Conversation, rapport key to evolving world of medical history taking
■ How do you keep the patient at the center of the medical interview?
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted June 8, 2009.
Given the high-tech trend in patient encounters, how do you conduct the medical interview in a way that does not interfere with the patient relationship?
Reply: A recent article in American Medical News noted that clinicians are experiencing more difficulty in their traditional task of taking the patient's history because they're being asked to investigate more areas of the patient's life, have less time to do so, and are still adapting to the introduction of electronic medical records. The article quotes physicians who bemoan the delegation of this critical task to physician assistants and other office staff, or to the use of a mere checklist. To many physicians, this is a shocking notion that strikes at the ideal of thorough examination and data-gathering and prompts us to ask what our ethical responsibilities are in talking with a patient.
Answering this question requires that we understand our goals in the medical conversation and the procedures we use to accomplish those goals. It seems clear that the medical encounter asks us to fulfill three tasks, well described by Steven Cohen-Cole in his 1991 book, The Medical Interview: The Three-Function Approach:
- Develop a working relationship with the patient that creates rapport and trust.
- Collect key data about the patient as a person and about the illness or illnesses he or she has.
- Consider forward-moving steps such as patient education and patient enlistment in his or her own welfare.
Understanding these three tasks has led us to abandon the term "history taking," and replace it with a more inclusive term, the medical interview. Perhaps we understood taking a history to imply that through a series of questions we would extract a fully formed story of the patient's present illness and accompanying health history. Little did we know that a history does not exist to be taken, that it was always a joint creation of patient and clinician.
Optimally, the patient tells us something, we check to see that we heard it correctly, then we interpret it using our biopsychosocial technical knowledge and check back with the patient, who then corrects our understanding. We use this sequence over and over until we have arrived at a joint production, an invention of two authors, something that in the end has to make sense to the patient (fit with his or her symptoms, worries, ideas) and make sense to the clinician (fit in the context of the biomedical/psychosocial world).
Yet, because many physicians seem to discard that most important first task, the development of a therapeutic relationship, we find that they attempt to define their role simply as data acquisition and then often misunderstand the appropriate tools for that very task.
In fact, many physicians have mastered only one tool for data acquisition, the closed question, and as a result expose their patients to an inquisition-like barrage of yes/no questions that stops the patient from telling his or her story adequately, demolishes rapport, and leads to eventual distrust and poor patient compliance. Patients who experience such questioning often describe their physicians as neither listening nor understanding; they may suspect that the physician is interested in and expert about their kidneys, but not about them.
If our ethical responsibility to our patients is not that of taking a history, neither is it one of delegating such a task to an assistant or a checklist. If we are to connect with our patient, to develop trust and rapport, and to conjointly develop the patient's story and a joint plan for the future, the task requires a real conversation that respects both members of the dialogue.
So there are several potential problems: a defective interview technique, whether wielded by a physician or an associated health worker, then the lure of a checklist form of data acquisition, and finally the attraction of a medical chart or electronic medical record. What might we do?
First, we suggest replacing that defective technique -- use of closed or narrow questions -- with a open form of inquiry in which we invite the story, listen to it, then summarize what we have heard before inviting again. Invitations, listening and summarizing will suffice for 90% of the data acquisition, lead to a partnership in creating the story and greatly increase rapport. Patients interviewed in this manner report high regard for the interviewer and cooperate much more fully with suggestions. And, as surprising as it may sound, this mode of interviewing saves time.
To visualize the time saving, imagine going to a restaurant and having the waiter ask you, one dish at a time, what you wanted. "Do you want a steak?" ("No," you'd reply), then "How about fish and chips?" ("Nope!"), then "Hot fudge sundae?" ("No, again!"). What a waste of time! Instead, a competent waiter hands you the menu and says, "Tell me what you would like" -- an invitation rather than a question.
What about our charting? What about use of the computer? How about checklists? Attending more to the chart than to the patient is not a new problem, but use of computers seems to magnify that phenomenon. Computers hold us tightly. Haven't we all had the experience of buying a trivial item at the store and finding the clerk mesmerized by her computer, extending the time of the transaction, while we stand by, feeling unseen and unheard and wondering what in the world she and her computer can be doing?
Our computers have the same magnetic attraction for us. We have to fight that magnetism. I suggest parsing our use of the record, whether a paper chart or a computerized record, by first connecting to the patient, inviting his or her story, listening attentively until either he or she runs down or our brain is full, summarizing what we have heard, and only then asking permission to note some of what the patient has said into the record. If we use a computer, it should be placed so we can allow our patient to see what we are writing. What then? Repeat the process, of course. It might sound like this:
This sequence -- invite the story, listen to it, summarize what you have understood, then enter the data into the chart or computer -- can be repeated over and over until the patient cannot add more. Then, and only then, is it appropriate to ask leftover questions, filling in the few small gaps in the patient's story and our understanding.
What's going on? First, we have created a partnership with the patient, not with the computer. Then we use a time-efficient form of inquiry, by a sequence of inviting, listening, and summarizing what we have understood. Finally, we enter data into the record episodically after it is clear that we and our patient agree on the story.
Should we delegate this task? Probably not. Although ancillary interviewers can gather some of the story and even checklists can help, they should not be viewed as a replacement for a real conversation between the clinician and the patient. Do checklists help? Sometimes they remind the patient of topics she or he might otherwise forget to bring up. But they are no replacement for a conversation initiated by invitations such as "Tell me about ... ."
In the end, we will no longer suffer from conversation failure and our patients will no longer describe us as a limb of a machine. We will fulfill the cardinal rule of conversation: Nobody will be ready to listen to us until they are convinced that we have listened to and understood THEM! It makes the practice of medicine a lot more fun and effective for all of us and it is indeed our ethical responsibility.
Frederic W. Platt, MD, clinical professor of medicine, University of Colorado, Denver, School of Medicine; regional consultant for the Institute for Healthcare Communication
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.