Generalist's Approach to the Medical Interview

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[edit] Generalist's Approach to the Medical Interview

Wendy Levinson

The relationship between physician and patient forms the basis for high-quality medical care in any setting. Without a trusting relationship, physicians cannot accurately diagnose patients' problems and develop approaches to treatment of illness and health prevention. Trusting relationships are truly the bedrock for the practice of general medicine. The era of managed care has presented challenges to the physician-patient relationship, with many patients unsure whether the physician is working exclusively in their best interest. Patients wonder whether physicians have pressures to control cost that unduly influence the physicians' judgment. Simultaneously, physicians are under increasing pressure to see more patients in a limited period of time. More than ever, physicians need to communicate both efficiently and effectively with patients to maximize outcomes.

The medical interview is the primary care physician's tool for developing a trusting relationship, diagnosing illness, developing a treatment plan, educating patients about illness and health, and motivating behavior change. Effective interviewing skills lead to improved outcomes including greater patient satisfaction, greater patient adherence to treatment, enhanced biologic outcomes, and decreased risk of malpractice suits. In general, research demonstrates that patients prefer patient-centered interviewing. This style of interviewing encourages patients to become active partners in their medical care by being informed and helping select treatment options they believe best suited for their needs. A physician interview style that includes actively listening to patients' concerns, asking their opinions, presenting options, and letting patients choose is preferable for the majority of patients. Activated patients may actually have better biologic outcomes than patients who take a more passive role in care.

This chapter discusses the critical elements of the medical interview that make it both efficient and effective. It includes a discussion of the three major functions of the interview: data gathering, building a positive relationship and addressing patients' emotions, and educating and motivating patients. It suggests specific skills demonstrated to be effective in the interview and addresses particular communication strategies useful in challenging situations in managed care.

[edit] WHAT MAKES AN INTERVIEW EFFICIENT?

Several factors make the interview and patient care process efficient. Most important among these are getting the problem straight to begin with, listening and observing actively at several levels simultaneously (e.g., the story, how it is told, affect, and mental status), detecting and correcting barriers to communication (e.g., patient deafness, delirium), creating an efficient structure, completing the three functions of the interview, and using correct technique. The interview's structural elements and three functions are shown in Box 2-1. Table 2-1 describes some common errors leading to inefficiency, as well as possible solutions.

Table 2-1 Common Practices Leading to Inefficiency

[edit] STRUCTURE

[edit] Preparing Self and Environment

Effective preparation of the office environment, the medical data, and oneself can make the interview more efficient and effective. Usually patients first come in contact with the office by phone and then by interacting with office staff in the reception area or waiting room. The quality of all these initial interactions can have a significant effect on patients before they even meet the physician. Patients who have waited for a long time without explanation or who have had negative interactions with the office staff may be irritated, making a barrier to effective communication (Fig. 2-1). The environment of the consultation or examination room may also be important to the interview. Ensuring privacy, avoiding unnecessary distractions, and creating a comfortable seating environment for patients indicate concern and readiness on the part of the physician to address patient needs.

Figure 2-1 Patients in waiting room. (From the Collections of the Library of Congress.)

Preparation of the medical data can significantly increase the efficiency of the interview. Use of structured questionnaires that patients complete before meeting with the physician may provide clues about issues patients want to discuss. These forms can be particularly useful with new patients for efficient collection of data related to family history, allergies, and pertinent social history, but they generate many false-positives and false-negatives. For return patients, reviewing recent laboratory data, x-ray reports, and other results before the interview can help the physician maximize use of the interview time. Review of pertinent medical data before the visit also indicates that the physician has been thoughtful about the patient's problem since the last visit. This communicates the physician's concern for the patient and may enhance the sense of trust.

In addition to preparing the environment and the data, the physician is well advised to take a moment for self-preparation. There are many distractions in a busy day, and taking a moment on the threshold of the consultation room to look at the chart, take a deep breath, and prepare psychologically to work with the next patient increases effectiveness by focusing attention on the present task.

