Smith’s Patient Centered Interviewing An Evidence-Based Method by Auguste H. Fortin, Francesca C. Dwamena, Richard M. Frankel, Robert C Smith (z-lib.org) copy.pdf

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 w...

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 responsi- bility. 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, man- aging, 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 topsy- chosocial 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 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 biomedi- cal model was "no longer adequate for the scientific tasks and social respon- sibilities" 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 edi- tion 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 organ- elle to the largest community and culture and can be profoundly affected by changes in any of these systems. Unlike the biomedical the biopsy- chosocial 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 anxi- ety 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 vary- ing degrees. Some stoic patients can have serious disease but exhibit little illness behavior, while other more demonstrative patients may have little bio- logic disease yet be incapacitated. These are important distinctions relevant to daily clinical work, since patients come to clinicians with their illness expe- riences 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 biotechnol- ogy; we heal illnesses mainly through our words and the therapeutic relation- ships 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 dis- ease, 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 long- term 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 edu- cate 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  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 diagno- sis. Closed-ended questions also made the interview feel more like an inter- rogation. 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 relation- ship 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 devel- oped 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 conversa- tion. 17 This means the patient's ideas, concerns, and expectations, rather than the clinician's, are drawn out. The clinical benefits of this theoretical improve- ment 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 description- the 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' satis- faction 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 men- tioned may not be the most important one to the patient (or to the clini- cian) 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 addi- tional 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 inter- viewing 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 tell- ing 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 cathar- sis-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 men- tions something (such as being unable to do work duties and feeling wor- ried 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 psychologi- cal 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 Set the I! eg In n In g Set the Stage Agenda (Patient- Centered Skills) 9911nlcian-Cento9 9 Middle Skills) centered Pallent- Physical Exam End cenlerad Steps: 1, 2, 3,4,5, 6, 7, 8, 9, 10, 11 Components: [CC, HPI--- -- HPVOAP, PMH, SH, FH, ROS] Beginning: Patient-Centered = Middle: Clinician-Centered = Psychosocial and Symptom and Symptom Data 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 lon- ger. 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 com- ponents of the history are included: chief concern (CC), history of present ill- ness (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 pre- viously 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 per- sonal 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 health- promoting behaviors, health hazards, routine personal data, relevant ethical- social-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 avail- able. The CC and initial portions of HPI/OAP are developed in the begin- ning of the interview using patient-centered interviewing skills while in the middle of the interview the latter portions of the HPI/OAP and the remain- der 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 patient- centered 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 impor- tant psychosocial information. In contrast, the clinician-centered inter- viewing 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, ter- tiary 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 func- tions 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 edu- cation, is covered in Chapter 6. Chapters 7 to 9 will address advanced inter- viewing 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 web- based 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 interview- ing module presented in this book. 26 We have identified the general interviewing process, its content, and func- tions, 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. clinician-centered interviewing. See 2. Define the biopsychosocial model, Appendix B. patient-centered interviewing, and clinician- 7. Draw the full diagram of the interview and centered interviewing. How are they label the following: beginning, middle, related? physical examination, and end; CC and 3. Give examples of some patient needs that HPI/OAP, PMH, SH, FH, ROS. can be overlooked with isolated clinician- 8. What do each of the components of the centered interviewing. interview listed in question #7 contribute? 4. Under what circumstances would you not 9. Where does important disease informa- begin an interaction with a patient-centered tion first arise in the interview? Would you approach? expect personal and psychosocial infor- 5. Describe three problems encoun- mation to arise in the clinician-centered tered with isolated clinician-centered process? interviewing. 10. How do you think the interviewer might feel 6. List the benefits from integrating patient- in an isolated clinician-centered interview centered and clinician-centered interview- compared to an interview integrating ing that make this more scientific and patient-centered with clinician-centered more humanistic, as compared to isolated processes? Why is that the case? REFERENCES 1. LoB. Resolving Ethical Dilemmas: A Guide for Clinicians. 3rd ed. Philadelphia, PA: Lip- pincott 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: Cam- bridge 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;90:265- 270. 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.