;; .

Communicating
with Patients

Peter B. Zeldow & Gregory Makoul

not just a collection of malfunctioning organ systems. This

point deserves close consideration beca use it is often over-
looked in everyday clinical practice. When people become
patients, they enter a world in which their sense of control
is threatened. Not orily can perceived control be dirnin-
ished by the illnesses that cause patients to seek help, but
oppórtunities to regain control can be limited by the con-
.. sultation itself. This is especially true ifphysicians view pa-
tients as cases to be treated, not people to .be helped. Cases
require no information, no explanation, no choice. How-
ever, pecple dd, beca use information, explanaticn, and
choice enhance the sense of perceived control. In: other
words, withregard to the corisultation, patients can maín-.
tain control by obtaining inforrnation about their situation
Longstanding notions of cornmunication as bedside rnan- . ...and participating in decisions about. treatrrient. .
nÚ.or history taking have given way to viewingcommurii~· . ·Obviously the nature of an inteTvi~w depends ori the
cation as a fundamentalclinical skiil that is vital to both setting and ón the relationship berween thephysician and
patient well-being and to diagnostic and therapeutic suc~. patient, A delirious patient In anernergency room cannot
cess. This is the case thtoughout the continuum of medical engage in the kind of. dialogue possible during an office
school.résidency, andclinical practice. In fact, the Accred- visir with a patient who has chroriic- heart disease. Inter-
itation Council forGraduate Medical Education, which . views with children and adolescents alsorequíre modifica-
óversees U.S. residency prograrns.and the Am~rican BOard . tions in technique. Of course, an initial diagnostic inter-
.of Medica! Specialties, the umbrella organization for spe- view has differeri.t objectives trian a follow-up appointment
. cialty boards that certify physicians, have designated that· designed to provide ernotional support; rnanage medica-
interpersonal and coinmuni¿ation skíllsihatresult in effective tiori.or discuss lifestyle. Reading about interviewing is only
injar mation exchange and téaming with patients, tlietr [am- a first step toward becorning a cornpetent interviewer: su-
ilies, and othei health projessionals are a core afea of compe- pervised practice is also irnportant, Simply conduciing
tency [or áll physiáans. _ . many interviews does not improve technique, but anly cans- .
. Effectivecommuriication has be en linked to increases in olidates preexisting habits. Observation, feedback, and self-
physician arrd patient satisfaction, adherence to treatment r~flection are keys to more effective interviewing skills. Vid-
plans, more appropriate medical decisions, better health eotaped interviews with real or simulated patients provide
outcornes, and decreased incidence of rnalpractice suits. incontestable evidence of verbal and nonverbal strengths
Moreover, good interviewing skills can enrich the practice and weaknesses as an interviewer. Reviewing such tapes,
of medicine over the course of a lifetime, ensuring that the particularly with supervisors, can have a profourid effect
patient is treated as a living, breathing, feeling human, and on developing skills.
 202
r~_·_··:
....
:.:·:-:~7-7.~··~':·;-~~·~...,..·,·
-.- - "-.
¡: An ~igh,ty'fou~·yeari)ld wornan living in Maine has never had a
t complete medica] exarn, Her kids insist that she go to the doctor,
~, and although sbe's n.ever been sick, shegoes. She's ~ot.a very so- '
'phistkated woma'n, an,d theyoung dOcto~is amazed she's in such
'~G::;-/i._· ,>~
,goodsháp~it~ú</::'" . :i, ~';~~:::, ~'~::,:;L:::~,~...
r Aftér the EX9m he tells her, 'Everything seerns to be in good order,:
¡ ~but there are ádditional tests l'd like to runo Corneback next week
¡ and b~ing>a specimen.~ ~:: <.
-r '; .. ., ., " " •... ~:
í Th~ biéi,wOrD',frid'óesn't know what he IS talkingabout. .
!'.'.He say:~::Y{h~n ~eed is a ~.rinary5ample.Would you bring that in
!' and we'!! ruñ 'sorne additional tests:', She sti!! doesn't understa nd.
, The'd'~'ct~f:'sayt"Before you comein, VD id in ajar." The woman
, responds quizzically, ·Whatr . ',' "
The doctorfinally gets exasperated and says, "Look, lady, go piss in
a pcil'"Shégets r~d in the face, smacks him over the head with her
pocketbook, replies, •And you go shit in your hat," and promptly
walks out" ";;::,"; :¡ •
'. :,'
. . ~" ..:; "
RICHARD S. WURMAN
InformotionAnxiety
THE PATIENT
The first' thing to rernernber about the patient is that he or
she is anxíous, This may or may not be apparent but can
safelybe assumed to be true for several reasoris. The patient
is ill or subjectively distressed and may have already devel-
, oped theories about what is actually wrong: The possibility
of havingdisease evokes fear ofdeath and disability, fearof
bodilyharrn, and fear of separation from loved ones (e.g.,
through hospitalization). In addition, physicians often in-
" timidate patients, No matter how kind and eager to help the
physician may. be, the patient's 'reaction ro the physician's
presence cannot be controUed. Patients expect great things
, ,
from their physician and feel a strong sense of dependence
on the physician to meet their physical and emotional needs.
It is critical for the physician to realize that these anxieties
can complicare the interview, making it difficult té elicit in-
fo~mation andessential to check that the inforrnation pro-
vided to patients was heard and understood as in tended.
The physician cannot simply ask questions and assurne that
the desired answers will be returned. Patien t anxiety and the
emotion-laden nature of the physician-patientrelationshipfor
the patient require putting the patient at ease, establishing a
trustingrelationship, and monitoring the words spoken and the
phraseology of questions. '
A second important point is that patients and physicians
have different agendas during the interview. Typically pa-
tients are seeking relief from subjective complaints (syrnp-
toms) and speak the language of illness. Physicians are
seeking to elicit the objective signs that aid in diagnosis and
speak the language of d isea se. Although the physician
Part 4: Physician·Patient lnterartions
might prefer that the patierit present his or her complaint
and history in precisely the sequence required for write-up,
this rarely happeris and need not be encouraged. With in-
creased experience, the interviewer gradualIy becomes
more comfortable taking the naturally ernitted, occasion-
álly vague and disorganized words of the 'patient and
transforming them into a cornprehensive, meaningful, and
orderly medical history. While this medical history wil! be
'
useful for the health-care tearn, team members need to
subsequently translate clinical information and options in-
to terms that patients and families can understand.
THE PHYSICIAN
The role of the physician entitles him or her to inquire into
private and intima te details of the patient's life and to con-
duct a physical examination on a relative stranger. It also
obliges the physician to be professionally cornpctent, to put
the patient's interests ahead of personal interests, and ro
provide help and comfort whenever possibJe.
Although the prirnary purpose of the interview from the
physician's perspective may be diagnostic, an interview can
and should also be therapeuticfor the patient.Depending on
the physician's conduct, the patient can potentially come
away from every physician encounter feeling better under-
stocd, better informed, and reassured of thephysician's in- ,
terest and availability. Alternatively, he or she can come
away feeling rnisunderstood, confused, and alieriated.
The following vignette exemplifies an exchange with lit- .
tle therapeutic content:
The interviewer failed to knock at the patient's door. He
introduced himselfin a hastymumble so that the patient : ,
never had his name clearly in rnind.He mispronounced the
patient's name once and never. used it again, The physician
, conducted the interview while seat~d in a chair about 7 feet
from the patient. There was no physical contact dur ing the
interview, On severa! occasions the patient expressed her
ernotional distress. On each occasion the interviewer ig-
nored the emotional content of her staterne nts:
Doctor: Exactly where is this pain?
Patient: It's so hard for me to explain. I'rn tryin~ to do
as well as 1 can. (Turning to husband:) Areri't 1 doing as
well as 1 can?
Doctor: Wel!, is the pain up hi.gh in your belly, or down
low? (Platt & McMath, 1979.)
Severa] aspects of this vignette are worthy of comment. The
failure to knock and te learn the patierit's name and the
hasty introduction indicate a neglect of the most basic
amenities. The physicaí distance between physician and pa-
tient may also h ave been excessive, paralleting the emotiono!
distance created by the physician's [ailure to pursue the en70-
.' . Ch~pter 16.: Communicating with Patients 203

· The Wisdom of OLlVERWENDELLHOlJ/¡ES, 1809---1894

US humorist and physician .- : . .: -
~J_. • ;:~. ';:'

~-:;
Med(cal Es50Y5:' . ~: '
'.'fu e: 0F uL <f'
The~uth is, t~\medicine, professedlyfound on observation, i~~~:s .' ;: SJ...L i..JaJ6.J.· ~oLuarcL,;. -Hu. w~',:t~!.j s;;:;'.}.. '
· sensitive to outside influenres, political, religious, philosophkál ' SJ.v_ ~.}_
imaginative, as is the barometer to the changes of atmospheric ".Her ka:v<cL,; w;u;Ud.·· iv< lw- ~af'
density. .. . .
. 54~ aoob.J.. ker f'lAj~S ~o C.OIAual.~~ lAi~tilA~
.$tajv..~ a.lAcL biHw. lA~jts_ .,.'
A m~nof very modérate ábility may be el good physician if herle-
.votes himselffaithfully to his work. SJ.v_ c.~d. ~~ iv<~U S¡c1.t.. lw- Jo~er of ~ir- .
SJ.v_ ·f~6.J..~t -Hu. 'Ja5f ci(kU ~~.Jb~;J,::.f:
;', .;"".', : ':' ~'. .': ',"':, " . -: r -."

