents an effort to
extend that reality by examining its operation at the very heart of the doctorpatient encounter in the process of the interview.
The Patient's Story: Integrated Patient-Doctor Interviewing makes progress
in key areas, although such a claim becomes possible only after we see how
the book works in students' and other learners' hands. In the fmal analysis,
research on how effectively learners pick up this approach will be important,22
as will the impact that its patient centeredness has on the patient.23 For example, can it be shown that patients feel better or do better when the interviewer
uses this approach?23
Identifying a basic infrastructure of the interview carries much potential
for medicine as a science. The benefit, of course, is that a basic interviewing approach allows us to obtain human data in a more systematic way by
one interviewer on multiple occasions or across many interviewers. To the
extent that it is successful, this addresses Odegaard's concern that, as a means
of acquisition of data, the interview process should be demonstrated to be
as reliable as possible. Smith's emphasis on how idiosyncratic and confusing
the approaches to teaching interviewing to students have been in the past
is well taken. The lack of a basic methodology to medical interviewing may
itself have encouraged students to acquire patient data erratically and unsystematically. Although this method provides sufficient structure and necessarily detailed instructions for the beginner, the overall approach is still flexible
enough to offer promise that the personhood of the patient and humanity of
the interviewer will both be enhanced.
As Smith cautions, this interviewing approach must not be seen as a fmal
destination for the interviewer but rather as a point of departure. This prospect is facilitated by the text's incorporation of teaching directed specifically
at enhancing the doctor-patient relationship, especially by fostering the

Appendix A

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279

effectiveness of the intimacy between doctor and patient; by considering
introspection at the level of better understanding oneself and the importance
of opening such self-awareness to the patient; and by actively incorporating
the relational dimension of interviewing instruction and placing it on equal
footing with the informational aspects of interviewing.
An important distinction this book makes, often overlooked or misunderstood, is that although the biopsychosocial model provides a basis for the
description of the patient and the patient's problems, the ability to interview
effectively is indispensable for operationalizing the model, hence my earlier
reference to the significance of a "successful dialog."
George L. Engel
REFERENCES
1. Jennings HS. Behavior

of the Lower Organisms. New York.

NY: Columbia University

Press; 1923.
2. Engel GL. Homeostasis, behavioral adjustment, and the concept of health and disease. In: Grinker R, ed. Mid-century Psychiatry. Springfield, IL: Charles C. Thomas;
1953:33-59.

3. Engel GL. Selection of clinical material in psychosomatic medicine: the need for a new
physiology (special article). Psychosom Med. 1954;16:368-373.
4. Engel GL. A unified concept of health and disease. Perspect Biol Med. 1960;3:459-485.
5. Engel GL. Psychological Development in Health and Disease. Philadelphia, PA: WB Saunders; 1962.

6. Engel GL. The need for a new medical model: a challenge for biomedicine. Science.
1977;196:129-136.
7. Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry.
1980;137:535-544.
8. Engel GL. How much longer must medicine's science be bound by a seventeenth century
world view? In: White KL, ed The Task of Medicine: Dialogue at Wickenbu~. Menlo
Park. CA: Henry J. Kaiser Family Foundation; 1988:113-136.

9. Engel GL. On looking inward and being scientific. A tribute to Arthur H. Schmale, M.D.
Psychother Psychosom. 1990;54:63-69.
10. Sigerist HE. A History ofMedicine: VoL I: Primitive and Archaic Medicine. New York. NY:
Oxford University Press; 1951.
11. Heisenberg W. Physics and Philosophy: The Revolution in Modern Science. New York, NY:
Harper; 1958.
12. Odegaard CE. Dear Doctor. A Personal Letter to a Physician. Menlo Park, CA: The Henry
J. Kaiser Family Foundation; 1986.
13. Delbruck M. Mind from Matter? An Essay on Evolutionary Epistemology. Palo Alto, CA:
Blackwell; 1986.
14. Einstein A. Out of My Later Years. New York. NY: Philosophical Library; 1950.

280

SMITH'S PATIENT-CENTERED INTERVIEWING

15. Gignoux C, Bost R, Hostein J, et al. Role of upper esophageal reflex and belch reflex
dysfunctions in noncardiac chest pain. Dig Dis Sci. 1993;38:1909-1914.
16. Longcope WI. Methods and medicine. Bull Johns Hopkins Hosp. 1932;50:420.
17. Hunter KM. Doctors' Stories, the Narrative Structure
NJ: Princeton University Press; 1991.

of Medical Knowledge. Princeton,

18. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data.
Ann lnt Med. 1984;101:692-696.
19. Boleslavsky R. Acting. The First Six Lessons. New York, NY: Theatre Arts Books; 1962.
20. Engel GL. For whom the bells toll a second time. John Romano, physician and psychiatrist (1908-1994). Rochester Medicine. 1995;1012:36.
21. Romano J. When I first came upon Boleslavsky's little basic orientation and education of
the medical student. JAmMed Assoc. 1950;143:409-412.
22. Smith RC, Mettler JA, Stoffelmayr BE, et al. bnproving residents' confidence in using
psychosocial skills. J Gen Intern Med. 1995;10:315-320.
23. Smith RC, Lyles JS, Mettler JA, 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.

Research and
Humanistic Rationale
for Patient-Centered
Interviewing

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Nearly 40 years of research has confirmed the value of integrating patientcentered and clinician-centered interviewing skills into most encounters, a
few of which studies are summarized here.
Teachers, scholars, and researchers have advanced the field by identifying
three functions of the clinical interview1.2; refining patient-centered definitions3; acknowledging the role of nonverbal communication4.5; pinpointing
the shortcomings of isolated disease-oriented interviewinlf; demonstrating
the key components of the clinician-patient interaction7 •8 ; identifying interviewers' negative responses to patients9 •10; demonstrating the principles11 - 14
and effectiveness of teaching biopsychosocial/patient-centered modePs- 19;
integrating patient-centered principles into treatmenf0- 22 and prevention23;
exploring specific patient-centered approaches24.25 and alternative theories26;
critically reflecting on the biopsychosocial model27•28; going beyond the
dyadic interaction to other relational aspects of medical care29 - 31; identifying the important role of qualitative approaches in clinical research32.33 and
linguistic studf4; emphasizing the need for research to direct the interviewing skills that should be used35•36; and connecting patient-centeredness with
health outcomes, albeit with mixed results.37-40
In this chapter, we synthesize the arguments for adopting patient-centered,
biopsychosocial practices instead of a solely disease-oriented, biomedical
approach.
•

MORE HUMANISTIC

Most students recognize the powerful humanistic rationale for integrating
patient-centered principles: it gives them tools to respond to patients' biological, psychological, and social needs. Responding in this way allows us to hear
and understand our patients in a way that validates them as human beings
281

282

SMITH'S PATIENT-CENTERED INTERVIEWING

rather than as objects of study.41 This also strengthens our patients' involvement, sense of self-sufficiency, and feelings of responsibility, leading to selfactualization/2 an essential contributor to the improved patient outcomes
seen with patient-centered care.30 Thus, effective communication involves a
patient who is the expert on her/his needs and experiences, and a clinician
who is the expert at responding to these needs and experiences, identifying
the responsible diagnoses, and determining appropriate treatments.42-44
Clinicians also benefit from using a biopsychosociallpatient-centered
model. They report that they can more fully embody such human qualities
as respect, empathy, humility, and sensitivity. Because these qualities seemed
less valued during their training, physicians of the past often felt guilty in
expressing them, asking colleagues to "not tell anyone" if they were observed
doing so. The idea of developing meaningful relationships and feelings of
connectedness with patients, which was discouraged until the latter part of
the 20th century, has now been shown to have a variety of positive benefits45•46
for patients and clinicians alike.39•46•47

•

MORE SCIENTIFIC

Integrating patient-centered interviewing skills is more scientific than isolated clinician-centered interviewing.
1. Deficiencies of a solely clinician-centered approach.
a. Physicians do not allow patients to complete their opening statement
of symptoms and concerns in 69% of visits, interrupting patients after a
mean time of 18 seconds.6
b. Clinician-centered interviewing elicits only 6% of the primary problems
that were ultimately determined to be psychosocial.48
2. Superior results from integrating patient-centered skills with cliniciancentered ones.
a. Many studies show increased patient satisfaction when patient-centered skills are included, as compared to isolated clinician-centered
ones.7,39,47.49

b. Patient-centered approaches enhance patient adherence7•47•50 and patients' knowledge and recall.'-39.47
c. Improved patient health outcomes have been reported when clinicians
use a patient-centered approach, which includes the use of patient-centered interviewing skills, empathy, and psychosocial support. For example, patient-centered approaches lead to better blood pressure and diabetic
contro~ 51•52 improved perinatal outcomes, 53 shortened and less complicated

postoperative courses,54- 56 and improved cancer outcomes. 57- 64 Improved
results have not been invariably found,65 but this has often been due to

