History-Taking and Interview Techniques and the Physician-Patient Relationship
Fred M. Howard
Table Of Contents
Fred M. Howard, MS, MD
GOALS OF THE INTERVIEW|
THE PHYSICIAN-PATIENT RELATIONSHIP
With astounding information from laboratory and imaging techniques available in this era of “high-tech medicine,” it is easy to think that the interview to obtain a medical history is obsolete. This could not be more incorrect. Except in emergency conditions, the initial interview is the first contact between physician and patient. It is the beginning of the diagnostic and therapeutic process. It is much broader than the medical model of “history-taking” because it involves much more than the gathering of factual biologic data. It is the starting point from which physicians must integrate the art and the science of medicine. From the scientific perspective, medical practice demands an understanding of the pathophysiology, diagnosis, and treatment of disease. The explosive advance of scientific knowledge is so rapid that most of what a medical student learns is superseded before he or she completes a residency, and a constant effort is required of the practicing clinician to keep his or her knowledge current. Thus, undergraduate, graduate, and postgraduate medical education rightly stress the science of medicine, particularly stressing evidence-based medical practice. Yet, as physicians learn to practice medicine, almost all quickly realize that they cannot successfully care for their patients by being solely biologic scientists. They learn that they must also integrate knowledge of their patients’ social, psychological, and environmental milieu to provide the highest quality health care. It is the interview that provides much of this information. The interview thus involves much more than only a history of medical symptoms. Skilled interviewing opens communication channels between the participants, allowing positive or negative feelings to emerge in each.
The skills with which physicians integrate the science and art of medicine during the history and physical examination are major parts of what is called the physician’s “bedside manner,” and it is a significant part of the art of medical practice. The art of the practice of medicine requires that the physician understand an individual patient with an illness and develop a relationship that allows her or him to care for that individual, and not just the patient’s illness. The obstetrician-gynecologist is unique among all the specialties of medicine in dealing with severe disease such as cancer on one hand and with normative life changes that everyone undergoes on the other hand. Appropriate interventions in both situations may change the course of a person’s life. Since the obstetrician-gynecologist deals with a wide range of human experience, she or he must have a broad background in biopsychosocial medicine.
The skill with which the medical history is obtained also influences the physical examination, which has value similar to the interview in the care of patients. The examination is a part of care that engenders great anxiety in patients, especially with the intimacy of the examination in obstetrics and gynecology. The interview is vital to establishing the trust that allows the physical examination to be performed with the patient sufficiently relaxed and comfortable that a thorough and reliable examination can be done.
A well-taken history will be of little use if it is not recorded in the patient’s chart in a functional way. The medical chart provides permanent proof of the visit, which is also important from a liability perspective. Good records are (1) accurate, (2) objective, (3) legible, (4) timely, (5) comprehensive, and (6) unaltered.1 All entries in the chart should be reviewed by the physician to ensure these criteria are met. In addition, all entries should be dated and signed.
|GOALS OF THE INTERVIEW|
Many goals of the medical interview could be discussed. This chapter reviews only four: (1) making a medical diagnosis, (2) establishing a productive physician-patient relationship, (3) directing therapy, and (4) optimizing treatment. Accomplishing these four goals requires an integration of the science and the art of medical practice, and realistically, not all of them can always be accomplished in every doctor-patient encounter.
The medical education of physicians clearly stresses that a major goal of the interview is to take a medical history that will formulate the patient’s symptoms into a differential diagnosis. Similarly, at the time of preventive health care, a major goal is to identify symptoms that suggest any undiagnosed or potential diseases. The ability to skillfully take a medical history and formulate accurate diagnoses is vital to being a competent physician, and the importance of this ability cannot be overstated.
To accomplish the diagnostic goals of the interview, active listening is the technique that uses time efficiently while still establishing a trusting patient-physician relationship. This means encouraging the patient to tell her story in her own manner and make spontaneous associations with minimal interruptions by the physician. It does not mean allowing the patient to talk endlessly in a rambling manner that does not contribute useful medical, social, or psychological information. The physician must provide direction for the interview by systematically organizing the information derived and asking questions that follow logically on the patient’s story. The interview should not be a passive listening experience. The physician must be actively organizing the content of the interview and directing it, being alert to not directing the content at the expense of prejudicing the patient’s responses and obtaining a contrived story. The amount of direction will vary from patient to patient. Some patients require much direction and others very little. Flexibility on the physician’s part occurs with interviewing experience. Skill and practice are needed to do this without prejudicing the patient’s responses or keeping her from telling potentially important information. Traditionally, asking open-ended, nondirective questions initially, and then following up with specific, detailed questions on each important topic or symptom, does this best. The patient discusses a topic, then the physician begins to direct her into the areas that need clarification. As the patient talks about the medical problem, she may well get off into family and social areas, and it is wise to allow her to proceed in these areas. Patients can always be brought back to the present illness because they expect to talk about the medical problem. As long as the patient is talking freely about relevant information, the physician allows her to continue without interruption. If she becomes distracted with irrelevant information, the physician must note at what point this occurs because it may indicate that she has anxiety about this topic and therefore is changing the subject by giving irrelevant material. The physician then may bring her back to the present illness and present situation with a directive question.