The ~~st esserÍtial part 6f a student's instructi~n is obtained, as l'

:::":;:.'
l b~' 'o.
.. :-:.'.-"'~'
.su:
-sk¿' '$,o.i-d.._ ':,~ -
. ':' .~'.' <-'-_' - -
.Ó, ~'.:. - • •

believe, not in the ledure room, but at the bedside. . .:: b.úJ ~.: t.(v;·?5F6..·,~lAok JalA~j~;

I woúld never use a long' ~ord wh'~re a short ~n~would answerih~ .

purpose. I know there are professórs in this country who "liga te" .,
. arteries.Othersurgeons only tiethern, and ít'stops the bleeding ',;

;,~~~!~,~:\t~~k.i~' ·,:·" "•t..~~F:.;t.~

:;!l~;,:.t~0~;~'~}":
:~;:,~!;~.- .....- . :;';:,iyj
ei:~tayst;;; true (~,~;t\:tme~I~¿
::T~e;,{gf~ t~a[h::.: . '{lt;:l.
})Specla.F~~d.kno~ledgeY'.i!l do a rtiarí.~o harr:r1.ifhe also has c~iyj.~,:;j
x' mon s~(1se, but ifhe lack~ this, it canonly mgk,e him more danget~j

.r·.~us.f~~~l~:.~~.t:s~r:·•. ~::t#~~~.
~':~IT~_
:~.·~_:rt!t·._:__·.:, .: .:•.fJ~{1J
tional content of the patient's statement. Most of all, notice
the physician's insistence on eJiciting the site of the pain.
This is certainly a necessary aspect of the"int~rview;bt1t at '_ . ,-,,'
... ":¡~'-:. .
this moment the patient is incapable of answering. If the
physieian had been more willí"ng to explore the patient's dif- ',' ~
~,;
..••".
::,"

. :', ~;~-: :
.' [iculty' in explaíning, he might have learned sOliiething of crit-.
", .
ieal importance about the symptom nnd about the patient. . :.•..

The patient would be more likely to experience the physi-

·cían as a person who has patience.and pays attention, which '.-' . . '. ' .

c~uld only enhance ,the patient's futureconfidence in the . THE5ETTING

ability to describe her syrriptoms. Instead, the physician has
learn~d verylittle, and the patient is no better off than be- The setting for an interview can either facilitate or inhibir
· fore this exchange ..These are the consequences when a phy- . the spontaneous and open transrnission iriforrriation. .9f
sician is narrowly devoted to elicitirig disease-related infor- Privaey, comfort,and sLlffieient time are th~ee desircible as~
rnation at the expense oflearning abolir the patient who . pects ofsetting that may be difficu/t to a¿hi~~e, In a hospital
hosts the disease. . setting, privacy is threatened by the presence of roommates
· Physician anxiety ean also be a~ obstacle to effecti¡'e inte~- .and by the intrusions of visitors and other health-care pro-
viewing. (and. rnay have played a role in the vignette). Al- fessicnals. In a busy outpatient cllnic an interview conduc-
· though anxi ety on the part of the patient should always be ted in a cubicle may be hampered by lirnited privacy, phys-
assumed, sornehow a clinical encounter is supposed to be ical discornfort (including extraneous noise), and time lim-
a routine and entirely rational interaction for the physician. . itations. These factors are not cornpletely under the
This is simply not trueInsecuriry with the role of a physi- physician's control. However, being aviare of their potential
cian, discomfort with sud den access to the bodies of pa- to affect the interview, the physician should exercise con-
tients, concer ns about age and sex differences; and anxiety trol when possible. For example, if the interview is being
about exploring certain topics may be perfectly natural at conducted in an austere office with-uncornfortable chairs,
early stages of professionaJ development. The danger arises the physician can briefly acknowledge the problem and at
when such anxieties lead the physician to avoid ask.ing nec- least offer the more comfortable of the two chairs to the
essary questions or pursuing important leads. patient. If the problem is a noxious level of noise, it may
204 Part 4: Physician'Patient Inte'ractions '

...... _ - -- ..... :'._. -- .... - .... ~-,,":-- ~....• ,._- _-'.~ -

.. .. -;_ ....
. ..-.~
-.'~.....-.-_.'--::'
~:' ~.:~.)\:":/';:~' -::'"f:.~'~;.~/f..~
..~r.,:.:~~~ _;';'::i4 ::/~:~ •• ~ -'-.:~:' ':~ -: ,,:-. ," .~::" : .-'" • :" -.

The sad truth is that·o~/Úlli·i~n·~6Ilar'med\éal care system seems Touching with the naked ear was ene of the great advances in the
f
to feel that time spent.witn p~tYé~ts \{a I~~'ury it~imply. ~an:t af- history of medicine. Once it was learned that the heart and lungs
rnade sounds of their own, and that the sounds were sometimes

fO~::;s:~I~~!G;ii~J~i~~c_
.!

. useful for diagnosis. physkians placed an ear over the heart, and
over areas on the front and back oíthe chest, and listened. tt is hard
i to imagine a friendlier hurnan gesture. á more intirnate signal of
personal concern and affection, than these dese bowed heads af-
fixed to the skin. ' '
have to be endured, but perhaps the effort to give the pa- lEWI$ THOMAS··
tient undivided attention can be doubled and freedom House Ca115,
from other intrusions can be províded. Prívacy and com-
fort are important, but the physicían can compensate for
their absence with a cornbination of consideration and at-
tentive listening.
THE SEGUE FRAMEWORK:
A physician's time is valuable. In sorne practices, finan-
cial success is ptedicated on a policy oflimítíng office visits INTEGRATING CO'MMUNICATION
to 12 minutes. It is difficult to believe that the needs of ANO CLlNICAL TASKS
patients can be handled adequately when physicians are en-
couraged to focus en, the clock. However rushed the physi- At this point, it is important to provide a very tangible
.cian may feel and whatever the reason, he ot she must. be sense ofhow effective communication can be integrated
aware that the sense oj time urgency is antithetical to profes- into clinical work. The SEGUE Fr arriework, a research-
sional obligations. Patients know when they are being hur- based checklist developed by one of us (GM), has become
ried along and can recognize when the practitioner's mind the most widely used model for teaching and assessing
is not entirely on them. Some react with resentrnent and communication skills in North America. In addition te
others react by trying to extricate the physician frorn the serving as a reminder of the general áreas on which to focus
situatíon. This may take the form of omitting critical sym- (i.e., Set the Stage, Elicit Information, Give Information,
ptorns from their staternent of the problem, failing to ask Understand the Patient's Perspective, End the Encounter ),
questions that could clarify an instruction, or canceling a the SEGUEacronym connotes the transition or flow of the
futüre'appointment out of a genuine, albeit somewhat 'medical encounter: frorn beginrring to end, and from prob-
masochistic, desire not to overburden the physician. Nene lems to solutioris. The SEGUE Framework provides a com-
of. these reactioris is acceptable, and all can be avoided if mon vccáb ular y for teaching, learning, assessing,' and
the Type A impatience and irritability that medical envi- studying communication in medical ericounters.
ronrnents often irnpose is controlled. While the physician The checklist highlights a set of essential cornmunicatiori
is with the patient, full attention and unhurried participa- tasks (i.e., things that are irnportant.to do during a rnedical
tiorr in the interview rnust be practiced. Having command encounter). Since the tasks thernselvescan be accornplished
of the interviewing rechniques to be discussed helps make in a varieryof ways, it is irnportant to develcp a repertoire of
efficient use ofthe time spent with patients. communication skills and strategies that will workfor )'OLl
ThÉ: best intetview is a colloborative process between two and your patients. Thís built-in flexibiJity with resped to the
people ofequal status, no matter how different theirroles. It is skills and str ategies required to accomplish relevant tasks re-
better not ro si t behind a desk during an interview beca use ,flects the reaJity and individuality ofh uman communicatiOn.
the desk irnposes a barrier between the participants that is "In other words, SEC UE offers a flexible [ramework; not a script.
both real and syrnbolic. Similarly, it is better to sit at the sarne . ''''hile things might not progress in the order presented, the .
leve! as the patient rather than to stand, which makes the brief explanations and exarnples offered below are intended
patient feel dominated. Finally, interviewing a patient who to provide a better understanding of each SEGUE task.
is unclothed, partiaUy dressed, or dressed in a hospital gown
contributes to the patierit's sense of unequal status. It is usu-
ally best to keep the interview portio n of an examination •.'
sepárate from the physical exarnination as another mean s of Set the Stage (S)
emphasizing equal status. It may sound paradoxical, but tlie
more a patient petceives himsel] or herselfto be aneoua! parr- 1. Creet the patient appropriately.
ner in this health-care venture, the more likely he orshe will be
to accept the ph)'sicia 11 's infltlence. Along these lines, it is use- The key is to decide upfront what "appropriately" mean5,
fuI to recognize that you rnay be the relative expert in terms and then stick to that definition. Here are exarnples of the
of medicine, but patients are the.experts on their lives. criteria for this task:
 Chapter 16:.Communicating with Patients 205
'Jf you and, the patient have not met
Elicit Information (E)
You should confirrn (i.e., ask or say) the patierit's name and
6. Elicit the patient's view of heauh problem andlor progress.
introduce yourself using your first and last name. For in-
stance, if Dr. Robert Franklin is meeting Ms. Jane Srnith, it
Since patients have their own ideas about health and their
is often better to walk into the room and say: "Iane Smith?
own hypotheses about what might be causing and/or ex-
Hi, I'rn Dr. Bob Franklin," rather than assuming that she
acerbating a health problern, it is important to elicit their
prefers to be called [arre. A medical student or resident
perspectives.
should provide both his/her na me and role (e.g., "I'rn Ellie
You can accomplish this task by asking the patient an
Brown, a first-year medical student working with Dr.
open-e nded question such as "Can you tell me how you're
Franklin.").
doing?," "How have things been going?," or "How are you
doing now that you've started the treatment?" The patien t's
Jf you and the patient hove 'met previousiy ideas, worr ies, and concerns can often be elicited if you re-
main silent after asking the "What brought you in today?"
Yoú should acknowledge this in greeting ("Hi Ms. Srnith; question.
good to see you again" or "1 don't know if you remember
me from last time; I'rn Dr. Ianet Iones, a resident working 7. Explore physieal/physiological factors.
with Dr. Franklin.").
· You can accornplish this task by asking about signs or syrn-
2. Establish the reason for the visito ptoms regarding the health problern (e.g., duratíon, loca-
· tion, intensity, etc.).
You can accomplish this task in a number of ways by asking
such questions as: "What brings you in today?," "What can 8. Explore psychosociat/emotional [actots (e.g., living situa-
1 do for you todayi," or "So this is your 6-month recheck?" tion, family relations, stress, woik).

