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Chapter 1
The medical interview is central to clinical practice. It has been estimated that
doctors perform 200 000 consultations in a professional lifetime so it is worth
struggling to get it right.
The interview is the unit of medical time, a critical few minutes for the doctor to
help the patient with their problems. While the doctor may see each consultation as one of many routine encounters, for the patient it may be the most
important or stressful aspect of their week.
To achieve an eective interview, doctors need to be able to integrate four
aspects of their work which together determine their overall clinical competence:
knowledge
communication skills
problem solving
physical examination.
These four essential components of clinical competence are inextricably linked
outstanding expertise in any one alone is not sucient. For example, it is not
good enough to be factually excellent if communication diculties stand
between you and the patient and prevent you from discovering the reason
for the patient's attendance or from discussing a plan that the patient can
understand and wishes to put into action. Communication is a core clinical skill
rather than an optional extra.
How we communicate is just as important as what we say. Communication
bridges the gap between evidence-based medicine and working with individual
patients.
54% of patients' complaints and 45% of their concerns are not elicited
(Stewart et al. 1979).
In 50% of visits, the patient and the doctor do not agree on the nature of the
main presenting problem (Stareld et al. 1981).
Only a minority of health professionals identify more than 60% of their
patients' main concerns (Maguire et al. 1996).
Consultations with problem outcomes are frequently characterised by
unvoiced patient agenda items (Barry et al. 2000).
Doctors frequently interrupt patients so soon after they begin their opening
statement that patients fail to disclose signicant concerns (Beckman and
Frankel 1984; Marvel et al. 1999).
Doctors often interrupt patients after the initial concern has been voiced,
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apparently assuming that the rst complaint is the chief one, yet the order in
which patients present their problems is not related to their clinical importance
(Beckman and Frankel 1984).
Gathering information
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Patient adherence
.
Patients do not comply with or adhere to the plans that doctors make. On
average 50% do not take their medicine at all or take it incorrectly (Meichenbaum and Turk 1987; Butler et al. 1996).
Non-compliance is enormously expensive. The cost of funds wasted on
prescription medications that are used inappropriately or not used in Canada
amounts to CAN$5 billion a year, based on an annual expenditure of
CAN$10.3 billion and data indicating that 50% of prescription medications
are not used as prescribed. Estimates of the further costs of non-adherence
(including extra visits to physicians, laboratory tests, additional medications,
hospital and nursing home admissions, lost productivity and premature death)
were CAN$79 billion in Canada (Coambs et al. 1995) and at least US$100
billion in the USA (Berg et al. 1993).
Medico-legal issues
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Numerous reports of patient dissatisfaction with the doctorpatient relationship appear in the media. Many articles comment on doctors' lack of understanding of the patient as a person with individual concerns and wishes.
There are signicant problems in medical education in the development of
relationship-building skills. It is not correct to assume that doctors either have
the ability to communicate empathically with their patients or that they will
acquire this ability during their medical training (Sanson-Fisher and Poole
1978).
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many studies over the last 25 years have demonstrated that communication skills
can make a dierence in all of the following objective measurements of medical
care.
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The longer the doctor waits before interrupting at the beginning of the
interview, the more likely they are to discover the full spread of issues that
the patient wants to discuss and the less likely it will be that new complaints
arise at the end of the interview (Beckman and Frankel 1984; Joos et al. 1996;
Marvel et al. 1999).
Even patients with complex problems tend to be remarkably succinct. When
internists in a tertiary care centre were trained to actively listen without
interrupting until patients had completed their initial descriptions of their
problems, patients' mean talking time was only 92 seconds (Langewitz et al.
2002).
The use of open rather than closed questions and the use of attentive listening
lead to greater disclosure of patients' signicant concerns (Cox 1989; Wissow et
al. 1994; Maguire et al. 1996).
Asking `What worries you about this problem?' is not as eective a question as
`What concerns you about this problem?' in discovering unrecognised concerns
(Bass and Cohen 1982).
The more questions that patients are allowed to ask of the doctor, the more
information they obtain (Tuckett et al. 1985).
Picking up and responding to patient cues shortens rather than lengthens visits
(Levinson et al. 2000).
Patient satisfaction
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Greater `patient-centredness' in the interview leads to greater patient satisfaction (Stewart 1984; Arborelius and Bromberg 1992; Kinnersley et al. 1999;
Little et al. 2001).
Discovering and acknowledging patients' expectations improves patient satisfaction (Korsch et al. 1968; Eisenthal and Lazare 1976; Eisenthal et al. 1990;
Bell et al. 2002).
Asking patients if they have any questions and trying to ensure that they do
not leave with unanswered questions increases patient satisfaction (Shilling et
al. 2003).
Physician non-verbal communication (eye contact, posture, nods, distance,
communication of emotion through face and voice) is positively related to
patient satisfaction (Larsen and Smith 1981; Weinberger et al. 1981; DiMatteo
et al. 1986; Grith et al. 2003).
Patient satisfaction is directly related to the amount of information that
patients perceive they have been given by their doctors (Hall et al. 1988).
Information giving, expression of aect, relationship building, empathy and
greater patient-centredness lead to increased patient satisfaction (Williams et al.
1998).
In cancer patients, satisfaction with the consultation and satisfaction with the
amount of information and emotional support received are signicantly
greater in those who reported a shared role in decision making (Gattellari et al.
