The Doctor-Patient

Relationship and
Interviewing Techniques
 Models of Disease
 Biopsychosocial model
 Is derived from general systems theory
 The biological system deals with the anatomical,
structural, and molecular substrates of disease and
the effects on patients’ biological functioning;
 The psychological system treats the effects of
psychodynamic factors, motivation, and personality
on the experience of, and reaction to, illness;
 The social system examines cultural, environmental,
and familial influences on the expression and
experience of illness.
 George Engel postulates that each system
affects and is affected by all the others.
 His model does not treat medical illness as
a direct result of people’s psychological
and sociocultural makeup but, rather,
promotes a comprehensive understanding
of disease and treatment.
 The doctor-patient relationship is a critical
component of the biopsychosocial model.
 All physicians must not only have a working
knowledge of patients’ medical status but must
also be familiar with how patients’ individual
psychology and sociocultural milieu affect the
medical condition, the emotional responses to
the condition, and the involvement with the
doctor.
 Meaning of Being Sick
 Illness behavior describes patient’s
reactions to the experience of being sick.
 Sick role- the role that society ascribes to
sick people because they are ill.
 The sick role can include being excused
from responsibilities and being expected
to want to obtain help to get well.
 5 Stages of Illness Behavior
by Edward Schuman
 The symptom experience stage: a decision is
made that something is wrong;
 The assumption of the sick role stage: a decision
is made that a person is sick and needs
professional care;
 The medical care contact stage: a decision is
made to seek professional care
 The dependent-patient role stage: a decision is
made to transfer control to the doctor and to
follow prescribed treatment
 The recovery or rehabilitation stage: a decision
is made to give up the patient role
 Illness behavior and the sick role are
affected by people’s previous experiences
with illness and by their cultural beliefs
about disease.
 Assessment of Individual Illness
Behavior
Prior illness episodes, especially illnesses of
standard severity (childbirth, renal stones,
surgery)
Cultural degree of stoicism
Cultural beliefs concerning the specific
problem
Personal meaning or beliefs about the
particular problem
Specific questions to ask to elicit the patient’s
explanatory model:
1. What do you call your problem? What name
does it have?
2. What do you think caused your problem?
3. Why do you think it started when it did?
4. What does your sickness do to you? How does
it work?
5. How severe is it? Will it have a short or long
course?
6. What do you fear most about your sickness?
7. What are the chief problems that your
sickness has caused for you?
8. What kind of treatment do you think you
should receive? What are the most
important results you hope to receive from
treatment?
9. What have you done so far to treat your
sickness?
 Doctor-Patient Models
1. Active-passive model: implies a patient’s
complete passivity and a physician’s
taking control. In this model patients
assume virtually no responsibility for
their own care and take no part in
treatment. The model is appropriate
when patients are unconscious,
immobilized, or delirious.
2. Teacher-student model: the physician’s
dominance is assumed and emphasized.
The role of the physician is paternalistic
and controlling; the role of the patient is
essentially one of dependence and
acceptance. This model is often
observed during a patient’s recovery
from surgery.
3. Mutual participation model: implies equality
between doctor and patient; both participants
require and depend on each other’s input. The
need for a doctor-patient relationship based on
a model of mutual, active participation is most
obvious in the treatment of such chronic
illnesses as renal failure and diabetes, in which
a patient’s knowledge and acceptance of
treatment ramifications are critical to the
success of the treatment. The model may also
be effective when patients have conditions
such as pneumonia.
4. Friendship model: is generally considered
dysfunctional if not unethical. It most often
reflects a primary, underlying psychological
problem in the physician, who may have an
emotional need to turn the patient’s care into
a relationship of mutual sharing of personal
information and love. The model often
involves indeterminate perpetuation of the
relationship rather than an appropriate ending
and a blurring of boundaries between
professionalism and intimacy.
 Interviewing Effectively
 One of a physician’s most critical tools.
 Can gather data necessary to understand
and treat patients and, in the process, to
increase patient’s understanding of and
compliance with physicians’ advice.