The key here is learning about relevant factors in the pi-

3. Qutline an agenda for the visit (e.g., iS511es,sequence).
tient's life that might influence his or her health problem
and health status.
Oftentirnes, the patient has different pr.iorities than you do.
The key to chis task is to ask the paiient ¡fthere is anything
· 9. Discuss antecedent treatments (e.g., self-eare, lastvisit, oth-
he or she would like to discuss beyond the stated reason for 'er medical care).
tlie visit ("Anything else?"), This negotiation should occur
before you begin exploring specific issues in detail. Provid-
The point of.this task is to find out what the patient has
ing an outline ofhow the encounter will flow is also helpful.
done for the health problern before eoming to see you for
Outlining an agenda lets both parties know that their issues
this visi t.
will be addressed. . .
. .

10. Discuss how the health problem affec~5 the pntiimt's lijé '.,
4. Make a personal connection during visit (e:g., go beyond · (e.g., quality oflife). ..
niedicalissues at hand}. . . ,. .

Quality of life is subjective and is bestas);essed bydiseus- .

This task focuses on treating/acknowledging the patient as sion. Here, instead of exploring how thepatient's life affects
a persono While it is probably best if this happens early in the health problem, you are trying to lé'arn how the health .
the visit.It can occur at anytime during the visit, as long as problem affects the palien t's Efe. This task ean be accorn- .
ir is sincere. This is something patients notice, and appre- plished by asking general questions like "How has the
ciate. Exarnple: problem affected your life?," "How has this affected your
daily lifei," "Tell me about a typical day," "Is this préventing .
Patient: "I'rn incollege"
you from doing things you like to do?," or more specific .
Doctor: "Oh, what are you studying?"
questions (e.g., about activities of daily living).

~ 5. Maintain the patient's privacy (e.g., knock; close door). 11. Discuss lifestyle issues/prevention strategies (e.g., health
risks)
Self-explanatory: Ifthere is no door, you can maintain the
I
patient's privacy by standing or sitting nearby. This is also The idea here is that you identify health risks, as wel! as the
a consideration in physical exam situations (e.g., draping). extent to whieh the patient is managing them. Diet, exer-
 '" .
206 Part 4 Physician·Patient ínteractions
'.¡-

cise.ialcohol or drug use, smoking, and safe sex are exam- that you ask the patient to be more specific about vague
pIes' of the topics that could be discussed. This task is often information. Example:
facilitated when you provide the patient with a preface such
Doctor: "How much do you smoke?"
as "I'rn going to ask sorne questions to get a better picture
Patient: "Not rnuch."
of your over all health."
Doctor: "How muchis not much?"

~ 12. Avoid directive/leading ouestions.

"You're not having chest pain, are you?" is an example of a

directive, or leading, questicn. this kind of question sorne-
times sounds like a statement ("No problems with your Give Information (G)
chest?"). The probiem wlth these questions is that they pllt
words in the patient's mouth, and it is often very difficu/t for
patients to correct their provider. Similarly, if a physician 16. Explain th e rat io nale for diagnostic procedures (e.g.,
exam, tests). '
asks a directive question about an uncomfortable topic
(e.g., "So, no drugs!"), patients might take the opportunity
to let the topic slide. Directive/Jeading questions are dis- You should Jet the patierit know why you are conducting
tinct frorn closed-ended questions like "When did it start?," procedures. Exarnples include: "I'rn going to listen to your
"15 the pain sharp, dull, burning, squeezing, or does it feel lungs" before using a stethoscope, "Let's check the range of
like something else?" that are very helpful when asked at motion in your leg" before moving a patienr's leg, and "1
appropriate junctures. think we should check for str ep" before swabbing the pa-
tient's th roa t.
~ 13. Give the patient the opportunity/time to ta/k (e.g.,
, don't intetr upt}. . 17. Teach patient about hi: ot her own body and situatiou
(e.g., provide feedback and explan ations].
We are ~Il familiar with explicit .interruptions and their ef-
fect on conversations. It is also important that you avoid The medicaJ encounter provides an excellent opportunity
"jurnping" on the patient's last word, which sometimes cuts for giving information that can help the patient learn about
patients off before they are reaIly finished talking. If pa- his or her body or situation. Youcan accornplish this task " '
tients go off on a tangent, try to let them know that )'0 u are by telIing the pátient what you found in a physical exam ,
interested, but need to focus on their main concerns. ("Yoú seern a bit weaker on this side") or laboratory test
("Your str e p test carne back negative-e-that means you
don't havestrep throat").You can also accomplish this task
~ 14. Listen: Give the patiel;r;;our undivided atten tion (e:g.,
. by explaining relevant anatomy'("The rotator cuff is really ,
face patient, give feedback). ' .
a set of muscles ... "J, the diagnosis ("It looks like you're
having tension headaches-they're often related to stress
As Sir William Osl~r said aboút 100 years ago: ;'Listen to
and it sounds as if your new job is pretty stressfuJ ... "), or
the patient, for he [or shejis telling you the diagnosis."
treatment CThis kind of antibiotic works en a wide var iety
Facirig the patient, gi'Í'ing verbal acknowledgment, and
of bacteria, but has a few side-effects ... ").
providing nonverbal feedbackIe.g., nodding, "uh huh") ,
are examples of ways you can show )'OU are paying atten-
tio n. 18. Encourage patient to ask questions/Check: his or her Lln-

derstanding.
Patients notice, and tend to become less forthcoming,
when a clinician is not facing thern, rarely looks up from
11 is useful to actively solicit questions from the patient
taking notes, is reading the chart while the patient is talk-
, ("Do )'ou have any questiorisi," "15 that clear?," or "Does
ing, or is otherwise distracted frórn what the patient is say-
that make sense?"). Th is is a very effective \Vay to check the
mg.
patient's understanding. NOTE: AskingTs there anything
else?" is not the same as encourazinz the patient to ask
" i:)
~ 15. Checklclar~6' information (e.g., recap, ask "How much questions.
isnot much?"}.

~ 19. Adap: to patient's level of understandino t=s- avoid

At issue her e. is the accuracy of information. Checking or explain jargon). '
means that you recap what the patient has said to ensur e
that you interpreted ir correctly ("OK, so swelling tends to Self-explanatory: There is no need to say "ambulare" when
be worse in the morning, is that right?"). Clarifying means you mean "walk."
 (hapter 16: Communicating with Patients 207

l)nderstand the Patient's Perspective (U) "Please make an appointment to come back In 6
months."
20. Acknowledge the p atient', accomplishments/pro- "You can get dressed now."
gress/challenges. "The nurse wil! be in to show you how to do that."
"Dori't forget to pick up your prescription at the phar-
At issue here is whether or not you respond to a patient's macy."
overt statement about something perceived as very positive
or very difficult, or toan expression of emotion. Your re-
sponse (or lack thereof) very clearly suggests to the patient
the degree to which you are listening and the extent to
If You Suggested a New or Modified
which you careo
TreatmentjPrevention Plan
21. Acknowledge waiting time.
26. Discuss the patient's interestlexpectation/goal for the
If the patient has been waiting (or will have to wait) for a
plan.
long period of time, you can accomplish this task by letting
the patient know that you are aware of the wait. Does the patient see and/or agree with the need for this
p~n? .
~ 22. Express caring, concern, empathy.
27. lnvolve the patient in deciding upon a plan (e.g., options,
The focus here is on attention to the patierit's subjective
tationale, values, preferences, concerns).
experience. You can accomplish this task by letting the pa-
tient know that you understand= or at least appreci- Not al! patients want to be involved in decision making,
ate-the patient's perspective. This can be accomplished but all should be involved to the extent they are comfort-
either verbally or nonverbally; the key is to respondo Pa- able. In addition to providing options and discussing ra-·
tients tend to become less forthcorning when you appear tionale, it is especially important to explore the patient's
detached, aloof. or overly businesslike. values, preferences, and concerns.

