The Interviewer’s Questions

Speech Patterns

Speech patterns, referred to as paralanguage components, are relevant to the interview. By manipulating the intonation, rate, emphasis, and volume of speech, both the interviewer and the patient can convey significant emotional meaning through their dialogue. By controlling intonation, the interviewer or patient can change the entire meaning of words. Because many of these features are not under conscious control, they may provide an important statement about the patient's personal attributes. These audible parameters are useful in detecting a patient's anxiety or depression, as well as other affective and emotional states. The interviewer's use of a warm, soft tone is soothing to the patient and enhances the communication.

Body Language

A broad interest in body language has evolved. Body language, technically known as kinesics, is a significant aspect of modern communications and relationships. This type of nonverbal communication, in association with spoken language, can provide a more comprehensive picture of the patient's behavior. Your own body language reveals your feelings and meanings to others. Your patient's body language reveals his or her feelings and meanings to you. The sending and receiving of body language signals happens on both conscious and unconscious levels.

It is well known that the interviewer may learn more about the patient from the way the patient tells the story than from the story itself. A patient who moves about in a chair and looks embarrassed is uncomfortable. A frown indicates annoyance or disapproval. Lack of comprehension is indicated by knitted brows. Body language experts generally agree that hands send more signals than any part of the body except for the face. A patient who strikes a fist on a table while talking is dramatically emphasizing what he or she is saying. A patient who slips a wedding band on and off may be ambivalent about his or her marriage. A palm placed over the heart asserts sincerity or credibility. Many people rub or cover their eyes when they refuse to accept something that is pointed out. When patients disapprove of a statement made by the interviewer but restrain themselves from speaking, they may start to remove dust or lint from their clothing. See https://www.businessballs.com/self-awareness/body-language/ , which is a wonderful reference about body language.

Six universal emotional facial expressions are recognized around the world. The use and recognition of these expressions is genetically inherited rather than socially conditioned or learned. Although minor variations and differences are found among isolated people, the following basic human emotions are generally used, recognized, and part of humankind's genetic character:

• Happiness

• Sadness

• Fear

• Disgust

• Surprise

• Anger

Figure 1.1 shows some typical emotions. Of interest, Charles Darwin was first to make these claims in his book The Expressions of the Emotions in Man and Animals, published in 1872.

Smiling is an important part of body language. Generally, a genuine smile is symmetrical and produces creases around the eyes and mouth, whereas a fake smile tends to be a mouth-only gesture.

Arms act as defensive barriers when across the body, and conversely indicate feelings of openness and security when in open positions, especially combined with open palms. Arms are quite reliable indicators of mood and feeling, especially when interpreted with other body language. For example:

• Crossed arms may indicate defensiveness.

• Crossed arms and crossed legs probably indicate defensiveness.

• Crossed arms, crossed legs, frowning, and clenched fists definitely indicate defensiveness, and probably hostility.

Proxemics is the technical term for the personal space aspect of body language. Personal space is defined as the amount of space that people find comfortable between themselves and others. It can be visual, auditory, or kinesthetic, to name a few. Personal space dimensions depend notably on the individual, cultural and living background, the situation, and relationships. Individuals reared in different cultures live in different personal spaces. What is more important is that they are generally unaware of the degree to which the worlds of personal space may differ.

Full interpretation of body language can be made only in the context of the patient's cultural and ethnic background because different cultures may have different standards for nonverbal behavior. The interviewer may use facial expressions to facilitate the interview. An appearance of attention demonstrates an interest in what the patient is describing. Attentiveness on the part of the interviewer is often indicated by leaning slightly forward toward the patient.

Body language in a certain situation might not mean the same in another. Occasionally, body language isn't what it seems. For example:

• Someone rubbing his or her eye might have an irritation, rather than being disbelieving or upset.

• Someone with crossed arms might be keeping warm, rather than being defensive.

• Someone scratching his or her nose might actually have an itch, rather than concealing a lie.

A single body language signal isn't as reliable as several signals. As with any system of evidence, groups of body language signals provide much more reliable indication of meaning than one or two signals in isolation. Avoid interpreting only single signals. Look for combinations of signals that support an overall conclusion, especially for signals that can mean two or more quite different things. It is important to recognize that body language is not an exact science.

