WORDS THAT MAKE A DIFFERENCE

Medical Writings

Tell Me about Yourself: The Patient-Centered Interview

The following article initiates a series on Words That cerns are often raised that practice conditions may not
Make a Difference. Developed under the sponsorship of the allow clinicians the time to give attention to these issues,
American Academy on Physician and Patient, the series clear evidence indicates that interviews that attend to
will focus on the language physicians use when they talk patients feelings, ideas, and values actually save time
with patients. Although clinicians understand how impor- (33, 34). Physicians can refine their existing skills in
tant it is to communicate effectively with patients, they ways that allow them to attend better to the person of
often have difficulty knowing exactly what the best words the patient as well as the patients disease. The resultant
are for making the most of each patient interaction. Draw- patient-centered interview increases both patient and
ing on careful observation and research results, the authors physician satisfaction.
of this series of articles have identified words and expressions Recommendations to focus on the person of the
that have proven particularly powerful as tools for under- patient are not new. Osler (35) urged that physicians
standing patients and helping them manage their illnesses care more particularly for the individual patient than
effectively. We are interested in knowing what readers think for the special features of the disease, and Smyth (36)
of the series, and in learning about other uses of language provided this suggestion for effective doctoring: To
that readers have found important and helpful. know what kind of person has a disease is as essential as
to know what kind of a disease a person has. Despite
The Editors knowing this, physicians find it difficult to go beyond
disease-centered clinical encounters. Current social and
Patient: That specialist you sent me to is probably a economic constraints on practice, along with medical
pretty good doctor, but you cant talk to him. training that does not equip physicians to deal with the
Physician: What do you mean? patients expression of values, ideas, or feelings, lead to
Patient: Well, he just didnt seem interested in what clinical interviews that focus on understanding only the
I had to tell him. He might know about kidneys but he patients disease. Even well-motivated clinicians may
didnt want to know what I was worried about. find that they are uncomfortable with and untrained to
respond to the person of their patient. The spoken lan-
This disgruntled patient is not the first to wish that guage is the most important diagnostic and therapeutic
his physician would focus more attention on his con- tool in medicine, but physicians-in-training as well as
cerns, feelings, and ideas. Many patients complain experienced clinicians report that even when they wish
similarly, identifying a critical weakness in the medical to focus on the patient, they lack the words to do so.
interview and subsequent treatment. Unfortunately, Because they do not know what to say, they avoid the
patients may feel this way even about physicians who are challenge (37).
highly experienced and very skilled technically. Inatten- Developing a repertoire of carefully refined words is
tion to the person of the patient, to the patients char- useful, and such mastery of language plays a recognized
acteristics and concerns, leads to inadequate clinical role in educating physicians to interview patients. Clini-
data-gathering, nonadherence, and poor outcomes (1 cians all learn, for example, to define a patients physical
14). Because each patients experience of illness is pain with questions such as Where does it hurt?,
unique, the best patient care includes attention to the Where else?, and Have you noticed anything that
patients motivation, values, and desires; to her thoughts seems to increase the pain? In this article, we suggest
and feelings; and to the way she experiences her illness. language for conducting a patient-centered interview,
Growing evidence suggests that physicians who focus on offering words and phrases to help the physician who
the patient as well as the disease obtain more accurate desires a more effective relationship with patients and
and thorough historical data, increase patient adherence who wants to communicate that patients are understood
and satisfaction, and set the stage for more effective and valued. Of course, not all the questions cited should
patientphysician relationships (1532). Although con- be used in any one interview. Often one request to the
2001 American College of PhysiciansAmerican Society of Internal Medicine 1079
Medical Writings The Patient-Centered Interview