~ 23. Maintain a respectfu! tone. 28. Explain likely benefits of tne option (s) discussed.
Whether or not you agree with or like the patient, it is rnost Do the specific benefits relate to the goal for this plan?
inappropriate and unprofessional to be condescending, pa-
tron izing, or rude. 29. Explain likely side-effects and risks of the optionis¡ dis-
cussed.· '.

In addition tb providing the information, let the parient

End the Encounter (E) know what to do if he or she exper iences a pr oblern ..

24. Ask if tliere isanything elsepatien t would like to discuss. 30 ..Provide complete instructions for {he plan.

Sometimes patients feelthey need permission to bring up Make sure that the patient understands your instructions.
:~:~.
issues beyorid the: "ch ief co ncer n" or the main reason .

they've been hospitalized. Even if you do this as part of" 31. DisCLlSSthe patient's ability to [oüow :t"heplan (e.g., atti-
. outlining the agenda toward the beginning of the encoun- tude, time, resources). ."
ter, you should explicitly ask the patient about this at the This is an essential, and often neglectéd, component of the
end of the encounter as well. In order for the patient to feel process. A patient is unlikely to follow-or even start-a
that it is actually perrnissible to raise another issue, you treatrnent plan unless he or she thinks it is do-able. At the
should ask this question before getting up to leave. If time same time, many patients are unlikely to spontaneously of-
is a factor-'--'-and it often is-you can always suggest discuss-
fer their views on this subject.
ing new issues that com~. up in a subsequerit visit. .
32. Discuss the importance of the patient's role in treat-
25. Review next steps with patient.
men t/preven tion.
You can accomplish this task by saying either what you will
It certainly helps if patients understand that they are part-
do for the patient or what the patient should do once the
ners in the process. Talk about what they can do to facili~ate
visir is over. Exarnples inelude:
improvement (e.g., monitoring details of ·their situarion
"1 will check on the test results for you." and letting you know how things progress).
208 Part 4: Physician-Patient Interactio~

Th-e SEGU E.Fra mework

Patient: _ Physician or Student: _

Set the Stage Ves No

1. Greet patient appropriately

2_ Establish reason for visit:

3. Outline agenda for visit (e.g., "anything elsei." issues, sequence)

4. Make a personal connection during visit (e.g., go beyond medical issues at hand)

-75. Maintain patient's privacy (e.g., dese door)

Elicit Information n/a Ves ~ ~o

6. Elicit patient's view of health problem and /or progress

7. Explore physical/ physiological factors

8. Explore psychosocialjemotional factors (e g., living situation, family relations, stress)

9. Discuss antecedent treatments [e.g., self-care, last visit, other medical carel

1Q. Discuss how ~ealth problem affects patient's lífe (e.g., quality-of-life)

11. Discuss lifestyle issues/prevention strategies (e.g., health risks)

:

~12 . Avoid directi~e/lead¡ng questions.

~ 13. .Give patient opportunity/time to talk (e.g, don't interrupt) ..

. .

-714 ... Listen. Give patient undivided attention (e.g., face patient, verbal acknowledgernent, nonverbal feedback)

-715: Check/ clarify inforrnation (e.g., recap, ask "how rnuch")

Give Information n/a Ves No

16. Explain rationale for diagnostic procedures [e.g., exam, tests)

.. I
17_ Teach patient about his/her own body & situation (e.g., provide feedback from exam/tests, explain rationale,
anatomy / diagnosis)
.:~~.
18. Encourage patient to ask questions/Check understanding .1.'4

J
_, 19. Adapt to patient's level of understanding (e.g.. avoid/explain jargon) . .

--- .

:
.
 Cha ptel 16~Communicating with Patients 209

The SEGUE Framework continued

Understand the Patient's Perspective n/a Ves No

20. Acknowledge patient's accomplishments/ progress / challenges

21. Acknowledge waiting time

-122. Express caring. concern, empathy

-123. Maintain a respectful'tone

End the Encounter Ves Nó

24. Ask if there is anything else patient would like to discuss

25. Review next steps with patient

Ifsuggested a new or modified treatment/ prevention plan: n/a Ves No!

26. Oiscuss patient's expertatícn/ goal for treatment/ prevention -

27. Involve patient in deciding upon a plan (e.g., options, rationale, values, preferences, concerns)

28. Explain likely benefits of the option(s) discussed

29. Explaln likely side-efferts and risks of the option(s) d¡scussed

30. . Provide cornplete instrurtions for plan

31. Discuss patient's ability to follow plan

..

32. Oiscuss importanre of patient's role in treatrnentj prevention ~.~

.. .

. Cornrnents.

lterns without an arrow focuS'on.cóntent; mark 'iYe~" if done ot leasi ane time during the encounter.
. . .. .
Items with an arrow (-1) focus on process and should be maintalned throughout the encounter; mark "No" if at least one relevant instance when
not done (e.g., just one use of jargon).
© 1993/2005 Gregory Thomas Makoul- AH Rights Réserved

