For education, an initial medical interview:
In this chapter, you will find an educational model for an initial interview in general medicine and mental health.
Kraan, H. F., & Crijnen, A. A. M. (1987). The medical interview and related skills. In H. F. Kraan & A. A. M. Crijnen (Eds.), The Maastricht History-taking and Advice Checklist: studies of instrumental utility (pp. 29–68). Lundbeck, Amsterdam.
In their most simple form, initial medical interviews in general medicine as well as in primary mental health care, have three phases, i.e., Exploration of the Reasons for Encounter, History-taking and Presenting Solutions.
In this phase, the physician asks the patient to describe the complaint(s) in their own way. And the physician explores co-existing emotions and concerns.
This phase requires a patient-centered, non-directive, explorative, open style of questioning. The goal of this phase is to clarify in which way the patient desires to be helped with his problem.
The questions asked during this phase reflect the classical medical inquiry strategy which is the consequence of the clinical reasoning process.
The basic interviewing style during this phase is also non- directive. However, hypotheses-generation may require systematic questioning about major areas of life, whereas in hypotheses-testing, directive and closed-ended questions are often necessary. The goal of this phase is to collect the information necessary for diagnostics and clinical problem-solving.
During this phase, information is conveyed by the physician concerning his findings and about his clinical reasoning process.
In this phase, conveyance of information alternates with periods of exploration of ideas and emotions and of negotiation.
In this section, we discuss some general notions characterizing this model. Subsequently, the functions of the medical interview in relation to the medical consultation process, the background of its phasic structure, and the combination of patient and physician-centeredness are discussed.
The Three-function Model of the medical interview according to Schouten (1982):
The Primary Care Internal Medicine model by Lipkin et al. (1984) denote this functional relation by calling the medical interview the medium of the medical consultation.
The Initial Medical Consultation model elaborated by Pendleton et al. (1984), has been influential in general practice.
It is self-evident that current models of medical consultation determine our educational model of medical interviewing.
In primary mental health care, a model, named Customer’s Approach to Patienthood, extensively described by Lazare et al. (1975), has a strong impact on our educational model. It bears resemblance to the Pendleton model and to the well-known Dutch model of Methodisch Werken, a general model of care-giving for General Practitioners (Holten-Vriesema et al., 1978).
We provide a short description of Lazare’s model. It starts with the assumption that the patient has something in mind that he wants, what is called a need or goal. In addition, patients know with considerable specificity how they would like the physician to intervene on their behalf. It is the physician’s task to elicit the patient’s request for help, defined as How the patient would like the physician to help him to achieve the desired goal.
In Eisenthal and Lazare’s opinion, the elicitation of the request for help ‘turns out to be a very intimate revelation,’ requiring an optimal rapport between patient and physician. These requests show a great variety: advice, control, counseling, social intervention, nothing, etc. Complaints, the patient’s initial statement of what is bothering him, are invariably elicited. Goals are usually clarified by the physician, but requests are often not.
Requests for help are often not clarified
The authors further assert the special diagnostic value of eliciting the patient’s request: this is usually exactly what they need. Moreover, it yields a lot of information about the patient’s ideas about what is wrong.
The next step is negotiation, the core of this consultation model: the patient formulates what they think they need whereas the physician formulates what is medically appropriate. The statement of the request for help itself obliges the physician to consider the legitimacy of the patient’s demand and to explain why an alternative formulation might be more valid. The patient has the right to evaluate and, ultimately, to accept or reject any treatment proposal. They may expect additional explanations, alternative treatment plan(s) or a statement that the physician cannot meet his request.
By the achievement of these functions, the medical interview is the communicative, expressive dimension of the medical consultation. The notion of functionality also makes the relationship between content and process of the medical interview more clear:
This phasic structure is a consequence of the phasic course inherent to the medical consultation. The phasic structure is a universal phenomenon not only in problem solving, but in all creative processes.
The phasic structure is a universal phenomenon in creative processes
In these processes, thinking is always goal-directed. The attainment of a goal is a problem for the acting, problem solving or creating subject. It is problematic in so far as the means to attain the goal are not immediately available.
Although the medical interview is goal-directed, the means to achieve that goal are much less certain
Characteristic for this process is the freedom to choose a means of achieving the goal and the uncertainty about its adequacy. The tentative solutions will be checked in reality on the grounds of their effectiveness. According to De Groot (1961), the foundation of this phasic process is the empirical cycle with its successive steps in thinking and action of ‘observe-guess-predict-check,’ which is universal to all human thinking and creative processes.
