The Biopsychosocial Interview
The patient interview is the foundation of medical care. Lipkin, et al (1995), reports that physicians conduct a mean of 120,000 to 160,000 interviews in a practice lifetime. Physical or Occupational Therapists also conduct interviews before initiating a treatment program. Even a modest improvement in interview style can greatly affect treatment outcomes. The interview is an integral to the process and outcomes of treatment, supporting Engel’s (1988) view that, “the interview is the most powerful, sensitive and versatile instrument available to the clinician…” Apparently, patients are less concerned with how much their clinician knows than with how much their clinician convey care (Stein, et al, 1998). So, it would seem that conveying a sense of caring during the interview process can have a positive effect on outcomes.
Even challenging patients deserve courtesy, respect, and meticulousness in the interview. The interview must be thorough not only because of quality concerns, but in the case of an angry patient, for potential litigation concerns.
Frankel and Stein (1999), describe an approach to the medical interview called, “The Four Habits Model.” It is derived from empirical and conceptual work on the interview and represents a synthesis of the available research literature on interviewing effectiveness plus the authors’ clinical and teaching experience.
The “Habits” refer to the interview technique of the clinician to establish rapport/build trust, facilitate the exchange of information, demonstrate caring and concern, and increase the likelihood of patient compliance with the plan of care.
The ‘4 Habits’ are as follows:
- Invest in the Beginning
- Create Rapport Quickly
- Introduce yourself to the patient and anyone with the patient. Offer a handshake.
- If the patient had to wait, acknowledge the wait time.
- Review the chart ahead of time and convey knowledge of the problem.
- Attend to the patient’s comfort.
- Make a social comment or ask a non-medical question to put the patient at ease.
- Adapt your language, pace, and posture in response to the patient.
- Elicit the Patient’s Concerns
- Start with open ended questions
- “What would you like help with today.”
- “I understand that you’re here for…..”
- “Could you tell me more about that?”
- “What else?”
- Speak directly with the patient if using an interpreter.
- Planning the Visit
- Repeat concerns back to the patient to check understanding.
- Let the patient know what to expect.
- “How about if we start with talking more about….then I’ll do an exam, and then we’ll go over possible ways to address this? Sound OK?”
- Prioritize when necessary.
- “Let’s make sure we talk about X and Y. It sounds like you also want to make sure we cover Z. If we can’t get to the other concerns, let’s…”
- Elicit the Patient’s Perspective
- Ask for the Patient’s Ideas
- Assess the patient’s point of view.
- “What do you think is causing your symptoms?”
- What worries you most about this problem?”
- Ask about ideas from significant others
- Be careful, in the event the significant other is an enabler.
- Elicit Specific Requests
- Demonstrate the patient’s goal in seeking care
- “When you’ve been thinking about this visit, how were you hoping I could help?”
- Explore the Impact on the Patient’s Life
- Check the context
- “How has the illness affected your daily activities/work/family?”
- Demonstrate Empathy
- Be Open to the Patient’s Emotions
- Assess changes in body language and voice tone
- Look for opportunities to use brief empathic comments or gestures
- Make at Least One Empathetic Statement
- Name a likely emotion, “That sounds really upsetting.”
- Compliment the patient on efforts to address the problem.
- Convey Empathy Non-Verbally
- Use a pause, touch, or facial expression.
- Be Aware of Your Own Reactions
- Use your own emotional response as clue to what the patient might be feeling.
- Take a brief break if necessary if you feel angry or frustrated.
- Invest in the End
- Deliver Diagnostic Information
- Frame diagnosis in terms of patient’s original concerns.
- Test the patient’s comprehension.
- Provide Education
- Explain rationale for tests and treatments.
- Review possible side effects and expected course of recovery.
- Recommend lifestyle changes.
- Provide written materials and refer to other resources.
- Involve the Patient in Making Decisions
- Discuss treatment goals.
- Explore options, listening for the patient’s preferences.
- Set limits respectfully
- “I can understand how getting that (test, exercise, treatment) makes sense to you. From my point of view, since the results won’t help us treat you, I suggest we consider this instead.”
- Assess the patient’s ability and motivation to carry out plan
- Complete the Visit
- Ask for additional questions
- “What questions do you have?”
- Assess satisfaction
- “Did you get what you needed?”
- Reassure patient of ongoing care and your openness to modify treatment if results are not achieved with the initial plan of care.
For More information on the Biopsychosocial Model consider taking our online course: The Biopsychosocial Model and Assessment of Non-Organic Signs Tests
Frankel RM, Stein T., Getting the Most out of the Clinical Encounter: The Four Habits Model, The Permanente Journal, 3(3) Fall 1999.
Lipkin M Jr, Frankel RM, Beckman HB, Charon R, Fein O. Performing the interview. In: Lipkin M Jr, Putnam SM, Lazare A, editors. The medical interview: clinical care, education and research. New York: Springer-Verlag, 1995: 65-82.
Engel GL, How much longer must medicine’s science be bound by a seventeenth century world view? In: White KL, editor. The task of medicine: dialog at Wickenburg. Menlo Part (CA): Henry J. Kaiser Family Foundation; 1988: 133-77.
Stein TS, Nagy VT, Jacobs L. Caring for patients on conversation at a time: musings from the Interregional Clinician Patient Communication Leadership Group. Permanente J 1998 Fall: 2(4): 62-8.
– Vic Zuccarello, OTR/L, C.E.A.S. II, ABDA