 Interview
 Three main components:
 Beginning
 The interview itself
 Closing of the interview
 Psychiatric Interview
 Four dimensions taking place in a
psychiatric interview:
A. Establishing rapport
B. Assessing patients’ mental status
C. Using specific techniques
D. diagnosing
 Five Phases of the Interview and
the Four Components
 Phase
1. Warm-up and screening of problem
2. Follow-up of preliminary impressions
3. History and database
4. Diagnoses and feedback
5. Prognosis and treatment contract
 Rapport
1. Put patient at ease, set limits, emphatize
with suffering, become a compassionate
listener
2. Become an ally, make shifts in topics clear
3. Show expertise, interest, thoroughness,
leadership and motivate for testing
4. Secure acceptance of diagnosis
5. Assume the leadership role and assure
compliance
 Technique
1. Select productive and broad screening
questions
2. Shift topics, progress from open- to closed-
ended questions
3. Shift topics, handle defenses, fill in gaps,
follow up clues, reconcile inconsistencies
4. Explain disorders and treatment options
5. Discuss treatment contract
 Mental status
1. Observe appearance, psychomotor functions,
speech, thinking, affect, orientation, memory, and
explore mood, insight, memory, judgment
2. Assess thinking, thought content, suicidality
3. Evaluate judgment, memory, test specific mental
status functions and IQ
4. Discuss mental status findings, explore compliance
5. Make inferences about insight, judgment, and
compliance
 Diagnosis
1. Note clues, classify the chief complaint;
assess symptoms, severity, course,
stressors; list differential diagnosis
2. Verify or exclude diagnoses
3. Assess course of disorders, impact on social
life, family and medical history
4. Establish diagnoses on five axes
5. Give prognosis; predict treatment effects
 In general, interviewers must convey an
attitude that is:
1. Nonjudgmental
2. Interested
3. Concerned
4. Kind

Otherwise, potentially crucial information may

not be obtained.
 Many factors influence both the content and
the process of interviews:
1. Patient’s personalities and character styles
2. Various clinical situations– including whether
patients are seen on a general hospital ward, on a
psychiatric ward, in ER, or as outpatients.
3. Technical factors– telephone interruptions, use of an
interpreter, note taking, and a patient’s illness.
4. Interviewer’s style, orientations and experiences
 Psychiatric Interviewing
 Two styles of interviewing:
A. Insight-oriented interviewing: tends to
emphasize eliciting and interpreting
unconscious conflicts, anxieties, and
defenses;
B. Symptom-oriented approach: emphasizes
the classification of patients’ complaints and
dysfunctions as defined by specific
diagnostic categories.
 Beginning the Interview
 How a physician begins an interview
provides a powerful impression to
patients, and the manner in which a
doctor opens communication with a
patient has potentially powerful effects on
the way the remainder of the interview
proceeds.
 Patients are often anxious on first encounters
with physicians and feel both vulnerable and
intimidated.
 A physician who can establish rapport quickly,
put the patient at ease, and show respect is well
on the way to conducting a productive exchange
of information.
 This exchange is critical to formulate a correct
diagnosis and to establish treatment goals.
 All physicians should initially make sure that they
know the patient’s names and that patients
know physician’s names.
 Physicians should introduce themselves to any
other people who have come with the patient.
 If relatives or friends accompany a patient, the
physician should ascertain whether the patient
would like another person be present during the
initial interview.
 The physician, however, should also
attempt to speak to the patient
individually to make sure that the patient
has a chance to say anything he or she
may not want to say in front of the others.
 Patients have the right to know the
position and professional status of the
people involved with their care.
 How To Begin
 “Can you tell me about the troubles that
bring you in today?”
 “Tell me about the problems you have
been having.”
 “What other problems have you been
experiencing?”
 “Where shall we start?”
 “Where would you prefer to begin?”
 “Your doctor has told me something about
what has been troubling you (such as
cardiovascular symptoms or depression),
but I’d like to hear from you in your own
words about what is troubling you.”
 Most patients do not speak freely unless they
have privacy and are sure that their
conversations cannot be overheard.
 A patient may appear frightened or resistant at
the beginning of an interview and may not want
to answer questions. If this seems to be the
case, the physician may comment on this
impression directly in a gentle and supportive
way and encourage the patient to talk about his
or her feelings about the interview itself.
 “I can’t help but notice that you seem to be
feeling anxious about talking with me, and I
wonder if there is anything I can do or any
question I can answer that will make it easier for
you.”
