Benefits for Patient and Physician

Crijnen, A. A. M., & Kraan, H. F. (1987). The medical interview: effects on patient and physician. In H. F. Kraan & A. A. M. Crijnen (Eds.), The Maastricht History-taking and Advice Checklist: studies of instrumental utility (pp. 69–80). Lundbeck, Amsterdam.

Affective satisfaction

Affective satisfaction is defined as the patient’s perception of the quality of physician-patient communication, including feelings of trust and confidence in the physician, and their perception of the physician’s positive regard and willingness to listen to the concerns (Wolf et al., 1978).

Critique by patients

Although most patients are moderately to highly satisfied with the communication, 11% of all patients are moderately dissatisfied, whereas 15% were even highly dissatisfied (Korsch and Negrete, 1972; Francis et al., 1969).

The severest and most common complaint of dissatisfied patients is that physicians show too little interest in their concerns:

• 26% of all patients did not mention their greatest concern to the physician, because patients had no opportunity provided or were not encouraged to do so.
• Korsch et al. (1972) frequently observed a breakdown of communication under such circumstances.
• Some patients were so preoccupied with their dominant concerns that they were unable to respond to the physician’s questions and advice.
• Attention to the patients’ worries and concerns was found to correlate highly with success in satisfying them and obtaining their compliance with advice.

Elicit worries and concerns

Korsch recommends the opening of the medical consultation with open-ended questions pertaining to the reasons for the visit in order to elicit the patient’s concerns. 

Open the consultation with eliciting your patient’s concerns

Moreover, affective satisfaction has been significantly correlated with the absolute quantity of information conveyed by the patient to the physician. The exchange of patient-centered information can be enhanced by a physician’s interview behavior, allowing patients to tell their story in their own words (Stiles et al., 1979; Putnam et al., 1985).

Eisenthal and Lazare (1977) found that interview behavior aimed at helping the patient to put his request into words correlates significantly with measures of satisfaction and the feeling of being helped:

• They experienced that patients find it difficult to state their request, whilst, at the same time, feeling that verbalizing the request is very important.
• Patients can be helped in the expression of a request by a structuring activity from the physician or by a specific kind of collaborative involvement.
• Studies suggest that patients need to be given time to express their concerns and describe their illnesses. 

Structure and involvement help your patient to express their requests

Other studies indicate that the affective dimension of physician- patient communication plays an important part in the evaluation of the consultation, because patients lack the knowledge necessary to evaluate the physician’s medical competency. The perceived degree of emotional support given and physician’s time, interest and devotion are major dimensions in the evaluation of the consultation by the patient (Segal and Burnett, 1980). 

Patient-satisfaction is based on the physician’s affective behavior rather than on his technical performance in consultations where the presented problem incorporates emotional involvement due to the perceived seriousness of the problem and uncertainty about the consequences, and in the situation where the patient is unable to judge the quality of the presented solutions (Ben-Sira, 1976).

Insight

Insight refers to the explanations and information given by the physician and to the patient’s understanding of diagnosis, etiology, prognosis and effects of treatment (Wolf et al., 1978). This issue has been studied several times: some of these studies are focused on the process of information-exchange, whereas others describe the kind of information exchanged. 

Critique by Patients

The relation between explanation and information-giving on several outcomes of the consultation has been studied by Tuckett et al. (1985).

• At the end of a consultation, 10% of the patients were unable to remember what their physicians had told them about diagnosis, purpose of treatment or prevention.
• Of all patients who were able to recall important information, only 73% correctly interpreted one of the topics in the consultation (80% had a correct opinion on diagnosis, 92% about advice on therapy and 75% about advice on prevention).
• Of those patients who correctly interpreted important information, 25% disagreed with the physician’s view on at least one of the important points the physician made.

Tuckett (1985) therefore concludes that patients encounter difficulties in processing the information given by the physician; this is not due to a failure of memory, but occurs during the interpretation and evaluation of the physician’s information.