patientTell me about yourself will suffice. No little about yourself as a person. Those who prefer to get
one phrase works equally well for all physicians or all right down to the biomedical facts can make room for
patients, and a skilled interviewer will titrate the lan- such an inquiry later: Now that Ive heard a little about
guage to the patient and the circumstances. A reader this illness, and before we go on to review all your other
who wants to try these questions and directions might health issues, Id like to learn about you as a person. In
best choose a few favorite lines and try them out in either case, most patients will provide a capsule sum-
clinical encounters. mary, seldom longer than 30 seconds, of their lives and
interests. Occasionally a patient will hesitate and ask,
Like what? If so, the physician can reply, Well, your
WHAT DO PHYSICIANS NEED TO KNOW ABOUT THE
work, whos at home, what goes on in your lifethat sort of
PERSON OF A PATIENT?
thing. Sometimes the most open inquiry works best: Tell
In getting to know the person of a patient, there are five me about yourself. How would you describe yourself? If you
main areas of concern: had to describe yourself in 50 words or less, what would you
1. Who is this patient? What constitutes that per- say? What if you wanted to expand on that? Once the
sons life? What are the patients interests, work, impor- reluctant patient responds, the interviewer can ask for
tant relationships, major concerns? more details: Tell me about that.
2. What does this patient want from the physician? Sometimes the physician may offer to trade infor-
What are his values and fears? What does he hope to mation: We should take a little time to get to know each
accomplish here today or in the long run? other since we will be working together now. Lets start by
3. How does this patient experience this illness? my asking you to tell me about yourself, and later Ill be
Specifically, what has it done to her functionally; how glad to answer your questions about me. Sometimes, of
has it affected relationships; and what symbolic meaning course, the physician is the new kid on the block: Youve
does it hold for her? been coming here a long time, but Im new. Tell me a bit
4. What are the patients ideas about the illness? about yourself.
What is his understanding and perception of the dis- With returning patients, one can ask for interim
order and its cause? What would seem to him to be reports: Whats new in your life lately? Any changes in your
reasonable treatment for it? life since your last visit here? Or, if the physician knows
5. What are the patients main feelings about the about a big event in the patients life: How did that trip
illness, with special attention to the five common re- to Chicago go?
sponses: fear, distrust, anger, sadness, and ambivalence?
Physicians may touch on these areas of concern in
routine medical encounters but seldom explore them
2. What Does This Patient Want from the Physician and
fully. To do so lays the groundwork for a relationship
the Medical Team?
based on understanding and trust, a mutual dedication
Physicians often assume that their patients goals are
to the patients health that is truly therapeutic.
exactly the same as the clinicians. But especially at the
beginning of a relationship, it pays to inquire more fully:
HOW TO SAY IT Since were new to each other, it would help me to under-
1. Who Is This Patient? stand what youre most hoping for in a relationship with a
According to Stoeckle (38), Patients bring not only new doctor. Sometimes the patient has left a previous
their bodily complaints but also the circumstances of physician because of some dissatisfaction, perhaps a
their everyday liveswho they are and might hope to communication problem: Since you told me that you left
be . . . Elicitation of this psychosocial information about Dr. X because the two of you werent communicating very
the patient is useful for relationship building, diagnosis, well, can you tell me what works best for you in communi-
and the tasks of management. cating with a doctor? What can we do to avoid having
Some clinicians like to begin an interview with a another communication problem like the one you experi-
new patient by asking about the person himself: Before enced with Dr. X? Or, in the currently more common
we get to the medical problems, Id like you to tell me a scenario of change: I can imagine that it is a real loss for
1080 5 June 2001 Annals of Internal Medicine Volume 134 Number 11 www.annals.org
 The Patient-Centered Interview Medical Writings

you to have to leave Dr. Y just because your insurance disruptive of your life. Can you tell me about that? Or,
changed. Can you tell me what worked well for you in your From what you say, I imagine that this illness is very hard
relationship with Dr. Y? for you. Can you tell me what its been like for you? For-
Parenthetically, one should note that a question saking questions for simpler directions, nothing beats
such as Can you tell me . . . is theoretically answerable Tell me more about it (42 45).
with a yes or a no and thus appears to be a closed- If an interviewer wants to help her patient with
ended query, the sort physicians are urged to avoid. But more specific questions later on, she can ask about how
most patients would take this question to be an invita- the illness affects 1) his functioning: Since youve had this
tion to tell more and would respond with an appropriate problem, what are you no longer able to do or have trouble
story, not a one-word answer. doing that you used to be able to do?; 2) his relationships:
Sometimes physicians will discover that patient ex- Hows your family handling this?; and 3) his self-image:
pectations contrast strongly with the physicians own Do you think of yourself differently in any way since this
view of the patients role and possibilities. Physicians problem appeared?
may have to uncover that difference in their conversa-
tion with the patient: I see. It sounds as if what you expect
from me is A, B, and C. But the difficulty Im having is
4. What Are the Patients Ideas about the Illness?
that the way I see my role is to do D, E, and maybe F. So
Every sick person who goes to a healer has probably
we have different ideas about what I can do for you. How
devised an explanatory model that describes what is
can we best proceed? Do you see any place where we can get
wrong, how it came to happen, and what ought to be
together here? Unexpressed and ultimately conflicting
done about it. Physicians need to learn about patients
expectations have torpedoed many a promising medical
explanatory models, perhaps even noting these valuable
relationship, so its best to uncover them early.
data in the chart as EM. They can ask about etiology
An inquiry into the person of the patient segues
naturally into asking about symptoms: What sort of trou- theories: What do you think is causing these headaches?
bles are bothering you? What else? Tell me more about X, Y, What ideas do you have about why you might be having
and Z. But even here one is still interested in the pa- them? Why do you think this is happening right now?
tients expectations, hopes, and why he or she consulted About thoughts on prognosis: What are your concerns
the physician now: What led you to come in today, instead about this? When you think about what might happen to
of a few weeks ago or maybe a few weeks later? What were you because of this, what is most worrisome? And about
you most hoping to accomplish here today? It sounds like the appropriate therapy: What had you thought we ought to
two key issues are A and B. How can I help with these in do about this? Then, for patients who hesitate to voice
particular? (39, 40). their explanatory model or even deny having onefor
example, I havent a clue. Thats why I came to you
the physician can respond, I understand. But youve prob-
3. How Does This Patient Experience This Illness? ably had some thoughts on the matter. Or even, Well, if
Kleinman (41) noted that one unintended out- you DID have a theory, what would it be? Less colloquial
come of the modern transformation of the medical care phrasing might be, Well, I may have some ideas, but it is
system is that it does about everything to drive the prac- really important for me to understand as well as I can what
titioners attention away from the experience of illness. you think about what is wrong with you. Then we can
To Kleinman, illness refers to how the sick person and discuss our ideas together (46, 47).
the members of the family or wider social network per- What if the patients diagnosis or ideas about treat-
ceive, live with, and respond to symptoms and disabili- ment differ widely from the clinicians? Physicians can
ty, as opposed to disease, a construct that focuses on bring the difference to the surface and show that they
cause and mechanisms. When physicians ask about the are prepared to listen further: Sounds like youve been
patients experience of his or her illness, the more open thinking the problem is Y and that we ought to do Z for it.
the inquiry can be, the better: What has this illness been From my perspective it looks more like R or S. What do you
like for you? I can imagine that this illness has been pretty think? (48 57).
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Medical Writings The Patient-Centered Interview