Indeed, the notion of this phasic course is ubiquitous not only in care-giving or ‘planned change’ in its broad sense (Bennis et al., 1962; Ramme, 1967; Van Beugen, 1977), but also in the literature on the medical interview (Byrne and Long, 1976; Stiles et al., 1979; Verhaak, 1986).
The term patient-centered medicine was introduced by Balint et al. (1970) and denotes that the physician should enter into the patient’s world to see the illness through the patient’s eyes.
The term is often contrasted with doctor- or disease-centeredness. In the latter approach, the accent is on the physician ascertaining the patient’s complaint(s) and seeking information which will enable them to interpret the patient’s illness in terms of their own medical explanatory frame of reference (Levenstein et al., 1986).
Both patient- and physician-centered approaches to the consultation are not sufficient in themselves and should be combined as we have done in the model. Although the interviewing style differs in both approaches, providing a natural boundary between both, their order is not fixed and may be reversed. In the third phase, presenting solutions, the negotiation concerning problem definition and proposals for preventive and curative measures is a means to combine both approaches.
The combination of patient- and physician-centeredness is indispensable for primary care interviews
This combination of patient- and physician-centeredness is indispensable for primary care interviews in which the complaints are undifferentiated, i.e. somatic complaints, mixed with psychosocial and psychiatric problems often resulting from stressful life circumstances or otherwise.
However, the distinction between patient- and physician-centeredness fades away in mental health
In addition to an adequate assessment of the somatic aspects of the complaints, the physician receives an impression of the significance of the complaints and of the medical encounter. When the patient is allowed to express all the reasons for attendance, the physician is better able to tailor an appropriate response. This may prevent unfavorable patient careers, characterized by medicalization of living problems (Illich, 1976) or somatic fixation (Grol et al., 1981).
In the following section, we further elaborate on the educational model by defining more concretely the content elements and the process skills needed for the physician to perform a medical interview. It is, moreover, a further justification of our educational model based on data from the literature.
The skills discussed in this section contribute to the process of the initial medical interview, irrespective of its phase. An overview of the process skills of initial medical interviewing is given in Tables 1 – 3.
On reviewing the extensive literature, the reader easily falls into despair: every author uses (when he does at all) his own theoretical framework and definitions of skills, thus making results from empirical studies barely generalizable or comparable. We have therefore made a rather arbitrary selection of which skills to include in our educational model. We have built the systemacy of these skills on two pillars.
The distinction between interpersonal and communicative skills, made by Hess (1969), is based on a more universal distinction, characterising every human performance (art, craft, etc.): an affective, expressive and an instrumental, task-orientated component can always be discerned (Ben Sira, 1976, 1980; Philipsen, 1979).
Interpersonal skills refer to ‘behavior patterns which aid in the establishment of patient rapport, trust and acceptance.’ They are important in enhancing patient satisfaction and compliance (Korsch et al., 1968; Hulka et al., 1976).
Communicative skills are to promote the information flow between physician and patient: the skills to structure the interview in segments (e.g. opening gambits, data collection, prescription and explanation of therapy and closing), the use of appropriate questioning and of effective techniques to convey information.
Ivey’s microskills form the second guideline in our systemacy of process interviewing skills (1983). It is a taxonomy of interviewing skills which are, according to Ivey, common to various modes of task-orientated interviewing, such as medical interview, the Rogerian encounter, business problem-solving, correctional interrogation etc. Generalizability to every kind of intentional interviewing is claimed from this hierarchy of skills.
The importance of Ivey’s microskills for our study lies in his clear definitions of the interviewing skills to which we often adhere. Another argument for the use of the microskills taxonomy is Ivey’s claim (1983) that this approach can be taught effectively, witnessed by 150 data-based evaluation studies (Kasdorf et al., 1978).
Our systemacy describing the process skills of initial medical interviewing is as follows:
By means of these skills, the physician should establish rapport, trust and acceptance in the patient. Hess (1969) does not provide further theoretical insight on how to connect interviewing skills with establishing rapport, trust and acceptance. Study of the empirical literature reveals that several interviewing skills increase rapport with trust and acceptance in the patient. They are described in subsequent sections.
Non-verbal skills in the physician’s interviewing behavior have been attributed much importance (Friedman, 1979, 1982). Nevertheless, categorizations and meaningful behavioral descriptions of non-verbal interviewing behavior are scarce.
