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Medical Interviewing and the Doctor-Patient Relationship
Fall 2011
J. Schindelheim, MD
Tufts University School of Medicine

Interviewing Opportunities and Challenges

Introduction

The patient interview serves both as a source of information and an opportunity for establishing a strong doctor-patient relationship. Collecting and organizing the information effectively allows us to develop a diagnosis and present the patient coherently to colleagues. The interview can also offer important bio-psycho-social data, healing, and a profound sense of connection between the doctor and patient. This is because the patient’s concerns are often very personal and filled with feelings. They present themselves in the course of the interview at moments that represent important opportunities for building the doctor-patient relationship. They can also be quite challenging. Some of the lessons articulated in the lecture on "Talking with Patients with Psychiatric Problems" apply in talking with all patients. The strong feelings that patients bring to the doctor patient relationship require the mastery of some of those techniques for all doctors with all patients. As Dr. Erlich said, if this aspect of the relationship is handled poorly or ignored, the resultant patient dissatisfaction is often measured in poor compliance, malpractice lawsuits, doctor shopping, and bad medicine. For physicians, mishandling of this relational dimension during the interview decreases job satisfaction and contributes to our professions well documented high rate of occupational hazards. Developing the skills to handle this aspect of the doctor-patient relationship begins with the realization that talking with a patient as a doctor is not the same as "just talking," as for example with a friend. It requires a different mindset, learning specific techniques, personal growth, and practice.

Learning Objectives

By the end of the lecture, you will be able to:

  • Explain why emotions appear in the doctor-patient interview.

  • Describe how such moments can be opportunities for building the doctor-patient relationship.

  • Explain how/why doctors and patients find such moments challenging.

  • Describe the interviewing techniques needed for managing these challenging moments and turning them into opportunities

Specific competencies students are expected to perform within the context of practice after this lecture

  1. 1.Recognize potential moments of potential strong connection as they emerge in the interviews with patients/residents

  2. Use the following techniques in conveying empathy.

    1. Acknowledge the patient’s affect.

    2. Explore the patient’s underlying feelings.

    3. Communicate your understanding to the patient.

  3. Identify and manage your own feelings in the context of the patient interview.

Feelings as Challenging Opportunities in the Interview

If you have not already been faced with emotions in an interview, it is only a matter of time before while talking with a patient, emotions will emerge. This is because the doctor is the person to whom people bring their most painful, intimate, saddening, and stressful concerns. Soon you will be entering into a relationship in which people will be sharing their most intense feelings. It is important that as you begin to interview patients you are aware of this and prepared to face these moments.

Patients will come to your office hoping for a forum or venue to talk about their deepest concerns. They are often laden with emotion; they may be feelings of embarrassment, fears of dying, or feelings of anxiety. Patients will come to you with these emotionally charged topics in a vulnerable state, hoping for some form of help. In addition to listening to patients, we as doctors perform exams and deliver news that can also incite strong feelings. Doctors deliver bad news, tell people they are dying, and often cause pain with required procedures, all of which can evoke strong feelings. When you consider what both the doctor and patient bring individually to an interview you see that feelings are the active ingredient in the doctor-patient relationship.

How do I recognize these moments?

It’s not always clearly broadcast with tears or fits of rage. Some patients will be subtle in how they display (or try to not display) things that move them. You will need to pay close attention to cues the patient may offer so that valuable opportunities for relationship building are not lost. There are four type of emotional “cues” that you want to be conscious of are:

  • Verbal cues- often charged emotional cues that alert us that something is going with the patient

    • Curse words

    • Religious references

    • Trigger statements

      • "Mind-boggling"

      • "Oh my god"

  • Non-verbal cues

    • Body posture

    • Tears

    • Looking away

    • Coughing

    • No eye contact

    • General affect (external representation of an internal emotional state)

  • Behavioral cues

This can be when patients try to intimidate, manipulate, or coerce you in any way. These are all cues that there is something going on emotionally.