At times, the patient falls silent. This may occur because she has finished the train of thought and has nothing more to say or because she needs time to organize her thoughts. However, it may also occur because the question or train of thought has led to some very anxiety-provoking material. Often, it is wise for the physician to keep silent for a short time to see whether the patient will resume talking. If she does not resume talking, the physician hopefully now has some idea whether she is through with that topic or is too anxious to pursue it, and he or she can question accordingly. At times, patients need to stop to collect their thoughts, and the physician should not rush them at that time with another question. Conversely, if the physician senses the patient’s becoming very tense and anxious or depressed about the area in which she has been communicating, he or she may either bring this to her attention or, if it seems that this will make her too anxious, depressed, or guilty, may go on to another part of the problem by changing the subject. The skilled interviewer does not allow silence to persist too long because the patient may see this as lack of interest or coldness on the interviewer’s part. As with everything in interviewing, this is a delicate balance.
One of the areas that gynecologists deal with frequently that may cause considerable feelings of shame, embarrassment, or guilt is in the sexual area. Often, the physician can help the patient to explore this area by getting some physiologic history about the menstrual cycle, particularly menarche and its onset. Most women are quite ready to tell the physician about menarche and about periods over the previous years. By asking the open-ended question, “What do you remember about the first period?,” the patient is allowed to give her associations. The kinds of information the physician would like to know are how did she learn about periods, who told her, how did she communicate with peers, mother, sisters. This is a crucial point in the biopsychosocial development of the young woman. Most women remember this time in life quite vividly. The physician may learn what the family setting was and how readily the family could discuss sexual matters. It may be relevant at this point to ask how the patient learned about pregnancy and sexual intercourse and, in this way, get clues to the patient’s current sexual functioning. Asking about use of contraception may provide many clues about sexual functioning. Many couples are unable to use effective contraception because they have crucial sexual problems. A physician alert to this can start with contraceptive matters and gradually explore the area of the sexual problem without creating undue distress on the patient’s part. Having set the background with the questions just discussed, it is most logical to ask the open-ended question “How is your current sexual relationship?” If the physician asks this question out of context, unrelated to what the patient has been talking about, she may be offended that he or she has asked or be so anxious and embarrassed or ashamed that she may make some very brief statement and quickly change the topic. It is most important in the area of sexuality to allow the patient to tell her own story and learn what is important to her in her sexual experience. What may be acceptable sexual practice to one patient may be quite the opposite for another. It is important to know the patient’s standards. Other areas in gynecologic history that serve as transitions for exploring the current sexual situation are problems of the vulva and vaginal irritation, pelvic relaxation, urinary incontinence, and pregnancy. In these as well as other areas, the patient readily sees the connection with sexual functioning and can often talk very easily about it.
Certain questions may be reserved and asked during the physical examination. For example, directive questions of the review of systems can be asked at this time and can save valuable office time. After the examination, the physician should summarize her or his thoughts based on the history and physical examination. Ideally, this is done with the patient clothed in the consulting room. If this cannot be done, then every attempt should be made to keep the patient covered and have this discussion with the patient seated and at the same eye level as the physician. It is vital at this time to ask if there is anything else the patient would like to bring up. Some patients will bring up new, important data at this time because they feel more comfortable with the physician or because the completion of the physical examination and bodily exposure makes it permissible for her to reveal more information. On occasion, the physician will have misinterpreted some information, and the patient has the opportunity to correct her or him. If the patient has revealed distressing or embarrassing material, the physician has an opportunity to reassure her that this is permissible and that the physician understands without judgment or prejudice.
The physician will learn varying amounts of information during the initial interview and examination. For some patients, it may take several sessions to develop enough trust to be able to fully tell their stories. Others can do this easily during the initial appointment. Some stories will be long and involved and require several appointments for full elucidation. The physician does not have to feel that she or he must get all the information during the first session. Preprinted history forms are commonly used to record basic information, especially in busy practices, and can be extremely helpful in optimizing office time, as long as they are not allowed to replace having the patient tell her own story.