Appendix B

RESEARCH AND HUMANISTIC RATIONALE FOR PATIENT-CENTERED INTERVIEWING

283

issues of the definition of patient-centeredness,38 study design, and study
power. Several reviews have summarized the benefits to patients and clinicians.30.37·49·66 A meta-analysis of randomized controlled trials found a
small but significant effect of the clinician-patient relationship on health
outcomes, greater than the effect of aspirin use for preventing myocardial infarction or smoking cessation in men for decreasing mortality.67
d. Patient-centered interviewing efficiently elicits much of the physical
symptom data previously obtained via clinician-directed inquirf8and it adds physical symptom information not elicited at all by clinician-directed approaches.69 Sir William Osler captured this best in 1910,
"Listen to the patient, he is telling you the diagnosis;"70
e. Studies also show decreased risk of malpractice suits71 - 73 and decreased
doctor-shopping74 when clinicians integrate patient-centered skills.
3. Integrating patient-centered interviewing skills is more compatible with
general scientific principles.
a. An isolated clinician-centered approach produces biased data about the
patient. This is at odds with the basic scientific requirement that data
about the subject of any science be reliable (consistent, unbiased). 75-77
Experience shows that patient-centered interviewing skills elicit information that is less biased because it is far less influenced by the interviewer.44
b. Patient-centered interviewing elicits personal and emotional information that is not obtained by isolated clinician-centered interviewing78-80
and fulfills the scientific requirement that data about the subject of any
science be valid (complete, fully representative).75-77 By including the
psychosocial as well as the biomedical aspects of the patient's illness experience, an integrated approach produces more complete and, therefore, more valid data about the patient-who is, after all, the subject of
the science of medicine.6.44,4S,at- M
c. Not only are data more reliable and more valid, but patient-centered
interviewing skills also produce a biopsychosocial description ofthe patient rather than a simple disease description. Biopsychosocial medicine
stems from general system theory, which superseded the simple causeeffect model85-87 responsible for the disease-oriented biomedical model.

An additional attribute of patient-centered interviewing skills is that
they help clinicians to efficiently determine the most important concern the
patient has at a given time.44.88 Also importantly in the current era of medicine
where the emphasis is often on productivity, research has shown that integrating patient-centered skills takes no more time than a solely clinician-centered
approach.89 Because of the benefits listed above, using patient-centered interviewing likely saves time over time.

284

SMITH'S PATIENT-CENTERED INTERVIEWING

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285

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287

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66. Stewart MA. Effective physician-patient communication and health outcomes: a review.
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71. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication-the relationship with malpractice claims among primary care physicians and
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76. Spilker B. Guide to Clinical'llials. Philadelphia, PA: Lippincott-Raven; 1996;1156.
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Feelings and Emotions
Many people use the words "feelings" and "emotions" interchangeably, as
we do throughout the text, but there are important distinctions and several
theories drawn from more than a century and a half of research, beginning
with Charles Darwin. To summarize, feelings are cognitive and internal while
emotions are "expressed" and visible.
Paul Ekman has described 15 distinguishable emotions 1:

1.
2.
3.
4.
5.
6.
7.
8.

9.
10.
11.
12.
13.
14.
15.

Amusement
Anger
Contempt
Contentment
Disgust
Embarrassment
Excitement
Fear
Guilt
Pride in achievement
Relief
Sadness/distress
Satisfaction
Sensory pleasure
Shame

These emotions are all visible and discernable from one another by facial
expression and other nonvocal cues.
Feelings are the conscious, subjective experience of emotion, and are more
nuanced and numerous. Examples of some feelings are listed in the following
pages.
This dichotomous approach to feelings and emotions may be useful to
you as a beginning student because it gives you visible sign posts for emotion
289

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SMITH'S PATIENT-CENTERED INTERVIEWING

that you can observe in patients and see yourself exhibit on video recordings.
You can then process the feelings your observations trigger in you, thereby
increasing your personal awareness and improving your mindful practice.

• EXAMPLES OF SOME FEELINGS
Abandoned
Mraid
Aggravated
Agitated
Alienated
Alive
Alone
Amazed
Ambiguous
Ambivalent
Amused
Angry
Annoyed
Anxious
Appalled
Apprehensive
Ashamed
Astounded
Astonished
At ease
Awed
Awkward
Bad
Bashful
Betrayed
Bitchy
Bitter
Blamed
Blissful
Blocked
Blue
Bored
Bothered
Bugged
Bummed-out

Burdened
Calm
Capable
Captivated
Cautious
Challenged
Charmed
Cheated
Cheerful
Childish
Clever
Combative
Comfortable
Committed
Compassionate
Concerned
Condemned
Confident
Conflicted
Confused
Consumed
Contented
Contrite
Controlled
Creative
Crummy
Crushed
Curious
Deceitful
Deceived
Defeated
Defiant
Degraded
Dejected
Delighted

Depressed
Despair
Destructive
Determined
Devastated
Different
Dirty
Disappointed
Discouraged
Disgusted
Disoriented
Dissatisfied
Distracted
Distraught
Distressed
Distrustful
Disturbed
Dominated
Doubtful
Down
Downtrodden
Drained
Driven
Dumb
Eager
Ecstatic
Edgy
Elated
Embarrassed
Empty
Encouraged
Energetic
Engrossed
Engulfed
Enlightened

Appendix C

Enraged
Enthusiastic
Envious
Euphoric
Evil
Exasperated
Excited
Exhausted
Fearful
Flustered
Foolish
Forgotten
Forlorn
Fragmented
Frantic
Frenzied
Fretful
Friendly
Frightened
Frustrated
Funny
Furious
Gloomy
Glum
Good
Grateful
Gratified
Great
Grief
Groovy
Grouchy
Guilty
Gullible
Happy
Hassled
Hateful
Hdpful
Hdpless
Hesitant
High
Hopeful

Hopdess
Horrible
Horrified
Hostile
Hurt
Ignorant
Ignored
Impatient
Impulsive
Important
Inadequate
Incompetent
Independent
Indifferent
Inferior
Infuriated
Insecure
Insensitive
Inspired
Interested
Intimidated
Involved
Irritated
Isolated
Jealous
Jittery
Joyful
Jubilant
Jumpy

Lazy
Left out
Letdown
Lethargic
Light hearted
Listless
Lonely
Longing
Loved
Loving
Low
Mad

FEELINGS AND EMOTIONS

Manipulated
Marvelous
Maudlin
Mean
Meek
Mdancholy
Mellow
Miserable
Misunderstood
Mixed up
Modest
Morose
Mystified
Needed
Negative
Neglected
Nervous
Numb
Nutty
Obnoxious
Obsessed
Odd
Oppressed
Outraged
Overwhelmed
Pained
Panicked
Patient
Peaceful
Perplexed
Persecuted
Perturbed
Petrified
Phony
Picked on
Pity
Pleasant
Pleased
Positive
Pressured
Preoccupied

291

292

SMITH'S PATIENT-CENTERED INTERVIEWING

Proud
Pushed
Put down
Put upon
Puzzled
Quarrelsome
Querulous
Quixotic
Quiet
Rage
Refreshed
Regretful
Rejected
Rejuvenated
Relaxed
Relieved
Remorseful
Renewed
Resentful
Resigned
Restless
Rewarded
Righteous
Rotten
Sad
Safe
Satisfied
Scared
Scattered
Screwed up
Secure
Selfish
Sensitive
Sensuous
Serious
Shattered

Shocked
Shy
Smothered
Solemn
Sophisticated
Sorrowful
Sorry
Spiteful
Strange
Strong
Stubborn
Stuck
Stunned
Stupefied
Stupid
Successful
Suffering
Superfluous
Superior
Surprised
Suspicious
Sympathetic
Tense
Tentative
Terrible
Terrified
Testy
Threatened
Thwarted
Tired
Tormented
Torn
Tranquil
Trapped
Tremendous
Troubled

Tuned on
Turned off
Terrific
Terrified
Ugly
Uncertain
Uncomfortable
Uneasy
Unfortunate
Unhappy
Unimportant
Uninvolved
Unlucky
Unpleasant
Unsettled
Unwanted
Upset
Uptight
Useful
Useless
Violent
Vital
Vivacious
Vulnerable
Warm
Weak
Wary
Weepy
Whimsical
Whole
Wicked
Wonderful
Worried
Worthless
Worthwhile

REFERENCE
1. Ekman P. Basic emotions. In: Dalgleish T, Power MJ, eds. Handbook

Emotion. Chichester: John Wiley & Sons; 1999:45-60.

of Cognition and

Complete Write-up
of Ms. Jones' Initial
Evaluation

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• IDENTIFYING DATA
This is the first visit to the Clinical Center for this 38-year-old married, white
woman who is a local attorney with GHI Corporation. The interview was
obtained by M. White, a clinical student.

• SOURCE AND RELIABILITY OF INFORMATION
The patient was cooperative and reliable. No other informants or data sources
were available.

• CHIEF CONCERN/AGENDA
The chief concern is (1) headaches in the context of problem (2) difficulties
with her boss. Other agenda items are (3) cough, (4) "colitis," and (5) she
wants to know if medications for colitis need to be added.

