THE THREE DIMENSIONS OF A CLINICAL INTERVIEW

• Frederic W. Platt, MD• James Hardee, MD• Jim Binder, MD• Paul Haidet, MD

• AACH October 17, 2010

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The Problem

• Clinical Interviews seem too chaotic to describe in a rational fashion. Structures that have been useful in the past including a progression from open-ended inquiry towards closed ended, often labeled as “patient centered” vs. “doctor centered” do not seem to do justice to the complexity of the clinical conversations being described.

Even fragments of interviews are tough to classify.

Analysis of short segments can be difficult and confusing, much as longer interview transcripts

defy categorization.

Consider these scraps of clinical conversations:

Scrap #1

• Clinician: You have to quit smoking. If you continue you will have a twenty-fold increase in the likelihood of developing lung cancer.

• Patient: I know all that. But when I quit before, I was such a bear that all my friends at work told me to go back to smoking.

• WHAT’S GOING ON?

Scrap #2:

• Clinician: Do you have chest pain? Trouble breathing? Fever?

• Patient: No, no fever.

Scrap #3:

• Patient: I thought it might be West Nile Fever.

• Clinician: Sounds scary.

• Patient: It was. But then the big change was when I started sinking.

• Clinician: Sinking?

• Patient: Yes, I swim half a mile about three times a week. And Friday I couldn’t float. I sank.

Scrap #4:

• Clinician: Let’s get down to business; the nurse says your knees are bothering you.

• Patient: Well, yeah, but mostly …

• Clinician: (interrupting) Slip out of your trousers and we’ll take a look.

Finally Scrap #5:

• Clinician: You mentioned trouble in your knees.

• Patient: Yeah, my left knee, just when I walk downstairs or down a hill. It clicks and sometimes it hurts.

• Clinician: I see.

What is going on? How to analyze it?

• We find a three-dimensional analysis helpful. We can consider first our goals (“our” meaning both patient and clinician), then the topics of our scrutiny, and finally the tools we might use in our conversation.

Goals of the interview

• What does the patient want to achieve?

• What does the clinician want?

The patient’s goals

• Being heard and understood (common complaint: “My doctor doesn’t listen and doesn’t understand.”)

• Having our opinions and values counted.

• Having the clinical expertise of the doctor employed to ferret out diagnoses and pick treatments that will alleviate our suffering.

• What else?

The clinician’s goals.

• 1. Rapport and trust building; creating a working relationship.

• 2. Data retrieval. Understanding the patient’s symptoms, saga of medical care, and feelings, ideas, and values.

• 3. Forward moving steps: Patient education, behavior modification; enlisting the patient in his own health behavior; Involving and recruiting others; Future medical attention. J. Bird, S. Cohen Cole 1990

The Clinician’s goals: another model

• 1. Fostering the relationship

• 2. Gathering data

• 3. Providing information (education, informed consent.)

• 4. Decision making.

• 5. Behavior modification.

• 6. Responding to the patient’s values, ideas, and emotions.

– De Haas and Bensing 2009

The data base

• What are we interested in? What do we include in a thorough data base? Is there room for the person of the patient?

Topics for our scrutiny.

• Who is this patient? The person of the patient. Work, activities, relationships.

• Key symptoms and their development.

• Other current active medical problems: symptoms, history, treatments.

• Social situation and relationship issues.

• Health related behaviors: alcohol, tobacco, drugs, allergies auto behavior, family and other violence.

Topics to attend to (Continued)

• Health promotion activities: medical screening, exercise, diet pattern, …

• Mental state and personality.• Past medical history and events.• Review of systems.• Ideas and concerns. Explanatory model.• Current feelings and underlying values.

The clinician’s tools

• What really goes on?

• What does the clinician say and do? We must not get trapped in considering only what the clinician SHOULD say or do. This is descriptive, not prescriptive.

The Clinician’s conversational tools and techniques.

• Closed questions, answerable with a “yes,” a “no,” or a number.

• Invitations to tell a story.