Overall, the medical purposes of the interview are to formulate a differential diagnosis, possibly make a diagnosis, and to plan further diagnostic studies. The history-taking interview is a critical component of the diagnostic process. The physician must be thinking continuously, as he or she guides the patient in exploring her symptoms and issues as she talks. Again, this is an active listening skill on the part of the physician. He or she may at times verbally convey some of his or her thoughts to the patient in the form of a question or comment but, frequently, is not conveying these thoughts as he or she attempts to organize them in his or her own mind. As the patient is talking, the physician is thinking about causes and effects related to biologic symptoms. He or she is thinking of ways of testing hypotheses, both through redirecting the interview and later in physical examination and laboratory testing. During this active process of listening, the physician is learning as much as he or she can about biologic, psychological, and social areas of the patient’s life, while at the same time going through the rigorous mental discipline of making hypotheses and deciding ways to test these hypotheses. Again, the purpose is to arrive at a diagnosis and a therapeutic regime that can be helpful to the patient.
It is vital that the physician conveys her or his interest in helping the patient eliminate her symptoms or discomfort. The patient wants the physician to give her hope that she or he will work with her to discover the problem and work out a solution. Yet the physician must not reassure the patient prematurely about her or his ability to alleviate the problem. Not only is this unscientific, but patients will note the superficiality of this approach. An example might be prescribing a treatment before the physician has completed the history and a physical examination or any necessary laboratory testing. Because, unfortunately, there are problems that can be palliated but have no solutions, the wise physician does not suggest that she or he can solve all problems.
Obtaining the history with good, active listening skills guides further evaluation by physical examination, laboratory testing, and imaging studies in a consistent and efficient manner. It also conveys to the patient the physician’s thoughtful approach to care and his or her interest in helping and may aid in allaying the patient’s anxiety and angst. The details of the obstetricand gynecologic history are beyond the scope of this chapter and are thoroughly covered in other chapters in this text. Clearly. a thorough knowledge of obstetrics and gynecology is essential to diagnostic skill with the medical history of the obstetric-gynecologic patient.
Establish a Productive Physician-Patient Relationship
Although establishing a good physician-patient relationship is not generally viewed as the overriding purpose of the interview, it may well be, because without this, there can be no medical treatment. A good, productive physician-patient relationship facilitates diagnosis and treatment, whereas a poor, nonproductive relationship impairs both. Skilled interviewing opens communication between the patient and the physician and is crucial to establishing the mutual trust, understanding, and confidence essential to a good doctor-patient relationship. Trust and confidence in the physician must be established as part of the initial interview and sustained in subsequent interactions.
Our society’s medical tradition has expectations of both the patient and the physician to establish a good doctor-patient relationship. From the patient perspective, it encourages and entitles the patient to come to the physician to ask for help. The patient of course must recognize that she has a problem before she is going to consider consulting a physician. This, however, may not be easy. To do so is to indicate that she is no longer a self-sufficient individual who can solve her own problems. The ability to consult a physician requires the patient to put herself in the dependent role, which may stir up much anxiety. People differ in their ability to feel dependent needs; some enjoy this so much that they abuse physicians with constant calls and office appointments, whereas others are so threatened by dependent feelings that they do not seek a physician’s help when they should or do not call a physician when an important issue arises. This reluctance to seek help may exist for both medical and psychological symptoms. Certain patients have bled vaginally for a considerable amount of time before getting up the courage to go to a physician because they have not been able to tolerate the “sick role.” Likewise, couples with infertility or sexual problems may have difficulty admitting to themselves that they cannot solve these problems because to admit this may arouse strong feelings of shame and inferiority. There is still the strong myth in our society that a person should be able to take care of her or his own emotional and interpersonal problems alone without help from another person. Some patients have admitted the need for help but are still so anxious and ashamed of asking for help that it may take them months to years to get up the courage to consult a physician. They may make appointments and break several before actually getting into the office. Such patients, when forced to seek a physician’s help, may appear to be very hostile or anxious until they are reassured by the physician that he or she sees them as autonomous individuals who will be treated with respect.
Any hostility or anxiety must be overcome to establish a good doctor-patient relationship because part of the patient’s responsibilities are to be honest with the physician, willing to talk openly about her problem, willing to have an examination, and willing to undergo necessary diagnostic studies. The patient appropriately should expect to do this in an atmosphere that is free of exploitation and in which the physician will hold her revelations in confidence and without judgment.
From the physician perspective of the physician-patient relationship, it is expected that she or he will come to it viewing herself or himself as a helpful, caring person. To carry out her or his professional role, society has allowed the physician to make personal and intimate inquiry that few others are entitled to do. The physician has the responsibility to be properly trained, refrain from giving treatment in areas in which she or he is unfamiliar, and provide help and comfort to patients. The physician must remain aware that society places her or him in the role of authority and gives her or him power that she or he must be wary of using. For diagnosis and treatment to succeed, the patient must be able to trust the physician, and the physician must not abuse this trust by exploiting the patient for her or his own needs. For this reason, it is important that the physician know something about her or his own needs so that she or he will not subtly use the patient to satisfy them.