[edit] The Opening

The opening moments of the interview are critical in the relationship between the physician and patient and the effectiveness of the visit. From the moment the examination room door opens, the physician starts learning about the patient by actively observing mood, grooming, style of dress, and other nonverbal factors. These clues help in understanding the patient. The physician can use these initial nonverbal clues to make the patient more comfortable (e.g., “You look like you are in some discomfort. Can I help to make you more comfortable before we begin?”).

The physician starts the visit by greeting the patient and introducing himself or herself to new patients. These greetings set the tone, helping the patient to feel welcome. Asking patients what they prefer to be called (e.g., Ms., Mr., Dr., first name), communicates respect for patient preferences.

After introductions, we usually begin by eliciting the reason for the visit with open-ended questions like, “What is the problem that brings you here today?” or “What concerns have led to your visit today?” Studies support the importance of letting patients complete the opening statement about their concerns uninterrupted. Interrupting the patient before completion of the initial statement may be interpreted as a lack of interest or a lack of time. Furthermore, interrupting early in the interview may lead the patient to delay expressing real concerns until late in the visit or not at all. Although physicians often worry that the patient will take too long, most patients complete their opening statement within 90 seconds and provide important historic details.

After the patient has explained the initial concern, it is effective to ask the patient, “What else concerns you?” This is important, since on average patients have three problems at a first visit, and often the concern mentioned initially is not the most important. Allowing the patient to express all concerns at the beginning of the interview enhances efficiency because (1) the physician learns all of the problems that the patient is hoping to cover in the visit, instead of discovering them at the end of the visit (last-minute problems [“Oh, by the way…”] can be particularly frustrating to the physician); (2) the patient may remind himself or herself about concerns that have been forgotten initially; (3) this strategy enables the physician to prepare to negotiate with the patient about what concerns can be covered in this visit and what will be dealt with at a later time. After eliciting all of the patient's concerns, the physician can summarize before proceeding to in-depth questioning about any one of the problems. This communicates to the patient that the physician has listened attentively and allows the physician a moment to organize the problem list mentally.

[edit] Setting the Agenda for the Visit

Once the physician knows all of the patient's concerns, it may be necessary to work with the patient to negotiate the priorities for the visit. Particular concerns may be a high priority for the patient and must be addressed during that visit for the patient to feel the time was well spent. The physician may have other concerns, particularly about urgent medical problems. A typical sequence of dialogue follows:

• Physician: So I understand that there are four concerns you would like to address today: your headache, shoulder pain, heart palpitations, and constipation. In the time we have available today, we may not be able to cover all of these. Which is most important to address today?
  
• Patient: I would like to make sure we talk about my headaches.
  
• Physician: That's fine. I'd be happy to address that. In addition, I want to discuss your heart palpitations just to be sure that everything is okay there. Why don't we start with those two and plan to address the shoulder pain and constipation at a follow-up visit if we don't have time today? Would that be all right?
  
• Patient: That sounds fine as long as you can help me get an appointment about the other problems within a few weeks.
  
• Physician: I think we can arrange that before you leave.
  

Negotiation allows the physician and patient to plan together how to use the time available. In this manner the patient is assured that the important problems will be addressed and the physician is assured that there is adequate time for investigation of medical concerns.

[edit] Allowing the Patient to Tell a Story

Allowing the patient to tell the story of the illness in his or her own words is the most efficient and comfortable way to begin to assess a problem. The patient frames what he or she perceives as relevant, revealing personal views of cause and effect. The patient mentions details and facts a physician would not think to ask about. While the patient is talking, the physician can be thinking about what is said and developing hypotheses about the nature of the problem and approaches to ruling in and ruling out these hypotheses. Inviting the patient to tell the story of the illness also reveals the context of the illness—the nature of the patient's work, the home in its complexity, and important relationships. This understanding is needed in planning approaches to care. Telling a story also improves patient recall because it places the patient's attention in a remembered context, where the fine details are accessible to recall.