Mehrabian (1972) discerns 3 major areas of non-verbal communication:
However, the validity of such distinctions has barely been established (Larsen et al., 1981). Further, ‘non-verbal cues are only meaningful and interpretable within a situational context’, as DiMatteo and DiNicola (1982) contend. They interact with verbal cues and serve as accentuation or addition to verbal messages. A well-known example of non-verbal interviewing skills is active listening, denoting the physician’s openness to important – often patient-centered – information. Moreover, active listening is claimed to convey acceptance and respect to the patient. It further indicates the physician’s willingness to share power and control with the patient in the interview (Stone, 1979).
This example shows the intricacies in the operationalization of non- verbal behavior. Active listening is an observation skill of the patient’s (non-)verbal behavior as well as a physician’s behavior that radiates acceptance and respect.
In summation, we state that great importance has always been attributed to non-verbal behavior, but the effect of well-defined non-verbal behavior on the patient has not yet been established. Empirical data from this complex area are scarce and controversial to date. In any case non-verbal behavior is difficult to operationalize in a teaching program of medical interviewing skills.
Closely related to active listening and the physician’s non-verbal behavior are the facilitative skills which, according to Baekeland and Lundwall (1975), have the purpose of ensuring that the patient is given the opportunity to express himself in the relationship: not only to tell his own version of the history, but also to display his own emotions.
Facilitative skills, called encouragers by Ivey (1983), are a verbal or non-verbal means which the physician can use to encourage the patient to continue talking, such as nods of the head, ‘uh-huh’- statements and the simple repetition of keywords the patient has uttered.
Facilitative skills is, in a way, a misleading term, because much interviewing behavior may have facilitative properties, such as open questions, self-disclosure by the physician, summarizing and directive questions.
Reflections of feelings have the purpose of making – partially – implicit feelings underlying the patient’s words and behavior explicit and clear to the patient (Ivey, 1983).
Reflections on the process of the interviewing are a kind of meta- communication by the physician, commenting on the course of the interview. In particular, when the flow of communication between physician and patient is hampered by strong defense mechanisms or antagonistic feelings by the patient, it may be helpful to discuss these underlying problems in order to restore communication.
This complex skill is part of the Rogerian trias: empathy, unconditional warmth and positive regard, genuineness (Rogers, 1951). Empathy is the capacity to understand and – perhaps – to feel the patient’s experiences, needs, sorrow, joy, anxiety, etc., as if they were one’s own feelings.
Empathy consists of two types of skills:
Psychological factors, such as anxiety, fear and distress, have a profound impact on the patient’s physical state (a.o. Pelletier, 1979) and on the outcome of medical treatment, e.g., surgery (Langer, et al., 1975). In such cases, reassurance may be indicated. It is a generally optimistic and hopeful attitude expressed in specific statements based on data and/or experience designed to allay any exaggerated or unfounded fears of the patient (Leigh et al., 1980). For reassurance to be effective, the physician should know the sources of the patient’s fears. The physician, however, should not pacify realistic fears.
The physician should not pacify realistic fears
In reassurance, two skills are recommended when used with discretion (Bramher, 1973):
Although the definition of reassurance is clear, operationalization on the skills level (by Brammer) remains rather vague.
Self-disclosure is the act of revealing personal information to others (Jourard et al., 1970). It is considered to be a key-element in the formation of trust in patients (Johnson et al., 1975), whereas it may also help to break down same of the interactional barriers between physician and patient (DiMatteo et al., 1982). Self-disclosure by the physician may help the patient to understand the normality of his behavior and to establish a basis of similarity between both partners. In this sense, it is effective when errors in treatment are detected, because trying to hide obvious failures will once again raise the barriers to communication.
Concrete guidelines for self-disclosure are given by Ivey (1983):
Communicative skills are necessary for:
We start the next sections with the promotion of the flow of information and turn then to structuring.
The exchange of information pertains to factual information as well as to emotions related to these medical facts. The quality of this information exchange is expressed by means of the theory of effective communication:
The communication between two persons is effective when both partners are mutually aware of the meaning that the one attaches to the exchanged messages of the other
This theory (Schouten, 1982; citing Fraser, 1976), expressing the mutuality of physician-patient communication, is as important regarding:
In line with the definition of effective communication, we define a group of skills that pertain to the control of whether both parties in the interview attach the same meaning to the exchanged messages: appropriate methods of questioning and effective conveyance of information.
