Medical interviewing is the foundation of medical care
and is the clinician's most important activity. A growing body
of evidence suggests that clinicians use distinctive, describable
behaviors to conduct medical interviews. This article describes
four patterns of behavior that we term Habits and reviews the
research evidence that links each Habit with both biomedical and
functional outcomes of care.
The Four Habits are: Invest in the Beginning, Elicit the
Patient's Perspective, Demonstrate Empathy, and Invest in the
End. Each Habit refers to a family of skills. In addition, the
Habits bear a sequential relationship to one another and are thus
interdependent. The Four Habits approach offers an efficient and
practical framework for organizing the flow of medical visits.
It is unique because it concentrates on families of interviewing
skills and on their inter-relationships.
Introduction
Medical interviewing is the foundation of medical care1
and the clinician's most important activity. Physicians conduct
a mean of 120,000 to 160,000 interviews in a practice lifetime.2
Even a modest improvement in efficiency, diagnostic accuracy,
and adherence can greatly affect outcomes, satisfaction, and cost.
A growing body of evidence suggests that clinicians behave according
to distinct, describable patterns. What was once called "bedside
manner" and considered a matter of etiquette and personal
style has now been the subject of a large number of empirical
studies. The results of these studies suggest that the interview
is integral to the process and outcomes of medical care, supporting
Engel's view that "the interview is the most powerful, ...
sensitive and versatile instrument available to the physician
..."3: (p 115) Apparently, patients are less concerned
with how much their physicians know than with how much they care.4
Recently, several conceptual models of the medical interview
have also been proposed.5-10 These models have been
quite helpful in laying out the basic tasks or functions of the
interview. What has been lacking to date is a conceptualization
of how the elements of the encounter relate to one another during
and across encounters.
We describe a new approach to the medical interview called "The
Four Habits Model." It is derived from previous empirical
and conceptual work on the interview and represents a synthesis
of the available research literature on interviewing effectiveness
plus our own clinical and teaching experience. The advantages
of the Four Habits Model are that families of skills known to
be related to outcomes of care are organized together into Habits
and that the relationships among the Habits are made explicit.
We use the term Habit to denote an organized way of thinking
and acting during the clinical encounter. The Four Habits are:
Invest in the Beginning, Elicit the Patient's Perspective, Demonstrate
Empathy, and Invest in the End. The goals of the Four Habits are
to establish rapport and build trust rapidly, facilitate the effective
exchange of information, demonstrate caring and concern, and increase
the likelihood of adherence and positive health outcomes.
Numerous studies show that both patients and physicians derive
considerable satisfaction from interpersonal aspects of care and
suggest that certain clinician behaviors affect the likelihood
of achieving desired outcomes. Fortunately, growing evidence indicates
that clinical communication skills can be taught, learned, and
practiced11 (Table 1).
However, many practicing physicians receive little or no training
in this area.
Overview of the Model
Four Habits Grid
In the Four Habits Model (Table 2),
the various communication tasks that make up each Habit are organized
into families of skills, techniques, and payoffs. In addition,
the Habits are seen as nested and interrelated. For example, failure
to elicit the full spectrum of concerns at the beginning of the
encounter and to assess their importance from the patient's point
of view leads to premature hypothesis testing, misplaced empathy
and support, and the emergence of hidden concerns at the end.
In contrast, eliciting and prioritizing all of a patient's concerns,
exploring the patient's perspective, and showing appropriate empathy
set the stage for successfully engaging the patient in joint decision-making
and education. Understanding each of the skills individually and
how they work together is important for creating mutually satisfying
and effective encounters. The importance ofthe skills associated
with each Habit relates not only to their support of that Habit
but to their support of the other Habits as well.
Habit 1: Invest in the Beginning
Three tasks must be accomplished at the beginning of the interview:
creating rapport quickly, eliciting the patient's concerns, and
planning the visit.
Creating rapport quickly. The first few moments of the
medical encounter are often overlooked by physicians as a pleasantry
or as preliminary to the clinical "business" of the
interview, but they are key elements for establishing a trusting
relationship and often affect the outcome of the visit.