210
SHARING INFORMATION
A primar)' purpose of the clinical interview is to share in-
formation, an activiry that takes two forms: (l) eliciting
information from patients to diagnose their condition and
understand them, and (2) providing patients with infor-
, ters with expensive medical technology. not all ofwhich is esse~tlal
mation such as diagnoses, prognoses, prescriptions, and
treatment recommendations. The interview also helps es-
tablish a positive relationship with the patient that can be
the foundation of the eventual therapeutic reJationship.
Informatíon about patient symptoms is necessary be-
fore a diagnosis is made, but it is not sufficient for effective
treatment. A broader aim of the interview is to under stand
the patient more fl/l/y and to develop hypotheses about per-
sonality, life experiences, assets and liabilities, and reactions
to illness. lf a physician cannot anticipate that a patient \\'111
have difficulty adher ing to a treatment regimen or will be
at risk to develop psychiatric complications, an accurate
diagnosis by itself hardly guarantees successful treatme nt.
A physician seeking diagnostic and psychosocial infor-
rnation from a patient should make every effort to elicit
informatian that is as [ull-bodied and spontaneous as pos-
I '.:. ;- ..•. :.
. he or she is trained to do-to
. The interviewing techniques discussed in this section forrn
Sorrow Vincent van Cogh (1882). Drawing, 38.5 x 29 cm. van Gogh Mu·
seu m Foundation, Amsterdam.
.,
Part 4: PhysirianPatient Interactions
Dortors don't get paid for talking to patients.ln a medical economy
dominated by third-party paymasters-insurance companies, the
government, health plans, etc. -the harsh reality is that doctors
get paid rnostly for tests and procedures.lt is not surprising, there-
fore, that patients should be subjected 10 a multitude of enco~n'
or without risk ... Even more serious, of course, is the reduced time
for the careful questioning by the physician that has he Id such a
high place in medical tradition.
NORMAN (OUSINS
Heod First: The Biofogy of Hope
síble. Patient descriptions that are full-bodied have a live
and organic qualiry to them that is unmistakable. The phy-
sician can sense the effort that has gone into making the
description accurate and elaborare. Patient descriptions
that lack this quality tend to be brief, flat, unidimensional,
and stereotyped, and they make it more difficul: to diag-
nose the condition or understand the patient. Sirnilarly,
spontaneity in patient verbalizations indica tes that the pa-
tient is speaking freely, without hesitancy and without ed-
itinzo his or her rernarks. This is the ideal to which an in-
tervie\~er should aspire beca use it means tha t the broadest
range of information is being elicited. Patients who edit
their responses to inquiries are withholding inforrnatiori
and depriving the physician of the opportunity to do what
separa te essential from irrel-
evant details. The creatio n of such full-bodied and spo nta-
neously offered information is a joint product of the phy-
sician and the patient. It inay be impossible to change a
pat ient's innate descriptive abilities, but it should also be
evident that how questions are posed and how the physician
listens profoundly inj7Lle/7ce the qua lit y of the inforl71atíon the
patíent provides. Information giving is the second way in
which inforrnation is shared dur ing a clinical interview; it
will. be considered in more detaillater in this chapter.
INTERVIEWINGTECHNIQUES:
FOCUS ON ELlCITING INFORMATION
a continuum of interviewer control. At one end ofthe spec-
trurn is the use of silence, which imposes minimal inter-
viewer control over the patient and affords the patient a
wide range of response alternatives. At the other end of the
spectrum is the kind of direct question that affords the pa-
tien t the opportunity to answer only yes or no. Both of these
tech iuoues have their place in the clinical interview (although
not at the begirming)
b ;:, , alonzo with facilitation, confronta-
tion, and a var iety of other c1ínical (0015. Because the phy-
 Chapter 16':Communicating with Patients
sician is seeking a full-bodied and spontaneous account of
the parient's difficulties, the best use of these techniques
often involves moving through a cycle of information seek-
ing that begins with modest control and proceeds to pro-
gressively greater use of authority. Whichever technique
you choose, the key to successful interviewing lies in re-
membering to listen to the information elicited.
Open-Ended Questions
Stai-ting the interview with 'questions such as "What brings
you in today?," "How are you?," "How can 1 help you?" and
"What kind of problerns have you be en having?" cornrnu-
nicate to the patient that he or she can begin anywhere,
without restriction. They also put the momentaryburden
of responsibility on the patient (which is perfectly appro-
priate), and they minimize bias. To begin an interviewwith
more specific or direct questions ("Tell me about your
headaches. ") restricts the field of discourse prematurely
and may suggest to the patient that other topics are inap-
propriate or not medically relevant.
Starting an intetview with an open-ended question facili-
tates the diagnostic process beca use the answer that the patient
chooses to give in response to the open-ended question has a · ed to get the patient to elaborate on his or her problems.
special significance. However, two observational studies in- .
dicate that few physicians give patients the opportunity to
make a complete opening statement of their concern. In on-
Iy about 25% of office visits studied did physicians allow
patients to complete their opening statement. Most of the ·stopped speaking to cailect his or her thoughts or to find
time, physicians interrupted and redirected patients to discuss . the rightword to describe a concern. Interruptions or in- .
the first concern expressed. As the authors of one of these
studies noted, physicians "frequently and perhaps unwit-
tingly inhibit or interrupt their patients' initial expression of
concerns."
Medical students sometimes justify their avoidance of
open-ended questiorís by claiming they take up too much
time; (Presumably the students are referring not to the . cian may deem it essential to pursue .whar the patient said.
questio ns thernselves but to the time patients take to an-
swer thern.) This is a rationalization based on a misun-
derstanding of interviewing technique and purpose. An
interview that employs open-ended questions is tising
those questicns to elicit a free flow of information in the
service of making a diagnosis and understanding the pa-
tient. It is the interviewer's responsibility to guide the pa-
tient's discourse ir needed. Open-ended questions are rec-
ommended because they are often the most effic'ient
rrieans to this end. However, physicians should not think
of an open-ended interview as one that ernploys open-
ended questions exclusively,
Students arrd physicians sometimes come away from an
interview in which they used open-ended questions but
were not impressed with their yield. However, an open-
ended question does not guarantee an elaborate answer; it
211
merely in creases its likelihood. Children, adolescents, and
even sorne adults may not be able to respond to such
questions with e labo rate accounts. For exarnple, SOrne
very literal-minded patients (as well as those with organic
mental disorders) respond to a question such as "What
brought you to the clinic?" with an answer such as "1
drove my Toyota." Physicians should not be discouraged
by their early efforts to use a new skill and should not be
seduced into asking only direct questions when sorne
open-ended questions fail.
Silence
[fa patient responds to an open-ended inouiry with a mini-
mal response, consider using silence to signal that you want
to hear more. Silence imposes minimal control on the pa-
· tient. It communicates to the tight-lipped patient that the
physician wants to hear more and is willing to wait. Sorne-
times patients are guarded in responding to open-erided
questions simply beca use they imagine that a brief ni-
sponse is required or because thathas been their experience
with physicians in the pasto An expectant and attentive si-
lence on the part of the interviewer is often al! that is need-
When a patient is talkirig in a full-bodiedand sporitane-
ous way, silence is the most appropriate response. When
the patient becomes silent, a brief silt~nce on the interview-
er's partis again appropriate, beca use the patient may have
terjections would likely be premature. The patient whose
pause signals the end of a train of thought aften turns his
or her gaze on the physician, indicating a willingness to give
him or her a chance to spéak, Whether the physiciarí de-
cides to do so or remain silent depends on his or her as-:
sessment of the siruation. Early in the interview, the physi-
Or the physician may decide that he or she wishes to give
the patient more time to tal k. SiJences a~e less likely later
in the interview after a full account of ths patient's difficul-
ties has been gathered. At such times, the physician may
more confidently proceed with direct questions with very
specific airns.
vVhen a patient is overwheimed with emotion, often the best
thing to do is to remain silent. To say something at such a
juncture is to run the risk of inhibiting the expression of the
emotion that is alrnost always therapeutic or cathartic. To
say nothing, to simply be with the patient while he or she
weeps, for example, gives the patient control over how much
or how little emotion to display.
In certain situations the use of silence is not advised.
Patients with neurological disorders, for exarnple, often
need a fair arnount of structure to perrnit them to respand
212 Part 4: Physician-Patient lntelacuons

adequately and may become confused and disoriented if The following are the responses of three physicians w¡th'
silence is used where guidance is needed. Adolescents may a patient whose initial complaint is expressed by the words,
be intolerant ofambiguity for other reasons and find an "My head is killing me," Physician A asks, "Have you had
interviewer's silence discomforting. Occasionally a patient headaches before?" This is a reasonable question, but it is
is overly talkative, although paradoxically such patients , likely that the answer wil! emerge natural!y if the patient is
never seern to be very informative. Here is a clear case in given the opportuniry to give an account of his or her dif-
which silent indulgence ofthe patierit does little good, and ficulties without physician interference. By asking this
the physician rnay have to interrupt the patient to gain con- question at this time, the physician is interrupting the pa-
trol of the interview and guide it in more meaningful di- tient's flow of ideas and narrowing the range of response
rections. alternatives.
Physician B responds by saying, "Tell me more about
how your head is killing ycu." This is a legitimate request,
but it is 10 words long and may be too formal and profes-
Facilitation sional so unding to facilitate good rapport. '
Physician C responds by noticing the violent irnagery in
"Encoutaging communication by manner, gestur e, or the patierit's brief description of her headache. She decides
words that do not specify the kind of information sought that such an emotion-filled word deserves to be articulated
is called facilitation" (Enelow & Swisher, 1986). Facilitation at greater length ("unpacked"), and she replies, "Killing
involves slightlymore control than silence and subsumes a you?" This imposes only modest control over the patient's
wide variety ofinterventions that require little experiditur e next response and follows the patient's lead as closely as
of energy on the part of the interviewer. Despite their seem- possible. It increases the probability that the patienr's re-
=s simplicity, faeilitatirig tecimiques play a powerful role in sponses wil! provide a fuller account of this symptorn, one
both elieiting information and guiding the interview to de- that spontaneously includes the information about site,
sired topies. An attentive facial expression, a raised eyebrow, onset, duration, and history that any physician desires. It
a shrug of the shoulders, and a nod all are mannerisms or may also elicit significant material concerning the patie nt's
gestures that can encourage a patient to continue with his fears and fantasies regarding what is wrong, fears legiti-
or her associations. The physician does not speak a word, ma tely assumed to exist if the patient's descr iption is taken
yet the patient knows that the inrerviewer is interested in a t face value.
what is being said and is curious to hear more. \Vords such Two additional facilitating remarks are "How do you
as "yes," "okay,' "go on," and "I see" serve essentially the mean?" and "How so?" They serve the same function as the
same function, as does the utterance "mmrn-hhh." Such 'repetition of key words and phrases, can be used In the
vocalizations serve as reinforcers and increase the proba- same situations, and put a little more variery into the in-':
bility that the patient wil! talk more freely about the subject terviewing repertoire. Variery is important beca use as soon
that has been reinforced in this wa)'; However, interviewers as a patient becomes conscious that the physician is ern-
must guardagainsternployingsuch easy-to-use and potent ployirig these techniques, the interview suffers. ..
techniques rnechanically or in stereoryped ways that may
have the unintended effect of distracting and inhibiting the
patient. Listening to interviews on audiotape and watching . , If your news mustbe bad, tell it soberly and promptly.
, ,
them o n videotape provide safeguards against abuse of
SIR HENRY HOWARTH BASHFORD
these techniques.. '
The Comer 01 Harley Street '
Another set of facilitating techniques that involves a bit,
more control on the interviewer 's par t is any intervention,
verbal or nonverbal, that conveys to the .patient that "I
do n't understand" or "I am puzzled by what you are telling Confrontation
me." This communication can be made directly or indirec-
tly for example,via a quizzicallook. Confrontation involves pointing out to patients aspects oI '
A very pOlVerful fCI(::i/itating technique, if used appropri- their beh avtor of which theywere u:;aware. It repr esents a
ate/y and in moderation, involves the judicious repetition of moderately high degree of control on the part of the inrer-
key words spoken by tlie patient. Words condense and sum- viewer. lt I:S a technique to be used sparil1gly. ,
marize patient experiences. They can sornetimes be taken Co nfro ntat ion can be appropriate in several ci r cu rn-
at face value; in other situations they need to be explored srances. If a patient continues to offer orily br ief, unelabo-
ingreater depth for what they connote. An economical and rated responses to open-ended questioris, silences, and fa-
effective way of inviting patients to elaborate on the mean- cilitatioris, and if this seems related to some distress that
ing of their words is sirnply to repeat words that are of in- the patient is experiencing, a comment along the lines of
terest, with a slight interrogative vocal inflection. "You seem uncomfortable talkins b about this" makes rhe
 Chápler 16: Communicating with Patients 213
"',

