With an eye on outcomes, doctors work on perfecting the art of the interview

Robert C. Smith, M.D., Sc.M., told the 45 physicians at a workshop on interviewing skills last fall that he was about to demonstrate either an unskilled patient interview or an artful one. Afterward, he would ask the audience at the Yale faculty development workshop to judge which type he’d done.

Smith then interviewed a doctor posing as a patient with debilitating back pain. Smith extended his hand to the patient but did not introduce himself or greet the patient by name. When the patient began telling his story, Smith launched into a series of yes-or-no questions about the back pain but asked nothing about three other problems the patient mentioned: insomnia, worries about work and marital friction. Smith asked the audience: “Which sort of interview was that?”

“The regular one,” replied one physician in the audience in Hope 216—and everyone laughed.

Smith, a professor of medicine and psychiatry at Michigan State University, specializes in helping physicians improve upon that “regular” interview, the one in which, according to studies, physicians interrupt patients after a mean time of 18 seconds and miss 94 percent of problems linked to psychosocial distress. Smith argues that it is unscientific to focus solely on problems that are biomedical in nature. By largely ignoring psychosocial problems, physicians collect biased and incomplete data. The study of the interview, Smith said, “has brought the scientific method to the doctor-patient relationship.”

Smith taught the group how to conduct a more balanced interview, one that allows doctors to elicit and absorb the patient’s story while still meeting the doctor’s need for concrete information about the patient’s history of disease. Smith reported that research has shown that when physicians conduct skilled interviews, patients are more satisfied, compliant and knowledgeable; less likely to introduce last-minute “doorknob” complaints; and less likely to sue or to “doctor-shop.” Smith said skillful interviewing also improves outcomes: cancer patients live longer, blood pressures drop, surgery patients recover more quickly and perinatal outcomes are better.

Auguste H. Fortin VI, M.D., who directs the psychosocial curriculum for Yale’s primary care residency program, said that learning Smith’s technique for patient-centered interviewing “revolutionized my practice of internal medicine.” He said patients began telling him they felt better simply because they’d seen him. Interviewing is central to the physician’s work, said Frederick D. Haeseler, M.D., FW ’76, who directs the primary care clerkship and established an interview skills program at Yale in 1993. Haeseler said the average primary care physician conducts at least 100 patient interviews each week and more than 150,000 in a career, underscoring the need for students to learn how to communicate with patients both efficiently and effectively. “You really need to make connections with patients quickly,” he said.

Smith advised the group to begin by making the patient feel welcome, stating how much time is available (generally 15 minutes) and negotiating an agenda for using that time. (“When it’s crushing pressure on the chest radiating to the jaw, you say ‘We’ll deal with that first, not the discolored fingernail,’ ” Smith said with a laugh.)

He told the physicians to listen to the patient’s story during the patient-centered portion of the interview, by asking “focusing” questions. Next, when the patient has told his or her story, the physician should ask “emotion-seeking” questions and express respect and support. As Fortin put it, “Get an emotion on the table and handle it with empathy.” The doctor should inform the patient when it’s time to shift to the doctor-centered part of the interview, in which the doctor controls the conversation.

Smith’s approach saves time, according to Haeseler, because patients tell more coherent stories and make connections between physical symptoms, psychosocial factors and their experience of the illness, connections that might otherwise be collected piecemeal. Studies have proven the efficiency of including a patient-centered segment in the interview, according to Smith.

After Smith’s talk, workshop participants practiced interviewing each other, as well as actors trained to portray patients. Margaret J. Bia, M.D., FW ’78, said she was delighted that so many physicians had taken time off to learn how to build relationships with patients. “It’s getting harder and harder to do in the toxic atmosphere of the business model in which we’re all practicing medicine,” she said.

The purpose of the workshop was to train physicians to teach interviewing skills when they mentor Yale medical students in the “Doctor-Patient Encounter” course and in clinical clerkships. Smith said Yale was one of the few medical schools in the nation to teach interviewing skills to medical students not only in the first year but also in the third and fourth years, when students work with patients.