5. What Are the Patients Main Feelings about the see. So this experience with the breast cancer has been pretty
Illness? frightening both to you and to your husband. I can under-
Not only are many physicians hesitant to ask about stand how that would be. Once he has communicated
feelings, their patients are often hesitant or simply un- that understanding and the patient has acknowledged it,
able to express feelings to them (58). They may offer the physicians next action is often no action at all. Cli-
hints that the physician can follow up: You know, nicians often fear opening Pandoras box and discov-
when you find a lump in your breast? You feel, kinda, ering powerful feelings that they dont know what to do
well, you know. Physicians may need to use both direct about. In fact, the physician can simply remain silent,
and indirect techniques to discover patients emotions. present, and attentive while reflecting on his under-
They can ask directly: How does that make you feel? standing and allowing the patient to absorb the sense of
Whats the feeling that goes with that? You know, the emo- being understood.
tions? Sometimes asking about emotions yields an an-
swer that is not an emotion but rather a generic theory RESPECTFUL ATTENTION
of how people might be constructed or act: Along with the words that encourage a patient to
Physician: How did it feel to have this injury just share hopes and concerns, respectful attention is a way
when you were going to do the New York Marathon? of building a long-lasting therapeutic relationship. A
Patient: Well, you have to understand how your physicians nonverbal communication of attitude and
muscles work and that they can get strained. feelings speaks as loud as what she says, and undivided
The physician may have to reiterate that feelings are attention is the strongest evidence of a desire to help the
important. For example, Im interested in knowing why patient. Leaning slightly toward the patient, nodding,
you think it happened, but I also want to know what your making eye contact, and using facilitative hums and
personal reaction was; you know, the emotions that you murmurs all show interest. Interviewers should not al-
experienced when your Achilles tendon snapped. When di- low the pace of questions to interfere with close listen-
rect questions still elicit no emotion or when the patient ing. Similarly, observing common culturally appropriate
says he or she has none, the next step is to prime the courtesies, such as using patients names in the way the
pump by self-disclosure or suggestions of possible im- patients choose to have them used, shaking their hands,
pact on the patients life or the lives of others: If I were and showing concern for their comfort and privacy,
working toward something like running a marathon and demonstrates the physicians respect. To be truly patient
then at the last minute I couldnt do it, I know that Id feel centered, physicians must demonstrate both verbally
angry (or frustrated or depressed). and nonverbally that the most important part of the
As a general rule, it is important to persist gently in medical interview is the person facing them (59 61).
asking the patient about emotions because many pa-
tients are not used to expressing their feelings to anyone, DISCUSSION
even to a physician. If the patient remains reticent and Studies that demonstrate poor patient adherence
perhaps even expresses his or her difficulty by saying, make it clear that patients frequently disagree with phy-
for example, I dont like all these questions about my sicians diagnoses and treatment plans; this leads to un-
feelingsthe physician can respond as he does when filled prescriptions, partially used medications, lack of
any of his inquiries touches a sensitive topic: I see that follow-up with referrals and return visits, and poor out-
you dont want to talk about this. Of course, you dont have comes (1, 5, 6, 61 65). Understanding how the patient
to tell me anything that is too uncomfortable to talk about. views his or her illness and the physicians role in treat-
But as a doctor I have to try to understand as fully and as ing it will help increase adherence and the physicians
precisely as I can, so I sometimes ask questions that seem effectiveness. Investigators of clinical decision making
intrusive. The better I can understand you, the more helpful come to the same conclusions about the need to inves-
I can be to you. tigate patients ideas, as do those who study and use
Once the physician has uncovered a powerful feel- patient-centered techniques (49, 50).
ing, he may wonder what to do next. His first task is to These techniques and the supportive language are
communicate his understanding clearly to the patient: I not instinctive. They may indeed feel awkward at first.
1082 5 June 2001 Annals of Internal Medicine Volume 134 Number 11 www.annals.org
 The Patient-Centered Interview Medical Writings