Recall & Interpretation

The interpretation given by patients of the information provided by the physician, depends on patients’ attributions before the consultation and their scope for using them afterwards. Tuckett recommended that physicians should pay heed to the content of the ideas they communicate. Moreover, they should establish and discuss points of difference between their own and their patients’ health beliefs and explanatory models. Earlier studies have also pointed in the same direction: the effectiveness of the information provided depends on the extent to which it addresses the patient’s concerns and expectations (Bartlett, 1981). 

Support your patient with interpreting and evaluating the information provided

Other studies have revealed that patients recalled only 40% of information correctly (Anderson et al., 1979), whereas 48% of what patients thought was said, was imagined or misconstrued. The more information given, the more is recalled, although proportionately less of this is correct. Patients remember more information about treatment and medication correctly than about diagnosis. 

Ley et al. (1973) attempted to enhance the patient’s recall of information by organizing medical information into explicitly labelled categories. The use of explicit categorization increased recall of information, especially in the category on what patients should do about their complaints. 

What patients expect to hear from you?

The kind of information that patients expect to acquire during a medical consultation does not differ between patients from different classes or educational backgrounds.

All patients expect to receive information about (Waitzkin, 1985):

• Diagnosis;
• Causes;
• Prognosis about their complaints;
• Proposal for further treatment. 

Patients’ insight will be increased as a result of the exchange of information. The explanation given correlates significantly with the perceived controllability of the illness.

Patients who feel they have control over their illness, obtain more information from their physician and feel more confident

Patients who consider their illness to be more controllable obtain more explanation from the physician and feel more confident about managing their illnesses (Putnam et al., 1985). This is probably achieved by influence over patients’ health understanding (Pendleton, 1983).

Moreover, patients’ rapport and cooperation are stimulated by specific instructions, expressions of trust in patients’ ability for self-care, warm concern and individualization of advice. 

Unfortunately, many factors impinge on the quality of information exchange:

• The Korsch study (1972) discloses that nearly a fifth of all patients did not receive a clear statement of what was wrong, whereas half of all patients were still wondering what had caused their illness when they left the physician’s office.
• Prognoses were never offered.
• When the expected information about causation and nature of the illness is not provided, satisfaction and compliance with treatment decreases significantly.
• Medical jargon leaves many patients uninformed about the nature of their problem.
• Technical discussions about the patient’s condition using impersonal or institutional expressions are less likely to stimulate patient rapport and cooperation.
• Reducing the exchange of information by truncating the interaction is negatively associated with insight (Stiles et al., 1979).

We conclude, therefore, that patients expect to receive information about their condition, but that the quality of information exchange is easily impaired.

Compliance

Compliance or rather: Non-compliance

Compliance or rather, non-compliance, with the medical regimen has been well-studied as an outcome measure of the medical interview:

• Davis (1966, 1968) classified 37% of patients as non-compliant, whereas Francis et al. (1969) measured 38% as moderately compliant and 11% as non-compliant.
• In a well-known study, it was reported that 58% of all patients made errors in the taking of medication (Nulka et al., 1976). 

Communication and Non-compliance

Non-compliance appears to be partly related to the quality of physician-patient communication.

Davis (1968) describes several types of communication between patient and physician which are associated with non-compliance. These communication types are a patient with malintegrative behavior, an authoritarian physician, a non-directive physician, or a physician who collects information without giving any feedback.

A communication style which is positively related to patient- compliance is characterized by joking, laughing, signs of satisfaction with the physician-patient relationship and tension release.

Davis concludes, therefore, that compliance is a function of a delicate balance between providing and obtaining information presented in a manner that is acceptable to the patient. 

Patients tend to be compliant to the best of their knowledge

Furthermore, the clarity of physicians’ instructions, followed by the interest in patients’ symptoms, the amount of information given about the disease and several dimensions of physicians’ medical competence, discriminates most effectively with regard to patients’ compliance with physicians’ instructions (Vuori, 1972).

The lack of congruity, between what the patient thinks he is supposed to do and what the physician thinks the patient should do, was found furthermore to induce non-compliance (Nulka et al., 1976). Patients tend to be compliant to the best of their knowledge, but they are sometimes acting on misinformation which leads to misunderstanding and confusion.