In this section, we discuss the proper use of open, closed and probing questions:
Open questions
Open questions have no bias against the patient and cannot be answered in a few short words (Ivey, 1983). The patient should feel free to bring up the topic which seems to him the most appropriate answer to the question. Open questions are helpful in facilitating the patient to narrate his experiences, emotions and fears according to his own frame of reference.
Closed questions
Closed questions have the advantage of focusing the interview and obtaining specific information (Ivey, 1983). They lead to Yes or No answers.
The proper way of asking closed questions is:
Closed questioning is indicated when:
Closed questions are contra-indicated, when:
Although the definitions of open- and closed questions look rather sharp, the distinction may – in practice – be difficult. Sometimes, open questions may refer to a restricted content domain, leaving few response-possibilities open to the patient, whereas closed questions, for example, may hit the nail right on the head and invite the patient to provide a lot of information from his own frame of reference.
Probing or directive questions
Probing or directive questions have a position between open- and closed questions. Often used in response to an answer to an open question, the physician focuses on a specific element in this answer and attempts to make this topic more specific, concrete or personal.
The well-indicated use of probing questions, especially during Exploring Reason for Encounter and History-taking, is summarized in the term concretization. The result of well-indicated concretization(s) leads to a more personal, concrete and specific discussion of the important topics in the interview.
In the conveyance of information, cognitive and emotional aspects are to be distinguished (Schouten et al., 1982).
Cognitive aspects of conveying information
Several methods have been evolved for the presentation of information to patients in a way which will enhance the probability of its recall. Ley (a.o. 1983) summarizes the research in the following recommendations by which means the understanding and recall of information provided to the patient might be increased:
In addition to these recommendations, recall and understanding of conveyed information may also be influenced by two psychological factors: the primacy and importancy effects:
Criticism of Ley’s recommendations is given by Schouten et al. (1982), who advices explorative interventions after providing important pieces of information in order to avoid one-way-traffic. In this way, the physician should get feedback from the patient on whether he has understood the conveyed information. If the patient forgets or does not understand something, the physician may add, clarify or modify information.
Exploration after providing important information helps to avoid one-way-traffic in communication
Summarizing is, in this respect, an appropriate interviewing skill. Summaries feed back to the patient the essence of what has just been said by shortening and clarifying his statements. Besides providing more insight, it may increase in the patient the feeling of being understood and accepted.
Recall and comprehension The important distinction between the patient’s ability to recall information and its comprehension is made by Tuckett (1985). He shows that patients are able to recall the majority of information conveyed to them, but that they do not understand a considerable amount of it. He interprets this finding by claiming that the physician does not attune his information during this phase to the explanatory model of the illness/condition as developed by the patient and as asked for by the physician during the phase Exploring Reasons for Encounter.
Tuckett recommends that the physician should communicate his understanding of the illness/condition and encourage the patient to communicate his explanatory model. Opportunity must be given to explore questions and doubts on either side, and to check and clarify what is being meant and understood. In this sense, a kind of negotiation about the problem definition is taking place.
Emotional aspects of conveying information
Bad news may provoke defense mechanisms in patients that are insufficiently helpful in adapting to the new situation.
For acceptance of the new situation, it is necessary that the patient is aware that the news is true and pertains to him. In this sense, the recommendations of Tuckett et al. (1984), that the consequences which the illness/condition has for the daily life of the patient, should be discussed, bringing about acceptance.
The same holds true for the consequences of treatment and preventive measures. Their acceptance is necessary for compliance: the willingness to cooperate with preventive and therapeutic regimes. The importance of acceptance of bad news is also witnessed by the general recommendation (a.o. Schouten et al., 1982) that the interview should be started with the conveyance of the bad news. The physician may then use much of the available time of the interview for working through the bad news and the fostering of its acceptance.
In this respect, Schouten et al. (1982) give guidelines on how to handle defensive reactions of the patient:
The physician should give structure or order to the medical interview.
Unstructured interviews are often witnessed in student or inexperienced physicians, who pay too much attention to the first complaint presented by the patient, whereas other, and even more important, complaints may be put forward later in the interview. A danger of paying too much attention to less important topics may ensue. The skills to structure the interview, such as opening and terminating the interview, introduction and closure of its phases, are ranged by Hess (1969, Schouten et al., 1982) under ‘communicative skills’.