This storytelling is initiated by asking the patient, “So, tell me what happened,” or “Let's go back to the beginning and tell me the story of your problem.” This creates a narrative thread that organizes the interview. Once the patient is telling the story, the physician can quietly ask for elaboration on points about the person, the context, and relationships; learn as much as needed (“Tell me more about your husband”), and then return to the narrative thread by asking, “And then what happened?”

[edit] Progressing from Open-to Closed-Ended Questions

Note that the above questions begin with “Tell me” and little else. This is because it is more efficient and more thorough to begin each line of inquiry with an open-ended question, which invites a free-form response to a query rather than a short, specific answer (e.g., “Tell me about your chest pain” rather than “Where does it hurt?”). Studies have documented that open-ended questions produce more information, more efficiently, with greater satisfaction for both physician and patient. In addition, the patient includes unanticipated information and connections. Initially the advantages of open-ended questions seemed counterintuitive to us, but our experience has borne them out. Once the patient has responded, the physician can then begin to focus on smaller aspects of the situation. Once the open-ended approach has been exhausted (often quickly), one then can ask close-ended questions about facts not covered. Use of specific routine questions to screen risk behaviors is helpful. Effective screening questions are presented in Table 2-2.

Table 2-2 Screening Questions

[edit] Understanding the Patient as a Person

Although the importance of understanding the patient as a person in the process of assessing the problem cannot be overstated, the process of acquiring that understanding can be highly efficient and minimalistic. The opening observation often reveals ethnicity, style, socioeconomic status, and sometimes work and marital status. The content and presentation of speech provides information about the patient's reasoning and beliefs. The affect (e.g., a frown or sadness) shows feelings about the subject, as does gesturing (e.g., covering the face, looking down and away, suddenly brightening).

[edit] Understanding the Setting of the Illness

One cannot be sure in advance what aspects of the patient's life will be crucial or contributory. Several dimensions are usually relevant in most patients. First is social setting—who is at home (if there is a home), who is close or painfully distant, what are the supports. Environmental features may be critical, such as type of work and location of home or work (e.g., isolated in the country, a fifth-floor walk-up, a violent neighborhood with strong pressures to drink or use drugs). Ethnic and cultural background may determine health care–seeking behavior, adherence to agreed plans, or use of dangerous remedies.

[edit] Eliciting the Patient's Beliefs About the Problem

The patient's beliefs about the problem, health care in general, and how to relate to physicians can be crucial to the outcomes of care. If the patient believes the problem is due to an excess of hot or cold humors, as some Puerto Ricans believe, then prescribing the wrong remedy (e.g., a hot remedy for a hot disease, such as orange juice with potassium supplementation for hypertensive patients on diuretics) leads to total noncompliance. Therefore it is necessary to check, probably several times, to what the patient attributes the problem. Similarly, if the patient believes that physicians are judgmental, are not to be trusted, or are out to do things only for money, he or she will reveal less and cooperate less. If the patient's culture dictates that seeking care is shameful, he or she will not come for care soon enough, even for emergencies. If the patient believes that the physician should not be upset, the difficult facts will be hidden (e.g., by many persons of orthodox or authoritarian background and by some traditional Chinese).

This method deviates from the idea that one should collect the social history separately. This is because when social and personal information are collected simultaneously with biomedical information, more is revealed, patient recall is improved, and the process proves more efficient. One can always complete information not elicited later.

[edit] Summary of Thoughts and Findings

The end of the consultation is pivotal in most interviews. The patient feels increasingly vulnerable, since the physician now has information he or she does not—information the patient fears may be bad news. At this point plans must be created and negotiated with the patient. Therefore it is always important at this stage to summarize thoughts, findings, and preliminary ideas about the next steps in discussion and planning.