• HISTORY OF THE PRESENT IU.NESS {HPI)
The patient's headache began rather suddenly at work 3 months ago.
Headaches are accompanied by nausea during the last month and she vomited once last week during the most severe headache ever, which prompted
this appointment.
The headaches are located diffusely over the right temporal region and do
not radiate elsewhere. They feel deep within the head, are not associated with
tenderness or increased sensitivity of the scalp, and are described as pounding
and throbbing. They begin suddenly and then increase in intensity, described

293

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SMITH'S PATIENT-CENTERED INTERVIEWING

as "worse than having a baby" when severe. Ms. Jones has had to miss work a
few days because of the intense pain. The headaches occur two to three times
per week and can last as long as 12 hours at a time, although initially they
occurred no more often than once weekly and lasted only a couple of hours.
The headache is getting worse but seems to clear on the weekends when she is
not at work. Nevertheless, the headaches have progressively worsened and are
interfering with her life. Bright lights make the headache worse (photophobia). Lying in a dark room and placing an ice bag on her head seem to help.
Drinking wine may also have been a precipitant once or twice. Nausea accompanies all headaches and she vomited a small amount of nonbloody material
with one severe headache a week ago. The patient feels entirely well between
her episodes of headache and nausea.
Except for a problem of being carsick a couple times as a youngster, there
have been no other associated symptoms in neurological, gastrointestinal, or
other body systems. In particular, there has been no loss of consciousness,
change in vision, paralysis, stiff neck, rash, fever, chills, change in memory, or
history of seizures. She feels well otherwise, has a good appetite, and enjoys
outside activities. There is no history of joint pain or swelling.
An injection in the emergency room 1 week ago provided relief, but the
exact medication is not yet known to us; only a blood and urine test were
obtained, the results of which are not yet available. Except for no more than
six to eight aspirin daily and this one injection, she takes nothing for the headaches and has seen no other caretakers. Regarding possible causative factors,
she has been taking birth control pills for 6 years and there is a possible history of migraine in an aunt. There is no history of head injury or neck injury.
As noted below, the headaches seem clearly to be precipitated by stress she is
having on the job.
Ms. Jones' headaches occur at times of conflict with her boss. She is the
corporation's new lead attorney and was brought in to replace the man who
is now her boss, and promised there would be no problem during a year of
transition prior to his retirement. He has been pushing and criticizing her,
which makes her angry, and this leads to the headaches. She is also angry at
the Board for promising that this problem would not occur. The relationship
of anger and headache is similar to what she experienced as a child when
her mother would unfairly criticize her. She believes her boss is the problem
because, when she can avoid him, she has no headaches. Although she believes
stress is a major precipitator of her headaches, Ms. Jones also attributes her
headaches to the possibility of having a brain tumor. This makes her even
more anxious. She wants help with the headaches and coping with the stress
because she is afraid they will adversely affect her and her family's personal
lives. She is considering leaving her job. She has friends who provide support

Appendix D

COMPLETE WRITE-UP OF MS. JONES' INITIAL EVALUATION

295

at work and her husband is supportive, but he does not say much because he
encouraged her to take the job. Ms. Jones has been satisfied with her sexual
life until the last 3 months when her interest has decreased. Sexual intercourse
now occurs about once every few weeks, but was a few times a week before
starting this job. She is not worried about this, thinks that it relates to her
work problems, and was not interested in further discussing it.

• PAST MEDICAL HISTORY
General State of Health and Past Illnesses
1. She was followed regularly by her gastroenterologist Dr. Jergens for ulcer-

ative colitis (see Hospitalizations) and he also acted as her primary physician until she moved here 4 months ago, since which time she has seen no
one except for one emergency room visit. Dr. Jergens urged her to get a
primary care physician when she moved here.
2. Cough and stuffy nose 3 weeks ago with a slight persisting cough. There
was no sore throat, earache, or fever and the cough is nearly gone. She took
an over-the-counter cough medication for a week at the beginning, but
does not recall the name.
3. Her first and only episode of urinary tract infection occurred in July 2017
with symptoms of increased frequency and dysuria. She felt well otherwise and there was no hematuria, fever, chills, or back pain. She received a
3-day course of trimethoprim/sulfamethoxazole tablets (twice daily) from
an emergency room in Colorado, where they were vacationing, and was
symptom free within 2 days.
4. Knows she had measles and chickenpox as child and thinks she had a mild
case of the mumps.

Screen for MaJor Diseases
1. There is no history of rheumatic fever, scarlet fever, diabetes mellitus, can-

cer, tuberculosis, heart disease, sexually transmitted infections, or stroke.
2. She has never received blood transfusions, insulin, anticoagulants, heart
medications, or blood pressure medications.
3. Past injuries, accidents: Fracture ofleft ulna 21 years ago as the result of a
fall. It was casted for several weeks, and there has been no problem since.

Hospitalizations
1. 2010-She was hospitalized for 3 days, and a diagnosis of mild ulcerative
colitis was made. She had presented with a 3-month history of periodic
loose stools with occasional blood and mild abdominal cramping. Tests
for "parasites and other germs" were negative at the University Hospital

298

SMITH'S PATIENT-CENTERED INTERVIEWING

in the city where she was attending law school. She was cared for by a Dr.
Jergens. Colonoscopy led to the diagnosis of ulcerative colitis, and she was
told she did not need surgery but to follow-up closely, which she did at
about 6-month intervals. She took prednisone for the first 3 months following discharge, starting at 40 mg daily and slowly reducing the dosage.
She also took sulfasalazine, starting at eight tablets daily (presumably 500
mg tablets but not yet verified). After 3 months, when the prednisone
was stopped, the dose of sulfasalazine was slowly reduced to four tablets
daily over the ensuing 3 months. This was stopped altogether a year later.
She was asymptomatic until November 2015 when some diarrhea without blood developed. Colonoscopy by Dr. Jergens showed a mild flare-up.
Again, no surgery was advised and she was treated with sulfasalazine (she
brought this pharmacy label), 1.0 g qid for about 2 months. It was then
gradually reduced to 0.5 g qid for 6 months and then it was stopped. There
has been no recurrence of symptoms. At her most recent colonoscopy with
Dr. Jergens 6 months ago, she was told her colon looked essentially normal
and that nothing further was necessary except close follow-up.
2. Two uncomplicated vaginal deliveries 6 and 8 years ago, productive of
healthy children. She was hospitalized less than 72 hours each time.
3. Tonsillectomy and adenoidectomy as a child.

Immunizations
She has had all of the usual "baby shots" but does not know exactly what they
were. A tetanus shot was given 2 years ago following a puncture wound to the
hand. She does not think flu shots work and does not want any more because
she got sick after the last one 3 years ago.

Women's Health History
1. Menses began at age 12 and are attended by only slight discomfort for a day
or so. They last 5 days, require five pads daily. and occur regularly every
month since she has been on the birth control pill.
2. She is gravida (pregnancies) 2, para (deliveries) 2, abortus (spontaneous
and induced abortions) 0 with 2 healthy living children. There have been
no complications of her pregnancies, both vaginal deliveries.

Medications and Other Treatments
1. Aspirin, two 325 mg tablets daily with her headaches during the last 4 to 6
weeks, with smaller amounts during the preceding 6 weeks. No adverse effect.
2. "Birth control pill" of uncertain type for the past 6 years. She will call in the
dosage and type.
3. No use of laxatives, vitamins, eye drops, other hormones, herbal, homeopathic, or over-the-counter medications.

Appendix D

COMPLETE WRITE-UP OF MS. JONES' INITIAL EVALUATION

297

4. Except for Dr. Jergens, she has seen no one else and has not sought care
from CAM providers. Nor does she use any complementary or alternative
healing remedies.

Allergies and Drug Reactions
1. There is no history of allergies to drugs or other drug reactions.
2. There is no known allergic disease and no history of asthma, hives, or hay
fever.
3. There are no known food or environmental substances to which she is
sensitive.

• SOCIAL HISTORY
Occupation
The patient is 38 years old and just moved here with her husband and two
children 5 months ago. She left a job as a corporate attorney in the city where
she had trained as a lawyer to come here with GHI Corporation as the lead
attorney. See the History of Past Illness (HPI).
She views her new job here as a big professional step upward in corporate
law. It provides the opportunity for leadership and creativity that did not exist
previously. Her husband also is a lawyer with GHI but works in a different
area. His job was a big step upward for him, and he has been quite happy here
and is getting along well. Both were happy in their previous jobs but felt the
need to progress professionally.
She has no financial problems and is well covered by health insurance.

Health Promotion
Diet: The patient adheres carefully to a low-fat, low-salt diet.
Exercise: Exercises actively in an aerobics class four to five times weekly
for 45 minutes or so; this is vigorous enough to bring the pulse rate to
150 per minute and prompt a drenching sweat. Her weight is stable in
the 120-pound range.