Touch

Touching the patient can also be very useful. Touch can communicate warmth, affection, caring, and understanding. Many factors, including gender and cultural background, as well as the location of the touch, influence the response to the touch. Although there are wide variations within each cultural group, Latinos and people of Mediterranean descent tend to use a great deal of contact, whereas British, Asians, and people from India tend not to use contact. Scandinavians and Anglo-Saxon Americans are in the middle of this range. Be aware, however, that certain religious groups prohibit touching a person of the opposite sex. In general, the older the patient, the more important touch is. Appropriate placement of a hand on a patient's shoulder suggests support. Never place a hand on a patient's leg or thigh, because this is a threatening touch. An interviewer who walks with good posture to a patient's bedside can hope to gain the patient's respect and confidence. An interviewer who maintains eye contact with the patient conveys interest in the patient.

Depersonalization of the Doctor–Patient Relationship

In this age of biomedical advancements, a new problem has arisen: a depersonalization of the doctor–patient relationship. Health care providers may spend more time looking at a computer screen than looking at their patient. Clinicians may order computed tomography scans or sonograms without taking the appropriate time to speak with the patient about the tests. Both doctor and patient may feel increasingly neglected, rejected, or abused. Patients may feel dehumanized on admission to the hospital. Many find themselves in a strange environment, lying naked while clothed people march in and out of the room and touch them, tell them what to do, and so forth. They may be apprehensive because they have a problem that their health care provider considers too serious to be treated on an outpatient basis. Their future is filled with uncertainty. A patient admitted to the hospital is stripped of clothing and often of dentures, glasses, hearing aids, and other personal belongings. A name tag is placed on the patient's wrist, and he or she becomes “the patient in 9W-310.” This lowers the morale of the patient even more. At the same time, clinicians may be pressed for time, overworked, and sometimes unable to cope with everyday pressures. They may be irritable and pay inadequate attention to the patient's story. They may eventually come to rely on the technical results and reports. This failure to communicate weakens the doctor–patient relationship.

Inexperienced interviewers not only must learn about the patient's problems but also must gain insight into their own feelings, attitudes, and vulnerabilities. Such introspection enhances the self-image of the interviewer and results in the interviewer's being perceived by the patient as a more careful and compassionate human being to whom the patient can turn in a time of crisis. This is discussed further in Chapter 5 , Mitigating Racism and Bias in Clinical Medicine.

A good interviewing session determines what the patients comprehend about their own health problems. What do the patients think is wrong with them? Do not accept merely the diagnosis. Inquire specifically as to what the patient thinks is happening. What kind of effect does the illness have on the patient's work, family, or financial situation? Is there a feeling of loss of control? Does the patient feel guilt about the illness? Does the patient think that he or she will die? By pondering these questions, you can learn much about patients, and patients will realize that you are interested in them as whole persons, not merely as statistics among the hospital admissions.

Medical Malpractice and Communication Skills

The literature indicates that malpractice suits have increased at an alarming rate. A good doctor–patient relationship is probably the most important factor in avoiding malpractice claims. As mentioned previously, most malpractice litigation is the result of a deterioration in communication and of patient dissatisfaction rather than of true medical negligence. The patient who is likely to sue has become dissatisfied with the clinician and may have lost respect for him or her. From the patient's point of view, the most serious barriers to a good relationship are the clinician's lack of time; seeming lack of concern for the patient's problem; inability to be reached; attitude of superiority, arrogance, or indifference; and failure to inform the patient adequately about his or her illness. Failure to discuss the patient's illness and treatment in understandable terms is viewed as a rejection by the patient. In addition, the congeniality and competence of a physician's office staff can go a long way toward avoiding malpractice suits. Physicians who have never been sued orient their patients to the process of the visit, use facilitative comments, ask the patient for opinions, use active learning, use humor and laughter, and have longer visits. A doctor–patient relationship based on honesty and understanding is thus recognized as essential for good medical practice and the well-being of the patient.

It is sometimes difficult for a novice interviewer to remember that there is no need to try to make a diagnosis out of every bit of information obtained from the interview. Accept all the clues and then work with them later when trying to establish a diagnosis.

If during the interview you cannot answer a question, do not. You can always act as the patient's advocate; listen to the question and then find someone who can provide an appropriate answer.