Entering the examination room ready to engage the patient and
using the first few seconds to establish a welcoming atmosphere
can give the patient a sense of safety. For new patients in particular,
a handshake during the introduction indicates an egalitarian stance
and initiates touch. Finding out the names of each person in the
room and their relationship to the patient also creates a personal
connection without taking much extra time. Adapting voice tone,
language level, and posture in response to the patient early in
the visit underscores the clinician's attentiveness and caring
and can further set the patient at ease.
Issues of power and authority as reflected in the greeting can
inhibit communication and rapport. To achieve trust and respect,
the principle is to match terms of address by using the same terms
with which the clinician would like to be addressed. For example,
to greet a patient as Mary Jones or Mary and to refer to oneself
as Dr. Baker is to select terms with different levels of formality.
Patients thus addressed often feel that the relationship is being
established on an unequal footing with the patient in an inferior
position. This is avoided if Dr. Baker introduces herself as such
and uses the formal term, "Ms. Jones," in addressing
the patient.
Physician preparedness has been associated with professionalism
by Inui and Carter20 and with patient satisfaction
by Frankel and Treger (Frankel RM, Treger N, unpublished material).a
In both studies, patients rated physicians who were unfamiliar
with their cases or repeatedly referred to the chart during the
encounter as less professional and as providing less satisfying
care. Reviewing the case and planning the visit before entering
the room is good practice. Saying explicitly, "I've reviewed
your record," conveys some familiarity with the patient's
history.
When the clinician has kept the patient waiting, it is effective
to address this directly. Comments like "Thank you for waiting,"
or "I'm sorry for keeping you waiting. I'm here now and you
have my full attention," can usually diffuse the patient's
irritation. Lengthy explanations about the reason for the delay,
unless requested, reinforce the power differential and may worsen
the patient's resentment.
Eliciting the full spectrum of concerns. The second initial
interview task is to accurately determine the reason(s) a person
seeks care. Two strategies are recommended. The first involves
drawing out the patient's concerns with openended questions like
"I'd like to begin today by getting a good idea of what concerns
you'd like me to address" or "What would you like help
with today?" or "I understand you've been having pain
in your foot. Could you tell me about that?" After the first
concern, saying "That's an important concern which I'll come
back to in a moment. Before I do, is there anything else?"
is useful. This statement can be followed by asking "Anything
else?" until the patient either says no or a silence of more
than three seconds elapses.
The second strategy is to draw upon a set of linguistic devices
known as "continuers." These include vocalizations such
as "uh huh," phrases such as "I see," "Go
on," and "Tell me more," and nonverbal behaviors
such as silence, vertical head shaking, and an engaged listening
posture. Continuers encourage the patient to elaborate.
Traditional medical education teaches that a single chief complaint
exists and that this complaint is either obvious or the first
thing the patient mentions.
This assumption causes tremendous difficulty during primary care
visits if patients have a concern which may be socially stigmatizing
or difficult to disclose, even though it may be the most important
one they have. The technique and sensitivity with which the provider
assesses patient concerns at the beginning of the visit are crucial
(Table 3).
Planning the visit. Repeating the concerns to check understanding
and letting the patient know what to expect establishes a clear
agenda for the rest of the visit. A summary statement like, "So
you've had shortness of breath, weight gain, and trouble sleeping.
Is that right? ... What I'd like to do is to get more details
about those symptoms, do an exam, and then we'll talk about a
plan together," also signals a transition into a deeper level
of informationgathering.
A common source of frustration for many clinicians is the mismatch
between number and type of concerns a patient may bring to a single
visit and the time they have to address those concerns. As a result,
many providers limit themselves to established problems and exclude
problems of a psychologic or social nature. Such an approach at
best confuses the patient and at worst erodes the covenant of
trust which is the heart of the physicianpatient relationship.
Two strategies are suggested for handling this frequent dilemma:
prioritizing and time-framing.
Prioritizing involves using positive language to set limits on
what can be accomplished. For example, "In the time we have
today, I want to make sure we talk about your chest pain and weight
loss. You also mentioned your desire to get a cholesterol test.