Functional Status
Ms. Jones has no functional limitations.
Safety: She always uses her seat belt. She does not ride bicycles or motorcycles, there are no weapons in the home, all medications are out of reach of
the children, and the home has smoke and carbon monoxide detectors.
Health screening: She has had regular physical examinations with Dr.
Jergens, who has also acted as her primary care physician, including a
Pap smear 1 year ago; she does not know what blood tests he performed

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SMITH'S PATIENT-CENTERED INTERVIEWING

but some were done. She thinks her cholesterol was normal when hospitalized in 2010. She has not seen a dentist since a cavity was filled 4 years
ago, although she has no symptoms.

Substance Use
Except for a rare cup of coffee and glass of wine, the patient has not used
addicting substances.

•

PERSONAL

The patient and her husband are monogamous and heterosexual She had two
other sexual partners prior to marriage. There is no history ofsexually transmitted diseases or of sexual abuse. Her husband has had problems with occasional
erectile dysfunction. She is not worried about her decreased libido. thinks that
it relates to her current stressors, and was not interested in further discussing it
There is no history of physical or sexual abuse directed toward Ms. Jones
nor has she ever been abusive.
Life stress (see HPI): She would like to take time for relaxation but does not
do so now. She enjoys painting but worries that she is getting so busy that it
will fall into the background. She describes herself as a "workaholic" and says
that this prevents her from doing more interesting things like her painting,
but that it does not keep her away from her children. She would like to curtail
her work activities but sees no way to do this now in a busy new job. She and
her husband also "socialize" a lot. Although neither seems to enjoy it much, it
is part of their businesses and she sees no alternatives.

Spirituality
She wants to resume church activities, which have faltered during the last few
years as life got busier but, she says, "I don't want all that guilt stuff." Ms. Jones
indicates that her children have brought her more meaning in life than anything else, and that she and her husband are often able to "get out of ourselves"
through them.

Legal Issues
Ms. Jones has never considered advance directives. She and her husband have
arranged for power of attorney, but she does not think it includes directions
for health issues .

•

FAMILY HISTORY

General and Speclflc Inquiry
There are no known diseases the patient is aware of that seem to run in the
family and, in particular, the patient is aware of no familial problems with

Appendix D

COMPLETE WRITE-UP OF MS. JONES' INITIAL EVALUATION

299

80
Hip fracture

66
"Sick HAs"

HBP

70

FIGURE D-1.. Ms. Jonas' ganogram. Age of family members appears to the right of
each. Under some figures Is listed the cause of death (deceased persons) or the current status of living persons. , mala; , female; ~ deceased; ---+--• divorced; ~
close (good) relationship; - . conflicted relationship; ..,_, close and conflicted
relationship; ______, distant relationship; _____, the patient. HA, headaches; HBP, hlgb
blood pressure. (Adapted from Mullins HC, Chrlsti.Seely J. Collection and recording
family data: the genogram. In: Chrlsti.Seely J, eel. Working with the Family In Primary
care: A Systems Approach to Healtll and Illness. New York, NY: Praeger; 1.984:1.791.91.. Reproduced with permission of ABC-CUO, LLC.)

the following: tuberculosis, cancer, heart disease, bleeding problems, kidney
failure, dialysis, alcoholism, tobacco use, weight problems, asthma, or mental
illness. Her paternal grandmother has diabetes mellitus (Fig. D-1).
•

REVIEW OF SYSTEMS

General-nothing additional
Skin-had rash while traveling that seemed due to harsh soaps; no recurrence
since moving here
Hematopoietic-excessive bruising years ago when taking prednisone but
none since

300

SMITH'S PATIENT-CENTERED INTERVIEWING

Head-nothing additional
Eyes, ears, nose, throat-uses reading glasses when doing much reading
Neck-nothing additional
Breasts-breasts are generally iumpy" around her periods but never has felt
any masses; did not nurse her children
Cardiac and puhnonary-nothing additional
Vascular-nothing additional
Gastrointestinal-nothing additional except moderately painful hemorrhoids
in the later stages of each pregnancy
Urinary-nothing additional except for brief period of enuresis around age 5
Genital-nothing additional
Neuropsychiatric-nothing additional
Musculoskeletal-nothing additional
Endocrine-nothing additional

• PHYSICAL EXAMINATION
[Because this text does not address the physical examination, we will only
summarize pertinent fmdings.] Ms. Jones had a blood pressure of 110/70,
a pulse rate of 66, and 12 respirations per minute. There was no evidence of
neurological or gastrointestinal abnormality; these are the areas most likely to
have explanatory value for her symptoms if abnormalities were found. There
were no other abnormalities on physical examination.

• INITIAL DIAGNOSTIC AND TREATMENT INTERVENTIONs•
None
•

ASSESSMENT: PROBLEM LIST

1. Intermittent right temporal headaches, throbbing, associated with nausea
and photophobia, increasing in frequency and severity over 3 months; on
birth control pills; headache associated with severe stress; no historical or
physical exam evidence of neurological dysfunction. The following are the
diagnostic possibilities, in order oflikelihood:
a. Migraine headache-by far the best explanation
b. Stress-tension headache-possible but less likely
c. Chronic meningitis-very unlikely
d. Vasculitis, for example, systemic lupus erythematosus-very unlikely
'Included for completeness but not addressed in this book.

Appendix D

COMPLETE WRITE-UP OF MS. JONES' INITIAL EVALUATION

301.

e. Chronic subdural hematoma-very unlikely
f. Cerebral artery aneurysm-very unlikely
2. Severe stress without depression due to work-related problems, resulting in
anger [closely associated with headaches]. Additional stress brought on by
the fear that she may have a brain tumor.
3. Recent respiratory tract infection ("cold"), cleared
4. Wcerative colitis, quiescent and mild by her report. But, these patients can
have a higher incidence of colon cancer.
5. Past history of one lower urinary tract infection in 2017.

• TREATMENT AND INVESTIGATIVE PLANb
Headaches
1. Obtain records from recent emergency room visit.
2. Start treatment of migraine headaches with ibuprofen or sumatriptan tablets.
3. Will consider later addition of prophylactic treatment with a beta blocker
or calcium channel blocker if #2 is not effective.
4. Also, will need to consider discontinuing the birth control pill and finding
an alternative means of contraception if #2 and #3 are not effective.
5. Defer any further investigation of the headaches until observing the impact of treatment upon what appears to be a typical migraine pattern.
6. Further discuss specific strategies for dealing with her boss at the next visit
in 1 week.
7. Instruct her in a relaxation procedure.

Ulcerative Colitis
1. Obtain outside records from Dr. Jergens.
2. Referral to gastroenterology for evaluation.

hrncluded for completeness but not addressed in this book.

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Evaluation

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• COMPLETE MENTAL STATUS EVALUATION
1. Appearance
Observe the gestalt or overall appearance of the patient: whether they appear older or younger than the stated age, the presence of unique physical
attributes (prosthetic leg), grooming and neatness, if slhe appears depressed or anxious, and apparent state of health (ill appearing).
2. Attitude
Observe the patient's attitudes, both exhibited, and expressed during
the interview (particularly for cooperativeness). Other attitudes include
angry, guarded, suspicious, attentive, seductive, playful, and obsequious.
3. Activity
Note the patient's motor activity: increased (hyperactivity, agitation), decreased, catatonic, and abnormal movements (tics, tremors). One also
asks the patient to draw a simple figure, such as a clock set at a specific
time or a square inside a circle, to assess visual-motor integrity.
4. Mood
Determine, primarily by inquiry, the patient's sustained, day-in and dayout, emotional feeling, for example, sad, happy, anxious, angry, depressed,
detached, and irritable.
5. Affect
Primarily by observation note how the patient expresses her/his immediate emotional state. Is the patient fully and appropriately responsive
to stimuli and circumstances or, are her or his responses flat or blunted
(dulled emotional responsiveness), inappropriate (laughing when most
would be serious), anhedonic (no enjoyment of anything), or labile? To

303

304

SMITH'S PATIENT-CENTERED INTERVIEWING

6.

7.

8.

9.

10.