After the physician presents ideas and thoughts about the patient's diagnosis, it is important to check the patient's feelings and reactions. The patient may have beliefs about the nature of the illness that either fit or are in disagreement with the physician's opinion. To explore the patient's reactions and beliefs, the physician might ask a sequence of questions:

• Physician: I've explained to you that I think your symptoms may be due to a peptic ulcer. How does that fit with your ideas about your stomach pain?
  
• Patient: I'm a bit uncertain; I thought that ulcers only occurred when people were stressed and I feel like everything is going well in my life. How could I have an ulcer?
  
• Physician: That's a good question, since lots of people believe that stress and ulcers are related. In fact, a number of factors contribute to the formation of ulcers, such as fatigue, a genetic disposition, and a stomach infection. So people commonly develop ulcers even without stress.
  

A simple explanation helps the patient accept the physician's diagnosis and be more prepared to work with the physician to plan the treatment course. In other cases it is necessary to integrate the patient's beliefs into the diagnostic explanation, even if the patient's ideas come from a different frame of reference than the physician's. For example, patients may have beliefs about illnesses due to certain food substances that do not fit with the physician's scientific approach to the nature of the illness. Whenever the physician can accept the patient's beliefs as possible and can integrate these beliefs with a scientific explanation, the patient may be more likely to collaborate in the treatment plan.

[edit] Planning Treatment

As with the presentation of the diagnosis, the physician often presents the options for treatment. It is essential to involve the patient in the planning process. If a patient does not believe that the treatment plan is likely to succeed or does not understand the details of the treatment, follow-through is unlikely. It is important for the physician to check the patient's beliefs and feelings about the treatment options just as he or she checked beliefs about the diagnosis. Then the physician can engage in a dialogue with the patient about which treatment the patient believes is most appropriate.

• Physician: I've suggested that you use these pills to treat your peptic ulcer disease. What do you think of that?
  
• Patient: It seems reasonable to me, although I've always heard that diet is important for ulcer treatment. Couldn't I treat this by avoiding certain foods and not use the pills?
  

By probing the patient's beliefs, the physician can identify barriers that might lead the patient to leave the physician's office without intending to fill the prescription or follow the treatment plan. If the patient and physician are in agreement about the treatment, it is useful to help the patient anticipate the problems in implementing the treatment.

• Physician: It's difficult to remember pills three times a day. What do you think the hard part of this will be for you? How might you provide reminders to yourself?
  

This gives the patient permission to express the possibility of forgetting the pills and allows an opportunity for the doctor and patient to discuss ways to help the patient remember.

Other simple strategies can help the patient in the planning phase, including writing down instructions, referring patients to educational programs available in the health care facility or in public, giving the patient educational pamphlets pertinent to the illness, and sending a visiting nurse to follow up (e.g., with a new diabetic patient).

It is essential to ask the patient whether there are questions and to have the patient review the main points before moving to the closing phase of the interview. By having the patient reiterate and the physician clarify before ending the interview, the physician can increase the likelihood that the patient will understand and comply with the treatment planned. Ultimately this makes the physician's work much more efficient by avoiding unnecessary treatment failures.

[edit] Closure

After the educational phase of the interview, the final few moments are spent in closure. During closure the physician reviews the immediate next steps: “Now I'd like you to go to the reception desk with this laboratory slip. They will direct you to the laboratory.” The physician also can reiterate the plan for the timing of the next visit, checking with the patient about whether that seems appropriate: “Perhaps we can see each other in approximately 4 weeks. Does that seem about the right length of time from your perspective?” The physician can outline the plan for contact in the interim between visits if this is appropriate. Understanding how to reach the physician in an emergency or how to get the results of pertinent laboratory tests can save time-consuming phone calls to the office. Finally, in saying goodbye to the patient, the physician often sets the tone for the next visit and can do some planning: “I look forward to seeing you in a month and will be eager to see your headache diary so we can explore this problem further.”