A part of the physician’s responsibility in building a strong physician-patient relationship is to endeavor to allay the patient’s anxiety, fear, or hostility. The physician should take steps to help do this. For example, the history should be obtained in as relaxed and private a setting as possible. Under other than emergency conditions, the patient should never be interviewed for the first time in the examining room disrobed. In this situation, the patient is put at a very definite disadvantage, is going to feel more, not less, anxious, and therefore, may not be able to communicate in an open fashion. Ordinarily, the patient should be interviewed alone. Exceptions may be necessary for children, adolescents, and mentally impaired women or if the patient specifically requests that an attendant or family member be present. Even in these situations, it is a good idea to give the patient an opportunity to speak with the physician privately.
The appropriate manner of addressing patients has aroused controversy.2,3 It is not clear which manner best serves the physician-patient relationship; it probably varies with each relationship. Many physicians are in the habit of addressing their patients by their first names but, in turn, expect to be addressed as “doctor.” Some patients have objected to this practice, believing that it further accentuates the power differential between patient and physician. It is suggested that physicians should initially address patients by their surname. As the physician-patient relationship develops, this may change at the patient’s request. If the physician’s preference is to use the patient’s first name, then he or she should introduce himself or herself by both first and last name, and be sure he or she is comfortable if the patient calls him or her by first name also. A reasonable script to address this issue individually is with a script such as: “Good morning (afternoon, evening). You’re Jane Doe? I’m Judy Smith; I don’t believe we’ve met before? (Offer handshake.) Do you (prefer to) go by Jane or Ms. Doe?” Most patients will correct the physician to “Mrs.” if that is their preference. Interestingly, my experience has been that the great majority of patients have preferred to be called by first name even though they prefer to call me by “Doctor Howard.” The physician should remember to be consistent on phone calls. If he or she asks for “Jane,” then he or she should identify himself as “John (or Mary) Smith,” not Dr. Smith. (The physician can aid the patient in identifying him or her by using the practice’s name or reminding the patient that she called the office earlier.)
The effect of diplomas on the wall is another debatable matter. Some patients will find them assuring, a way of knowing the physician’s credentials; others may find them distracting or may even be put off by them. Certainly attractive pictures and sculptures help to create a calming, relaxing atmosphere.
The physician’s attitude and sensitivity are important to the physician-patient relationship with any patient, but they assume particular significance during the gynecologic evaluation. Discussing reproductive system problems is difficult for some women; in addition, these problems often have an emotional impact that physicians may fail to appreciate. For example, the patient may be experiencing or anticipating disruption of sexual activity or may be concerned about the effects of her problem on future fertility. Such concerns can be present even in a discussion of birth control or the evaluation of a vaginal infection.
One of the important techniques essential to establishing a good doctor-patient relationship is accepting the patient’s statements nonjudgmentally, so as to encourage her to tell her story in her own words, in her own way. The physician must be able to listen closely to the patient to elicit and understand her feelings about her condition. Listening to the patient starts with the first interview and continues throughout all the contacts that the physician has with the patient. Whereas there are many appropriate styles of interacting with patients, all styles should incorporate traits that patients desire in physicians: honesty, thoroughness, a nonjudgmental attitude, and a sincere interest in the individual patient.
Nonverbal communication also plays an important role in forming a physician-patient relationship and establishing mutual trust and confidence. One of the major ways in which the physician communicates to the patient nonverbally is in her or his choice of the physical setting in which to interview the patient. This has already been stated but is worth repeating; assuming that no acute emergency exists, the most appropriate place to hold the interview is in a consulting room with the patient clothed. The room should be serene and comfortable, with comfortable chairs and adequate lighting. By arranging for comfortable furnishings, the physician has shown her or his interest in the comfort and dignity of the patient. The interview should be a room in which interruptions will not occur during the interview. If a secretary or nurse constantly interrupts them, the patient may interpret this as lack of concern for herself and lack of attentiveness on the physician’s part. Privacy must be assured. In arranging the furniture, the physician must consider the nonverbal communication given by the physical distances between herself or himself and the patient. If the physician sits across a large desk from the patient, she or he is indicating that she or he does not wish a close relationship with the patient. A desk sets the physician apart from the patient, tending to make the physician more of an authority figure. It seems wiser for physician and patient to sit at a comfortable distance in comfortable chairs facing each other. Chairs should also be provided for other members of the family or friends whose presence is appropriate for the interview.
The physician’s appearance likewise communicates nonverbally to the patient. In general, it is advisable that the physician be dressed in acceptable professional attire. Some patients will be offended if the physician is casually dressed. Therefore, it is wiser to err on the side of conservative dress until one knows the patient. Dress in scrub suits presents a particular issue for obstetrician-gynecologists. Whenever possible, it is probably best to avoid doing initial interviews of patients in a scrub suit because the suggestion of surgery and operating rooms may add to the patient’s anxiety.