How about if we start our next visit discussing the other issues
you mentioned?" This kind of respectful limitsetting reduces
the chance that the patient will feel shortchanged. If the patient
presses further, it can be useful to use "I wish" statements.
"I wish we had time to talk about all your concerns today"
conveys a sense of alliance, whereas a rebuttal like, "I
just don't have time today for all those issues" risks alienating
the patient.
Time-framing is another strategy which allows the physician to
negotiate the agenda with the patient. This strategy is used to
state the amount of time allocated for the visit and asking the
patient to state the issues of highest concern. For example, "Mr.
Smith, you are scheduled for a 15minute visit. What are the concerns
you most want us to cover today? ... If we are unable to address
some issues, I will schedule a followup visit." Using good
clinical judgment about extending a visit should outweigh scheduling
considerations. However, in general, being explicit about time
saves time and distress.
Habit 2: Elicit the Patient's Perspective
Habit 2 is used to assess the patient's point of view concerning
the meaning of symptoms and the request for care. It serves at
least 2 important functions: showing respect for the patient's
experience and individuality and gathering clinical information
in an efficient way. Eliciting the patient's perspective during
this phase of the encounter consists of three skills: assessing
patient attribution, identifying patient requests for care, and
exploring the impact of symptoms on the patient's physical, psychological,
and social well-being. Eliciting the patient's perspective is
not limited to Habit 2. It is useful in discussing treatment options
and issues of nonadherence, for instance. Our focus in Habit 2,
however, is on the context of understanding the meaning and impact
symptoms have for the patient.
Assessing patient attribution. Assessing patient attribution
consists of determining the patient's perspective about what caused
the problem. This approach requires asking directly, "What
have you been thinking might be the cause of these symptoms?"
or "What are you worried about most?" Patients frequently
engage in a process quite similar to differential diagnosis; that
is, they exclude certain causes and include others. Knowing specifically
what meaning the patient is giving to the symptoms allows the
clinician to frame the rest of the dialogue accordingly. For example,
a patient with a mild headache who is worried about a brain tumor
is more likely to leave the visit reassured that the diagnosis
is benign if the discussion includes consideration of a tumor.
Assessing the patient's attribution thus reduces the potential
for miscommunication and misunderstanding. Tuckett et al25
found that patients who were able to fully explain their illnesses
recalled more information and were more committed to treatment.
Arthur Kleinman, who is both a physician and an anthropologist,
refers to the sensemaking practices patients use to understand
the experience of illness as an "explanatory model."
According to Kleinman,26 explanatory models allow patients
to place an experience in a personal and cultural context which
is often overlooked in the clinical interview (Table
4).
Exploring the patient's explanatory model provides the clinician
with a "context of meaning" for the actions and actors
participating in a patient's experience of illness. In the example,
if Dr. Phelps or the emergency department physician had asked
what Mrs. Lue's symptoms meant to her, they might have saved her
additional distress by explaining that anniversary reactions frequently
include experiencing the same symptoms as the person who died.
A deeper exploration of the meaning Mrs. Lue's symptoms had for
her might have saved valuable medical resources. The cost of a
thallium stress test is several hundred dollars; the cost of exploring
Mrs. Lue's explanatory model was two minutes of physician time.
Identifying patient requests. Unmet expectations for care
occur in about 18% of visits according to one study.27
Factors which influence patient expectations include the nature
of their somatic symptoms, perceived vulnerability to illness,
past experiences, and knowledge acquired from the media and other
sources. Soliciting the specific reason(s) the patient is seeking
care can help reduce the extent of unmet expectations. To address
this problem, Lazare et al28 described what they called
"the customer approach" to providing care. They theorized
that, as customers, patients bring to the encounter both problems
and expectations or desires about how they should be dealt with.
They coined the term "patient requests for care" to
characterize these expectations and desires and suggested using
variations of the question, "How were you hoping I could
help you with your concern?" to improve clinical effectiveness.
For example, if the concern elicited in Habit 1 is the "what"
of the visit ("I have pain in my knee"), Habit 2 helps
define the "how" ("I was hoping for a referral
to Physical Therapy and medication for pain").