Initial medical interviews may be structured on three levels:
Agenda The whole interview may be structured by means of an agenda. It may run as follows:
Completing the three phases, Exploring Reasons for Encounter, History-taking and Presenting Solutions, is the most important issue on the physician’s agenda. Although the literature provides no clear preference (a.o. Levenstein et al., 1986), in our educational model, Exploring Reasons for Encounter should proceed History-taking in general medicine as well as in primary mental health care. It is important to attune History-taking to data collected during Exploring Reasons for Encounter. This argument is especially valid for primary mental health care, but for general practice, the request for help and the patient’s causal attributions may have great diagnostic value.
Introducing and closing phases Even more important, however, is the introduction and closing of phases. For example, it is useful to close the phase Exploring Reasons for Encounter with a summary. The physician shows his understanding in this way and allows the patient to amend or to correct this summary.
Announcing topics Finally, the physician should announce the subject to be discussed before starting to ask questions.
Such a statement should:
Concluding a subject, which has been sufficiently discussed, should be done by summarizing. The physician checks whether he has attached the proper meaning to the words of the patient. A summary is submitted to the patient for judgment, correction and/or completion.
Several authors (a.o. Van Dorp, 1977; Ivey, 1983; Holten-Vriesaria et al., 1978; Goldberg, 1979) recommend such structuring procedures. Over-structuring, however, may lead to a tight interview with little opportunity for the patient to put forward his own thoughts or ideas: in other words, the patient’s frame of reference may not emerge sufficiently in the interview (Schouten et al., 1982). Another restrictive observation about structuring concerns the fact that, empirically, its contribution to the positive outcome of the medical interview has not yet clearly been established.
The theoretical dividing line between interpersonal and communicative skills becomes more difficult to draw in complex skills, where emotional and instrumental elements are closely united. In this residual category, we discuss the skills of confrontation and interpretation.
Confrontation means pointing out incongruities, discrepancies or mixed messages in behavior, thoughts, feelings or meaning (Ivey, 1983).
It involves two major steps:
The purpose is to promote the solution of psychological problems connected with these incongruities or discrepancies through increased insight.
Interpretation provides the patient with an alternative frame of reference to reconsider living situations (Ivey, 1983). The purpose of this skill is similar to the skill previously described: resolving psychological problems by increasing insight.
This skill consists, in most instances:
It is evident that both skills represent a borderline area between the skills pertinent to initial medical interviews and more ‘problem solving’, ‘counseling’ or ‘psychotherapeutic’ follow-up interviews.
In the following paragraphs, where the phases Exploring Reasons for Encounter, History-taking and Presenting Solutions are discussed, we first pay attention to the content and then to the process skills.
The information collected during this phase is concentrated around two aspects:
Patient-centered Information Patient-centered information was first discovered as content relevant to the medical interview by Korsch and co-workers (1968, 1972). When, according to them, the physician neglects information concerning the patient’s worries, anxieties and expectations, he causes dissatisfaction entailing non-compliance from the side of the patient.
As important aspects of patient-centered information are considered:
These explanations are based on the human need to make sense of the environment and to search for causes of experiences. Important in understanding the patient’s attributions is the general finding, described by Kelley et al. (1980), that persons attribute unfavorable events to the environment rather than to themselves, whereas, in cases of favorable events, the reverse occurs.
Attributions that patients have about their complaints shape their expectations concerning help, in a technical as well as in an emotional sense (Stoeckle et al., 1980). The attributions are also strongly connected with their beliefs about the prognosis of the illness/condition. Correction of misattributions results in improved medical outcomes, such as in post-operative pain (Egbert et al., 1964), after child tonsillectomy (Skipper et al., 1968) and in insomnia (Storms et al., 1970);
Patient-centered information, such as interpersonal crisis, interference of symptoms with social, personal and vocational functioning etc. are important (Zola, 1973). These data give the physician insight into why the patient is seeking medical help for a certain complaint at that very moment (Holten-Vriesema et al., 1978).
This type of information gives insight into the impact of the complaint(s) on the daily life of the patient. Moreover, they show how the patient has dealt with the complaint(s) in his primary group and how the decision to seek help has been reached;
This issue has to be explored: How has the patient attempted to gain relief? What solutions have proved successful in the past? etc. These aspects are barely discussed in the literature.
Non-biomedical Reasons for Visit Non-biomedical reasons for why patients consult physicians have been reviewed by Barsky (1981), who assigns them into 4 categories:
First, attention is paid to minor psychiatric disorders. In epidemiological studies, it is found that the incidence (14% of the British population in the course of one year; Shepherd et al., 1966) and the prevalence of these ‘minor psychiatric syndromes’ is high (20 – 25%) (Goldberg et al., 1980; Shepherd et al., 1982). These minor psychiatric syndromes encompass mainly depressive, anxiety-related and psychosomatic symptomatology, often in combination with somatic disorders.