The physician likewise communicates nonverbally through his or her body language with gestures, facial expressions, posture, and so forth. The physician must be aware of cultural interpretations of physical contact between patient and physician during the interview. Obviously, during the physical examination, there is close physical contact. Middle-class Americans tend to become uneasy about such closeness. People often draw away if a stranger attempts to come too close to their “space.” Conversely, a handshake with the patient as she is greeted or laying a hand on the patient’s hand or shoulder if she seems distressed is often very helpful and supportive during the interview. The experienced physician will learn to judge this and act accordingly. The physician, regardless of gender, of course should not use inappropriate physical contact such as slapping on the back, knee, or buttock, which may be offensive to patients.
In addition to being aware of the physician’s own nonverbal communication, she or he must also learn to perceive the patient’s nonverbal communication. She or he must learn to acutely observe the patient’s behavior including gait, demeanor, posture, facial expressions, and tone of voice, both during the interview and during the physical examination. Verbal messages are consciously controlled, whereas nonverbal messages are unconsciously controlled and, therefore, often are more important. The physician should observe whether the nonverbal behavior is congruent with the verbal behavior. For example, the patient may be talking about a very sad event and yet be smiling and laughing. This may be a clue that the person is having difficulty dealing with the sadness and is trying to deny it or cover it up with the smiling and laughing. The physician should note the topic and, as the interview proceeds, may want to ask about the topic with such incongruent behavior. The physician can be gently supportive and encourage her to talk about the distressing subject. She may then be able to discuss her real feelings about the situation. On occasion, she will indicate she does not wish to, and if so, the physician can leave the subject and perhaps return to it later in the interview or at another time.
Crying is an important nonverbal communication and allows for release of built-up tensions in the patient. Crying conveys that the topic is of great significance. Physicians often feel uncomfortable when patients cry. They must learn to deal with this discomfort.
The patient’s posture may also communicate her feeling tone. The person who is slightly bent toward the physician may be indicating that she wishes to communicate with him or her, in contrast to the one who tries to get as far away from the physician as possible. Tapping of fingers or feet often indicates anxieties, as does gripping the arms of the chair with white knuckles. Slumped shoulders or bowed head are often marks of sadness.
Gestures are important information. A patient may be talking about a given pain and repeatedly pointing to a certain area of the body. This is important to observe. At a later time, the same patient may be talking about symptoms a close family member had and point to the same area of the body. This may give clues to the physician about similar symptoms in family members.
Many clinicians feel uncomfortable observing body language, but with practice, they can usually overcome this discomfort and add much to their knowledge of the patient and, therefore, their ability to help her. Also, becoming more sensitive to the patient’s nonverbal communication can help the physician become more aware of her or his own nonverbal communication during the interview.
Ethnicity can be important and the physician must be aware that it may be more difficult to relate to patients from ethnic, cultural, and economic backgrounds different from his or her own. Indeed, a physician may need to spend more time with a patient from a different background to understand that background before being able to help the patient.
The busy practitioner can easily forget the anxiety that is generated by a visit to the physician. The physician assumes that the patient will tell the total truth about intimate details of her life, and in obstetrics and gynecology, these details are often especially intimate and exposing. There are no caring professionals other than physicians in whom such implicit trust is routinely given with both personal and medical information. When one recognizes that these disclosures are combined with the bodily exposure of the physical examination, in particular the pelvic examination, the anxiety and apprehension produced are readily appreciated. In most cultures, exposing one’s personal history and one’s body in this way is not a natural thing. Establishing a trusting physician-patient relationship greatly allays much of the anxiety associated with medical care, and this almost certainly improves the physician’s ability to provide diagnosis and treatment.
There is general acceptance that therapy should be evidence-based. Initially, the skills described as necessary for evidence-based practice included the ability to precisely define the patient’s problem, find out what information is required to resolve the problem, conduct an efficient literature search, select the best of the relevant studies, determine the validity of the studies and extract the clinical significance, and finally, apply the information to the patient’s problem. To these skills must be added an understanding of how the patient’s values affect the balance between advantages and disadvantages of the available therapeutic options, and the ability to appropriately involve the patient in therapeutic decisions. To accomplish these additional skills requires compassion, sensitive listening ability, and general perspectives from the humanities and social sciences. These attributes allow understanding of patients’ illnesses in the context of their experience, personalities, and cultures. A competently obtained history is a major factor in establishing a physician-patient relationship that allows such information to be revealed. A sensitive understanding of the patient is important to evidence-based therapy in a number of ways. For example, this understanding will attune the physician to the fact that for some patients, their values will mean that a full discussion should cover of all possible benefits, risks, and inconvenience associated with each therapeutic option. In contrast, other patients will have values that make them uncomfortable with an explicit discussion of benefits and risks because they perceive the physician is shifting an excessive responsibility for decision-making onto their shoulders. In such patients who want the physician to make the decision on their behalf, the physician’s responsibility is to develop sufficient insight into the patients’ values and preferences to ensure that choices are congruent. Only through sustained efforts to skillfully conduct the medical interview will the physician develop the ability to understand the patient’s narrative and the person behind that narrative in a way that permits the sort of decision-making process the patient desires and leads to effective communication of the information she requires.