Recall & Understanding

Providing knowledge of drug-function and demonstrating which drugs should be taken for which purpose during follow-up visits, are recommended as inducing compliance. When patients were informed about what was expected of them, more than 85% complied.

Two factors seem particularly important in inducing adherence to the medical regimen. These factors are:

• The extent to which the patient understands the information presented;
• To which the patient remembers the message (Ley, 1983).

Adherence to medication is mediated by patient satisfaction and recall of information which are induced by the effect of physicians’ interpersonal skills and the provision of information (Bartlett, 1981). 

Eisenthal and Lazare (1977) advocate a customer approach consisting of the elicitation, negotiation and disposition of the patient’s request during the initial psychiatric interview in a walk-in clinic. Satisfaction and feelings of having been helped correlate highly with patient participation in the treatment planning. Adherence to the treatment-regimen is significantly related to negotiation. 

Solicit your patient to participate in treatment planning

Negotiation results in the legitimization of patients’ ideas about treatment and the sollicitation of their participation in the treatment planning. Even patients who do not get the treatment they want, comply well.

Anxiety reduction and reassurance

Anxiety reduction and reassurance are often mentioned as important outcomes of the medical interview, although they are rarely studied. 

Sprecher et al. (1983) tried to reduce patients’ anxiety by encouraging patients to disclose underlying concerns and then either confirming or disproving these concerns: this proved to be an effective way of reducing patients’ anxiety.

The exact mechanism by which this was achieved is not yet understood: a physician’s interview behavior might communicate that the physician has understood or heard the patient’s fears accurately, or it might mean that the patient’s uncertainties have been further resolved.

Anxiety, Fear & Communication

Reynolds (1978) interviewed patients on a surgical ward in a large hospital and observed that 24 % of the patients wanted more information about investigations and 38% about the results of their investigations. Anxiety and fear were the inevitable consequences of the poor communication. To most hospitalized patients, fear of the unknown is a much heavier burden to bear than full knowledge of their illness.

Your patient can’t learn when they are too anxious

According to DiMatteo and DiNicola (1982), patients who are emotionally upset rarely comprehend information clearly. Learning appears to be most effective when patients experience a moderate level of anxiety. Therefore, explanations given to the patient might do little to change his state of knowledge about his condition unless the patient’s anxiety level is also reduced.

Changes in health status

Improvement in patients’ health status has been recognized and studied only recently as a long-term outcome of the medical consultation. A significant association was found between the number of patients’ utterances during history-taking and the improvement of their symptom status (Putnam et al., 1985). Greenfield et al. (1985) increased patients’ involvement in the medical consultation and found that two months after the intervention, fewer limitations in physical and role-related activities were reported in comparison with a control group.

Patients who showed more commitment to the therapeutic regimen and who had an increased sense of self control, were better able to regulate their blood sugar and showed lowered díastolic blood pressures (Kaplan, 1986). 

These studies stress that good physician-patient communication is important for the improvement of patients’ health status. 

Diagnosis

The importance of the medical interview for the physician is mainly studied from the perspective of diagnosis.

Quality of Data Equals Quality of problem-solving

Diagnosis

Hampton et al. (1975) have assessed the relative contributions of history-taking, physical examination and laboratory investigations to diagnosis and management of medical outpatients. The medical history provided enough information to make an initial diagnosis in approximately 80% of the consultations. Others found that history-taking is of major importance in establishing diagnosis and the treatment plan (Sandler, 1980). 

In 80% of consultations, History-taking provided enough information for diagnosis

Request for Help

Closely related to diagnosis is the physician’s awareness of the patient’s request for help. Taylor (1980) observed disagreement between the physician’s and the patient’s definition of the reason for encounter in one third of all consultations and recommended an early discussion of the primary purpose of the visit to prevent the development of misperceptions.

Clinical Problem-solving

Other researchers have studied the process of clinical problem-solving (Elstein et al. 1978; Kassirer et al., 1978; Neufeld et al., 1981) and have found a strong association between history-taking and clinical problem-solving. History-taking is the verbal (or behavioral) dimension and problem-solving the cognitive dimension of the same process.