2001).
Patients who have undergone joint replacement surgery perceive the quality of
their care to be considerably higher in hospitals whose healthcare providers
demonstrate greater relational competence and co-ordination of care (Hoer
Gittel et al. 2000).
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Asking patients to repeat in their own words what they understand of the
information they have just been given increases their retention of that
information by 30% (Bertakis 1977).
There is decreased understanding of information given if the patient's and
doctor's explanatory frameworks are at odds and if this is not discovered and
addressed during the interview (Tuckett et al. 1985).
Patient recall is increased by categorisation, signposting, summarising, repetition, clarity and use of diagrams (Ley 1988).
The provision of audio- or videotapes of the actual interview and writing to
patients after their consultation both increase patient satisfaction, recall,
understanding and patient activity (Tattersall et al. 1997; McConnell et al.
1999; Scott et al. 2001; Sowden et al. 2001).
Adherence
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Outcome
Symptom resolution
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Physiological outcome
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Giving the patient the opportunity to discuss their health concerns rather than
simply answer closed questions leads to better control of hypertension (Orth et
al. 1987).
A decreased need for analgesia after myocardial infarction is related to
information giving and discussion with the patient (Mumford et al. 1982).
Providing an atmosphere in which the patient can be involved in choices if
they are available leads to less anxiety and depression after breast cancer
surgery (Falloweld et al. 1990).
Patients who are coached in asking questions and negotiating with their doctor
not only obtain more information but actually achieve better blood pressure
control in hypertension and improved blood sugar control in diabetes (Kaplan
et al. 1989; Rost et al. 1991).
Costs
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Medico-legal issues
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In a study of 103 orthopaedic surgeons, those who had better rapport with
their patients, who took more time to explain and who were available had
fewer malpractice suits (Adamson et al. 2000).
Reduced malpractice rates were seen in physicians who oriented their patients
(signposted), asked for patients' opinions, checked for understanding, encouraged patients to talk, laughed and used humour (Levinson et al. 1997).
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physicians. Patients' understanding of their condition improved and compliance increased. Most startlingly however, there was also better control of
hypertension even 6 months after the tutorial!
Roter et al. (1995) showed in a randomised controlled trial that an 8-hour
communication skills course in CME for primary care physicians not only
improved the detection and management of psychosocial problems but also led
to a reduction in patients' emotional distress.
Langewitz et al. (1998) demonstrated that specic patient-centred communication skills can be taught to residents in internal medicine over a 6-month
period and that on assessment 10 months later trained residents continued to
be superior to controls.
Smith et al. (1998, 2000) showed that a 1-month intensive training course in
interviewing and related psychosocial topics for primary care residents
improved their knowledge of, attitudes toward and skills in interviewing
with both real and simulated patients.
Roter et al. (1998) investigated the eects of an 8-hour training programme on
the communication skills of doctors in ambulatory care settings in Trinidad and
Tobago. Trained doctors used signicantly more target skills after training than
did their untrained colleagues. Patient satisfaction was higher in interviews
with trained doctors.
Humphris and Kaney (2001b) demonstrated an improvement in communication skills in medical students over 17 months of their undergraduate
teaching following a comprehensive and ongoing communication skills
course.
Falloweld et al. (2002) showed that senior clinicians working in cancer
medicine have many diculties when communicating with patients, with
patients' relatives and with professional colleagues. Time and experience alone
had not helped them to resolve these problems but in a randomised controlled
trial of 160 oncologists from 34 UK cancer centres, an intensive 3-day training
course produced signicant subjective and objective changes in key communication skills 3 months later.
Yedidia et al. (2003) evaluated the eects of a communication curriculum
instituted at three US medical schools. The curriculum signicantly improved
third-year students' overall competence in communication as well as their
skills in relationship building, organisation and time management, patient
assessment, negotiation and shared decision making.
We explore the teaching methods that were used in these studies to bring about
such impressive changes in learners' communication skills in Chapter 3.
Maguire et al. (1986a) followed up their original students 5 years after their
training. They found that both groups had improved but those who had been
given communication skills training had maintained their superiority in key
skills such as the use of open questions, clarication, picking up verbal cues
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eciently discover the problems or issues that the patient wishes to address
accurately obtain the full history
collaboratively negotiate a mutually acceptable management plan
supportively form a relationship that helps to reduce conicts for both patient
and doctor.
A collaborative partnership
Together the skills that we identify in detail in our companion book support a
patient- or relationship-centred approach that promotes a collaborative partnership
between patient and health professional. This is not because of our own
subjective opinion or personal beliefs we take this approach because the skills
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What then can we say to our institutions to convince them of the need
to run communication skills programmes?
The message to our institutions is not just that we can provide a more patientcentred approach to the interview. However laudable an aim that is, and however
important we might consider the need to discover patients' concerns and needs
and to involve patients more in the consultation, it often cuts little ice with those
who have yet to see the light. The really important selling point is simple: eective
communication is essential to the practice of high-quality medicine. By establishing
communication skills programmes, we can enable learners to improve their
clinical performance. They will be more accurate and ecient diagnosticians
and they will have patients who both understand what has been discussed and
are in agreement with negotiated management plans. Ultimately, learners will
enhance their ability to work with patients to improve health, manage illness
and even achieve better physiological outcomes.