Minor psychiatric syndromes encompass depressive, anxiety-related and psychosomatic symptomatology combined with somatic disorders
Although spontaneous remission is also high, 10-15% of these ‘minor cases’ seem to become more seriously or chronically disabling. Johnstone et al. (1976) have shown that early detection and treatment of ‘minor cases’ results in relief of symptoms and psychological pain without ‘medicalizing’ the illness and with probable cost benefits. However, in other studies (Goldberg et al., 1982; Goldberg et al., 1970), it is shown that about 30% of these cases of patients with ‘minor psychiatric syndromes’ are not detected.
30% of minor psychiatric disorder goes undetected
In this phase of the medical interview, the physician may be alerted to the fact that same (minor) psychiatric disorder may be present.
Secondly, life stress and emotional distress, caused by major living changes, life events and socio-environmental factors, often lead to adopting the ‘sick role’. Persons often cope in this way with stress situations, which provoke anxiety, frustration and grief, but which do not lead to diagnosable psychiatric disorders. This psychological distress causes people to perceive their health status less favorably, so they consider themselves as ill (Tessler et al., 1978).
Thirdly, social isolation may be a motive for a medical encounter (McKinlay, 1980). Persons lacking adequate interpersonal relationships easily turn to physicians for advice, for a feeling of being cared for, and for an opportunity to express their feelings (Balint, 1957).
Fourthly, people distressed by physical symptoms visit physicians more for information (education, explanation or reassurance), than for treatment (Cartwright, 1964). However, the most important topic drawn from this patient-centered information is the way the patient desires to be helped to attain his needs or goals (Lazare et al., 1975).
The answer to the question: How the patient desires to be helped? is the main purpose of this phase
The answer to this question is the main purpose of this phase. It is the backbone of the model of the ‘consumer’s approach to patienthood’, extensively described earlier. Many of the afore-mentioned topics contribute to this issue.
Schouten et al. (1982) operationalizes the patient-centered style of interviewing by means of the following skills: open questioning, summarizing, reflections, active listening and concretizing (see Interpersonal Skills).
History-taking and clinical reasoning are strongly interwoven: the first is the verbal communicative and the second is the cognitive dimension of the same process.
Metz (1984) described clinical reasoning as a hypothetico-deductive strategy: a three-step mental process, repeated many times throughout the interview:
These clinical reasoning strategies largely determine the content of the medical interview during the History-taking phase. We first consider the content aspects for general practice and then for mental health problems. Finally, the process skills are given attention.
For general medicine, textbooks, like those of Morgan and Engel (1969) in de US or Formijne (1982) in the Netherlands, describe the content of the medical interview. We show in Table 4 an overview from such a textbook.
Morgan and Engel use 5 categories, of which the content is self-evident: present illness, past health, family health, personal and social history, systems review. As a more detailed illustration of such content descriptions, see Table 4.
Students have been traditionally taught to collect their information according to this schedule. Emphasis was on thoroughness and completeness of the information; no item should be overlooked. After the gathering of all these data and after completion of the physical examination, the student should generate hypotheses about the diagnosis of the complaint and its aetiology (Cutler, 1979). It is evident that such a schedule of the medical interview has a strong impact on the interviewing style: a tightly structured, doctor-centered interview ensues.
This procedure has been criticized by several investigators (Elstein et al., 1978; Kassirer et al., 1978) who stated that the problem-solving strategy of the physician during the medical consultation did not bear any resemblance to this linear procedure of checking a standardized list of symptoms and signs. Therefore, medical teachers now recommend to students the ‘natural pathway’ of interviewing, following the ‘systemacy’ of the clinical reasoning process. Finally, the physician may pose some ‘screening’ questions, especially from the system from which the main complaint originates.
Within content in mental health, two additional levels are distinguished:
The content dimension of the complaint and symptom level is given by the most elaborated psychiatric classification system, the Diagnostic and Statistical Manual for Classification of Mental Disorders (DSM- III, 1980; DSM-5, 2013).