Consequences for patient satisfaction and adherence relate to
this skill area. Eisenthal and Lazare29 found that
patients whose requests were fully listened to were more satisfied
with their care, regardless of whether the requests were granted.
Likewise, Froehlich and Welch30 showed that physician
humanism rather than ordering expected tests correlated with satisfaction.
A large number of studies of adherence to medical recommendations
have shown that 40% to 80% of patients who receive recommendations
do not follow them.31 Some patients do not follow recommendations
because the advice may not fit the question, need, or priority
they bring to the encounter. Therefore, finding out not only what
the full spectrum of concerns is but also what, if anything, the
patient wants the clinician to do about them is important.
Exploring the impact. The final skill in Habit 2 is determining
the impact of the patient's symptoms or illness on daily activities,
work, and family. Many clinicians hesitate to explore the impact
of illness on activities of daily living for fear of initiating
a lengthy discussion of problems for which they may have few solutions.
The benefit of asking this kind of focused question is that it
often provides important diagnostic information about the patient's
functional ability and mental health while conveying interest
in the broader context of the patient's life. In addition, information
on functional status is useful in planning treatment and negotiating
realistic expectations of outcome. Knowing that a widow with severe
degenerative joint disease is prevented from opening cans and
jars to cook helps the clinician assess whether treatment and
assistive devices are viable alternatives to nursing home placement.
Habit 3: Demonstrate Empathy
"... to know and understand, obviously is a dimension
of being scientific; ... to feel known and understood, is a
dimension of caring and being cared for."3: (p 125)
Caring and compassion have characterized the doctor-patient relationship
throughout history. In the modern era, great technological advances
and economic pressures have led to a relative de-emphasis on the
therapeutic benefits of caring and compassion both in training
and practice. Nevertheless, researchers have linked the presence
or absence of caring to medical outcomes such as satisfaction,
adherence to medical recommendations, and propensity to sue. If
caring and compassion form the core conceptual basis of the doctor-patient
relationship, empathy is the core skill for enacting it (Table
5).
Although building rapport and empathy may be employed at any
point in the medical encounter, the use of empathy in Habit 3
relates to responding to the core of the patient's concern(s).
In terms of the flow of the visit, this response usually occurs
after gathering data about the full spectrum of patient concerns.
Being open to the patient's emotions. One barrier to clinicians'
ability and willingness to show empathy toward patients can be
the sense of practicing medicine in a highly timepressured, stressful
environment. How is it possible to experience empathy while feeling
overwhelmed with patient care duties? One strategy is to look
for brief "windows of opportunity"33 for
responding to patients' emotions, a skill noted in "outstanding"
clinicians. Often a patient's appreciation of an empathic response
is sustaining to the clinician and adds meaning and depth to the
relationship. Research at the University of Western Ontario by
Stewart et al34 showed that physicians who are sensitive
to and explore patients' emotional concerns take a mean of one
minute longer to complete visits compared to physicians who do
not.
Accurately identifying emotions begins with observing nonverbal
behavior such as facial expression and body posture and listening
closely to the patient's description of the experience. For example,
in describing the impact of having a tremor, a patient with multiple
sclerosis may avoid using hand gestures to illustrate comments.
Careful observation of the patient's gestures and comments is
useful for identifying the feelings of shame and embarrassment
the symptom has caused. Physicians sensitive to nonverbal expression
of emotion have more satisfied patients.35 Physicians
who establish good eye contact are more likely to detect emotional
distress.36
Often patients only hint at an emotion. Statements such as "I'm
considering retirement" or "My child is moving out of
state" do not directly express an emotion. Suchman et al37
define these occurrences as "potential empathic opportunities"
and suggest that they are often used by patients as "trial
balloons" to test whether it is safe to talk about the underlying
emotion.
Conveying empathy. Two general options are available when
responding to a potential empathic opportunity. The clinician
can sidestep the opportunity by shifting the topic, by ignoring
the potential emotion, or by offering premature reassurance; or
he or she can encourage the expression of the emotion by using
openended continuers such as "I see," "Go on,"
or "Tell me more." Patients for whom an issue is emotionally
charged generally express their feelings at this point. For example,
in response to a "go ahead" signal from the clinician,
the patient who mentions retirement would characteristically add
a statement such as, "You know, retirement is really scary."