  • Doctor’s gut feelings

These also alert us that something is going on with the patient. If you suddenly start to feel anxious or sad, this may be your own emotional alarm clock alerting you that something is wrong with the patient. The individual may not be crying, but their general emotional state is translated through the doctor’s feelings.

What should I do at these moments?

There is a spectrum of how you can deal with these situations. On one end of the spectrum is setting limits and on the opposite end is fully exploring the emotions that the patient may be feeling. Setting limits on the discussion at these moments may be necessary in certain situations depending on the setting of the interview or the nature of what is being expressed. At the other end of the spectrum, emotions are approached with empathy and exploration. By setting limits you run the risk of leaving the patient feeling ashamed, abandoned, and vulnerable. By exploring, you run the risk of being deeply affected by intense emotions. The goal is to use the appropriate techniques for approaching such charged moments and to try and land somewhere in the middle of this spectrum.

4-step approach to charged moments:

1. Recognize and DOCUMENT the “emotional” cue.

Documenting an emotional cue indicates that you acknowledge that something is being displayed by the patient. This acknowledgement should be done in a matter-of-fact manner. Do not put a spin on your inquiry, read into it, or make it seem as if you understand what the patient is feeling. Use simple declarative statements such as:

  • I see that you are tearing up.

  • I see there are tears in your eyes.

  • I see you are pounding the table.

2. Using the interview techniques that you have learned, EXPLORE the cue.

By using open-ended questions, summarization, and reflection you want to begin to explore what feelings might be behind the patient’s “charged” display.

By using open-ended questions, summarization, and reflection you want to begin to explore what feelings might be behind the patient’s "charged" display.

3. UNDERSTAND the underlying feeling and why the patient is feeling it.

By exploring the feelings behind the external cue you will begin to gather information about what is going on for the patient. Example scenario:

Doctor: I see you are crying. Tell me about that.

Patient: Well my mother died recently.

Doctor: Tell me about that.

Patient: Well I hated her because of all that she did to me.

Doctor: Can you tell some more about that?

Patient: Well she abandoned me when I was 8 years old.

In this example, the doctor is collecting as much information about the patient as possible that lies behind the external affective cue. In this scenario we can see why it is important not to make assumptions. Many of us may be tempted to make the statement, “I am sorry, of course you must be sad” after learning the patient’s mother died. In this case, however, the tears were of rage, not sadness and without collecting all the facts we could miss this important distinction. Once you gather all the facts, then you can UNDERSTAND.

4. EMPATHIZE.

After exploring and understanding what is going on for the patient, then you will be in the position of being able to empathize – thought of as “being in the patient’s shoes.” The patient will feel better because not only have you taken the time to talk to them, but you have also gotten to know them in a deeper way.

Although you want to use the 4-step approach, you don’t want to be robotic when discussing feelings. These steps are useful because they prevent us from making assumptions. The less you assume the more the patient has to tell you. The more information the patient tells you, the more solid the ground the doctor-patient relationship will be on.

Troubleshooting

Addressing feelings of violence or anger: If you ever feel that you are in danger during an interview, you can excuse yourself from the room and get security. With more experience dealing with these types of situations, you can explore what is going on for the patient in greater depth. For now, get to safety. With more advanced training, asking questions allows you to gather more information and make important clinical assessments.

Suggestions for setting limits: If someone is being belittling or saying racist and sexist, comments, it is best to set limits. If a patient is making you feel uncomfortable, it is best to place limits on yourself rather than on the patient. Instead of saying, "You can’t talk about that", you should say "That makes ME feel uncomfortable when you talk like that. Could you please not speak to me in that way." By using this technique you are not directly challenging the patient.

Addressing feelings when you are pressed for time: Primary care doctors don’t have endless time to talk. If you are busy and do not have adequate time to have a long conversation, acknowledge the emotion and give the patient time to compose themselves. You can suggest that they should talk to someone else or offer to set up another visit to discuss the feelings. For example:

"I am so sorry for your loss. I can understand now that you have explained to me why you were upset. Can we go on or do you need a couple minutes?"