The evidence-based process of resolving a clinical question and instituting treatment will be fruitful only if the problem is formulated appropriately. Spending hours searching for the highest-quality evidence and reviewing the available randomized, clinical trials on therapy for a disease are worthless if one lacks the clinical acumen to have done a good medical history and examination and to have made the correct diagnosis. The story of a secondary care internist who developed a lesion on his lip shortly before an important presentation is exemplary of this problem. He was quite concerned and wondered if he should take acyclovir He proceeded to spend the next 2 hours searching for the highest-quality evidence and reviewing the available randomized clinical trials. When he began to discuss his remaining uncertainty with his spouse, an experienced dentist, she quickly cut short the discussion by exclaiming, “But, my dear, that isn’t herpes!” The essential skills of obtaining a history, conducting a physical examination, and the astute formulation of the clinical problem come only with thorough background training and extensive clinical experience.
Even with accurate diagnoses, treatment needs to be consistent with the patient’s expectations and wishes, beliefs and principles, and psychosocial situation. “Cookbook medicine” that does not take into account the patient’s individuality is suboptimal for numerous reasons, not the least of which may be poor patient compliance. Understanding the background from which the patient comes and her current psychological and social state significantly aids in giving optimum health care in which the patient will participate and comply. Health care professionals and especially physicians must be much more than biologic scientists. They must also have insights into human behavior and experience as well as into social and environmental factors that impinge on health. Physicians have tended to deal exclusively with the biologic because of the great strides that have been made in this area. It is often difficult to integrate biologic knowledge with social, psychological, and environmental factors, but it is important the physician endeavor to do so.
Physicians need to understand their patients’ health beliefs. These are determined by cultural patterns, previous experience with an illness, and information or misinformation from nonmedical sources. Once these are known, factual information can be given and related to a person’s actual feelings and experiences. Such education is particularly important in obstetrics and gynecology, in which much of what is done is preventive rather than treatment of an illness with symptoms. A relatively small percent of patients (possibly only one third) follow doctors’ and nurses’ instructions about drug intake, lifestyle changes (diet, exercise, rest), or appropriate follow-up evaluation of potential or actual medical problems.4 Noncompliance may result in unnecessary and costly diagnostic and treatment procedures, as well as produce negative attitudes in patients about their physicians and the health care system generally. Many factors other than the physician-patient relationship influence compliance, but a good relationship may at least help the physician and the patient become more aware of the problems and challenges to achieving appropriate compliance. Physicians have an ethical responsibility to inform patients in a manner they can understand, giving them the necessary knowledge and behavioral skills to comply and the freedom to make informed decisions.
Patients generally come to physicians with a biologic illness, psychosomatic disorder, or psychological problem. Some sort of discomfort usually accompanies these problems, be it physical pain, anxiety, a feeling of helplessness, or disturbances of the relationships between the patient and others around her. Often, there is a disruption in the patient’s family, work, or social life. She comes with the hope that the physician can be helpful in righting the distress, but also fearful that there is no help available. The physician, knowing that all patients come with some degree of distress, will help encourage trust and confidence by being kind and supportive and by respecting the patient’s feelings and integrity. The infrastructure for this relationship is set in the initial interview.
In general, patients may clinically improve for three reasons.5 One is that the prescribed treatment may actually have specific therapeutic effects that result in improvement. Most often, a randomized, placebo-controlled clinical trial is necessary to estimate the actual therapeutic effect of any treatment.
Another reason is that the typical natural history of many disorders, especially chronic conditions, is fluctuation of symptom severity. Thus, from severe symptom states, the natural course is a regression to the mean, which is seen as improvement by the clinician (and patient). Patients tend to seek medical care when their symptoms are at their worst, so the next likely change is improvement. This improvement is likely to be attributed to the treatment prescribed by the clinician.
