Book Reviews

Field Guide to the Difficult Patient Interview by Frederic W Platt, Geoffrey H Gordon Book review by Vincent J Felitti, MD

Believing deeply that the medical interview is a core clinical skill, George Engel, late Professor Emeritos at the University of Rochester, imprinted that belief onto the many physicians who knew him. Medical interviewing remains one of the most difficult skills clinicians must master. Indeed, most failure in clinical practice is not a failure of intellectual processing but instead reflects inadequacy of the interpersonal skills needed to obtain the information we need for intellectual processing.

Field Guide to the Difficult Patient Interview is a fine little book that is remarkably well thought out. Drs Platt and Gordon have held seminars on patient interviewing at many medical meetings over the years and, in the course of that work, have learned from innumerable physicians the problems of patient interviewing. More important for clinicians who read this book, the authors have categorized these problems into a helpful format that makes the book successful.

Principles, Procedures, Examples
For each category of problem, the book assigns a chapter that starts with a clinical vignette, states the associated principles, and outlines the procedures most helpful for addressing the problem. In the book's vernacular, the Principles presented are helpful clinical insights. For example, one Principle asserts that "any symptom or condition that goes on more than six months has outcomes more dependent on psychosocial and behavioral characteristics than on biological characteristics," and another Principle states that "treating a chronic condition demands different strategies than treating acute conditions" (p 123). To guide the reader toward using these Principles in everyday practice, each chapter provides brief examples of successful and unsuccessful conversational approaches. After listing pitfalls to avoid, the authors lavish upon us a number of clinical "pearls."

Skillfully executed drawings throughout the book identify a range of emotional states common to us as well as to our patients. In addition, the authors repeatedly emphasize and illustrate for us the need to explore with our patients the meaning of particular activities and events before prescribing or proscribing them. In Chapter 16, particularly excellent examples show the importance of exploring with patients what they perceive to be the benefits of smoking as well as patients' views on diabetes control.

Common Problems in Interviewing Patients
The types of problems selected for inclusion in the chapters are just the ones clinicians find most difficult: interacting constructively with an angry patient, dispensing bad news, talking with a patient's family in crisis circumstances, addressing disagreement about treatment, and managing mistrust of us as physicians. A frequently avoided subject, seduction, is discussed admirably in a four-page chapter. Discussion about the end of life--a topic also commonly avoided--is helpfully presented too. Indeed, if you have ever thought, "When are they going to send someone to me who doesn't have 12 problems on his list and expect me to handle them all in ten minutes?" or "When are they going to send someone to me who can answer a simple question with a simple answer instead of a saga" (p 64), this book is for you.

Later chapters of the book address disease prevention and the ambivalence commonly felt by physicians when discussing with patients their high-risk behaviors. The book also discusses the ambivalence felt by patients about reducing these behaviors. With this and other topics in mind, a highly appropriate closing chapter is titled, "The New HMO Patient."

Field Guide to the Difficult Patient Interview is an excellent little book that is both practical and helpful. In fact, reading it made me wish it had been available when I first entered medical practice; I found myself repeatedly seeing ways to speak more effectively with patients. The book is easy to use, and the chapter headings realistically enable readers to check their approach just before seeing the next difficult patient. Chiefs of primary care departments might do well to buy a copy of this field guide for each practitioner.

Philadelphia: Lippincott Williams & Wilkins, 1999 $29.95. ISBN: 0-7817-2044-3

Dr Vincent Felitti has been with the Southern California Permanente Medical Group since its opening in San Diego in the late 1960s.