The Medical Interview: Mastering Skills for Clinical Practice

John Coulehan, Marian Block
Philadelphia: F.A. Davis Company, 2006, 405pp.,

Coulehan and Block’s book, The Medical Interview: Mastering Skills for Clinical Practice,  is a wonderfully crafted instructional guide on the art and science of how to conduct a medical interview. It is primarily written for medical students who are just beginning their professional interaction with patients. However, it is also designed to serve as a resource for those who are further along in their education. This book is a complete and concise guide to teach the medical student how to perform the most important source of diagnostic information. The authors believe that seventy to eighty percent of all relevant data are derived from the medical interview. The hidden medical curriculum says that real medicine is based solely on objective data (such as numbers, graphs, and images) while subjective information (such as the patient’s story) lacks value because it lacks quantification. In other words, what patients feel, the suffering they experience, and the disability that haunts them are secondary in importance to physiologic quantities that can be directly observed. Thus, most of the clinician’s energy is devoted to tracking down and treating organ-based disease with little energy left over for the personal, social, cultural or spiritual dimensions of illness. The authors are hoping to convince medical professionals of the importance of nonquantifiable material to diagnose and treat a patient.

Medical professionals commonly blame the patient for poor interview outcomes, stating with little room for doubt that, whether as a result of illness or education, anger or undue worry, the patient is a poor historian. Stories of sickness and suffering gradually recede to the background as medical students become socialized into the technical culture of health care. Students seem to be more preoccupied with technical stories in which organs and instruments rather than people are the main protagonists. Sometimes, the patient’s personal narrative of illness becomes entirely forgotten. The patient may sometimes have trouble getting anyone to pay attention to what (s)he feels and experiences.

This narrow, reductionistic view of the medical interview is not the only concept available to medical students. Medical curricula and experienced clinicians continue to teach a holistic, patient-centered brand of medicine in the tradition of William Osler. Highly specialized, machine-intensive medicine is not necessarily the best medicine. Patients often find themselves doing better by the numbers, but still feel dissatisfied and sick. They may experience fatigue and morbidity, and even mortality as a result of poorly coordinated care or medical mistakes. Studies have shown that good clinician-patient communication leads to better clinical outcomes and more satisfied patients, while poor communication leads to poor clinical outcomes, dissatisfaction and malpractice litigation.

Clinicians have begun to understand that pain, suffering and dysfunction must not only be conceptualized in broad terms, but it must be translated into action if they are to be effective healers. The culture of teaching hospitals and clinics must be changed so that the conflict between the explicit and hidden curricula is lessened or eliminated altogether.

Residency programs must develop curricula to address core competencies in six domains: patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism, and systems-based practise. Medical professionalism and communication in medicine are two of the five required domains; once again, interviewing skills are critical to each.

The authors argue that good clinician-patient communication is essential to effective patient-centered health care. Clinical medicine itself is the practical science of helping people who are sick to get well, rather than that of understanding disease. Clinical medicine has basic units of observation. The basic quantities of measurement are words and sometimes numbers, and the most important instrument is the medical practitioner. The clinician must be objective, precise, sensitive, specific, and reliable when making observations about the patient’s illness. Interviewing and interactional skills are also fundamental to the science of medicine. Interviewing skills are at the core of the medical encounter. The first step in the process of active listening is to be objective, which requires putting aside your preconceived notions and focusing on what any patient is saying. It is essential for the medical student to observe what the patient is saying and to not prematurely interpret his/her symptoms.

Listening to the patient in an empathic manner is therapeutic to the patient. It may not repair the damaged myocardium or lower blood sugar but it will make the patient feel better. That is what the clinical interview is all about. The medical professional should exhibit respect, genuineness, and empathy towards the patient during the medical interview. Empathy, genuineness and respect can be understood as patterns of behaviour that can be practised and learned by medical professionals in order to connect with the patients. Respect is to value an individual’s traits and beliefs despite a professional’s own personal feelings about them and to see patient’s feelings and behavior as a valid adaptation to their illness or life circumstances. Respect, therefore, means being nonjudgmental towards patients and their ailments, even if some of what they are experiencing has been caused by bad habits on their part. Genuineness is not pretending to be somebody other than who you are. It means being yourself, both as a person and as a professional. Genuineness requires that the medical professional be clear with the patient about what can and cannot be done about an illness, and to negotiate a plan for future care based on their capabilities.

Empathy is a specific type of physician understanding. It should not be confused with feeling sympathetic or sorry for a patient, nor is it the same as compassion. In medical interviewing, being empathic means to listen to the patient’s total communication and letting him/her know that the physician really understand what (s)he is communicating.

The important point for medical professionals to remember is that when patients share their stories, they begin to make sense of their own illnesses, both cognitively and emotionally. For the clinician, gathering the information helps to establish a relationship with the patient which is one of the most important facets of the clinical encounter something that must be developed and nurtured. Given the centrality of the medical interview, the authors believe that if this aspect of the clinical encounter undermines the patient by failing to respect him/her, the whole clinical encounter and how the patient is treated will be lacking and problematic. Thus, an essential aspect of the medical encounter is to ensure that the patient feels cared for. A major aspect of recovery depends on how effective the medical interaction is between the medical professional and patient. It, therefore, becomes apparent that the clinical encounter is one of the most important for administering patient-centered medicine. This book goes a long way towards ensuring that the clinical encounter will become central to providing effective patient-centered care to physicians. And given the propensity of older chronically ill patients, it is essential to keep improving the medical interview so that it is empathic and helpful to the patient.

© Irene S. Roth

 

No related posts.

Related posts brought to you by Yet Another Related Posts Plugin.