11.

combine mood and affect, the clinician might say, "The patient's mood
was depressed and the affect blunted."
Speech
Observe the following speech characteristics: normal, slowed, reduced,
increased, pressured, mute, dysarthria, punning, rhyming.
Language
Observe the patient's use of language for the following characteristics:
bizarre, distracting, colorful, word salad (incoherent mix of words and
phrases seen in psychotic states), circumstantial, tangential, loosening
of associations (connections that are difficult to follow), and neologisms
(coining new words).
Thought content
Determine the presence or absence, via the patient's speech and language,
of the following features ofthe patient's thought content: logical, incoherent,
derailment, poverty of content, obsessive, delusional, paranoid. The clinician also notes the content of the thought, describing any delusions in detail
Perceptions
About abnormal perceptions, typically hallucinations that may be visual, auditory, olfactory, or tactile. Hallucinations are abnormal sensory perceptions
in the absence of a stimulus (voices coming from a picture on the wall) while
illusions are misinterpretations of stimuli (belief that the doorbell ringing is
someone speaking). Depersonalization is the perception that one's body is
strange and unreal, as though apart from the patient. Derealization is a similar perception of unreality and estrangement of objects in the environment
Judgment and insight
Determine if the patient is realistic or unrealistic about her or his problem
and other issues. An apparent obliviousness of a serious problem is called
"la belle indifference:'
Neuropsychiatric evaluation
a. Observe the patient's level of consciousness, for example, comatose,
stuporous, drowsy, alert, hyperalert.
b. Carefully investigate attention and concentration by asking the patient to repeat a series of from three to eight digits (e.g., repeat the
following: 8-1-6-3-9); having them subtract from 100 by 7 and continuing doing so with each answer, so-called "serial7s" (e.g., 100 - 7 =
93; 93 - 7 = 86; and so on); spelling a word (like "world") backward;
and inquiring about immediate occurrences in their environment (repeat the clinician's name after clearly stating it).

Appendix E

MENTAL STATUS EVALUATION

305

c. Also assess the patient's language function for fluency, comprehension, naming, repetition, reading, and writing. In addition to observing and listening to the patient, the clinician asks the patient to read
and explain a simple text and to write a sentence or two (without giving them the sentence); such exercises should be appropriate to the
patient's level of education.
d. Recent memory is tested by determining the patient's orientation to
time, place, and person; for example, the patient is asked to describe
the day. date, year, time, place, and her/his name and identity. Recent
memory also is tested by asking the patient to recall three words (object, animal, color) immediately after mentioning them (e.g., comb,
dog, yellow), then warning the patient they will be asked to recall the
three objects in 3 to 5 minutes and, finally. testing the patient's recall
at that time. Remote memory is evaluated by inquiring about events
of several days earlier as well as events months and years earlier; for
example, "What day did you come into the hospital" or "Who is the
president?" or "What are your daughters' names?"
e. Other higher functions include how well the patient thinks abstractly.
Interpreting proverbs, such as "People who live in glass houses
shouldn't throw stones," can vary from bizarre to very concrete to
quite abstract and interpretive. Similarly. the clinician can determine
the capacity for abstract thinking by inquiring how an apple and an
orange are alike and different. Calculations and testing general intelligence also can be helpful at times.

308

SMITH'S PATIENT-CENTERED INTERVIEWING

Instructions for Administration & Scoring

Mini-Cog©

ID:

Date: _ _ _ _ __

Step 1: Three-Word Registration
Look directly at person and say, "Please listen carefully. I am going to say three words that I want you to repeat back
to me now and try to remember. The words are [select a list of words from the versions below]. Please say them for
me now.• If the person is unable to repeat the words after three attempts, move on to Step 2 (clock drawing).
The following and other word lists have been used in one or more clinical studies.,_.. For repeated administrations,
use of an alternative word list is recommended.
Varsian 2
Leader
Seaaon
Table

Version 1
Banana
Sunrise
Chair

Versian3
Village
Kitchen
Baby

Version 4
River
Nation
Finger

VersionS
Captain
Garden
Picture

Varsian 6
Daughter
Heaven
Mountain

Step 2: Clock Drawing
Say: "Next, I want you to draw a clock for me. First, put in all of the numbers where they go~ When that is completed,
say: "Now, set the hands to 10 past 11."
Use preprinted circle (see next page) for this exercise. Repeat instructions as needed as this is not a memory test.
Move to Step 3 if the clock is not complete within 3 minutes.

Step 3: Three-Word Recall
Ask the person to recall the three words you stated in Step 1. Say: "What were the three words I asked you to
remember?" Record the word list version number and the person's answers below.
Word List Version: _ _ _ Person's Answers: _ _ _ _ _ __

Scoring
_

(0-3 points)

Word Recal:

_

Clock Draw:

_ _ (0 or 2 points)

1 point for each word spontaneously recalled without cueing.

Normal clock ~ 2 points. A normal clock has all numbers placed in the correel sequence and approximately correct position (e.g., 12, 3, 6, and 9 are in
anchor positions) with no missing or duplicate numbers. Hands are pointing to the 11 and 2 (11 :1 D). Hand length is not scored.
Inability or refusal to draw a clod< (abnorma~ ~ 0 points.
Total score ~ Word Recall score+ Clock Draw score.

Total Score:

_ _ (0-5 points)

A cut point of <3 on the Mini-Cog- has been validated for dementia screening,

but many individuals with clinically meaningful cognitive impairment will
score higher. When greater sensitivity is desired, a cut point of <4 is recornmended as it may indicate a need for further evaluation of cognitive status.

Mini-Cogn 0 s. Borson. All right• reserved. Reprinted with permiasion of the •uthor solely for clinical and edUCIIIio""l purp084!8.
May not be modified or uaed for commercial, m•rkeling. or reeHrch purposes wid'IOUI permission of the aU!hor (aoob@uw.edu).
v.01.19.16

Mini-Cog

Appendix E

Clock Drawing

MENTAL STATUS EVALUATION

ID: _ _ _ _ Date: _ _ _ _ __

References
1.

Borson S. Scanlan JM, Chen PJ, et al. The Mini-cog aa a screen for dementia: validation in a population baaed
sample. JAm Geriatr Soc. 2003;51 :1451 -1454.

2.

Borson S. Scanlan JM, Watanabe J, et al. Improving identification of cognitive impairment in primary care. lnt J
Geriatr Psyr:hiatry. 2006;21 :349-355.

3.

Lessig M, Scanlan J, et al. Time that tells: critical clock-ilrawing errurs for dementia screening.
lnt Psyr:hogeriat!. 2008 June;20(3):459-470.

<4.

Tsoi K. Chan J, et al. Cognitive tests to detect dementia: a systematic review and meta-l!nalysis. JAMA
Intern Med. 2015;E1-E9.

5.

Mccarten J, Anderson P. et al. Screening for cognitive impairment in an elderly veteran population:
acceptability and results using different versions ofthe Min~Cog. JAm Geriatr Soc. 2011 ;59:309-313.

6.

Mccarten J. Anderson P. et al. Finding dementia in primary care: the results of a clinical demonstration
project. JAm Gl!fiall Soc. 2012;60:21 0-217.

7.

Scanlan J, Borson S. The Min~Cog: receiver operating characteristics with the expert and naive raters. lnt J
Geriatr Psychiatry. 2001 ;16:216-222.

Mini-<:og• C S. B0101on. All right8 r..ervocl. Reprintecl with permiaaion of the author oolely for clinical and eclucational purposes.
May not be modified or uaed for commORlial, marketing, or reoear<>h purpooeo without permi11ion of the author (ooob@uw.edu).

v.01.19.16

307

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Index
Note: Page number followed by f and t indicates figure and table respectively.

A
Abuse/violence, 124-125
Acute, life-threatening medical illness visit,

177
Advance directives, 127
Agenda, obtaining, 40-45, 41 t
forecast what you would like to have happen
during interview, 41
indicate time available, 4Q-41
obtain a list of all issues the patient wants to
discuss, 41-42
summarize and finalize the agenda, 42-43
vignette, 44-45
Allergies and drug reactions, 114
American Sign Language (ASL), 186-187
ART (ask, respond, and teach) mnemonic, 145-146,
148, 159
Asking about relevant symptoms outside the body
system involved in the HPI, 100
Attentive listening, 46-47, 46t
Autonomic changes, 225

B
Balancing patient-centered and clinician-centered
interviewing skills, 169-170
Barriers to communication, addressing, 39
Beeson, Paul, 89
Beginning of the interview. See Patient-centered
interviewing
Bias from closed-ended questioning, minimizing,
107-107t
Biomedical model, 1
Biopsychosocial description, 251
Biopsychosocial model, 2
Biopsychosocial story, Sf, 90f

Blind patients, 187
Bulimia, screening for, 119

c
Cabot, Richard, 255
Caffeine, 120
CAGE questions, 121
Challenging communication situations, 185-189
blind patients, 187
cognitively impaired patients, 187-189, 189t
less talkative, reticent, embarrassed, or fearful
patient, 178-180
overly-talkative patient, 180-183
patients who are deaf or hard of hearing,
186-187
stoic/unemotional patient, 183-185
Characterizing symptoms, 77-86
onset and chronology, 78-81
duration of symptom, 79
periodicity and frequency, 79-80
position of symptom and its radiation, 81-82
quality of symptom, 82
quantify the symptom, 82-84
rate of onset, 79
time course, 80-81
time of symptom onset and intervals between
occurrences, 79
overview, 77-78t
precipitating and transforming factors, 86
related symptoms, 84-85
setting,85
Chief concern and agenda, 9, 242
Chronology. See Onset and chronology of symptoms
Clarifying next steps, 148
Clinical problem solving, example of, 102t