Nevertheless, some disadvantages of using this system as the content base for medical interviewing should be mentioned:
For the content dimension pertaining to aetiological conditions, we refer to a resource which is specially geared to primary mental health care: a classification system for social and psychological problems, proposed by Regier et al. (1982). This is a composite classification system based on Reason for Visit Classification, CHPPC and DSM-III (Lipkin et al., 1982). A short overview of the items in this classification is given in Table 6. This system encompasses the psychiatric examination and the systematic exploration of psychosocial problems.
In this section, we discuss the issue of how to collect the relevant information for diagnostics and clinical problem-solving. In the literature, the discussion of interviewing styles of history-taking moves on a continuum between two extreme positions.
On one side, the extreme is an interviewing style according to a structured schedule, such as the Present State Examination (Wing et al., 1974) or the Diagnostic Interview Schedule (Robins et al., 1979), which are used for research purposes. These comprehensive schedules entail systematic, screening questioning resulting in diagnostic classifications which describe the clinical picture and the personality structure of the patient.
At the other extreme, is a non-directive, patient-centered style that is sometimes found in time-restricted interviews in general practices.
This non-directive style, in which the patient takes the lead, is often criticized by (clinical) psychiatrists. They assert that important information might be missed, because it is not spontaneously brought up by the patient. When the questioning is more systematic, the interview yields a more comprehensive coverage of psychiatric pathology (Saghir, 1971). Therefore, in psychiatry, some systematic questioning called Psychiatric Examination is a common procedure (a.o. Kuiper, 1981).
However, disadvantages of a structured interviewing style with directive and systematic questioning should also be mentioned:
Nevertheless, a majority of authors seems to favor a rather structured interviewing style; for instance, along the guidelines of diagnostic decision-trees (Morgan et al., 1980; Giel, 1981). Cox, et al. (1981) also propose a more directive style with specific probes and requests for detailed descriptions and even systematic questioning. In their experimental studies, comparing several interviewing styles, they found that the advantages of systematic questioning for obtaining factual information were not associated with any disadvantage with respect to the eliciting of emotion and feelings.
We conclude this discussion of the pros and cons of a structured interviewing style by taking the mid-stream position which better suits interviewing on the primary mental health care level:
Three categories of interviewing skills suit the afore-mentioned styles of history-taking in both general medicine and in primary mental health care.
Questioning
It is advised that the questions posed should be as open as possible to avoid suggestive or hidden questions (question-sounding statements that do not demand immediate responses).
Open-to-closed-cone questioning suits the underlying hypothetico-deductive strategy of clinical reasoning
However, some authors (a.o. Goldberg et al., 1980) claim that the appropriate skill during this phase – in its typical form – is the so-called open-to-closed-cone questioning: some important cue is raised during the interview; next, the physician proceeds with more probing and directive questions, and may end with closed questions to acquire accurate, factual information.
This open-to-closed-cone questioning may suit the underlying hypothetico-deductive strategy of the clinical reasoning.
Active, unbiased listening
‘Unbiased’ listening is a high ideal for physicians who have to select the medical facts indispensable for a medical diagnosis. Nevertheless, the physician should be continuously aware of possible biases.
Summarizing
The physician summarizes the words of the patient in his own words and invites the patient to check his summary. This is a control against ‘biased’ listening.
After data collection (often including physical examination and some clinical methods in somatic problems), patients expect conclusive statements about the nature of the presented complaints, their diagnoses, aetiology and prognosis. Of course, advice on how to deal further with their problem is also desired.
Patients expect information about the nature of the complaint, the diagnosis, aetiology and prognosis, and about treatment
The term Presenting Solutions may be misleading, however. Taken as an extreme, it might suggest a one-sided situation in which the physician presents conclusive solutions to a passive, rather ignorant and incapable patient. Fortunately, a negotiation process with the patient generally originates on problem definition and about the proposed preventive and curative measures (Stimson and Webb, 1975; Lazare et al., 1975).
This negotiated consensus model does not fully apply to interviews with patients suffering from severe mental disorders, with disturbed perception or thought patterns and therefore not possessing the necessary interpersonal skills to negotiate.
In the following sections, we discuss the content aspects of this phase and the interviewing skills necessary for negotiation. We already discussed the skills needed for the conveyance of information.
The content of the conveyed information is a direct consequence of the ‘negotiated consensus’ consultation model. Within the negotiation process, the following ‘key-points of conveyed information’, as Tuckett (1985) calls them, are necessary:
The most important issue in this respect is: the prognosis of the problem. The patient’s anxiety and expectations should be confronted with the physician’s information in order to decrease unrealistic fears. Attention should also be paid to expected side-effects of drugs, because inappropriate interruptions of or halts in medication are frequently encountered with harmless or even transient side-effects.