The act of gathering data by means of asking questions forms input and output for the cognitive process of clinical problem-solving (see Clinical Competency):

• The quality of information- exchange is considered to be of importance to the quality of hypothesis-generation and testing and, through that, for the quality of diagnosis.
• The exchange of information can be distorted or inhibited by means of the use of medical vocabulary, ambiguous questions, two or more questions at the same time, etc. 

Mislabelling of symptoms by patients

The effect of patients’ mislabelling of symptoms on medical outcome has been studied (Dirks et al. (1982). More than one quarter of 587 chronic asthmatic patients mislabelled one or more airway obstruction symptoms as being an asthma attack. Mislabelling patients were more than 40% more likely to be hospitalized than non-mislabellers. The researchers attributed this effect to the distortion of the patients’ reports of their clinical picture. 

History-taking & Quality of Diagnosis

Furthermore, the number of questions asked during history-taking is not unequivocally related to the quality of diagnosis.

Your goal is to interview like an expert-specialist: ask fewer questions and mention the correct diagnosis earlier

Physicians who are specialists in a certain domain ask fewer questions during history-taking, mention the correct diagnosis earlier and are sooner convinced of the diagnosis than are non-specialists (Kassirer et al., 1978). Non- specialists, like students or residents, often revert to a general review of systems when they have no clear idea in which direction to proceed during history-taking. Obviously, physicians can choose between several strategies for achieving the goals of diagnosis. 

Accuracy in Detecting Minor Psychiatric Disorder

The relation between the accuracy of detecting minor psychiatric disorders and physicians’ medical interview behavior has been studied by Goldberg et al. (1980).

Maintain eye-contact to better detect minor psychiatric disorder

Ten types of medical interview behavior were related to the accuracy of detection and they appeared to improve significantly as a result of training: an important finding. These interview behavior patterns are:

• Eye contact;
• Clarification of presented complaints;
• Using open-to-closed cones;
• Empathic interview style;
• Sensitivity to verbal and non-verbal cues;
• Not reading notes during history-taking;
• Dealing adequately with over-talkative patients;
• Asking fewer questions about past history.

In addition to the physician’s interview style, his personality and academic ability were also related to the accuracy of detection of psychiatric disorder.

Concluding remarks

The studies reviewed have increased our understanding of the necessary ingredients of a medical interview.

Outcomes important for your patient are endorsed through interview behavior, especially the quality of the relationship is cherished by your patient

• Affective satisfaction is closely related to the patient-centered phase in the interview which allows the patient to express his thoughts and actions.
• Diagnosis can only be established by means of history-taking.
• Patients’ insight and compliance-induction are mainly the result of the presentation of solutions in which information is provided and commitment established.
• Anxiety reduction can be induced by listening to patients’ complaints and worries or by providing information.

The quality of the relationship appears to be of importance during all phases of the interview. All outcomes mentioned here can be influenced by a physician’s medical interviewing skills. They are therefore ideally suited to form criterion measures for the impact of interviewing skills on the patient. This allows us to establish the construct validity of our measures of medical interviewing skills and to develop theories on physician-patient communication.

Your skills in conducting a medical interview are valued by your patients

Concluding remarks

The studies reviewed have increased our understanding of the necessary ingredients of a medical interview.

Outcomes important for your patient are endorsed through interview behavior, especially the quality of the relationship is cherished by your patient

• Affective satisfaction is closely related to the patient-centered phase in the interview which allows the patient to express his thoughts and actions.
• Diagnosis can only be established by means of history-taking.
• Patients’ insight and compliance-induction are mainly the result of the presentation of solutions in which information is provided and commitment established.
• Anxiety reduction can be induced by listening to patients’ complaints and worries or by providing information.

The quality of the relationship appears to be of importance during all phases of the interview. All outcomes mentioned here can be influenced by a physician’s medical interviewing skills. They are therefore ideally suited to form criterion measures for the impact of interviewing skills on the patient. This allows us to establish the construct validity of our measures of medical interviewing skills and to develop theories on physician-patient communication.

Your skills in conducting a medical interview are valued by your patients