[edit] Other Issues

Should the interview continue during the physical? Does this common practice enhance time efficiency or does it breed error? No one really knows, although both are likely to some extent. The argument against talking during the physical examination is that it distracts the examiner, thereby decreasing sensitivity and causing him or her to miss physical findings, especially on auscultation and palpation.

The reality, however, is that most physicians do talk before and during the examination. It is very helpful to the patient to have the examination introduced and to explain what is being done, especially if painful, unusual, or in difficult areas (rectal and genital examinations). Clearly the physician's perceptions should be directed toward the examination. Social talk, chatting, or pursuing a review of systems will distract unduly.

Should a physical examination always be done? Obviously, there are some follow-up visits that do not require a physical reexamination. But there are several reasons to err on the side of examining. First, things change, sometimes unexpectedly. Second, it has become very clear that the act of physical touch has a reassuring, calming, and perhaps healing effect; if done gently and caringly, it also improves the physician-patient relationship and rapport. Third, patients expect to be examined. Failure to do so when the patient expects it leads to loss of trust in the physician's caring or competence, unless explained effectively. This then affects healing, comfort, and satisfaction. Many patients find the absence of physical examination unacceptable regardless of explanation.

[edit] FUNCTIONS

The broad functions of the interview fall into three categories: gathering data, developing a relationship and dealing with patient feelings, and educating the patient about diagnosis and treatment and encouraging behavior change. The process of data collection has been described in the previous section.

[edit] Developing and Maintaining a Relationship

Patients seeking care from their primary care physician often are worried about their health problems or have emotional distress about issues in their personal lives. They may come to the appointment feeling sadness, anger, frustration, or anxiety. To build trust and make the interview most effective, the physician must recognize and address patient feelings. This may be the most challenging task for the physician. It is often neglected.

The expression of empathy and understanding for patient feelings is a powerful communication skill that deepens the therapeutic relationship. Empathic listening indicates that the physician cares and understands the challenges in a patient's life. Demonstration of compassion and respect is key to providing a trusting environment that is therapeutic for patients. This communication skill, the expression of empathy, is one of the most important skills of doctoring and is at the heart of clinical medicine.^[1]

When patients are experiencing strong emotions, the physician may fear that discussing these emotions directly will slow the interview down by “opening a can of worms.” What to do if the patient expresses deep feelings of loneliness and the physician cannot fix the situation or make the patient feel better? What if the patient is angry and directs this at the physician? Often a physician's personal feelings or worries serve as barriers to discussing these emotional issues. In fact, studies show that talking to patients about their feelings and understanding their emotional experience is therapeutic and builds the relationship between patients and physicians.

It is best to address feelings when they first appear in the interview. This can be accomplished by first commenting directly on the feelings and then making a statement that indicates understanding the patient's experience.

• Physician: You seem pretty sad about these recent events.
  
• Patient: Yes, I feel so terrible. I had hoped this would never happen.
  
• Physician: I can understand feeling like that. It must feel so disappointing to you to have it turn out this way.
  

Such brief comments by the physician indicate recognition of the patient's pain and an understanding about the life experience of the patient. Furthermore, if appropriate, the physician can make a further statement of empathy, such as “I would feel the same way in your position” or “Many people would feel as you do in this situation.” These statements are appropriate only if genuine. Even if the physician disagrees with the patient's point of view, certain statements indicate understanding, for example, “I can understand your feeling frustrated or angry if you have felt that I have not been taking your complaints seriously” or “I can understand feeling angry with the delay in getting an appointment when you were worried there was something seriously wrong with your health.” In these examples the physician accepts how the patient feels even though he or she would not have had the same reaction as the patient in a similar situation or believes the patient's response is unreasonable.

In addition to direct discussion of patient feelings, a physician can indicate acceptance of a patient by echoing the patient's words or reiterating what the patient has said. Brief phrases can indicate attention and caring. For example, the physician listening to a patient's worries about an episode of shortness of breath can say “Sounds like it was frightening for you.”