These four key-points of provided information also hold for initial psychiatric interviews in primary care.
Negotiation is a central issue in Presenting Solutions. Earlier, we reframed it as a combination of the patient- and physician-centered approaches of the problem presented in the consultation process.
Lazare et al. (1975) consider negotiation as the ‘backbone’ of the Negotiated-Consensus Model of medical consultation. During the consultation, more explicit differences between physician and patient, such as the definition of the problem, the cause of the illness, the goals and priorities of treatment and the methods of treatment or preventive measures, may entail negotiation. How to negotiate with the patient? is a subject scarcely described in the literature. In contrast with the relatively rich literature on the phenomenon of negotiation in general, the necessary skills are discussed in rather broad terms by a few authors.
Katon et al. (1980) give the most concrete model of negotiation, prescribing the following steps for the physician:
In this model of negotiation, it is evident that the phase Exploring Reasons for Encounter is a necessary precondition. The patient’s request for help and his explanatory model of the illness/condition should have been discussed during this phase.
An educational model showing the ideal course of an initial interview in general medicine and in primary mental health care is presented. It is characterized by three phases:
In this patient-centered phase, the physician and the patient explore the concerns, expectations and causal attributions engendered by the complaint. Further important data on the patient’s living circumstances, on events precipitating the visit and on habitual styles of coping are collected. In this phase, minor psychiatric disorders or other emotional stressors might also become manifest. This phase is completed when the physician has a view of the way the patient could be helped in fulfilling his needs or goals. The interviewing style of this phase is characterized by active listening, open facilitative questioning, reflections, summarizing and concretizing.
This physician-centered phase is strongly interwoven with diagnostics and clinical problem-solving. In our educational model, the history-taking phase in general practice corresponds to three distinguishable phases in primary mental health care: history-taking (in sensu strictu), psychiatric examination and socio-emotional exploration.
The interviewing style in this phase is characterized by an open-to-closed questioning, suiting the underlying hypothetico-deductive strategy of the clinical reasoning. This style may be supplemented by periods of systematically structured questioning based on schedules covering frequently encountered symptoms and aetiological conditions.
This phase consists of the conveyance of information (diagnostics, preventive and treatment advice, prognosis) and negotiation about problem-definition and preventive and treatment advice. This negotiation entails a compromise as regards solution between physician and patient-centered contributions to the consultation.
This model is based on current consultation models, such as the task-model of Pendleton et al. (1984) and customers approach to patienthood of Lazare et al. (1975). Both models leave much room for patient-centered interviewing. A further feature of this educational model is its phasic character based on the ’empirical cycle’ (De Groot, 1961), which is, in itself, a general hallmark of all problem-solving activities.
The skills necessary for the process of interviewing are, according to Hess (1969), divided into interpersonal and communication skills.
In more complex interviewing skills, such as confrontation and interpretation, this theoretical distinction becomes fussy. Both interpersonal and communicative skills have been operationalized in behavioral terms, often referring to the definitions of the so-called micro-skills (Ivey, 1983). However, interpersonal skills, for a long time considered as the ‘art of medicine’ and related to ‘personal talents’ or ‘intuition’ (DiMatteo et al., 1982), turn out to be difficult to operationalize. Behavioral definitions are provided for active listening, facilitation, reflection, empathy, reassurance and self-disclosure.
Communicative skills are intended to establish a situation in which both physician and patient are mutually aware of the meaning the one attaches to the exchanged messages of the other. The communicative skills involved in this effective communication are divided into questioning skills (open, closed and probing questions), and into skills in conveying information (in its cognitive as well as in its emotional aspects).
Selected Reading
Barsky AJ. Hidden reasons some patients visit doctors. Annals of Internal Medicine, 1981; 94:492-498.
Elstein AS, Shulman LS, Sprafka SA. Medical problem-solving. An analysis of clinical reasoning. Harvard University Press, Cambridge Mass., 1978.
Ivey AE. Intentional interviewing and counselling. Wadsworth, Belmend Calif., 1983.
Lazare A, Eisenthal S, Wasserman L. The customers approach to patienthood. Attending to patient requests in a walk-in clinic. Archives of General Psychiatry, 1975; 32: 553-558.
Schouten JAM. Anamnese en advies. Stafleis, Alphen a/d Rijn/Brussel, 1982.
All references
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