A third reason is there may be nonspecific effects of the treatment that are attributable to factors other than any specific activity of the treatment, that is, a placebo effect.5 The term placebo is often used synonymously with nonspecific effects, but it should be distinguished from the term placebo effect. Placebo refers to an intervention designed to simulate medical treatment, but not believed by the clinician to be a specific treatment for the target condition. In clinical practice, a placebo is used for its psychological effect and has a limited, if any, role. In research, it is used to eliminate observer bias in the experimental setting. Placebo may also be applied to a treatment now believed ineffective, although previously it was believed to be effective. Placebo response refers to any change in the patient’s condition following the administration of a placebo. Placebo effect refers to a change in the patient’s condition or illness attributable to the symbolic importance of a treatment rather than a specific pharmacologic or physiologic property. The placebo effect does not require a placebo. Placebo effects are found with drugs, medical treatments, surgery, biofeedback, psychotherapy, and diagnostic tests. It may occur whenever the patient or physician perceives the “treatment” as effective. For example, it may occur simply owing to a visit with a physician. It has been suggested that physicians are, by far, the most important moderators of the placebo effect.6
It seems likely that a great deal of the response of the patient to a therapeutic physician-patient relationship may be attributed to the placebo effect. This placebo effect seems to result from a combination of factors involving the doctor, patient, and their relationship to one another.7 Only a few factors are discussed in this chapter: those particularly related to the history-taking and interview.
One such factor is the perception of the physician as having great expertise as an acknowledged scientist and healer. Thus, it is ideal when patients come to the physician from a background of trust and optimism. This can be due to referral by a close friend or family member who has been helped or to referral by a colleague whom the patient trusts and who has highly recommended the physician. These situations are not always under the physician’s control, but they should be optimized whenever possible. In addition, as already mentioned several times, the skill, knowledge, and meticulousness with which the physician takes a medical history can do much to bolster the patient’s confidence.
Another factor is the congruence between the doctor’s approach to therapy and the patient’s attitudes toward illness and treatment. When the patient can express her emotions freely during the taking of the history, it allows the physician to understand the important developmental and situational highlights of the patient’s life and illness, thus establishing a helpful doctor-patient relationship and optimizing the placebo effect of the interaction.
A third factor in the placebo effect from the physician-patient interaction is the time spent with the patient. In the current era, spending adequate time is difficult because time constraints on physicians are consistently greater. Yet, anything that can be done to optimize this is important. Also, techniques that increase the perception of time spent may be helpful (although not well-studied). Taking the history, at least at the initial encounter, with the patient clothed not only increases the patient’s comfort and anxiety levels but also gives the impression that the physician has time for the patient and is not hurrying. Sitting down while talking to the patient and taking her history also improves the perception of time spent.
The physician’s demeanor also influences the placebo effect of the interaction. The physician must create the air of a professional person whose aim is to help and who puts the patient above his or her own personal needs. For instance, asking a patient to give him or her advice about the patient’s area of expertise is not appropriate for the initial few interviews before trust and confidence have been established. The patient may well see this as a form of exploitation. It is important that interactions be viewed as positive by both patient and physician. An interesting study of nonspecific effects by a general practitioner showed that 64% of patients improved after a positive encounter with the physician compared with 39% after a negative encounter (statistically different, p = .001).8
Clearly to the extent that is ethical, physicians should use the placebo effect to their and their patients’ advantage. As an aside, this does not mean that it is appropriate to use a placebo in general clinical practice. It is a gross error to use a placebo to assess whether a patient’s symptoms or pain are real or to dismiss or delegitimize the complaints on the basis of a placebo response. For example, patients suffering from organic pain respond to a more marked degree to placebo than those with nonorganic pain, indicating the importance of strong motivation. It is a clinical misconception that if a patient responds favorably to a placebo medication, then the pain must be of psychological origin. This is simply not true.9
Although the placebo effect is an irritant in scientific studies, clinically it is one of a doctor’s best allies and is not infrequently the only thing she or he has to offer. The physician’s skill in the art of medicine is reflected in (and by) her or his bedside manner. The patient’s perception of the physician’s bedside manner is to a large degree set by the interactions at the initial interview, and the quality of this bedside manner is a major part of the physician’s contribution to the placebo effect. Placebo is not a weak therapy. In Beecher’s classic review of 15 studies, he found an average of 35% of patients improved with placebo treatment.10 Furthermore, the placebo effect seems ubiquitous, occurring in diseases involving any organ system in the body. It would seem then that the wise clinician would incorporate into the doctor-patient relationship whatever might enhance the placebo effect.
|THE PHYSICIAN-PATIENT RELATIONSHIP|
Much of this chapter has dealt with the importance of the medical interview in establishing a good physician-patient relationship. The physician-patient relationship is a vital part of health care, but the actual characteristics of that relationship vary greatly with different doctor-patient dyads. Several classifications of the types of physician-patient relationship have been proposed. Clearly, there is overlap in these classifications and in the types of relationships described. In addition, the type of relationship can change transiently or permanently within a physician-patient dyad, depending on the particular circumstances. This seems to be particularly true for obstetricians-gynecologists. Although there certainly are other classifications that are just as useful, only the classification of relationships suggested by Hollender are discussed in this chapter.