Doctor–Patient Engagement

A very important task of communication is to engage the patient. A helpful way of building rapport with a patient is to be curious about the person as a whole. Ask, “Before we begin, tell me something about yourself.” When the patient returns, mention something personal that you learned from a previous visit—for instance, “How was your trip to Seattle to see your son?” Another part of engagement is to determine the patient's expectations from the visit; for instance, ask, “What are you hoping to accomplish today?” At the conclusion of the visit, ask “Is there anything else you are concerned about?” If the patient has several problems, it is acceptable to say, “We might need to discuss that problem at another visit. I want to be certain that we completely evaluate your main concern today.”

Privacy Standards

On April 14, 2003, the first federal privacy standards were put in place to protect the medical records and other health information of patients. The U.S. Congress asked the Department of Health and Human Services to issue privacy protection as part of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA regulations include provisions designed to encourage electronic transactions and to safeguard the security and confidentiality of health information. The final regulations cover health plans, health care clearinghouses, and health care providers who conduct financial and administrative transactions electronically. In short, these regulations regarding patient confidentiality limit the ways in which health care providers, health plans, pharmacies, hospitals, clinics, and other entities can use patients’ personal medical information. These regulations ensure that medical records and other identifiable health information, whether on paper, in computers, or orally communicated, are protected. See Chapter 30 , Clinical Ethics and Professionalism, and https://www.hhs.gov/hipaa/index.html for further information about privacy standards.

In summary, the medical interview is a blend of the cognitive and technical skills of the interviewer and the feelings and personalities of both the patient and the interviewer. The interview should be flexible and spontaneous and not interrogative. When used correctly, it is a powerful diagnostic tool.

Getting Started and Introduction

The diagnostic process begins at the first moment of meeting. You should be dressed appropriately, wearing a white coat with your name badge identifying you as a member of the health care team. Patients expect this standard of professional attire. Casual attire may signify condescension.

It is important to assess gender identity at the start of a patient encounter. This prevents assumptions of a patient's gender identity, mitigates potential biases, and normalizes discussions around gender identity for the patient. It is recommended that clinicians call their patient by first and last name until gender identity and preferred name and pronouns are established. This prevents using a salutation that does not align with a patient's gender identity (i.e., calling a patient who identifies as female “Mr. Smith”). Chapter 5 , Mitigating Racism and Bias in Clinical Medicine, discusses this topic in more detail.

Introduce yourself, greet the patient by name, make eye contact, shake hands firmly, and smile. You may wish to say something like:

“Good morning, I'm Mary Jones; are you Francis Smith? [Pause and wait for answer.] I am a medical student at the XXX School of Medicine. I've been asked to interview and examine you in the next hour.”

or

“Good morning, I'm Mary Jones; please tell me how to pronounce your name? [Pause and wait for answer.] I am a medical student at the XXX School of Medicine. I've been asked to interview and examine you in the next hour.”

or

“Good morning, I'm Mary Jones, are you Francis Macaffy? Did I pronounce your name correctly? [Pause and wait for answer.] I am a medical student at the XXX School of Medicine. I've been asked to interview and examine you in the next hour.”

At the start of the encounter, ask the patient to clarify their gender identity and establish the patient's preferred name and pronouns. A simple way to ask includes:

“I don't like to assume anything about my patients, so I always start my initial encounters by asking how you would like to be addressed.”

It is appropriate to address patients by their preferred titles—“Mr.,” “Mrs.,” “Miss,” “Dr.,” “Ms.”—unless they are adolescents or younger. A formal address clarifies the professional nature of the interview. For a woman, the default always is “Ms.” unless you know positively that a woman wishes to be addressed as “Miss” or “Mrs.” Name substitutes such as “dear,” “honey,” or “grandpa” are not to be used. Also, avoid using “Sir” or “Ma'am.” “Ma'am” is mostly obsolete, with a few exceptions. It is commonly used to address any woman in the southern or southwestern areas of the United States. Use the patient's name. If you are not sure about the pronunciation, ask the patient how to say his or her name correctly.

The patient may elect to use the interviewer's first name. It is not correct for an interviewer to address the patient by his or her first name, because this changes the professional nature of this first meeting.