309

3:1.0

Index

Clinician-centered interviewing, 4-5, 89-137
knowledge exercises, 136
overview, 89-90f, 131t, 137
skills exercises. 136
step 6: Complete chronological description of
patient's chief concern and other active
problems, 89-110, 91t
addressing a predominantly psychological
problem, 108-109
general comments about the remainder of the
interview, 109-110
obtaining and describing data without
interpreting it, 92-110. See also Data,
obtaining and describing without
interpreting
procedural issues, 106-108, 107t
step 7: Past medical history, 110-117, lilt
allergies and drug reactions, 114
hospitalizations, 112-113
immunizations, 113
medications and other treatments, 114
other medical, surgical, or psychological
problems, 112
screening, 112-113
women's health history, 113-114
step 8: Social history, 117-130
advance directives, 127
functional status, 127
health promotion (diet, exercise, safety,
substance use), 119-122
occupation, 119
overview, 118t
personal, 122-126
step 9: Family history, 130-133
step 10: Review of systems (ROS), 134-136, 246
Clinician/patient/computer relationship,
256-265
enacting the visit, 260-263, 262f-263f
post-visit documentation, 263-265
preparing for the visit, 256-259
sources of stress. 256-257t
Clinician-patient relationship, 207-230
clinician's previously unrecognized responses
affect relationship with patient, 208-214
addressing previously unrecognized affect and
emotion,212-214,214t

diagnosing the problem, 211-212
extent of the problem, 209-211, 21 Ot
knowledge exercises, 228-229
nonverbal dimensions. 224-228
addressing nonverbal behaviors, 227-228
leading, 226-227
matching, 226
observing the patient's nonverbal
communication, 225-226
overview, 207-208,228
patient personality style and the relationship,
214-224
dependentstyle,216-217
histrionic style, 219-220
narcissistic style, 221-222
obsessive-compulsive style, 217-218
paranoid style, 222-223
schizoid style, 223-224
self-defeating (masochistic) style, 220-221
skills exercises. 230
as treatment, 202
Clock drawing, 306-307
Closed-ended data-gathering skills, 19-21
multiple-choice questions, 21
questions producing brief answers, 20
questions producing yes/no answers, 20
Closed-ended questions, 4-5
bias from, 107-107t
limitations of, 5
Closing the visit, 148-152
acknowledge and support the patient before
saying goodbye, 149
clarify next steps, as necessary, 148
encourage questions, 149
Cognitively impaired patients, 187-189, 189t
Commitment, obtaining, 159t, 160-161
Communication
barriers to, 39
challenges, caring for patients with blind
patients, 187
cognitively impaired patients, 187-189
hearing loss or older person, 186-187
Computers. See Clinician/patient/computer
relationship
Continuers, 17
Core patient-centered skills, 15-16f

Index

31.1.

Countertransference, 213
Cultural competence, 197-199, 199t

Diary products, 120
Diet, 119-120

D

Differential Diagnosis: Presented Through an Analysis
of 383 Cases, 255

Data, identifying. 242
Data, obtaining and describing without interpreting,
92-110
A: Expand description of symptoms already
introduced by patient, 92-97
B: Inquire about symptoms located in same body
systems not yet introduced (and general
health symptoms), 97-100
C: Ask about relevant symptoms outside the body
system involved in the HPI, 100
D: Inquire about presence or absence of relevant
non-symptom data not yet introduced by
patient, 100-103, 102t
understand the patient's perspective, 103-106
Data-gathering and empathy skills, 13-29
data-gathering skills, 15-21
closed-ended data-gathering skills, 19-21.
See also Closed-ended data-gathering
skills
open-ended data-gathering skills, 15-19. See
also Open-ended data-gathering skills
empathy skills, 21-27
emotion-seeking skills, 22-24
naming the feeling/emotion, 25
respecting. 26
supporting, 26
understanding, 25-26
integrating open-ended and closed-ended skills,
21
knowledge exercises, 29
overview, 13-14, 14f-1Sf, 28-29
practicing patient-centered skills, 27-28
skills exercises, 29
vignette using NURS quartet, 26-27
Deaf or hard of hearing patients, 186-187
sign language, 186-187
de Mello, Anthony, 235
Dependent personality; 216-217
basic need, 216
clinical presentation, 216-217
how to respond, 217
problems for clinician, 217

Difficult news, giving, 147t, 152-158
deliver the difficult news, 155-156
determine how much the patient wants to know,
154-155
establish what the patient already knows, 154
iteratively explain and negotiate next steps,
156-158
prepare to give the difficult news, 153-154
use relationship-building skills to express
empathy, 156
Digital age, remaining patient-centered in,
255-266
enacting the visit, 260-263, 262f-263f
history of medical record keeping, 255-256
overview, 255-256, 265-266t
post-visit documentation, 263-265
preparing for the visit, 256-259
sources of stress, 256-257t
Direct inquiry, 23
Disease-prevention visit, 176-177
Disease story, 236-237
DocCom, 10
Documentation, post-visit, 263-265
Drug reactions and allergies, 114

E
ECGN mnemonic, 159-163, 159t
Echoing. 17
Edison,Tho~,143

Educating the patient, 159-160, 159t
Elderly patients, 192-194
Electronic health record (EHR), 256-266. See also
Digital age, remaining patient-centered in
Emotional focus (emotional context), developing,
55-56
Emotions
versus feelings, 289-292
list of, 289
Emotion-seeking skills, 22-24
direct inquiry, 23
indirect inquiry, 23-24
Empathy, definition of, 22

3:1.2

Index

Empathy skills, 21-27, 56-58
emotion-seeking skills, 22-24
naming the feeling/emotion, 25
NURS (naming, understanding, respecting, and
supporting) mnemonic, 25,56-57, 145,
156, 176, 227
nonverbal equivalent, 226
respecting, 26
supporting, 26
understanding, 25-26
End of the interview (step 11), 143-164
assess understanding, 146
close the visit, 148-152
acknowledge and support the patient before
saying goodbye, 149
clarify next steps, as necessary, 148
encourage questions, 149
giving difficult news, 147t, 152-158
deliver the difficult news, 155-156
determine how much the patient wants to
know, 154-155
establish what the patient already knows, 154
iteratively explain and negotiate next steps,
156-158
prepare to give the difficult news, 153-154
use relationship-building skills to express
empathy, 156
invite patient to participate in shared decision
making, 146-148
knowledge exercises, 163
motivating patients for behavioral change,
158-163, 159t
educate the patient, 159-160
help patient set realistic goals, 161-162
negotiate a specific plan, 162-163
obtain a commitment, 160-161
overview, 143-144, 144t, 163
share information, 144-146
frame the discussion according to patient's
perspective, 145-146, 146t
orient patient to end of the interview and ask
permission to begin discussion, 144
skill exercises, 164
Ensuring privacy, 38-39

Evidence-based interviewing method, 4-St
Exercise, 120
Expanding description of symptoms already
introduced by patient, 92-97
Expanding the story to new chapters, 58-63, 59f
Explanatory model of a patient, determining,
198-199, 199t

F
Facilitating skills, dynamic use of, 1Sf
Family history (FH), 9, 130-133, 245-246
Fat, 120
Feeling/emotion, naming, 25
Feelings
versus emotions, 289-292
list of, 290-292
Feelings and emotions, 289-292
examples of some feelings, 290-292
fifteen distinguishable emotions, 289
Fiber, 120
FICA mnemonic for asking about spiritual and
religious beliefs, 125-126
Five-step patient-centered interviewing, 34t, ee
Focusing skills, 17-19
echoing, 17
open-ended requests, 18-19, 18f
summarizing, paraphrasing, 19
Follow-up inpatient or outpatient without urgent or
complex personal problems, 171-173
Follow-up patient with urgent or complex personal
problems, 173-176
Foreword to the first edition, 269-279
Frame discussion according to patient's perspective,
145-146, 146t
Functional status, 127
Further investigative and treatment plan, 247

G
Gender nonconforming patients, 37
General system theory, 2-2f
Genogram, developing, 131t, 132
Giving difficult news. See Difficult news, giving
Goals, helping patient set, 159t, 161-162
Greeting/welcoming the patient, 36-37

Index

H
Hard of hearing or deaf patients, 186-187
Harmful clinician behaviors, 201t
Health literacy, 126
Health promotion, 119-122
diet, 119-120
exercise, 120
safety, 121
substance use, 121-122
Heisenberg, Werner, 1958
Helpful clinician behaviors, 201t
Herrick, James B., 33
Hierarchy of natural systems, 2-2f
History of present illness (HPI), 9, 243-245,
249-250
continuing, 48-63, 48t
address feelings and emotions with empathy
skills, 56-58
develop an emotional focus (emotional
context), 55-56
develop the psychological and social context of
the symptom (personal context), 51-54
expand the story to new chapters, 58-63, 59f
obtain a further description of the symptom,
49-51
vignette,49-51,55-58,60-62
openll1g,45-48,46t
obtain additional data from nonverbal sources.
47
start with open-ended beginning question/
statement, 46
use "nonfocusing" open-ended skills (attentive
listening), 46-47
vignette, 47-48
Histrionic personality, 219-220
basic need, 219
clinical presentation, 219
how to respond, 219-220
problems for clinician, 220
Hospitalizations, 112-113