Hollender has described three types of physician-patient relationships: activity-passivity, guidance-cooperation, and mutual participation.11 In the activity-passivity relationship, the physician is dominant. The physician is an authority who does things to and works on the patient and the patient does not actively participate in her treatment. As a surgical specialist, the obstetrician-gynecologist frequently and appropriately acts in this role in the operating room or in the emergency room. The activity-passivity relationship is appropriate in these situations because surgery could not be performed if the physician did not act in the dominant, active role. Similarly, if a patient comes into the emergency department in shock from an ectopic pregnancy, the interview should be very truncated. It is crucial in this situation that the physician make a quick diagnosis and get the patient to the operating room. The relationship again will tend to activity-passivity in such a situation. Conversely, this kind of relationship would be inappropriate if the same patient came to the physician’s office with a long-term sexual problem. For the physician to make a quick diagnosis and tell the patient and her partner what to do to solve the “problem” is unlikely to ever be correct in this case.
In the second type of relationship, the guidance-cooperation type, the physician is still seen as an authority figure, but the patient has a greater sense of autonomy and feels a greater sense of responsibility for her own care. In the interview in this type of relationship, the physician is very directive, asking mostly yes-no questions that allow the patient some input but not much spontaneous expression. This type of questioning is generally appropriate for the end of the interview when one is reviewing body systems and does not necessarily dictate the overall nature of the physician-patient relationship. The same may also be the case for follow-up interviews when time is quite limited and the physician must focus on one particular aspect of a problem. A guidance-cooperation type relationship may be appropriate in the therapeutic arena after the physician has considerable knowledge about the problem and begins to outline the treatment, giving the patient some basic medical data that can be useful to her in understanding her diagnosis. This may, for example, be an appropriate relationship regarding the treatment of gonococcal cervicitis, in which the treatment options are limited, and it would be extremely rare to have a scenario in which treatment was not obligatory.
The most productive long-term type of physician-patient relationship is the mutual participatory relationship. In this type of relationship, the patient has the greatest opportunity to express in her own words how she has experienced the problem and all of its ramifications. She is encouraged to act like a responsible adult who has responsibility for participating in the outcome of the treatment. It is the type relationship that is most productive in the initial interview of the patient and is crucial to achieving the previously reviewed goals of the interview. Similarly, in a therapeutic situation, it is usually the most productive relationship because the patient must learn to take responsibility for her own actions and the physician is responsible for encouraging independence consistent with good treatment.
Clinicians should temper their enthusiasm for active patient involvement in decision-making with an awareness that many patients prefer parental approaches. A survey of 2472 patients suffering from various chronic diseases (hypertension, diabetes, heart failure, myocardial infarction, or depression) illustrates this point. In response to the statement, “I prefer to leave decisions about my medical care up to my doctor,” the responses were strongly agreed, 17.1%; agreed, 45.5%; uncertain, 11.1%; disagreed, 22.5%; and strongly disagreed, 4.8%. This survey was completed between 1986 and 1990, and although it is likely that patients now are more enthusiastic about active involvement in decision-making, these results suggest that many patients still prefer the physician to assume a primary role.
Regardless of the physician-patient relationship chosen by the patient and clinician, evidence-based medicine injects into the process the challenge that clinicians consider quantitative estimates of benefits and risks, rather than just qualitative global assessments of whether a diagnostic test is safe, a treatment works, or toxicity occurs. Clinical medicine is rarely, if ever, so black and white, all or nothing. If clinicians are to leave decisions to patients, they must effectively communicate the probabilities of the outcomes associated with alternative choices. If physicians choose to take responsibility for combining patient values with the evidence, an evidence-based medicine approach challenges that they must try to quantify those values. A vague sense of the patient’s preferences cannot fully satisfy the rigor of the optimal evidence-based medicine approach.
The interview to obtain a medical history is the beginning of the diagnostic and therapeutic process. It is the starting point from which physicians must integrate the art and the science of medicine and establish a good physician-patient relationship. Skilled interviewing opens communication between the patient and the physician and is crucial to establishing the mutual trust, understanding, and confidence essential to a good doctor-patient relationship. The following bullets summarize some of the points reviewed in this chapter that may help make the medical interview and the doctor-patient relationship good and productive.
The physician continues to occupy a position of special privilege in our society. Few others are permitted such an intimacy of relationship with fellow human beings who are not their relatives or chosen partners. The physician is the only professional entitled to ask intimate details about another’s life, to minutely examine the entire physical body, as well as to examine closely the psychological status of a given human being. Such privileges should be treasured and sustained by traits that patients desire in physicians: honesty, thoroughness, a nonjudgmental attitude, and a sincere interest in the individual patient.