The patient interview is a crucial, if overlooked, part of every physician’s practice. What questions you ask – and how you ask them – will determine what information you receive, and the quality of the diagnosis to follow rests on that information.
Dr. Peter Bernad, MD, MPH, FACP writes, in his book Closed Head Injury, that while examinations “help to localize” issues, they are “only one part of a more complete evaluation of the patient. The most important information is nearly always obtained from the patient history.”
As a neurologist specifically discussing diagnosis of closed-head injury, Dr. Bernad nevertheless speaks a general truth of medicine; the patient interview is a crucial aspect of the differential diagnosis process.
So what makes for an excellent interview? For this article, I spoke with AMIQT preceptor and clinical psychiatrist, Dr. Martin Stein, to get his insight on the importance of the patient interview and the best way to properly interview patients.
AMIQT: How do you begin a patient interview?
Dr. Stein: Walk into the waiting room and call the patient’s name. Look at how they walk and their facial expressions, take them to your office, offer a seat, and say, “how can I help you?” Introduce yourself, say, I’m Dr. ____, how do you want me to call you, and how can I help you today?
What elements do you make sure to include?
You want to get the patient’s story: what’s wrong, why they came to see you. It’s very simple these days, with EMR softwares that have all the right questions loaded. More importantly, you want to find out: who is this person coming to see you? What kind of a person are they, what is their experience? Are they frightened, are they scared, what is their facial expression? How do they make you feel? This is a very important thing. Do they make you feel comfortable? Do they make you feel irritated? All these kinds of internal perceptions are very important in the patient interview. Anybody can ask the questions, but getting a sense of who the patient is and the feeling of the patient is more of the art of it.
Why are your personal reflections important?
How the patient makes you feel is just as important as what the patient says. For example, the patient may say very little, but their eyes are wide, a fearful look is on their face. You may find a patient with past abuse experience filled with horror or dread, or you may find the patient incredibly comfortable to talk with. These all give you a sense of what’s going on inside the patient’s head. How careful the patient is, are they afraid of you, are they embarrassed? All these observations are important when you’re talking to the patient.
How do you make a patient comfortable when asking personal questions about their health?
Well, I would say: this may be embarrassing but it’s important to find out. For example, “would it be okay if I asked you some personal questions?” Ask the patient directly what they want to do, using an “Is it okay if I” beginning. Is it okay if I examine you? It’s important to ask the questions in a way that the patient has the power to say no. Patients may feel very disempowered at the doctor. The more that they can feel in charge, the better the result.
You may not get everything the first time. One of the reasons it’s important to see patients on a follow-up basis is that it takes time to get a whole history. People only say what they’re comfortable saying at the time they’re meeting with you.
Often if a patient is abused, for example, and the effects of the abuse are a very deep secret, the abuse will belong to this category called unspeakable truths, which things people do not speak about but are critical. One has to tread very delicately in an interview. You never know when you’re going to touch an area where the patient is very upset or very affected, so you kind of tip-toe at times.
Why is the patient interview important in addition to clinical tests?
The first question, once you say hello to the patient, is How can I help you? or What brings you here today? And what then comes out is what we call the chief complaint. We train to try to get the chief complaint in the patient’s own words. Unfortunately, most doctors interrupt the patient within the first 20-30 seconds, but ideally, the patient should be able to spend 2-3 minutes talking about what bothers them.
Often, what brings them in the office is not really what the problem is. That is their “ticket of admission.” The person has to have some problem to come to the doctor, but underneath it there may be other problems that are of more concern. The patient may come with a headache, but it turns out that as they talk you may find they have been harassed by a boss or by family member, and the fact that they’ve been harassed or the fact that they’ve been in a physical situation may be more important than the headache itself.
What advice would you have to a doctor in a rotation about a patient interview?
Take your time. Be friendly but not too friendly. If you’re a student, don’t be afraid to say you’re a student. Most important, don’t be afraid to say “I don’t know.”
How do you assist AMIQT participants with patient skills?
AMIQT participants watch experts talk to patients. In our program, Dr. Bernad is one of the best historians I’ve ever met. He has a great way of finding some way to connect with almost every patient. He often stops, while taking full history. He wants to know first “who is the patient”: what kind of work do they do? What’s their outlook on life? Where do they live? Where do they come from? In the process, he seems to find a way to identify some small piece of his life experience and find a way to connect with the patient. When our students observe that kind of behavior, it gives them a sense of how they can use their lived experience in patient interviews.
I want to emphasize that the personhood of the doctor, who you are, is as important as the questions you ask the patient.
What goes into who you are as a doctor?
You come into medicine with a whole set of personal experiences. You’re more than a question taker, you’re a person talking to somebody in distress. Just stating the facts will not necessarily help the person in distress. You have to make a connection with them; you also want to give them some kind of reassurance that coming to you is a positive experience. Even if you have to give them negative information, you need them to feel they have made the right decision by coming to see you, that you’re making sense to them, that you’re a person they can trust, and that somehow, you give them some hope. One of the things Dr. Bernad says is, “I will try to help you.” He says, “I will do everything in my power to try and help you. I will try to make you better.” And in many studies, hope is up to 40% of the cure. It’s scary to have a concern. People don’t come to a doctor’s office for nothing. They come with a worry or concern and want to feel that it’s being taken seriously.