I
Immunizations, 113
Indirect inquiry, 23-24

3:13

Information
sharing. See Sharing information
source and reliability ot 242
Initial diagnostic formulations and treatment
interventions, 246, 251
Inquiring
about presence or absence of relevant nonsymptom data not yet introduced by
patient, 100-103, 102t
about symptoms located in same body systems
not yet introduced (and general health
symptoms), 97-100
indirect, 23-24
Integrated medical interviewing, 8-10, Sf, 10,
89-90
Interpreter, working with, 196-197, 197t
Interview, 169-203
addressll1g common challenging communication
situations, 185-189
blind patients, 187
cognitively impaired patients, 187-189,
189t
patients who are deaf or hard of hearing,
186-187
addressing common patient communication styles
and challenges, 178-185
less talkative, reticent, embarrassed, or fearful
patient, 178-180
overly-talkative patient, 180-183
stoic/unemotional patient, 183-185
addressing various medical encounters and
challenges, 170-177
acute, life-threatening medical illness visit,
177
disease-prevention visit, 176-177
follow-up inpatient or outpatient without
urgent or complex personal problems,
171-173
follow-up patient with urgent or complex
personal problems, 173-176
new inpatient or outpatient without urgent or
complex personal problems, 170
new patient with urgent or complex personal!
behavioral health problems, 170-171

3:1.4

Index

Interview (continued)
balancing patient-centered and clinician-centered
interviewing skills, 169-170
clinician centered. See Clinician-centered
interviewing
cultural competence, 197-199, 199t
effective clinician-patient relationship as
treatment, 202
elderly patients, 192-194
end of, 143-164
assess understanding, 146
close the visit, 148-152
acknowledge and support the patient before
saying goodbye, 149
clarify next steps, as necessary, 148
encourage questions, 149
giving difficult news, 147t, 152-158
deliver the difficult news, 155-156
determine how much the patient wants to
know, 154-155
establish what the patient already knows, 154
iteratively explain and negotiate next steps,
156-158
prepare to give the difficult news, 153-154
use relationship-building skills to express
empathy, 156
invite patient to participate in shared decision
making, 146-148
knowledge exercises, 163
motivating patients for behavioral change,
158-163, 159t
educate the patient, 159-160
help patient set realistic goals, 161-162
negotiate a specific plan, 162-163
obtain a commitment, 160-161
overview, 143-144, 144t, 163
share information, 144-146
frame the discussion according to patient's
perspective, 145-146, 146t
orient patient to end of the interview and ask
permission to begin discussion, 144
skill exercises, 164
integrated, 8-10, Sf, 10, 89-90
interpreter, working with, 196-197, 197t
knowledge exercises, 203

overview, 169,202-203
patient-centered See Patient-centered interviewing
pediatric patients, 190-192
setting the stage for, 35-40, 36t
address barriers to communication, 39
ensure comfort and put the patient at ease, 40
ensure patient readiness and privacy, 38-39
introduce yourself and identify your specific
role, 37-38
use the patient's name, 37
vignette, 43-44
welcome/greet the patient, 36-37
skill exercises, 203
time required for, 199
transition to middle of, 63-64
unique issues for the new learner, 199-202
clinical conduct, 200-202, 20lt
recording interviews, 200
taking notes, 200
time required for interview, 199
when more than one person is present, 194-196
Interview, recording, 200
Intimate partner violence/abuse, 124-125
Investigative and treatment plan, 247-248
Inviting patient to participate in shared decision
making, 146-148

K
Kinesics, 225
Kipling, Rudyard, 71

L
Leading,226-227
Life-threatening medical illness visit, 177
Listening, attentive, 46-47, 46t
Living arrangement and personal relationships, 122123

M
Major diseases, screening for, 112
Masochistic (self-defeating) personality, 220-221
basic need, 220
clinical presentation, 220-221
how to respond, 221
problems for the clinician, 221

Index

Matching, 226
Medical, surgical, or psychological problems, 112
Medical interview. See Interview
Medical record ("write-up" of patient's story),
237-247
assessment: the biophyschosocial description,
246
chief concern and agenda, 242
family history (FH), 245-246
further investigative and treatment plan, 247
history of present illness (HPI) and other active
problems (AOP), 243-245
identifying data, 242
initial diagnostic formulations and treatment
interventions, 246
overview, 238t-242t
past medical history (PMH), 245
physical examination, 246
review of systems (ROS), 246
social history (SH), 245
source and reliability of information, 242
Medications and other treatments, 114
Mental status evaluation (MSE), 188-189t, 303-307
complete mental status evaluation, 303-305
Mini-Cog, 188, 306-307
Middle of the interview. See Clinician-centered
interviewing
Mini-Cog, 306-307
Mood, 125
More than one person present at interview,
194-196
Motivating patients for behavioral change, 158-163,
159t
educate the patient, 159-160
help patient set realistic goals, 161-162
negotiate a specific plan, 162-163
obtain a commitment, 160-161
MSE (mental status evaluation), 188-189t, 303-307
complete mental status evaluation, 303-305
Mini-Cog, 188, 306-307
Multiple-choice questions, 21

N
Narcissistic personality, 221-222
basic need, 221

3:15

clinical presentation, 221-222
how to respond, 222
problems for the clinician, 222
Natural systems, hierarchy of, 2-2f
Needs communicated by patients, 7-8, 7t
Negotiation, 159t, 162-163
New inpatient or outpatient without urgent or
complex personal problems, 170
New patient with urgent or complex personall
behavioral health problems, 170-171
Next steps, clarifying, 148
Nonfocusing skills, 15-17, 16f
continuers, 17
nonverbal encouragement, 17
silence, 16-17
Nonverbal dimensions, 224-228
addressing nonverbal behaviors, 227-228
encouragement, 17
leading, 226-227
matching, 226
observing the patient's nonverbal communication,
225-226
NURS (naming, understanding, respecting, and
supporting) mnemonic, 25,56-57, 145,
156,176,227
nonverbal equivalent, 226

0
OAP (other active problems), 9
Obsessive-compulsive personality, 217-218
basic need, 217
clinical presentation, 217-218
how to respond, 218
problems for clinician, 218
Occupation, 119-120
Onset and chronology of symptoms, 78-81
duration of symptom, 79
periodicity and frequency, 79-80
position of symptom and its radiation, 81-82
quality of symptom, 82
quantify the symptom, 82-84
rate of onset, 79
time course, 80-81
time of symptom onset and intervals between
occurrences, 79

3:1.8

Index

Open-ended data-gathering skills, 15-19, 15f
focusing skills, 15f, 17-19
echoing, 17
open-ended requests, 18-19, 18f
summarizing, paraphrasing, 19
nonfocusing skills, 15-17, 15f-16f
continuers, 17
nonverbal encouragement, 17
silence, 16-17
OPPQQRRST mnemonic, 77-78t, 90, 92, 243
Osler, Sir William, 1
Other active problems (OAP), 9
Overly-talkative patient, 180-183

p
Paralanguage,225
Paranoid personality style, 222-223
basic need, 222
clinical presentation, 222-223
how to respond, 223
problems for the clinician, 223
Past medical history (PMH), 9, 110-117, lilt,
245
allergies and drug reactions, 114
hospitalizations, 112-113
immunizations, 113
medications and other treatments, 114
other medical, surgical, or psychological
problems, 112
screen for major diseases, 112
screening, 113
women's health history, 113-114
Patient, educating, 159-160, 159t
Patient-centered approach, 5-8, 7t
Patient-centered interviewing, 13-14£, 33-66
beyond basic interviewing, 64
history of, 4-5, 4t
knowledge exercises, 66
overview, 33-35, 34t, 64-65, 65f
skills exercises. 66
step 1: Setting the stage for the interview, 35-40,
36t
address barriers to communication, 39
ensure comfort and put the patient at ease, 40

ensure patient readiness and privacy, 38-39
introduce yourself and identify your specific
role, 37-38
use the patient's name, 37
vignette, 43-44
welcome/greet the patient, 36-37
step 2: Obtaining the agenda, 40-45, 41t
forecast what you would like to have happen
during interview, 41
indicate time available, 40-41
obtain a list of all issues the patient wants to
discuss, 41-42
summarize and finalize the agenda, 42-43
vignette, 44-45
step 3: Opening the history of present illness,
45-48,46t
obtain additional data from nonverbal sources,
47
start with open-ended beginning question/
statement, 46
use "nonfocusing" open-ended skills (attentive
listening), 46-47
vignette, 47-48
step 4: Continuing the patient-centered HPI,
48-63,48t
address feelings and emotions with empathy
skills, 56-58
develop an emotional focus (emotional
context), 55-56
develop the psychological and social context of
the symptom (personal context), 51-54
expand the story to new chapters, 58-63, 59{
obtain a further description of the symptom,
49-51
vignette,49-51,55-58,60-62
step 5: Transition to middle of interview, 63-64
Patient personality styles, 214-224
dependentstyle,216-217
histrionic style, 219-220
narcissistic style, 221-222
obsessive-compulsive style, 217-218
paranoid style, 222-223
schizoid style, 223-224
self-defeating (masochistic) style, 220-221