patient aware th at the discomfort has been noted and such fear in your voice." Many other situations exist in
somewhat lengthier responses are expected. The comment which the patient's no nverbal behavior communicates
is made in the form of an observation by the interviewer. something that is not being addressed. Confrontation gives
This allows the patient more latitude in responding. By us- the patient both permission and the opportunity to express
ing the tentative phrase "yo u seern," rather than the more ernotions verbally.
presumptuous "you are," the interviewer avoids coming
across as al! knowing and can retreat frorn the observation
more gracefully if it preves to be wrong.
Once the confrontation has been made, the patient can
Direct Questions
either admit or deny it. If the confrontation is acknowl-
edged, the patient can proceed to elaborare on the nature
of the difficulty. A patient might say, for example, "Yes, I The highest level of control among all the interviewin« o
am uncomfortable; 1 really dcn't know how much detail techniques is found in closed, or direct, questions. An en-
to go into." Or, "Yes, 1 am uncomfortable; 1 haven't told treaty phrased as "Tell me how you're doing" is broader in
you something that 1 think you need lb know." Whatever focus and less coritrolling than "Tell me what is wrong,"
the reason for the patient's reticence, confrontations of which, in turn, is broader in focus than "Tell me when the
this sort help to clear the air and set the stage for the re- nausea began." For -sorne patients and in some situations,
sumption of more open discussion. Should the patient be interviewers may have to relyrnore heavily on direct ques-
genuinely confused by the confrontation, he or she can tions. A questiori such as "How would you describe the
simply ask for clarification. If this happens, the interview- pain?" may yield only an equivocal response. In this case it
er should describe the patient behaviors that Jed to the would be appropriate to give the patient a question with a
inference of patient d'is'~omfort to clarify the situation and rnultiple-choice format: "It is a burning, aching, or prick-
promete greater understanding, and the patient can easily ing rype of pain?" Direct questions are very helpful when
deny the observation if he or she desires. The observation used appropriately: they serve to fill in missing details, tie
may be correct, but the patient does not trust the inter- up loose ends, and sharpen the foeus of the interview. They
viewer sufficiently to admit such private concerns, Even are also associated with a nurnber of potential pitfalls.
in this case, the fact that the interviewer rnade the appro- One problem is the possibility that a direct question can
priate inquiry, used the appropriate technique, and did bias the patient's answer through the inadvertent use of an
not insist on a certairi answer signals. to the patient that emotion-laden word or through poor phrasing. For exarnple,
this is an observant physician interest~d in rérnoving ob- asking patients if they have a history of mental illness has
stacles to a better physician-patient relationship and not a more pejorative quality than ask..ing if they have ever seen-
afraid to tread (gently) into potentially delicate areas. This a mental health professional (and following an affirmative
augurs well for the future of the relationship. response with a request for more detailed information).
Other circumstarices in which confrcntation is useful Asking marriedpatients whether they ha~e had any affairs
occur when a dispar ity is observed in different aspects of .' is judgrnerital . .'
and may evoke a les s honest answer than .
á
the patient's behavior. For exarnple, thé dispariry.may be a question about other sexual partners. Similarly, ask..ing
contradiction between two of the patient's rernarks, and about "illicit.drugs" or "illegal drugs" is unlikely to yield an;
the confrontation could take the following form: "You say honest respónsé.it is more appropr iate to ask about "any
your foot doesn't bother you, but just a moment ago you drugs like marijuana or cocaine, that sort of thing." Simi-
said you can't put any weight on it." Notice how gentle such lady, it is often difficult for patients to p.rovide honest an-
a confrontation can be. It is not accusatory; the physician swers to a cornrno n form of direct q)i~stions-le<i.ding
. is simply juxtaposing two 0[' the patient's statements. lm- questions-e-such as "So, no drugs?" or "Ycu're not having
plicit in this statement is the same exltortation thct underlies chest pain, are you?"either beca use patients are reluctant
atl the othet inteiventions jLlst discussed: "Telt me more." The to correct the physician or rnight prefer not to discuss the
only difference is thatin th~ case ofconfrontation,' the in- topic at al!. . .'
terviewer is exerting more control over the nature of the The other major problern with direct questions is the .
material to be elicited. chilling effect they can have on patierit spontaneity. The .
Often the disparity tobe confronted is between whatthe . following exchange demonstrates how, the excessive use of
patient says and does.A patient may blandly discuss sui- direct questions deprives the patient of the chance to de-
cid al thoughts or maydiscuss the most seemingly insignif- velop a more full-bodied accoun t of her problem:
icant matters with great trepidation: These discrepancies
between verbal and nonverbal aspects ofbehavior must be Doctor: What sorts of troubles have you been having? .
investigated. The physician might confront the suicidal pa- Patient: I've been going downhill for 2 years. Nothing
tient by saving, "You seem so nonchalant." To the nervous seems to be working right.
patient, the physician might say, "You're shak.ing" or "1 hear Doctor: What is the worst part?
214 Part 4: PhysicianPatient lríterac',ion;

Patient: My legs.l have constant pain in my legs. It's got-

ten so bad 1 can't sleep. The doctor may also learn more about the illness from the way the
I

Doctor: \I\'hat about your breathing? patient tells the story than from the story itself.
Patient: Oh, that's al! right. 1 can breathe fine. 1 just hurt JAMES B. HERRICK, M.O.
so bad in my legs. Memoirs 01 Eighty Years
Doctor: Are you still smoking?
Patient: Yes, with this pain I've gane back to cigarettes for
relief. But I'm down to half a pack or so a day.
Doctor: Are you having pains in your chest? STRATEGIES FOR GIVING
Patient: No. INFORMATION: FOCUS ON CHECKING
Doctor: How about cough?
UNDERSTANDING
Patient: No, 1 hardly ever cough.
Doctor: How much are you actual!y able to do? _
Physicians approach the interview with a primary interest
Patient: V'/ell, 1 was able to do everything until about 2
in gathering inforrnatio n. Patients have a slightly different
years ago, but now 1 can hardJy walk half a block.
interest: they want to know what the physician thinks
Doctor: Why is that? . about their complaint and what course of treatment will
Patient: My legs. They hurt. be recommended. They want an explanation of their illness
Doctor: Do they swell up? and a statement about the benefits and risks of treatment.
Pa tient: \Nell, they've been a bit swollen the last 2 or 3 More often than 110t, patients leave the interview disappoin-
weeks but the pain is there whether they swell or ted wttl: the information received. In the best study available
not. on this topic, physicians spent little more than 1 minute
Doctor: All right, 1 want to ask you some things about (on average) of a lO-minute interview giving information.
your medical history now. (Platt & McMath, Yet they perceived themselves to spend more than 9 min-
1979) utes informing their patients. This is a gross distortion of
what actually takes place, and this misperception is a major
The physician's first question is fairly open ended. By fol- factor in both patient dissatisfaction with phvsicians and poor
lowing up with "\l\'hat is the worst part?"he allows the pa- patient adherence to treatment tegimens. The problern was
tient <in opportunity todescribe the chief coinplaint. But particularly acute when the patient was poorly educated or
his next four cornments are all syrnptorn-oriented ques- from a lower-class background, when the physician had a
tions imposed on the pátient. They do not follow the pa- busy practice (defined as more than 20 outpatients per
tient's lead. She clearly wants to discuss her legs, and he day), arid when the physician was from a lower-middle-
dearly has an agenda oE his own. By the end of this ex- class or lower-class background. Male patíents tended to
change he still knows Iittle about her Ieg pain and isforced receive less attention and fewer explanatio ns than fernale .
to endure a second rcund of description of the leg pain that patients, perhaps because female .patients ask more ques-
is no more détailed than thdirst round. (Compare "I have tions and are more verbally active during an interview,
constant pain in m)' legs" with "My legs. They hurt," six Even if the arno unt of time spént in explanations and
responses later.) The physician is wcirking hard, but this o th er forms of info r matio n giving were increased, the
interview has not gane anywhere. This encounter is an ex- problern of the quality of the .inforrnation given would re-
arnple oran interview style known as high physician con- main. lnsttuctions should be as simple, brieJ, and jargon-free
trol-low patient control. According to em piricalresearch this C1S possible. Telling a patient to take medication on an as-
style is highly prevaíent in ctnucatsetting». During such in- needed basis is nct a good idea. Even telling a patient to
terviews the physician terids to talk more and the patient take medication ever y 6 hours is subject to misunderstand-
less as time gces on. This is in direct contradiction to good ing, unless it is made clear that the patient should take it
interviewing technique. After the preceding interview, the four times through the day and night.
physician described the patient as "not warning to talk." In It can bé difficult to anticipate all the potential misunder-
fact, the interviewer 's use of direct questions to control and standings that can occur when an already anx.ious patient is
li m it the interview hadforced her to this point. trying to assimilate your instructicns. One colleague intcr-
. Direct questioris are an absolutely essential component viewed a longshoreman who had sought treatrnent at a clin-
of a clinical interview: Physicians and other health-care ic for patients with chronic pain. As he told his story about
professionals cannot do without thern. The problem is that his earlier experiences with physicians, he suddenly began ro
they are easily misused and frequently used to the exclusion cry. It seems that he had been told, 3 months earlier, that he
of other techniques that do a better job of eliciting unb i- had degenerative arthritis, and he had been depressed ever
ased information and develcpinga sense of productive col- since. For this man, degenerative arthritis meant that his
laboration. spinal cord was degenerating, or crumbling, and that he
 Chapter J6:tommunicating with Patients
..
would 5000 be totally disabled, unable to walk, wo rk, or sup-
port his family. His anguish could have been avoided if his
physician had taken the time to explain the meaning ofthis
diagnosis in terms that the patient could readily understand,
and checked to rnake sure he understood.
Hospitalized patients are often par ticularly deprived of
information concerning their condition and future treat-
ment. This only imposes additional uncertainty in a situa-
tion that is already stressful and anxiety provoking. Several
years ago, one of us (PBZ) was at the bedside of a cáncer
patient who was complaining about how his physicians
were keeping him in the dark about their plans for him. As
we spoke, the surgical resident entered, introduced himself,
and announced that the patient would have surgery in the
morning. He then turned and left the room. Such conduct
is not only unprofessional, it is countertherapeutic.
Studies that compare the medical outcomes of patients
with and without adequate information about their treat-
ment frequently show that provision of information is ad-
vantageous for both the physician and the patient. In one
such study, anesthesiologists visited patients in the experi-
mental group preoperatively to describe what the patients
would experience when they awoke after surgery. The phy-
sicians indicated that the patients would experience pain,
told them where it would hurt, and how itwould fee!, ern-
phasized that this was normal and would be self-limiting,
and urged the patients to ask for analgesics ir the pain be-
carne too great. When compared with a control group,
these patients were judged readyfor discharge 2.7 days ear-
lier and made 50% fewer requests for pain medication.
Patients almost invariably have a different frarne-of-re-
ference than that of their physicians. Moreover, there is a
limit to the amount and cornplexiry of information that
humans can' absorb in a short time span. Accordingly,
checking understariding of explanations and recommeri-
datioris is absolutely essential. We reccimmend the fo11ow-
ing technique to ensure that eaeh patient has heard what
was intended: After an explanation ot recommendation, csl:
the patient to repeat, what has jLlst been said in ¡Jis or her OWI1
words, notverbatim. Physicians wil! be surprised at wha t
they hear and at the frequency with which explanations and
instruetions are distorted and miseonstrued. More impor-
tantly, this exercise gives the opportunity to correct any
misunderstandings and to clarify any earlier ambiguities.
In addition, physicians can be more secure in the knowl-
edge that patients understand the medical advice on their
own terrns.'
HANDLING PATIENT EMOTIONS
Illness is frequently accompanied by negative psychological
sta tes. When patients are anxious, angry, or depressed, it
can be difficult to elicit a fu]] and spontaneous account of
215
their difficulties. On many occasions the patient's psycho-
logical state is the prirnary problern. The ability to handle
such situations smoothly and therapeutically takes time
and practice, but a number of general guidelines can be
considered.
Anxiety
If a patient is fidgety, restless, or easily startled, seems ner-
vous; or has a tremor in his or her voice, the patient may
be anxious. Proceeding with the interview may be difficult
until the anxiety is discussed. The technique of confronta-
tion is most useful in these circumstances, with the physi-
cian simply saying to the patient, "You seem upset," or ner-
vous, or whatever descriptor is most appropriate. Usually
the patient seizes on this opportunity to speak about his or
. her anxiety. This sharing helps diminish anxiety and re-
store the alliance between physician and patient.
Sorne patients may be chronically anxio us, but many
others may be anxious as a function of the situation in
which they find themselves. For some, the prospect of sub-
mitting to a physical examination with a relative stranger
is anxiety arousing. For others, the passivity and loss of
independence associated with being ill (and hospitalized)
can be threatening. For still others, anxiery may be associ-
ated with earlier, unpleasant experiences with a physician
or a procedure. In any of these instances, and in any other
instance of patient anxiery, the prescription is the same: the
'. physician's responsibiliry is to elicit the source of the pa-
tierit's concern understand it, and take appropriate mea-
sures ro diminish it.
We spoke ofdirninishing and not elimináting the pa-
tient's anxiety. Anxiety cannot be completely eliminated,
and its elimination is not necessaryfor a successful inter-
view. Once anxiery has diminished to a point af which the .
, interview can proceed, the iritetviewer cariconclude that he /
or she has handled the problern satisfacto~Jy. With a patient
who is anxious about being exposed dur~'~g a physical ex-
arnination, it inight be best, once the natbre of the anxiety
has been established, sirnply to deferthephysical examina-
tion until better rapport has been achieved with the patient.
With a highly active patient, threatened by thé enforced pas-
siviry arrd dependency of illness, the physician rnight ac-
knowledge the discomfort that the situation entails, review
why it is necessary, and prornise to take the necessary steps
to increase the patient's activity and sen;;e of personal con-
trol. With a patient who anticipates an unpleasant proce-
dure; accurate information is often enough to reduce anxi-
ery, If the procedure is a painful one, and if anxiery is so high
as to threaten patient participation, hypnosis, modeling, or
medication might be helpful. In refractory cases, referral to
a psychologist or psychiatrist may be necessary. I
Anxiety often presents itself in subtle ways. For exarn-
216 Part 4: Physician·Patient Interactions