The final step in helping the patient move from hinting at an
emotion to fully expressing it is to show empathy. The patient's
response to the question, "Is there something in particular
which scares you?" might be, "I've been very successful
in business and don't really need the money. But I'm not really
sure what I would do with myself if I retired. After my wife died
last year, it's been hard to focus on the future."
Several empathic responses are possible at this juncture. Cohen-Cole
and Bird10 identified five types of empathic responses
and suggest a generic format for each. They are:
- Reflection--"I can see that you are ... "
- Legitimation--"I can understand why you feel ... "
- Support--"I want to help."
- Partnership--"Let's work together ... "
- Respect--"You're doing great."
Returning to the example, it is possible to analyze the emotions
elicited by the clinician and decide which empathic response best
fits the situation. The primary feelings experienced by the patient
are loss and fear. The accuracy of the assessment may be tested
by using a statement of reflection such as, "It sounds like
your wife's passing has made the future look uncertain for you."
If this is an accurate statement, the patient will agree. Assuming
that this occurs, the next step is to determine which need in
the patient's hierarchy of needs is most important. A supportive
statement such as, "I am sorry you are faced with such uncertainty
and such a difficult decision. I would like to help if I can ..."
is likely to be most useful. The result of using empathy is that
patients feel known and understood.
Researchers have begun to focus on the potential link between
perceived lack of caring and dissatisfaction, including the decision
to litigate for medical malpractice. Three recent studies, by
Lester and Smith,17 Beckman et al,18 and
Hickson et al,38 support the assertion that lack of
empathy is a risk factor for dissatisfaction and malpractice suits
in the event of a negligent outcome.
Investing in the relationship and getting to the heart of the
problem by showing empathy is a rewarding strategy which can be
learned, taught, and practiced.39,40 The time required
to implement this strategy is minimal--a mean of <1 min.34
Including expressions of empathy during medical visits can add
depth and meaning to clinical practice. Francis Peabody's famous
dictum that "the secret of the care of the patient is in
caring for the patient" captures the essence of Habit 3,
its importance for the relationship, and its potential for healing.41
Habit 4: Invest in the End
Unlike the first three Habits, which primarily require information
gathering, the last, Habit 4, requires information sharing. This
difference in emphasis is reflected in the tasks of the end of
the encounter: delivering diagnostic information (giving good
news, bad news, or no news); encouraging patients to participate
in decision making; and negotiating treatment plans and probing
for adherence.
Delivering diagnostic information. Patients generally
seek medical care with at least two questions in mind: "Why
am I experiencing these symptoms?" and "What can be
done to relieve them?" Because the patient's frame of reference
and experience initiate both the search for care and what they
are likely to do with answers to questions, the most important
principle of delivering diagnostic information is to use the patient's
original statement of concerns to frame information to be shared.
Table 6 is an example of an actual
encounter that shows information sharing that fails to incorporate
the patient's original statement of concerns.
Traditional teaching about the logic of the clinical encounter
suggests that delivering diagnostic information should be followed
by prognosis and treatment planning with the patient. Abundant
anecdotal evidence indicates that, once given a diagnosis, especially
if the news is bad, patients' ability to retain information is
limited. One suggestion that has been tested successfully by Ley42
and his colleagues is to deliver prognostic information first
followed by the diagnosis. This approach might mean making a statement
such as, "After reviewing all the information, I feel confident
that you have an excellent chance (95% or better) of making a
full recovery from the problem(s) you've been experiencing, and
those problems we've diagnosed as prostate cancer."
Involving Patients in Decision Making
A number of research studies have confirmed that increasing patient
participation in decision making leads to positive functional
and biomedical outcomes. Patient participation is particularly
important at the conclusion of the visit when clear understanding
and agreement on courses of action to be pursued become operative.
The importance of checking patient comprehension cannot be overemphasized.
In addition to sharing decision making responsibilities, using
this tactic provides the opportunity to educate patients about
the condition and to correct misinformation or misunderstanding.