Nonverbal indicators of concern can also be powerful in building the relationship with the patient. This can include maintaining a relaxed and nondefensive posture when a patient is expressing anger directly at the physician. Body posture may indicate acceptance. Also, touching the patient as an expression of caring (e.g., a patient who is crying) is often a strong statement of a physical and psychologic connection.

[edit] EDUCATING AND MOTIVATING PATIENTS

One of the most important roles of the medical interview is to inform the patient about the diagnosis and treatment options. In fact, studies of patient satisfaction frequently reveal that patients believe that they do not receive an adequate amount of information from their physician. Particularly as the pressures to see an increasing number of patients intensifies, physicians may tend to allocate the majority of their time gathering information and performing the physical examination, hence cutting short the time available for educating patients. It is essential to budget time to allow an adequate period for discussion and to permit patients an opportunity to ask questions. In addition, physicians should consider the language used to describe medical problems and avoid medical jargon. Selection of simple nonmedical words helps ensure that patients understand the meaning of a physician's explanation.

As discussed previously, it is particularly important to check how the explanations of the disease or the treatment fit with the patient's own beliefs. A recent study demonstrates that, overall, patients visit alternative medicine providers twice as frequently as they do traditional primary care physicians. Patients are also unlikely to disclose information about the treatment prescribed by alternative medicine healers. Careful nonjudgmental inquiry may allow patients to share discussions about herbal remedies, acupuncture, or dietary programs that they are either using or would prefer. Obtaining this information enables physicians to tailor their instructions appropriately.

During the last few years a useful approach to motivating patients to change risk behaviors has been developed based on a model by Prochaska and Demeclenti. Although most of the research pertaining to motivational interviewing has been tested in alcohol use, there is an increasing amount of information about the utility of this model in a variety of risk behaviors including smoking, weight reduction, and dietary changes.

The model proposes that certain patients are in different stages of “readiness to change” at any particular time. Patients may be in a stage of precontemplation, contemplation, preparation, action, maintenance, or relapse. A patient in the precontemplation stage may appear defensive and totally uninterested in changing smoking habits. A patient in the contemplation stage may have thought about the pros and cons of stopping smoking but has not done anything about it. A patient in the preparation stage has not only thought about stopping but has started to make some plans concerning how to do it; however, those plans have not been implemented yet. A patient in the action stage has implemented the plans and is making a genuine effort to stop. A patient in the maintenance stage has had a period of maintaining the appropriate behavior and is consciously trying to avoid falling back into the old pattern. A patient in the relapse stage has successfully stopped for a period of time but is now smoking again. Using this model the role of the physician is to help identify the stage of change for a particular patient at a point in time and encourage the patient to move to the next stage. Hence it is unrealistic to expect every patient to be willing to move to an action stage after several brief discussions with the physician, since many patients may be in the precontemplation stage and are not prepared to move to the action stage. In fact, studies demonstrate that it often takes patients several weeks, months, or years to move into the action and maintenance stages, and most likely patients will relapse and reenter the cycle several more times in order to ultimately become successful. Details of this model are provided in Chapter 51 .

[edit] MANAGED CARE AND THE PHYSICIAN-PATIENT RELATIONSHIP

Managed care presents specific challenges in the routine practice of medicine (Table 2-3). Both patients and physicians are confronted with situations that may be unique to the managed care setting or more challenging than in the previous fee-for-service environment. For example, patients frequently have to change their primary care physician, leaving a longstanding trusting relationship for a new physician found on a provider list. In another instance patients may suspect that a managed care physician has a financial incentive that limits the use of diagnostic procedures. Patients may wonder if the reason the physician is not ordering a test is to avoid cost. Similarly the patient may believe that the primary care physician is limiting referrals to a particular specialist for cost reasons rather than quality-of-care reasons.