ple, patient questions ma)' actually be veiled expressions of Doctor: What they mean?
anxiety, Whell a middle-aged patient asks a resident how o/d Patient: Brain tumors. Cáncer. Deep down 1 think 1'm
he ~r she is, it is fair/), certain that the patient doubts that already convinced 1 have an inoperable tumor.
s o.neo ne so )'Oll1lg, and presumably inexperienced, can be Doctor: It must be a frightening thought to live with .
he/pfu/. \A/hen a mother of five beset by her childreri's be- . Patient: Well, I've probably lived with it most of my life.
havioral problems asks a student on a pediatric rotation if My father died of a brain tumor when 1 was 5.
he or she has children of his or her own, we can assume Doctor: (after a brief silence) And now you're worried
again that the question is not being asked out of idle cur i- that it's your turno
osity, In ordinary social conversation it is considered rude Patient: Mmrn-rnrnrn. Yes and no. 1 realize I'rn jumping
not to answer a direct question. However, in a c1inical con- the gun. What my father died from was not a
text, to take such a question at face value and to answer it hereditary disease. And my symptoms could be
immediately and directly is to fail to address the underlying the result of a rnillion things. It's just hard not to
concern of the patient. think like this with my family histor y. If 1 were
Such expressions of anxiety and concern masquerading going ro bet on what's wrong, I wouldri't really
as direct questio ns take many different forms. "Should I bet on cáncer. I'd bet this whole thing is stress
marry my girlfriend?" "Is a 20-po\Jnd weight loss anything related.
to be concerned about?" "Shculd 1 accept chemotherapy?" Doctor: How so?
"Can jogging cause a heart attack?" These may be perfectly
legitimate questions, and they may even be within the ex-
pertise of a physician. But it is never appropriate simply to
give a n affirmative or negative answer and leave itat that. Depression
Instead, the clinician's responsibility is to c1arify the precise
nature of the question and, if appropriate, to provide the Depressed mood is another common response to physical
information needed by the patient to make an informed illness, o ne expressed in terrns of hopelessness, guilt, low
decisión. For direct questions such as these, a response that self-esteem, and fatigue. Interviews with depressed patients
puts the responsibility for clarificatíon back on the patient can be laboriously slow arid unproductive. Here, too, con-
(e.g., "You seem unsure" or "You seem concerned") is the frontation can be a useful technique. Cornrnenting on the
most appropriate first step, Only when it is understood why slow process of the interview ("You seernto be having trou-
the patient asks and how the patient iritends to use the an- ble keeping pace with me") or on the patient's mood itself
swer is it proper to respondo Even at this juncture a distinc- ("You seem tired" or "You seem kind of blue") gives the
tion should be made between advice and information. If a patient a chance to discuss his or her difficulty with the in-
40-year-old woman asks whether she should attempt to terviewer if he or she so wishes. Acknowledging that the pa-
have a baby, it is one thing to provide her with information tient appears to be on the verge of aying ("Yoú loo]: like you're
abcut the risks and something else entirely to advise or.di- about to ay") effectively grants tlie patient permission to ay
rect her in one direction
.
or another, .
.or not to ay and can open the door: to important emotional
Another response to patient anxiety that ought to be materiat., .
avoided is the falsely reassuririg response that says to the If the physician is con cerned about the tnagnitude of
patient that everything will be all right. Reassurance that depressive affect, the patient's suicide potential should be
is based on the facts of the case anddoes not raise unrea- assessed. Usually it is best to begin indirectly, asking if the
sonable expectatioris is a uséful way to allay patient anxiety. patient feels hcpeless, derives any rneaning from life, or has
Too ofie/J, liowever, reaSSLmmce is used to protect the feeJings ever wished he or she were dead. Broaching the subject in
of ttie physician and does llothing to reassure the patient. If a progressive or gradual fashion is not the same as being
the patient senses that the cliniciari's efforts at reassurarrce evasive. Jf tlie patient senses that the plvysician is timid aboLlt
are not genuine, the clinician becomes still another person asking about suicidal intent, he or she is more likel)' to give
from whom the patient must conceal intimare feelings. an evasive answer. Eventually, ir the answers convince the
The following vignette demonstrates that responses to a physician that the patient is conternplating suicide, direct
patient that acknowledge his or her concerns and reflect inquiry must be made: "Have you thought about taking
true understanding arethe most reassuring responses of your lifer," "Have ycu thought about how you would do
al], Imagine how differently this encounter would have it"," or "Have you thought about how other people would
been if the physician responded with reassur irig platitudes feeli" Clear expressions of suicidal intent m ust alwavs be tak-
of the "Of course you're not going to die" or "I'rn sure you en seriously. The more lethai the method contemplated, the
don'! have cáncer" var iery. easier the patient's access to the method, and the more vivid
his or her [antasies about how others would be affected, the
Patient: I'm worried about these headaches. 1 know what greater the risk, At this point the clinician must be fran!.:
. headaches can mean. with the patient, declaring the intention ro plan for the pa-
 ,
I
-.;J'