Index

Patient's chief concern, complete chronological
description of, 89-110, 91t
addressing a predominantly psychological
problem, 108-109
general comments about the remainder of the
interview, 109-110
obtaining and describing data without
interpreting it, 92-110. See also Data,
obtaining and describing without
interpreting
procedural issues, 106-108, 107t
Patient's name, using, 37
Patient's perspective, understanding, 103-106
Patient's story. See Story, patient's
Pediatric patients, 190-192
Personal awareness group work, guidelines for,
213-214, 214t
Personal history; 122-126
Personal matters, 122-126
health literacy, 126
intimate partner violence/abuse, 124-125
living arrangement and personal relationships,
122-123
mood, 125
sexuality, 123-124
spirituality/religion, 125-126
stress, 125
Physical examination, 246, 251
Plato, 207
PMH (past medical history). See Past medical
history (PMH)
Practicing patient-centered skills, 27-28
Privacy, 195
Problem-Oriented Medical Record (POMR), 255
Proxemics, 225
Psychological, medical, or surgical problems, 112
Psychological and social context of the symptom
(personal context), developing, 51-54
Putting the patient at ease, 40

Q
Questions
CAGE, 121
closed-ended, 4-5

bias from 107
limitations of, 5
encouraging,149
multiple choice, 21
"SAFE;" 124-125
those that produce brief answers, 20
those that produce yes/no answers, 20

R
Recording interviews, 200
Religion/spirituality, 125-126
Research and humanistic rationale for patientcentered interviewing, 281-283
more humanistic, 281-282
more scientific, 282-283
Respecting, 26
Review of systems (ROS), 9, 72-75, 73t-75t,
134-136, 246

s
"SAFE" questions, 124-125
Safety, 121
Schizoid personality, 223-224
basic need, 223
clinical presentation, 223-224
how to respond, 224
problems for the clinician, 224
Screening, 112-113
Seduction,219-220
Self-defeating (masochistic) personality, 220-221
basic need, 220
clinical presentation, 220-221
how to respond, 221
problems for the clinician, 221
Sexuality, 123-124
Shared decision making, inviting patient to
participate in, 146-148
Sharing information, 144-146
frame the discussion according to patient's
perspective, 145-146, 146t
orient patient to end of the interview and ask
permission to begin discussion, 144
SH (social history). See Social history (SH)
Sign language, 186-187

31.7

3:1.8

Index

Silence, use of, 16-17
SOAP (Subjective, Objective, Assessment, and Plan)
note, 255
Social history (SH), 9, 117-130, 245
advance directives, 127
functional status, 127
health promotion, 119-122
diet, 119-120
exercise, 120
safety, 121
substance use, 121-122
occupation, 119-120
overview, 118t
personal, 122-126
health literacy, 126
intimate partner violence/abuse, 124-125
living arrangement and personal relationships,
122-123
mood,125
sexuality, 123-124
spirituality/religion, 125-126
stress, 125
Sodium, 120
Source and reliability of information, 242
Spirituality/religion, 125-126
Step 1: Setting the stage for the interview, 35-40, 36t
address barriers to communication, 39
ensure comfort and put the patient at ease, 40
ensure patient readiness and privacy, 38-39
introduce yourself and identify your specific role,
37-38
use the patient's name, 37
vignette, 43-44
welcome/greet the patient, 36-37
Step 2: Obtaining the agenda, 40-45, 41t
forecast what you would like to have happen
during interview, 41
indicate time available, 40-41
obtain a list of all issues the patient wants to
discuss, 41-42
summarize and finalize the agenda, 42-43
vignette, 44-45
Step 3: Opening the history of present illness (HPI),
45-48, 46t
obtain additional data from nonverbal sources, 47

start with open-ended beginning question/
statement, 46
use "nonfocusing" open-ended skills (attentive
listening), 46-47
vignette, 47-48
Step 4: Continuing the patient-centered HPI, 48-63,
48t
address feelings and emotions with empathy
skills, 56-58
develop an emotional focus (emotional context),
55-56
develop the psychological and social context of
the symptom (personal context), 51-54
expand the story to new chapters, 58-63, 59f
obtain a further description of the symptom,
49-51
vignette,49-51,55-58,60-62
Step 5: Transition to middle of interview, 63-64
Step 6: Complete chronological description of
patient's chief concern and other active
problems, 89-110, 9lt
addressing a predominantly psychological
problem, 108-109
general comments about the remainder of the
interview, 109-110
obtaining and describing data without
interpreting it, 92-110. See also Data,
obtaining and describing without
interpreting
procedural issues, 106-108, 107t
Step 7: Past medical history, 110-117, 111t
allergies and drug reactions, 114
hospitalizations, 112-113
immunizations, 113
medications and other treatments, 114
other medical, surgical, or psychological
problems, 112
screening, 112-113
women's health history, 113-114
Step 8: Social history, 117-130
advance directives, 127
functional status, 127
health promotion (diet, exercise, safety, substance
use), 119-122
occupation, 119

Index

Step 8: Social history (continued)
overview, liSt
personal, 122-126
Step 9: Family history, 130-133
Step 10: Review of systems (ROS), 134-136, 246
Step 11: End of the interview, 143-164
assess understanding, 146
close the visit, 148-152
acknowledge and support the patient before
saying goodbye, 149
clarify next steps, as necessary, 148
encourage questions, 149
giving difficult news, 147t, 152-158
deliver the difficult news, 155-156
determine how much the patient wants to
know, 154-155
establish what the patient already knows, 154
iteratively explain and negotiate next steps,
156-158
prepare to give the difficult news, 153-154
use relationship-building skills to express
empathy, 156
invite patient to participate in shared decision
making, 146-148
knowledge exercises, 163
motivating patients for behavioral change,
158-163, 159t
educate the patient, 159-160
help patient set realistic goals, 161-162
negotiate a specific plan, 162-163
obtain a commitment, 160-161
overview, 143-144, 144t, 163
share information, 144-146
frame the discussion according to patient's
perspective, 145-146, 146t
orient patient to end of the interview and ask
permission to begin discussion, 144
skill exercises, 164
Stoic/unemotional patient, 183-185
Story, patient's, 59£, 62£, 235-253
knowledge exercises, 252
medical record ("write-up" of patient's story),
237-247
assessment: the biophyschosocial description,
246

31.9

chief concern and agenda, 242
family history (FH), 245-246
further investigative and treatment plan, 247
history of present illness (HPI) and other active
problems (AOP), 243-245
identifying data, 242
initial diagnostic formulations and treatment
interventions, 246
overview, 59£, 62f, 238t-242t
past medical history (PMH), 245
physical examination, 246
review of systems (ROS), 246
social history (SH), 245
source and reliability of information, 242
overview, 235, 252
presenting,247-252
assessment: the biopsychosocial description,
251
guidelines, 247t
history of present illness (HPI), 249-250
identifying data, source and reliability of data,
chief complaint, and other major agenda
items, 249
initial diagnostic formulations and treatment
interventions, 251
investigative and treatment plan, 247-248
physical examination, 251
skills exercises, 253
~arizing,235-237

disease story, 236-237
personal story, 236
relationship story, 235-236
Stress, 125
Substance use, 121-122
Summarizing, paraphrasing, 19
Supporting,26
Surgical, medical, or psychological problems,
112
Symptom-defining skills, 71-87
characterizing symptoms, 77-86. See also
Characterizing symptoms
distinguishing closely related material (secondary
data) from symptoms (primary data), 75
knowledge exercises, 87
overview, 71-72,86-87

320

Index

Symptom-defining skills (continued)
review of symptoms (ROS), 72-75, 73t-75t
skills exercises, 87
translating concerns into specific medical
symptoms, 76-77, 76t
Symptoms, characterizing, 77-86
onset and chronology, 78-81
duration of symptom, 79
periodicity and frequency, 79-80
position of symptom and its radiation,
81-82
quality of symptom, 82
quantify the symptom, 82-84
rate of onset, 79
time course, 80-81
time of symptom onset and intervals between
occurrences, 79
overview, 77-78t
precipitating and transforming factors, 86
related symptoms, 84-85
setting, 85

T
Taking notes, 200
Three-word recall, 306

Time required for interview, 199
Translating concerns into specific medical
symptoms, 76-77, 76t

u
Understanding, 25-26
assessing, 146
Unemotional/stoic patient, 183-185
Unique issues for the new learner, 199-202
clinical conduct, 200-202, 201t
recording interviews, 200
taking notes, 200
time required for interview, 199

v
Vignette (Ms. Jones), complete write-up of initial
evaluation
293-301
Violence/abuse, 124-125

w
Weed, Lawrence, 255
Welcoming/greeting the patient, 36-37
Wheat, 120
Women's health history, 113-114