Evidence-Based Patient-Centered Interviewing

1 Patient-Centered INTERVIEW28 JCOMJuly 2001 Vol. 8, No. Patient-Centered InterviewingJudith Swiss Lyles, PhD, Francesca C. Dwamena, MD, Catherine Lein, MS, FNP, and Robert C. Smith, MD, ScMInterest in the medical interview has increased dramati-cally over the past 2 decades as researchers have come tobetter understand the relationship between communica-tion and health. Until the early 1970s, the clinical perspectiveof illness was almost entirely biomedical, and disease wasdefined as deviations from the norm of measurable biolog-ical (somatic) variables [1]. Data gathered for diagnosis andtreatment almost exclusively consisted of information con-cerning possible disease symptoms, biomedical history, anddiagnostic tests.

2 In 1977, George Engel advocated expandingthe medical paradigm [1]. He argued that to fully account forhealth or disease, the social and psychological dimensions ofhuman existence had to be considered along with biomed-ical data. This requires not only gathering personal or psy-chosocial data from patients but also competency in in-terviewing techniques that elicit this information as well asrelationship -building skills that nurture confidence andhuman understanding [2 4].The application of these skills in practice is called Patient-Centered Interviewing [2 6]. In doctor - centered Interviewing , thedoctor takes the lead to obtain symptom details and otherdata to make a disease diagnosis [2,4].

3 A problem in medicalpractice has been the use of doctor - centered skills in isolation,an approach that excludes the personal and emotional com-ponents of patient health [2,4]. However, when the Patient-Centered interview is integrated with the doctor -centeredinterview, patients have an opportunity to be heard beforedisease data are collected. During the patient- centered inter-view, the patient is encouraged to take the conversationallead [7], initiating topics in the areas of their experience andexpertise: symptoms, worries, preferences, and values [2].The physician does not insert new ideas into conversationbut instead allows and facilitates the patient to direct the con-versation [7].

4 The approach is aptly labeled patient- centeredbecause the physician acknowledges and meets the patient sneed to express problems, emotions, and concerns, obtaininformation, and help determine the agenda for the medicalappointment. When well performed, the patient- centeredinterview operationalizes the biopsychosocial model and, assuch, is associated with numerous positive outcomes for bothpatients and this article, we give a brief overview of the positiveoutcomes associated with Patient-Centered Interviewing anddescribe an Evidence-Based method for conducting a Patient-Centered Benefits of Patient-Centered InterviewingResearch on the impact of communication patterns betweenphysicians and patients has reinforced the importance ofpatient- centered Interviewing .

5 Patient- centered interview-ing skills have proved to be advantageous in a number ofareas, including patient health, patient and physician satis-faction, and general practice OutcomesResearch has linked effective patient- centered interviewingwith improved health outcomes. Among patients withchronic diseases, reduced physician information-giving andlow levels of patient control in the doctor -patient dialoguehave been directly associated with poorer health outcomes[8]. Kaplan, Greenfield, and Ware found that patients whowere encouraged to participate in their care by asking ques-tions during medical appointments had greater improve-ment in blood pressure and glucose levels and functionalstatus compared with patients whose doctors were moreauthoritarian [8].

6 These researchers posit that the physician sact of giving information at the patient s request affects theoutcomes of patients with chronic disease by shaping howpatients feel about disease, their sense of commitment to thetreatment process, and their ability to control or contain itsimpact on their lives [8]. This work demonstrated that pa-tients benefit from relationships in which control of the med-ical interview is shared and in which their information needsare met. Such relationships are consistent with a Patient-Centered Interviewing research has linked effective patient- centeredinterviews with improved health outcomes.

7 In Stewart s com-prehensive review of 21 studies in which the relationshipbetween effective doctor -patient communication and variousaspects of physical and mental health were explored, 16 re-ported positive results [9]. The data from those studies indi-cated that reduction in psychological distress and symptom From the Departments of Medicine (Drs. Lyles, Dwamena, and Smith) and theCollege of Nursing (Ms. Lein), Michigan State University, East Lansing, were associated with physicians checking on pa-tients concerns, expectations, and understanding of the prob-lem; asking about feelings; and showing support and empa-thy [9].

8 Several other studies in Stewart s review reported thatpatients expressions of feelings, opinions, and informationand their perception that their problem had been fully dis-cussed led to reduced role and physical limitations, improvedhealth or functional status, blood pressure reduction, or symp-tom resolution. Similar findings were associated with effectivediscussion of the management plan in which patient- centeredapproaches (eg, eliciting patient questions, giving clear infor-mation and emotional support, sharing decision-making)were used [9]. A more recent summary of research involvingrelationship - centered care focusing on support of patients autonomy corroborated and complemented previous find-ings: relationship - centered care was more likely to increasecompliance with medications, weight loss, smoking cessation,and the maintenance of these effects [10].

9 Patient Satisfaction and Quality of LifeAmong the positive outcomes of patient- centered interview-ing is the satisfaction that it brings to both patients [11,12] andphysicians [13 16]. Patient satisfaction is important because itinfluences patients compliance with medical treatment,which in turn impacts health [13,14,17]. There is a body of lit-erature that relates patients dissatisfaction with physicians communication skills (eg, lack of warmth, poor explanations,failure to address patient concerns) to noncompliance withmedical treatment [18 21], breaking appointments, and seek-ing other medical providers [18].

10 On quantitative measures,patient- centered Interviewing has been associated with bothhigher general satisfaction and greater confidence in thephysician [12]. There is also evidence that patient- centered approachesimprove patients well-being in ways not always captured inquantitative research. In a recent study, patients were askedabout symptom reduction and activity levels [22]. Qualitativemethods corroborated the quantitative findings, and alsoprovided significant additional information. During follow-up interviews, patients talked about quality of life issues,such as coping better with their symptoms between treat-ments, having more hope, and feeling supported [22].