Core Communication Skills in the Medical Interview

Date:
01/11/2016
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Introduction

The medical interview is probably the most important and most frequently used clinical tool. An average physician in active clinical practice would be doing six to seven thousand medical interviews in a year. Good medical interview skills ensure that the doctor collects all the important and relevant facts necessary for making an accurate diagnosis, developing an effective patient-centred management plan and building a strong therapeutic relationship.

Effective communication between patients and physicians is fundamental for good medical practice. Patients in primary care have identified interpersonal communication skills as the most important and desirable attribute of professionalism that affects the process of healthcare.1 Good communication skills have benefits for patients, doctors and the process of care. Organisation-wide relationship-centred communication skills training at the Cleveland Clinic has improved patient satisfaction scores, physician empathy and self-efficacy, and reduced physician burnout.2

Core communication skills

A consensus among medical educators in the US identified the seven essential elements of communication in medical encounters as: building the doctorpatient relationship; open the discussion; gather information; understand the patient’s perspective; share information; reach an agreement on problems and plans; and provide closure.3 Similar core communication skills and strategies are essential for all clinical encounters, including giving a new diagnosis and starting a new therapy. In this article, six core or essential communication skills in the medical interview are explained. The micro skills are not discussed.

Introduction or invest in the beginning (open the discussion or make the personal connection): The introduction involves a greeting: the doctor’s name and designation in the team; the patient’s name and identification; a brief of the proposed agenda for the encounter; and finally, ensuring the patient’s comfort and consent before starting. A good introduction ensures smooth flow for the interview.

Active listening (gather information): This skill is demonstrated by making good eye contact, listening without any interruptions, appreciating the facts (cognitive) of the patient’s narrative and perceiving the emotional and other impact that the illness has on the patient. Start with open-ended questions, and use body language and facilitating gestures to elicit the patient’s story. It is important to permit the patient to complete the opening statement without interruptions. Only when there is no new information in the narrative does the doctor use clarifying questions and closed-ended questions to seek specific data to test the medical diagnostic hypothesis.

Expressing empathy: The first step in demonstrating this skill is by picking up the emotional cues in the words and body language of the patient when the patient is narrating the story of illness.

The second step involves naming the emotion (eg, worried, sad, upset and confused) followed by paraphrasing (using the patient’s own words) or using a reflective statement (eg,“I hear from what you are saying that the pain has made daily life difficult for you.”) and conveying it to the patient.

The third step is to give a brief supportive statement (eg, “Knowing how difficult it has been, we will do all that is necessary to help.”).

When physicians were empathic and used reflective statements, patients were more likely to report high satisfaction with the physician and feel understood, supported and confident in adherence to medical advice.4

Eliciting the patient’s perspective: In building an effective therapeutic relationship in the medical interview, it is not adequate to elicit only the biomedical facts of the disease, but explore empathically the psychosocial, economic and cultural aspects and impact of the illness. The best way to elicit the patient’s concerns, ideas, feelings and expectations is to ask the patient.

Ask questions on the events surrounding the onset of the illness (eg, “Tell me in your own words what was happening in your life when the symptoms started.”) and the effect of illness on the patient’s life (eg, “How has all this affected what you can and cannot do?”). Elicit the patient’s ideas (eg, “What do you think is the cause of your problem?”) and feelings (eg, “How has all this made you feel?” or “How are you coping with the illness?”). Elicit the patient’s expectations from the clinical encounter and expected outcomes (eg, “What are your expectations?” or “How are you hoping we could be of help?”).

The surveying technique is to ask a “what else” question (eg, “Is there anything else you have missed saying?”, “Are there any other questions you have?” or “Are there any other concerns or worries?”). When used at different points of the interview, it will often encourage the reluctant patient to share more and elicit a hidden agenda, if any.

Summarising: Summaries are good opportunities to ensure that the doctor has understood and appreciated the context of the narrative, and to check on its accuracy.

This skill is demonstrated by asking the patient to relate what you have heard to ensure you got it right (eg, “Let me make a summary of what you have said and let me know if I have gotten the facts right.”). Summarise the medical facts of the narrative, the emotional and other impact the illness has on the patient, and the patient’s expectations. A good summary makes the patient feel – this doctor has heard me, he knows the facts and he cares. A summary is timely at the end of the history of present illness and if needed, at the end of the consultation.

Closure and journey (invest in the end): The skill in closure of the interview involves thanking the patient for the sharing and stating the action plan to follow. Make a final check to ensure the patient has no outstanding issues or concerns, using a “what else” question.

A closing solidarity statement, affirming that the healthcare team is committed in working with the patient to resolve the medical problems, gives the feeling of support.

Conclusion

The medical interview still remains an essential clinical tool for diagnosis and management of the medical problems of patients, in addition to building an effective therapeutic relationship.

A strong therapeutic relationship is established by extending the interview beyond the biomedical aspects to the psychosocial aspects and other contextual issues of the illness experience. Active empathic listening with reflective responses is the heart of compassionate communication.

Effective communication skills are core skills and essential components of clinical competence for all clinicians and should not be downplayed as optional soft skills. Communication skills can be learnt, practised and continually improved like other clinical skills in medical practice. Even with all the technological advances, the doctor who practises effective communication skills with competence and compassion remains as the most efficient diagnostic and therapeutic agent in medicine.


References

  1. Sari MI, Prabandari YS, Claramita M. Physicians' professionalism at primary care facilities from patients' perspective: The importance of doctors' communication skills. J Family Med Prim Care 2016; 5(1):56-60.
  2. Boissy A, Windover AK, Bokar D, et al. Communication Skills Training for Physicians Improves Patient Satisfaction. J Gen Intern Med 2016; 31(7):755-61.
  3. Makoul G. Essential elements of communication in medical encounters: The Kalamazoo consensus statement. Acad Med 2001; 76:390-3.
  4. Pollak KI, Alexander SC, Tulsky JA, et al. Physician empathy and listening: associations with patient satisfaction and autonomy. J Am Board Fam Med 2011; 24(6):665-72.