Table 2-3 Communication Dilemmas Common in Managed Care

These types of situations place the physician in an awkward position and raise challenging questions for the physician. How can a physician maintain the trust of a patient while disclosing the internal utilization review process the health organization uses for consideration of referral requests? Should physicians discuss possible financial conflicts of interest with their patients? Although there are no straightforward answers to these questions, communication skills of negotiation are critically important to resolving potential conflicts. It is essential that physicians understand the patients' perspective, validate their concerns, and find a common goal for both patient and physician. This is an example of a patient with diabetes seeing a new primary care physician.

• Patient: I have always been careful with my diabetes and seen my ophthalmologist and cardiologist every 6 months. In addition, I see the diabetes specialist who helps me adjust my insulin dose. I hope you will complete referral forms for these providers for me.
  
• Physician: It sounds like you take good care of your diabetes and that's excellent. It also sounds like you have a lot of trust in the specialists who have helped you take care of your diabetes. I would like to help you continue to receive the highest quality care for your diabetes and to work with your specialist. I would also like to help coordinate your care as a primary care provider. Perhaps we can work together to determine what role I will play in coordinating your diabetic care and the role your specialist will have. After we do that, we can decide which of the referrals to the specialists seems important. How does that sound to you?
  
• Patient: That's fine as long as there is an opportunity for me to see the specialists that I have relationships with.
  
• Physician: I'm sure that we can arrange things so that you will continue to work with those doctors in an appropriate and ongoing fashion. Let's start by working together so that we get to know each other and I understand your health and your diabetes.
  

Through the process of negotiation the doctor and patient may be able to establish a common goal and avoid the conflicts that result from differences in doctors' and patients' expectations. This kind of negotiation requires physicians to have excellent communication skills.

[edit] COMMUNICATION AND MALPRACTICE

Not only is the quality of the physician-patient relationship important to patient satisfaction, adherence, and biologic outcomes, it is particularly important to medical malpractice prevention. Patients initiate medical malpractice suits not only when there has been a breach in the quality of medical care, but also when they believe that the physician was not as attentive or caring as he or she should have been. The best evidence supporting the relationship of communication to medical malpractice in different specialties is derived from two recent studies. A study by Entman et al^[2] compared obstetricians/gynecologists who had never been sued with those with prior suits. It demonstrated that patients of sued physicians had twice as many complaints about their care, including feeling rushed, ignored, and inadequately informed about their medical condition.

Along with several colleagues, I conducted a major study examining the differences between the communication style of physicians who have and those who have not been sued. The study included examination of 1265 audio tapes of routine visits between primary care physicians and patients and between surgeons (orthopedic and general surgery) and their patients. The data revealed that the communication styles of primary care physicians who had never been sued differed significantly from the styles of the physicians who had been sued. Never-sued primary care physicians used more facilitative language (encouraging the patients to talk, asking their opinions), laughed more, oriented the patient to medical care (explaining what was going on in the course of care), and elicited more information about therapy for their patients than sued physicians. Although there were no statistically significant differences between sued and never-sued surgeons, similar trends were evident. Table 2-4 summarizes the characteristics of never-sued primary care visits.

Table 2-4 Characteristics of Never-sued Primary Care Physician Visits

In conclusion, it is evident that communication breakdowns between physicians and patients may contribute to the initiation of medical malpractice litigation. Whether individual physicians can prevent malpractice risks by communication skills training has not been proven, but such training could help physicians modify many of the high-risk communication behaviors.

[edit] REFERENCES

[edit] ADDITIONAL READINGS

• SH Kaplan, S Greenfield, JE Ware: Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989; 27:S110 - S127.
• W Levinson, D Roter, J Mullooly,et al.: Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997; 227:553 - 559.
• Lipkin M SM Putnam Lazare A The medical interview: clinical care, education, and research. New York: Springer; 1995:
• D O'Connell: Behavior change. Behavioral medicine in primary care—a practical guide. Stamford, Conn: Appleton & Lange; 1997:125 - 135.