Initially, some physicians may see a patient-centered ap- John L. Coulehan, MD, MPH
proach as impractical, claiming that there is insufficient State University of New York at Stony Brook
time to learn more about the person of the patient. Stony Brook, NY 11794
However, a skilled physician can obtain a useful sketch
Lucy Fox, MD
of the patient as a person in less than a minute. The
Renal Medical Associates Ltd.
picture then becomes richer and more complex as the
Albuquerque, NM 97106
relationship develops. In fact, studies show that contrary
to intuition, permitting patients to state all of their con- Andrew J. Adler, MD
cerns without interruption does not add substantially to Brooklyn Veterans Affairs Medical Center
the length of the interview (59, 33, 34). Brooklyn, NY 11209
Another common belief is that patients expect a
more disease-centered or physician-oriented approach. If W. Wayne Weston, MD
physicians focus too much on personhood, especially University of Western Ontario
early in the relationship, the argument goes, patients London, Ontario NGK 1C7, Canada
who expect a disease-focused interview might think that
the physician is minimizing the seriousness of their Robert C. Smith, MD
physical symptoms or ascribing them to psychological Michigan State University School of Medicine
causes. However, patient surveys and lay literature make East Lansing, MI 48824
it clear that many patients are dissatisfied with the status
Moira Stewart, PhD
quo and would prefer that their physicians listen better
Centre for Studies in Family Medicine
and interact more with them as persons (66 78).
London, Ontario N6G 4X8, Canada
A final concern is that patient centering might risk
getting too close to the patient, thereby compromising Acknowledgments: The observations that doctors lack words came out
objectivity and professionalism. For example, encourag- of work by many of the 550 faculty to the Bayer Institute for Health
ing patients to express their emotions or sharing ones Care Communication. Drs. Platt, Fox, Adler, and Weston are among
own feelings or values with patients might impair clini- these faculty. Support for attempts to explicate such words came from
the publications committee of the American Academy on Physician and
cal detachment. This belief is based on the mistaken
Patient (AAPP). Drs. Platt, Coulehan, Smith, and Stewart are members
premise that good clinical decision making requires the of AAPP.
physician to be unemotional and distant. On the con-
trary, for physicians to be therapeutic, they must con- Requests for Single Reprints: Frederic W. Platt, MD, University of
nect with their patients on at least some emotional level Colorado, 1901 East 20th Avenue, Denver, CO 80205.
to motivate them toward healing (79).
Current Author Addresses: Dr. Platt: University of Colorado, 1901
To center the medical interview on the patient as
East 20th Avenue, Denver, CO 80205.
well as the disease, the physician must offer both non- Dr. Gaspar: University of Colorado, 9200 East Ninth Avenue, Denver,
verbal and verbal evidence that what the patient has to CO 80262.
say is important. Careful listening and considerate treat- Dr. Coulehan: State University of New York at Stony Brook, HSC-
ment can be paired with inquiries about the patients L3086, Stony Brook, NY 11794-8036.
Dr. Fox: Renal Medical Associates Ltd., 201 Cedar Street #800, Albu-
current status, experience of the illness, and expectations
querque, NM 87106.
of the physician to build a therapeutic bond. In the end, Dr. Adler: New York Harbor Veterans Affairs Medical Center, 800 Poly
the two most useful physician qualities may be curiosity Place, Brooklyn, NY 11209.
and patience curiosity to ask questions such as Tell Dr. Weston: University of Western Ontario, 1228 Commissioners Road
me about yourself, and patience to wait for the answer. West, London, Ontario NGK 1C7, Canada.
Dr. Smith: Michigan State University School of Medicine, B306 Clinical
Center, 138 Service Road, East Lansing, MI 48824
Frederic W. Platt, MD
Dr. Stewart: Centre for Studies in Family Medicine, 100 Collip Circle
David L. Gaspar, MD #245, London, Ontario N6G 4X8, Canada.
University of Colorado
Denver, CO 80205 Ann Intern Med. 2001;134:1079-1085.

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Medical Writings The Patient-Centered Interview

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