Part 4: Physician·Patient lnterartíon,

A second ccmmon nusconception is the notion that psycho-
therapy is equal to psycnoanaiysis. The patient must be 35-
su~ed that referral does not mean a 5 day/week treatment
of long duration in which he or she is asked to lie on a
couch and free associate to a silent individual sitting out of
view. Only a fraction of patients in need of psychotherapy
are interested in and suited for this form of treatment.
A third misconception is the idea that th« psychiatric re-
ferral is being used to get rid of the patient. Th is misconcep-
tion is common among chronically ill patients who are es-
pecially dependent on their physicians and among patients
whose relationships with their physicians have been char-
acterized by disagreement and strain. Sucli patients must
know that the pliysician is not.givil1g up 011 thern and that
this is not the end of the retationship. It simply mearis that
certain aspects of their lives are beyond the physician's
competence and could be better handled by someone 'else.
Once the physician has given the explanation for the refer-
ral and discussed these common misconceptions, the patient
needs an opportunity to ask questions and express additional
concerns. Patients who characteristicaUy deny emotional dif-
ficulties and patients who lack insight into the inappropriate-
ness of their behavior are particularly resistant toreferral for
psychological evaluation or treatrnent. Therefore the physi-
cian must not feel cornpelled to complete discussion of a
referral in a single session. Sorne physicians routinely rnen-
tion the possibility of future referrals in their first contact
with a patient if they have an)' reason tosuspect that a referral
may be necessary, If a referral to a psychiatrist or psychologist
is mentioned in passing at this point, in conjunctiori with the
possibility of referraI to a neurologist. cardiologist, or other
specialist, it becomes easier to reintroduce the idea.
SUMMARY
Attention to interpersonal and communication skills can
facilitate effective and efficient clinical encounters. This
chapter provides useful approaches, but practice, rettection
and feedback are the keys lo developil1g and improving yOLa
interactions with patients. The notion that patients and pro-
viders have different - but equally valuable - perspectives
and roles in clinical encounters was captured in the title of
a book by Tuckett et al, published 20 years ago: Meetings
between Experts. Keeping this deceptively simple idea in
mind as you progress in your rraining will help you and the
pa ti en ts you serve,
testing has not revealed any abnormality. Al! results were .
within nor mal lirnits. -
Dr. falles: How are you toda)', Mr. Smith?
Mr. Sl1lith: Ihings are pretty bad at work. Ihis is our busy
time and everyone's stressed out. I'm doing okay, though.
Dr. falles: Well, I've reviewed your tests with our cardiolo-
gist, and we agree that there realiy isn't anything wrong.
Chances are it's just a combination of thinzsu ' mavbe
,
stress
or indigestion.
Mr. Sniith: Okay, but 1 dori't see it getting any better, Sooner
or later, 1'11have a blowout.
Dr. lenes: 1 don't think that's likely. You're young and in
good health; ycu do n't srnoke or have a family history of
heart disease. Some people get chest pain when they're un-
der stress.
Mr. Sniitt»: You say it's not likely, but 1 dori't know, I've got
a lot of problems, and all 1 hear from everyone is that it's
in my head.
DI'. [ones: It's not in your head. The pain is real, but you're
not having a heart attack. \A/e can order more tests, but
they're not going to show anything.
Mr. Smith: 1 don't know how you can be so sure. I've been
having trouble catching my breath lately too. And my
brother-in-law ran 10 miles a day and never smoked or
drank, and he dropped dead of a heart attack just 1 mo nth
before 1 carne to see you.
This is not an example of a good interview. Dr. Iones has a
nice manner and was trying very hard in this instance, but
the physician and patient were largelytalking atcross-pur-
poses". Review this intervicw line by line, and see if)'Oll can
improve 011 Dr.Tones' interviewing technique. Canyou find
examples of open-ended questions or facilitation? H01V rnight
the interview have been differe~t if Dr. [enes had used these
techn iques and tried to [ollow the patient's le~d -rather than
convince Mr. SI~;ith that he does not hai/e heart disease? Hoi-v
m;ght the patient fee! when the phys.ician is willíng to-order
more tests despite his skepticism? '

CASE STUDY
This is an excerpt from the second clinic visit of a 38-year-
old plant foreman with intermittent chest pain. Extensive
Cnapter 16 Communicating with Patients
, tient's protection andrécovecy'by involving famiJy rnern-
bers and a mental health professional. Patients may object
strongly,but as a rule they are grateful that the practitioner
has assumed responsibility for the burden of the immedi-
ate future. ' '
Anger
If a patient is covertly angry, the appropriate response of
the physician is to use the technique of confrontation, just
.as a physician would respond in the case of the patient's
unacknowledged anxiety or depression. One of the authors
once interviewed a patient who was giving brief and un-
elaborate responses to his questions. Al! the while his face
was redderiing, his fists were clenched, and his voice was
becoming more hostile. It was not difficult to sense his an-
ger, and the interviewer braced himself for his response. 1t
developed that he thought that his interviewer was in his
hospital room to give him a spinal tap, and he believed the
extensive questicns and leisurely pace were part of an effort
to delay the inevitable. The patient wanted to get on with
the procedure. Had the.interviewer not been willing to con-
front the patient, an altercation would have been likely.
This encounter demonstrates the need for an interviewer
to clarify the purpose of the interview at the outset as part
of his or her introductory remarks.
Perhaps more common in clinical practice is the overtly
angry patierit fórwhorn the use of confrontation may be
redundant Patients get angry- for numerous reasons, but
these reasons can be conveniently grouped into rwo cate-
gories. First, a patient may be angry beca use of something
said or not said, or done or no t done. The possibiJities are
Jegion and inelude the physician failing to introduce him-
selforherself, rnaking the patient wait a long time, failing
to remernber sorne critical fact about the patient, hurting
the patient, making accusatory or rnoralistic-sounding re-
rnarks, withholdinginformation, orfailing to allow the pa-
tient tothink he or she has given a full account of the ill-
ness. Ifthephysician is the source of the ariger, whether or
not by design, no alternative exists other than owning u p
to this resporisibility, taking appropriate rernedial mea-
sures, and, if necessary, apologizing.
The second possibility is that the patient is the so urce of
the anger and would be angry whether or not thephysician
did something provocative. Anger is often n compnrntively
safe wny!or a patienr to Express [ear. Patients are often
frightened by their iJlnesses"or by the proposed treatments
and may use anger as a méans of both discharging and de-
nying such anxiety. In addition, sorne patients are fright-
ened by the 1055 ofcontrol that assumption of the sick role
entails and respond with anger as a means of reasserting
their authority. The sensitive clinician learns to listen for
(he feelings of powerlessness that underlie such overt anger
and does not respond reflexively or in a way that merfly
engenders the same feelings of powerlessness that made the
patient angry at the outset. In addition, the physician must
appreciate that anger is often displaced from another petson
who has [rustrated the patient. If the receptioriist offended
the patient or ifthe patient has been disappointed by phy-
sicians in the past, the clinician may well be the innocent
recipient of unwarranted hostility.
1n each of these cases the natural tendency is to become
defensive and want to retaliate. Su eh responses might be
momentarily cathartic but are generally ill advised beeause
they are not in the patient's best interest. The ideal way to
handle an angry patient is to make a concerted effort to
understand the nature of the anger. If the anger is justified,
the acknowledgment of responsibility is often enough to
resto re the physician-patient alliance to a productive level
of functioning. If the anger is not justified by the physi-
cian's behavior, accepting the patient's anger and perrnit-
ting its full expression are cathartic for the patient and give
him or her greater insight into its actual so urce.
REFERRAL TO A PSYCHOTHERAPIST
Mak.ing referrals is a neglected but important aspect of pa-
tient care, and perhaps the most difficult referral is one to
a psychiatrist or another mental health professional. Ir is
relativety cettain that if the physician does nothingbut say to
the patient that consultation with a psychiatrist is recom-
mended, thot recommendation will not be followed. Most pa-
tients find this threatening, and 20% to 40% of patients
reject psychotherapy when it is offered. Su eh referrals are
most successful when they are discussed over several ses-
sions, when the physician is able to provide a straightfor-
ward and nonthreatening rationale, arrd whenthe patient
is encouraged to express reservations.
Three common rnisconceptions about psychotherapy
should be routinely addressed whenever the issue of a re-
ferral arises. The first misconceptiori is the notion tliat only
crazy people need to see psychotherapists. Whether or not tbe
patients voice this concern, it is generally useful for the in-
terviewer to say that he or she does not think they are crazy,
does not believe their problems are a1l in their head, and
does believe their complaints are real. Then, a nontechnical
explanation of the recommendation should be offered: for
exarnple, that most illnesses have an ernotional component
and that even greater concern would be raised if the patient
were displaying no psychological effects. Or the physician
might say that almost anybody undergoing the same phys-
ical difficulties or stresses wou ld be Ii.kely to exper ience psy-
chological symptoms. At any [ate, an expression of contern
coupled with a statemerit to the effect that a mental health
professional is better equipped to help with the problem
ought to make the idea of a referral more palatable. '