Addressing feelings in a resistant patient: Even if you approach their emotions in an appropriate and respectful manner, some patients may not want to discuss their feelings with you. If after asking patients to share their feelings they are resistant, you can say:

"That is quite alright, I certainly respect that, but could you tell me why you don’t want to discuss ____."

"I won’t go into that, but I am curious as to why you don’t want to talk about it."

If they are still resistant, respect the patient and drop the topic. What we want to avoid is failing to ask the questions. Never assume that a person doesn’t want to talk because it may be a difficult subject. It is important to give the patient an opportunity to share their feelings in a safe and comfortable environment. They may say nothing or disregard your question, but at least you are acknowledging the presence of the feelings in the room.

What NOT to do when a patient displays emotion: Most people aren’t brought up actively learning how to deal with feelings. When people display emotions in front of others it is a common reaction to feel uncomfortable and awkward. Since we feel uncomfortable our first response may be to change the subject or ignore the display of emotions. We react in this way because we haven’t developed the ability to deal with feelings. As medical students you are being thrown right in the middle of these types of emotionally charged situations, so if you find yourself floundering remember what NOT to do:

  • Do not change the subject.

  • Don’t ignore the feelings.

  • Don’t assume you understand.

  • Don’t invalidate feelings by saying:

    • It won’t be that bad.

    • Don’t worry about it.

    • It could be worse.

    • I also had a friend die and it was worse than your loss.

When physicians avoid emotionally charged moments with patients or change the subject, bad things happen. The patient has taken an emotional risk by confiding in you with private matters. Don’t slam the door in their face; doing this can leave the person feeling embarrassed, shamed, angry, and enraged. Patients are very attuned to detecting our comfort level at such moments. If we are uncomfortable and change the subject, patients recognize this and may resent a doctor who doesn’t acknowledge these crucial emotional moments. The most frequent reason for malpractice suits is not medical mistakes, but because the patient doesn’t feel interacted with on an emotional level or feels disrespected. There are always reasons to not ask difficult questions. You may feel embarrassed or uncomfortable, but you need to ask the questions and broach the subject.

Take Away

If a patient opens up to you, take advantage of the moment and connect with the patient, never shut them down. A doctor who changes the subject at such moments, demonstrates a lack of training, experience, and practice in dealing with these most intimate aspects of doctoring and undermines a very basic principles of doctoring.

PRACTICE. At this point you are not expected to solve the patients problem, we are just trying to collect the data. You want to be able to respectfully create an opening in the conversation to discuss sensitive and emotional topics.

Recommended Readings

Wedding & Stuber, Behavior & Medicine, Cambridge, MA; Toronto: Hogrefe & Huber Publishers, 2006, Chapter 15.

SA Cohen-Cole, J Bird, The Medical Interview: a Three-Function Approach, St. Louis: Mosby, 2000, Chapters 1, 2, 3, 4, 5, 15.

RC Smith, RB Hoppe, "The Patient’s Story: Integrating the Patient and Physician Centered Approaches to Interviewing," Annals of Internal Medicine. 115(6):470-7, 1991 Sep 15.

R.B. Weinberg "The Laying On of Hands", Annals of Internal Medicine. 117(1):83-4, 1992 Jul 1.

Al Suchman, DA Matthews, "What Makes the Patient-Doctor Relationship Therapeutic? Exploring the Connexional Dimension of Medical Care", Annals of Internal Medicine.
Ann Intern Med. 1988 Jan;108(1):125-30. Erratum in: Ann Intern Med 1988 Jul;109(2):173.

Rita Charon, M.D., Ph.D. “Narrative Medicine: A Model for Empathy, Reflection, Profession and Trust”, JAMA, Vol 286, No. 15, pp1897-1902 Oct 17 2001.