"Tell me about yourself": The patient-centered interview.

The following article initiates a series on Words That Make a Difference. Developed under the sponsorship of the American Academy on Physician and Patient, the series will focus on the language physicians use when they talk with patients. Although clinicians understand how important it is to communicate effectively with patients, they often have difficulty knowing exactly what the best words are for making the most of each patient interaction. Drawing on careful observation and research results, the authors of this series of articles have identified words and expressions that have proven particularly powerful as tools for understanding patients and helping them manage their illnesses effectively. We are interested in knowing what readers think of the series, and in learning about other uses of language that readers have found important and helpful. The Editors Patient: That specialist you sent me to is probably a pretty good doctor, but you can't talk to him. Physician: What do you mean? Patient: Well, he just didn't seem interested in what I had to tell him. He might know about kidneys but he didn't want to know what I was worried about. This disgruntled patient is not the first to wish that his physician would focus more attention on his concerns, feelings, and ideas. Many patients complain similarly, identifying a critical weakness in the medical interview and subsequent treatment. Unfortunately, patients may feel this way even about physicians who are highly experienced and very skilled technically. Inattention to the person of the patient, to the patient's characteristics and concerns, leads to inadequate clinical data-gathering, nonadherence, and poor outcomes (1-14). Because each patient's experience of illness is unique, the best patient care includes attention to the patient's motivation, values, and desires; to her thoughts and feelings; and to the way she experiences her illness. Growing evidence suggests that physicians who focus on the patient as well as the disease obtain more accurate and thorough historical data, increase patient adherence and satisfaction, and set the stage for more effective patientphysician relationships (15-32). Although concerns are often raised that practice conditions may not allow clinicians the time to give attention to these issues, clear evidence indicates that interviews that attend to patients' feelings, ideas, and values actually save time (33, 34). Physicians can refine their existing skills in ways that allow them to attend better to the person of the patient as well as the patient's disease. The resultant patient-centered interview increases both patient and physician satisfaction. Recommendations to focus on the person of the patient are not new. Osler (35) urged that physicians care more particularly for the individual patient than for the special features of the disease, and Smyth (36) provided this suggestion for effective doctoring: To know what kind of person has a disease is as essential as to know what kind of a disease a person has. Despite knowing this, physicians find it difficult to go beyond disease-centered clinical encounters. Current social and economic constraints on practice, along with medical training that does not equip physicians to deal with the patient's expression of values, ideas, or feelings, lead to clinical interviews that focus on understanding only the patient's disease. Even well-motivated clinicians may find that they are uncomfortable with and untrained to respond to the person of their patient. The spoken language is the most important diagnostic and therapeutic tool in medicine, but physicians-in-training as well as experienced clinicians report that even when they wish to focus on the patient, they lack the words to do so. Because they do not know what to say, they avoid the challenge (37). Developing a repertoire of carefully refined words is useful, and such mastery of language plays a recognized role in educating physicians to interview patients. Clinicians all learn, for example, to define a patient's physical pain with questions such as Where does it hurt?, Where else?, and Have you noticed anything that seems to increase the pain? In this article, we suggest language for conducting a patient-centered interview, offering words and phrases to help the physician who desires a more effective relationship with patients and who wants to communicate that patients are understood and valued. Of course, not all the questions cited should be used in any one interview. Often one request to the patientTell me about yourselfwill suffice. No one phrase works equally well for all physicians or all patients, and a skilled interviewer will titrate the language to the patient and the circumstances. A reader who wants to try these questions and directions might best choose a few favorite lines and try them out in clinical encounters. What Do Physicians Need To Know about the Person of a Patient? In getting to know the person of a patient, there are five main areas of concern: 1. Who is this patient? What constitutes that person's life? What are the patient's interests, work, important relationships, major concerns? 2. What does this patient want from the physician? What are his values and fears? What does he hope to accomplish here today or in the long run? 3. How does this patient experience this illness? Specifically, what has it done to her functionally; how has it affected relationships; and what symbolic meaning does it hold for her? 4. What are the patient's ideas about the illness? What is his understanding and perception of the disorder and its cause? What would seem to him to be reasonable treatment for it? 5. What are the patient's main feelings about the illness, with special attention to the five common responses: fear, distrust, anger, sadness, and ambivalence? Physicians may touch on these areas of concern in routine medical encounters but seldom explore them fully. To do so lays the groundwork for a relationship based on understanding and trust, a mutual dedication to the patient's health that is truly therapeutic. How To Say It 1. Who Is This Patient? According to Stoeckle (38), Patients bring not only their bodily complaints but also the circumstances of their everyday liveswho they are and might hope to be Elicitation of this psychosocial information about the patient is useful for relationship building, diagnosis, and the tasks of management. Some clinicians like to begin an interview with a new patient by asking about the person himself: Before we get to the medical problems, I'd like you to tell me a little about yourself as a person. Those who prefer to get right down to the biomedical facts can make room for such an inquiry later: Now that I've heard a little about this illness, and before we go on to review all your other health issues, I'd like to learn about you as a person. In either case, most patients will provide a capsule summary, seldom longer than 30 seconds, of their lives and interests. Occasionally a patient will hesitate and ask, Like what? If so, the physician can reply, Well, your work, who's at home, what goes on in your lifethat sort of thing. Sometimes the most open inquiry works best: Tell me about yourself. How would you describe yourself? If you had to describe yourself in 50 words or less, what would you say? What if you wanted to expand on that? Once the reluctant patient responds, the interviewer can ask for more details: Tell me about that. Sometimes the physician may offer to trade information: We should take a little time to get to know each other since we will be working together now. Let's start by my asking you to tell me about yourself, and later I'll be glad to answer your questions about me. Sometimes, of course, the physician is the new kid on the block: You've been coming here a long time, but I'm new. Tell me a bit about yourself. With returning patients, one can ask for interim reports: What's new in your life lately? Any changes in your life since your last visit here? Or, if the physician knows about a big event in the patient's life: How did that trip to Chicago go? 2. What Does This Patient Want from the Physician and the Medical Team? Physicians often assume that their patients' goals are exactly the same as the clinician's. But especially at the beginning of a relationship, it pays to inquire more fully: Since we're new to each other, it would help me to understand what you're most hoping for in a relationship with a new doctor. Sometimes the patient has left a previous physician because of some dissatisfaction, perhaps a communication problem: Since you told me that you left Dr. X because the two of you weren't communicating very well, can you tell me what works best for you in communicating with a doctor? What can we do to avoid having another communication problem like the one you experienced with Dr. X? Or, in the currently more common scenario of change: I can imagine that it is a real loss for you to have to leave Dr. Y just because your insurance changed. Can you tell me what worked well for you in your relationship with Dr. Y? Parenthetically, one should note that a question such as Can you tell me is theoretically answerable with a yes or a no and thus appears to be a closed-ended query, the sort physicians are urged to avoid. But most patients would take this question to be an invitation to tell more and would respond with an appropriate story, not a one-word answer. Sometimes physicians will discover that patient expectations contrast strongly with the physicians' own view of the patient's role and possibilities. Physicians may have to uncover that difference in their conversation with the patient: I see. It sounds as if what you expect from me is A, B, and C. But the difficulty I'm having is that the way I see my role is to do D, E, and maybe F. So we have different ideas about what I can do for you. How can we best proceed? Do you see any place where we can g