Grueninger et al43 suggested several helpful questions
for use in educating patients and testing for comprehension. These
include:
- What do you know about this condition?
- What have you tried in the past to help you deal with this
problem?
- What has worked? What hasn't?
These authors suggest that many patient requests or demands can
be met with education instead of confrontation. For instance,
the patient who comes to the office complaining of headaches and
demanding a computed tomography (CT) scan can present a daunting
challenge when confronted. An alternative approach is to explore
what the person knows and has experienced regarding the demand.
A constructed example (Table 7) illustrates this approach.
Completing the visit: negotiating a plan, probing for adherence.
Unlike the inpatient setting, where patient activities can be
monitored, ambulatory patients are solely responsible for implementing
recommended treatment and lifestyle changes. The therapeutic alliance
between the physician and patient becomes the basis for negotiating
realistic management and treatment plans. Key skills required
at the end of the visit are providing a clear rationale, exploring
potential barriers to implementation of the plan, and offering
support.
Providing a clear rationale. A key concept in establishing
a partnership with patients is ensuring that they understand not
just that the clinician is proposing a diagnostic or therapeutic
plan but why. Like so many other aspects of effective clinical
communication, providing a rationale depends on the patient's
level of comprehension and interest in the information. At minimum,
providing a rationale should include a statement of intent, eg,
"I'd like to spend a few minutes discussing your treatment
plan so you will understand what I'm suggesting and why,"
and an invitation to the patient or family to use memory aids
(written notes, tape recording) and pre-existing information (pamphlets,
videotapes, brochures) to optimize comprehension. Memory aids
provide patients and family members with a resource which can
be reliably consulted after the visit and are likely to increase
information retention and adherence between visits.
Exploring potential barriers to implementation of the plan.
After providing a clear rationale for the plan, checking with
the patient to determine what barriers to its implementation exist
is important. A question such as "What might prevent you
from carrying out the treatment plan?" is often useful. For
example, a highly visible advertising executive may be concerned
about excusing himself or herself from meetings with clients to
comply with 24-hour urine testing. Unless this concern is identified
and an alternative testing strategy is negotiated, this patient
may not comply with the plan.
Providing support. Acknowledging the difficulty in following
a plan or making lifestyle changes and then providing support
are critical. Patients are gratified to know that the physician
understands and cares about the path they have embarked on. Viewing
the physician as a "coach"--that is, as someone who
is interested in and understands the intricacy of the "game
plan" and has the skills and commitment to help the patient
achieve the goals--also reinforces patient autonomy.
In a busy office practice, in which time is short, doctors may
be tempted to "cut corners" by giving patients their
diagnosis, recommending a treatment plan, and moving quickly to
closure. As is true for the beginning moments of the encounter,
investing in the end ensures that genuine partnership exists between
doctor and patient and that both parties know and understand each
other well enough to minimize the potential for misunderstanding
and miscommunication.
Conclusion
An extensive body of literature on the medical interview and related
skills already exists,44 and a number of elements of
the interview known to relate to satisfaction and outcome have
been identified.16 The Four Habits Model builds on
previous empirical and conceptual contributions to the field by
focusing attention on the sequence of events that typically takes
place during a medical encounter and the influence communication
in one Habit or domain has on others. In this respect, the Model
is an attempt to respond to the challenge identified by Inui and
Carter20 to address the gap between associations of
individual, isolated behaviors and the broader context of social
interaction and meaning in which physicians and patients encounter
one another.
We have found the Four Habits Model to be both practical and
understandable to practicing physicians. Experienced clinicians
intuitively understand that they must seamlessly blend the logic
of clinical decision making, which is the basis for making an
accurate diagnosis, with the logic of social interaction, within
which successful relationships are established and which often
determines how effective treatment and satisfaction with care
will be (Vanderford ML, unpublished material).b Investing
in the Four Habits provides a stepwise approach to enhancing patient
relationships, optimizing the amount and quality of information
available for making clinical decisions, and making the practice
of medicine more mutually satisfying for doctor and patient.
aDepartment of
Internal Medicine, Highland Hospital, Rochester, New York.
bDepartment of Communication, University
of South Florida. Tampa, FL 33606.
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