 “I know that it can be difficult or frightening to
talk to a doctor, especially one you have never
met before, but I would like to make it as
comfortable for you as possible. Is there
anything that you can put your finger on that is
making it tough for you to talk to me?”
 “Why now?”
 Interview Proper
 In the interview proper, physicians discover in
detail what is troubling patients.
 Content- literally what is said between doctor
and patient: the topics discussed, the subjects
mentioned.
 Process- what occurs nonverbally between
doctor and patient: what is happening in the
interview beneath the surface. This involves
feelings and reactions that are unacknowledged
or unconscious.
 Specific Techniques
 Open-ended questions versus closed-ended
questions.
 Reflection: a doctor repeats to a patient in a
supportive manner something that the patient
has said. The purpose of the reflection is
twofold: to assure the doctor that he or she has
correctly understood what the patient is trying
to say and to let the patient know that the
doctor is perceiving what is being said.
 Facilitation: doctors help patients continue in the
interview by providing both verbal and nonverbal
cues that encourage patients to keep talking.
 Silence: may be constructive and in certain
situations may allow patients to contemplate, to
cry, or just to sit in an accepting, supportive
environment where the doctor makes it clear
that not every moment must be filled with talk.
 Confrontation: meant to point out to a
patient something that the doctor thinks
the patient is not paying attention to, is
missing, or in some way denying.
 Clarification: doctors attempt to get details
from patients about what they have
already said.
 Interpretation: used when a doctor states
something about a patient’s behavior or
thinking that a patient may not be aware
of.
 Summation: periodically during the
interview, a doctor can take a moment
and briefly summarize what a patient has
said thus far.
 Explanation: doctors explain treatment
plans to patients in easily understandable
language and allow patients to respond
and ask questions.
 Transition: allows doctors to convey the
idea that enough information has been
obtained on one subject; the doctor’s
words encourage patients to continue on
to another subject.
 Self-revelation: limited, discreet self-
disclosure by physicians should feel at
ease and should communicate a sense of
self-comfort. Conveying this sense may
involve answering a patient’s questions
about whether a physician is married and
where he or she comes from.
 Positive reinforcement: allows patients to
feel comfortable in telling a doctor
anything, even about such things as
noncompliance with treatment. By
encouraging a patient to feel that the
doctor is not upset by whatever the
patient has to say, the doctor facilitates an
open exchange.
 Reassurance: truthful reassurance of a
patient can lead to increased trust and
compliance and can be experienced as an
emphatic response of a concerned
physician. False reassurance, however, is
essentially lying to a patient and can badly
impair the patient’s trust and compliance.
 Advice: in many situations it is not only
acceptable but desirable for physicians to
give patients advice. The advice should be
given only after patients are allowed to
talk freely about their problems, so that
physicians have an adequate information
base from which to make suggestions.
 Psychotic Patients
 Patients who are psychotic often have
limited insight, are more concrete than
abstract in their thinking, and are not
always psychologically minded or
introspective.
 A physician’s role with a psychotic person
is supportive rather than insight oriented.
 Do not attempt to talk patients out of
delusional beliefs.
 Do not laugh at bizarre psychotic material.
 Maintain a certain formality with patients,
so that they do not feel threatened by
what they perceive as frightening
closeness.
 Focus on patient’s achieving concrete,
day-to-day survival and social skills.
 Decrease pressure on patients to achieve more
than they may feel capable of achieving.
 Structure the interview sessions so that patients
know what to expect and are not left, for
instance, with long periods of silence if these
periods seem to increase anxiety.
 Be sensitive to how easily humiliated or shamed
patients may feel about relatively minor
inadequacies.
 Ending The Interview
 Physicians want patients to leave an interview
feeling understood and respected and believing
that all the pertinent and important information
has been conveyed to an informed, emphatic
listener.
 Doctors should give patients a chance to ask
questions and should let patients know as much
as possible about future plans.
 Doctors should thank patients for sharing
the necessary information and let patients
know that the information conveyed has
been helpful in clarifying the next steps.
 Any prescription of medication should be
clearly and simply spelled out, and doctors
should ascertain whether patients
understand the prescription and how to
take it.
 Doctors should make another appointment
or give a referral and some indication
about how patients can reach help quickly
if it is necessary before the next
appointment.