• Listening, accompanied by non-verbal attention evidence.

• Listening while focus is elsewhere.

• Arguing.

• Urging specific behaviors or changes in behavior.

Clinician’s conversational tools. (continuted)

• Reception devices: “I see,” “OK,” “Gosh!,” “Wow!,” “Sounds good,” “That’s awful,” …

• Silence.• Nonverbal behaviors including eye-contact

or its lack, touch, nods, head shakes, body posture, and wordless sounds. (hmmm, ah, …)

• Disregard• Facilitation.

Clinician’s conversational tools (continued)

• Summarization, echo, reflection, empathy• Gentle commands• Harsh orders• Requests for permission to enter a tender

subject or explain.• Warnings and threats.• Promises• …

Fragment analysis in three dimensions:

• Case 1: Doctor’s tools: warning, even threatening.

• Topic: patient’s cigarette smoking, an item from “Harmful Behaviors.”

• Clinician’s goal: behavior change. Patient’s goal: maintain productive relationships with his social network. (n.b. “denial” = difference in cost-benefit analysis.)

Case #2:

• Clinician tool: series of narrow-ended questions (most pervasive in our observed interviews).

• Topic: current symptoms.• Goal: data acquisition. Patient’s goal

invisible and likely given up already.

Case #3:

• Topic: patient’s symptoms and ideas (EM)• Clinician’s goal: data retrieval but includes

patient ideas as well as symptoms.• Patient’s goal: to voice her own ideas and tell

her story and be heard and understood.• Clinician’s technique: empathic response; open-

ended inquiry. Curiosity and a willingness to hear.

Case #4 and #5

• Clinician’s tool: appears to be an invitation but then focuses on a second-hand datum. Disregard of patient’s effort to clarify.

• Target topic: symptom and location.

• In case #5 the clinician gently returns the patient to a previously mentioned symptom and gets further patient clarification.

Consider two Emergency Department conversations:

• #6.• Clinician: I’m Dr. Jones. What seems to

be the trouble? What brings you to us today? (This doctor did not look at his patient, did not offer a handshake, and seemed focused on the chart.)

• Patient: I think I might have that H1N1 flu.• Clinician: Why do you think that?• Patient: Mostly it’s my wife’s idea.

#7. A different beginning.

• Clinician: (sitting down facing the patient and offering a handshake) Hello, I’m Dr. Jones. Are you Mr. January?

• Patient: Yes, that’s me, doctor.

• Clinician: OK, well how about starting by telling me a little about yourself and what sort of trouble you’ve been having.

More?

• Patient: OK, doctor. I’m Jim January. I’m a plumber but I haven’t been working for a week because of this cough and the fever I’ve got. My wife thinks I might have that H1N1 flu.

• Clinician: I see. Cough and fever. And what else?

Another approach to patient #1?

• Clinician: I know we’ve talked about your breathing trouble and your cough but now I wonder if we might talk some about your smoking.

• Patient: I know, doc, it’s part of the problem. I watched that 20-20 program about cigarettes and I don’t want to end up with lung cancer.

• Clinician: So tell me more about the smoking.

Case #1a. Continued.

• Patient: I’ve been doing it since I was 15. I smoke about a pack a day and I’ve tried to quit a couple of times but I get so cross and irritable that people tell me to go back to smoking.

• Clinician: So you’ve tried to quit but it didn’t stick.

• Patient: Exactly!

What of multiple interviewees? e.g. Pediatrics or Geriatrics.

• Invitations may work well with parents. Less effectively with young patients who may limit their responses.

• Consider offering the patient a chance to talk when he/she is ready.

What works best?

• Avoid rapport-diminishing techniques.

• The trap of closed questions.

• Somewhere in there, discover the person of the patient.

• Three dimensions to consider: goals, topics, and techniques.

• Time provides a fourth dimension. Relationships stretch over time.

Thanks, now tell us:

• What other goals, topics, techniques fit in with your work?

• What works best for you?

• What further dimensions need to be considered?

• What else?