Prior to establishing the patient's sexual orientation and practices, clinicians should use inclusive terminology that avoids assumptions. For example, use terms such as “partner,” as opposed to “husband or wife,” until the patient's preferred terminology is established. Much more about this important subject is discussed in Chapter 5 , Mitigating Racism and Bias in Clinical Medicine.

The term student doctor should generally be avoided because patients may not actually understand this term; they may hear only the word doctor . The introduction also includes a statement of the purpose of the visit. The welcoming handshake can serve to relax the patient. It establishes a contract between the patient and the health care provider. Of course, we need to remember cultural and religious reasons for not shaking hands.

If the patient is having a meal, ask whether you can return when he or she has finished eating. If the patient is using a urinal or bedpan, allow privacy. Do not begin an interview in this setting. If the patient has a visitor, you may inquire whether the patient wishes the visitor to stay. Do not assume that the visitor is a family member. Allow the patient to introduce the person to you.

The interview can be helped or hindered by the physical setting in which the interview is conducted. If possible, the interview should take place in a quiet, well-lit room. Unfortunately, most hospital rooms do not afford such luxury. The teaching hospital with four patients in a room is rarely conducive to good human interactions. Therefore, make the best of the existing environment. The curtains should be drawn around the patient's bed to create privacy and minimize distractions. You may request that the volume of neighboring patients’ radios or televisions be turned down. Lights and window shades can be adjusted to eliminate excessive glare or shade. Arrange the patient's bed light so that the patient does not feel as if he or she is under interrogation.

You should make the patient as comfortable as possible. If the patient's eyeglasses, hearing aids, or dentures were removed, ask whether the patient would like to use them. It may be useful to use your stethoscope as a hearing aid for hearing-impaired patients. The ear tips are placed in the ears of the patient, and the diaphragm serves as a microphone. The patient may be in a chair or lying in bed. Allow the patient the choice of position. This makes the patient feel that you are interested and concerned, and it allows the patient some control over the interview. If the patient is in bed, it is a nice gesture to ask whether the pillows should be arranged to make him or her more comfortable before the interview begins.

To Stand or to Sit?

Normally, the interviewer and patient should be seated comfortably at the same level. Often, it is useful to have the patient sitting even higher than the interviewer to give the patient the visual advantage. In this position, the patient may find it easier to open up to questions. If the patient is seated on the examination table, the interviewer should sit on the stool or in a chair, slightly off center, facing the patient to make good eye contact. Sitting down while speaking to the patient conveys the unspoken understanding that the interviewer is not in a rush and has time to spend with the patient. Sitting on the bed is too familiar and not appropriate. It is generally preferred that the interviewer sit at a distance of about 3 to 4 feet from the patient. Distances greater than 5 feet are impersonal, and distances closer than 3 feet interfere with the patient's “private space.” The interviewer should sit in a relaxed position without crossing arms across the chest. The crossed-arms position is not appropriate because this body language projects an attitude of superiority and may interfere with the progress of the interview. If the patient is lying on the examination table, it is preferable for the interviewer to stand, as it may be uncomfortable for the patient to turn his/her head to speak to the interviewer.

If the patient is bedridden, raise the head of the bed, or ask the patient to sit so that your eyes and the patient's eyes are at the same level. Avoid standing directly over the patient. Try to lower the bed rail so that it does not act as a barrier to communication and remember to put it back up at the conclusion of the session.

Regardless of whether the patient is sitting in a chair or lying in bed, make sure that he or she is appropriately draped with a sheet or robe.

The Opening Statement

Once the introduction has been made, the interview may begin with a general, open-ended question, such as “How may I help you?” or “What medical problem has brought you to the hospital?” or “I understand you are having… Tell me more about the problem.” This type of opening remark allows the patient to speak first. The interviewer can then determine the patient's chief complaint: the problem that is regarded as paramount. If the patient asks, “Haven't you read my records?,” it is correct to say, “No, I've been asked to interview you without any prior information.” Alternatively, the interviewer could say, “I would like to hear your story in your own words.”

Patients can determine very quickly if you are friendly and personally interested in them. You may want to establish rapport by asking them something about themselves before you begin diagnostic questioning. Take a few minutes to get to know the patient. If the patient is not acutely ill, you may want to say, “Before I find out about your headache, tell me a little about yourself.” This technique puts the patient at ease and encourages him or her to start talking. The patient usually talks about happy things in his or her life rather than the medical problems. It also conveys your interest in the patient as a person, not just as a vehicle of disease.

