Opening the Interview/Setting the Agenda

The Trouble with Physicians

In one study, physicians did not allow patients to complete their opening statements 69% of the time. The mean time until the first interruption was 18 seconds. Once interrupted, fewer than 2% of patients went on to complete their statements. [1]

"Data are thus very much physician-determined, skewed toward problems that are biomedical in nature... It has been proposed that current interviewing practices are at odds with scientific requirements: They produce biased, incomplete data about the patient." [2]

Physician-Centered vs. Patient-Centered Interviewing

An Outline for the Opening the Interview

Setting the Stage

Goal: To establish a favorable context for the interview

• Welcome the patient
• Know and use the patient's name
• Introduce and identify yourself
• Ensure comfort and privacy

Chief Complaint/Setting the Agenda

Goal: To establish the agenda for the interview

• Obtain list of all issues - avoid detail
  • Chief Complaint
  • Other complaints or symptoms
  • Specific requests (i.e. medication refills)
• Patient's expectations for this visit
• Ask the patient "Why now?"

Eliciting the Patient's Story

Goal: To establish a good flow of information

• Open-ended questions initially
• Encourage with silence, nonverbal cues, and verbal cues
• Focus by paraphrasing and summarizing

Transition

Goal: To smoothly shift into physician-centered interviewing

• Summarize interview up to that point
• Verbalize your intention to make the transition [3]

The Physician-Centered Interview

• Prioritize Problems
• Pursue the Most Urgent Problem (The Chief Complaint)
  • Move from general to specific
  • Flow from open-ended to closed-ended questions
  • The History of Present Illness "Funnel"
    

The "WH" Questions

• Where is It?
• When Did It Start?
• How Often Does it Happen?
• What Does It Feel Like?
• What Else Happens?

Notes

1. The Effect of Physician Behavior on the Collection of Data. Beckman HB; Frankel RM; Annals of Internal Medicine (1984) 101(6):692-696
2. The Patient's Story: Integrating the Patient- and Physician-Centered Approaches to Interviewing. Smith RC; Hoppe RB; Annals of Internal Medicine (1991) 115(6):470-477
3. Adapted from workshop materials provided by Robert C. Smith, MD - used with permission.