The Narrative

Novice interviewers are often worried about remembering the patient's history. However, it is poor form to write extensive notes during the interview. Attention should be focused more on what the person is saying and less on the written word. In addition, by taking notes, the interviewer cannot observe the facial expressions and body language that are so important to the patient's story. A pad of paper may be used to jot down important dates or names during the session.

After the introductory question, the interviewer should proceed to questions related to the chief complaint. These should naturally evolve into questions related to the other formal parts of the medical history, such as the present illness, past illnesses, social and family history, and review of body systems. Patients should largely be allowed to conduct the narrative in their own way. The interviewer must select certain aspects that require further details and guide the patient toward them. Overdirection is to be avoided because this stifles the interview and prevents important points from being clarified.

Small talk is a useful method of enhancing the narrative. Small talk, also known as “chit-chat,” is neither random nor pointless, and studies in conversation analysis indicate that it is actually useful in communication. It has been shown that during conversations, the individual who tells a humorous anecdote is the one who is in control. For example, if an interviewer interjects a humorous remark during an interview and the patient laughs, the interviewer is in control of the conversation. If the patient does not laugh, the patient may take control.

Be alert when a patient says, “Let me ask you a hypothetical question” or “I have a friend with … ; what do you think about … ?” In each case, the question is probably related to the patient's own concerns.

A patient often uses utterances such as “uh,” “ah,” and “well” to avoid unpleasant topics. It is natural for a patient to delay talking about an unpleasant situation or condition. Pauses between words, as well as the use of these words, provide a means for the patient to put off discussing a painful subject.

When patients use vague terms such as “often,” “somewhat,” “a little,” “fair,” “reasonably well,” “sometimes,” “rarely,” or “average,” the interviewer must always ask for clarification: “What does sometimes mean?” “How often is often? ” Try to quantify a qualitative adverb. Even terms such as “dizzy,” “weak,” “diarrhea,” and “tired” necessitate explanation. Precise communication is always desirable, and these terms, among others, have significant variations in meaning.

The interviewer should be alert for subtle clues from the patient to guide the interview further. There are a variety of techniques to encourage and sustain the narrative. These guidelines consist of verbal and nonverbal facilitation, reflection, confrontation, interpretation, and directed questioning. These techniques are discussed later in this chapter.

The Closing

It is important that the interviewer pace the interview so that adequate time is left for the patient to ask questions and for the physical examination. About 5 minutes before the end of the interview, the interviewer should begin to summarize the important issues that were discussed.

By the conclusion of the interview, the interviewer should have a clear impression of the reason why the patient sought medical help, the history of the present illness, the patient's past medical history, and the patient's social and economic position. At this time, the interviewer may wish to say, “You’ve been very helpful. I am going to take a few notes.” If any part of the history needs clarification, this is the time to obtain it. The interviewer may wish to summarize for the patient the most important parts of the history to help illuminate the important points made.

If the patient asks for an opinion, it is prudent for the novice interviewer to answer, “I am a medical student. I think it would be best to ask your doctor that question.” You have not provided the patient with the answer that he or she was seeking; however, you have not jeopardized the existing doctor–patient relationship by possibly giving the wrong information or a different opinion.

At the conclusion, it is polite to encourage the patient to discuss any additional problems or to ask any questions: “Is there anything else you would like to tell me that I have not already asked?” “Are there any questions you might like to ask?” Usually, all possible avenues of discussion have been exhausted, but these remarks allow the patient the “final say.”

Thus, a good closure should consist of the following four parts:

• Provide a summary.

• Provide an opportunity for questions. Does the patient have any questions, and have you answered them?

• Provide reassurance only as appropriate. You could say, “It's a good thing that you came in today; I will do everything possible to help you.” Patients like to know that they did the right thing to seek medical attention. Do not give false reassurances.

• What happens next? Instruct the patient to get dressed and leave; wait for the nurse to draw blood; wait for the technician to do an electrocardiogram; or other activity.

Questioning

The secret of effective interviewing lies in the art of questioning. The wording of the question is often less important than the tone of voice used to ask it. In general, questions that stimulate the patient to talk freely are preferred.