Teach i ng medica I interviewing : a practical technique FERNANDO TAPIA Columbia School of Medicine, University of Missouri

A significant amount of a physician’s practice is spent in the interview situation. The significance is both in terms of time and in terms of import- ance. Interestingly enough, however, it has been only in the last few years that specific effort has been directed at teaching medical students some- thing about interviewing. Fortunately, there is a growing feeling that as far as interviewing goes, every physician should be professionally compe- tent. Kahn and Canndl (1957) remind us that ‘the diagnostic interview practised by the physi- cian is certainly one of the most complex and demanding of skilled interviewing techniques’.

Through his formal education the physician obtains the knowledge with which to analyse and process the information which he is to receive from the interview, But it is within this interview context that the physician will gather the informa- tion on which he is about to take action for which he must bear complete responsibility. It goes without saying, therefore, that a great portion of this success will be based on the information received in the interview. Furthermore it is in the interview situation where the doctor-patient relationship so important in medicine is estab- lished.

An approach to enhancing the skill of a future physician is being practised at the University of Missouri with what appears to be some degree of satisfactory reylts. As part of a course in human ecology and behavioural science’ the students are given introductory lectures on medical inter- viewing. They are also required to read the pro- grammed text by Froelich and Bishop (1969) on interviewing. Most important, however, they are given the assignment of interviewing patients

T h e course in human ecology and behavioural science is organized by P multidisciplinary committee, of which Dr Hans 0. Mauksch is the Chairman.

early in their first year. This interview is tape recorded and then played back to a supervisor,

It is mainly on the interviewing exercise and consequent supervisory review situation that the author wishes to elaborate. However, a few brief comments about the content of the course pro- gramme will facilitate the readers’ understanding of some of the points made later during discussion of the supervision of the tape-recordings.

Highlights of course content Setting the stage The student is reminded that a medical interview is not a social situation, though it might have a few social amenities. He must consider that as a student (one of several on a medical ward) he does not have the advantages of the culturally familiar roles of the patient-doctor situation and must therefore make some deliberate effort to set the stage and establish the premise on which his interview will take place. An attempt at estab- lishing rapport must be made by the student since it will facilitate his present task of interviewing and, at another place and at another time, the task of treatment.

Type of questions The student is taught that he has the wherewithal of ‘turning the patient on’ and keeping him pro- ducing useful material. It is suggested that he open with a broad question which does not limit the patient’s answer and that he shows that he is listening by overtly demonstrating his interest and understanding to &he patient. Other interview techniques such as reflection, interpretation, and wen confrontation are given to the student so that he can facilitate the patient’s flow of in- for mat i o n .

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Silence Social situations abhor silence and the medical student can be expected to be uncomfortable with silence even though the interview is not a social encounter. This will lead him to inoppor- tune questions and to poor listening since he may be concocting future questions merely to avoid gaps in the interview. Thus the matter of tolerat- ing silence is stressed. The student is taught that the burden of silence is also on the patient.

Pitfalls The student is alerted to several developments in an interview which will play havoc with it. Among these are his losing control, as for instance, with a patient who tends to ramble with tangential irrelevance. Perhaps one of the more important pitfalls to warn the student about is not to assitnie bvliat the parient means without further clarifica- tion.

Empathy Students are invariably interested in being able to convey empathy to the patient. However, we have to stress that cmpathy begins with an objec- tive and an insightful awareness of the feelings and emotion conveyed by the communication and behaviour of the person. This therefore will be stressed in the tape reviews.

Non-verbal communications The student is alerted to the potential flood of non-verbal communications that will come at him. Some of these communications are to be given as much credit as if they had been spoken. However, the student is to interpret for the patient what he sees or to confront the patient with his assumption and to verify the genuineness of the assumption. (Example: A student noted that a 68-year-old woman hesitated, choked somewhat, and got teary-eyed when responding with ‘my husband will be all right’ to the inquiry about his welfare during her hospitalization and illness. When he confronted her with this visible emo- tional reaction he was able to further elicit that she was particularly concerned with her hus- band’s ability to take care of himself should her illness be prolonged and that he might have to be pu t into a nursing-home if she could no longer take care of him.)

Closing the interview Students are taught that there are correct as well as incorrect ways of concluding an interview. As teachers we remind students that the patients they are interviewing, as taxpayers, own the hos- pital and pay part of their education, and that over and above that, they lend themselves graci- ously for their education. Thus, tapering off rather than abruptly concluding, giving the patient an opportunity to ask some questions of his own, and certainly thanking him, are desirable and appropriate concluding procedures.

Interview exercise Patients are selected throughout the hospital for their reasonable availability to be interviewed. This includes ‘0b.-Gyn.’, Alcoholism Ward, Medicine, Surgery, etc. Because a first semester, freshman medical student is not likely to enter the medical care programme of the patient, lie will interview the patient in terms of gaining information necessary to understand more fully the patient’s perspective with regard to his illness or impairment and his subsequent hospitaliza- tion. In other words he will interview regarding patienthood vis-Ci-vis the perception the patient has of his illness and the circumstances surround- ingit. This complements other parts of the human ecology and behavioural science course which contains aspects of hospitalization and health care. The student is further told that if there is any opportunity for him to become his patient’s advocate in an informal way, he should seize upon the opportunity. At thisjuncturethestudentisalso remindedthat interviews canaffectthepatientsin a positive way and that his sympathetic understand- ing might always prove a bonus to the patient.

The students are made responsible for at least two taped interviews within the semester and these must be reviewed soon thereafter. Although more interview and review tapes might be advan- tageous it is apparent that after three tapes a rapidly diminishing return sets in. After several years of reviewing extremely poor tape-record- ings the staff suggested that the students be given a short course in the proper and best use of a tape-recorder. This has enormously improved the quality of the tape-recordings.

Audio-tape review Audio tapes of course may be reviewed on a one-

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to-one basis in which it is possible to make a detailed review of the greater portion of a one- hour recording. However, I have found it a very satisfactory experience to review the tape of three or four students at one sitting. The procedure is to let the student briefly tell the group something about the patient and how he set the stage for the interview. (The preliminaries of the student- patient encounter are seldom on tape.) Once a sizable portion of the tape has been played the students are encouraged to comment on the interview, concentrating mostly on the techniques of the interviewer. Not surprisingly the inter- viewer himself is often the most severe critic of his performance. Suggestions are made as to how a question could have been worded differently, etc. The task of the instructor is then to extract as much more of the lesson as can be gained from that particular tape. The elements of interviewing most commonly highlighted and which seem to prove useful in teaching are given below.

Types of questions Students frequently have difficulty with pacY/ig, especially when the patient is slow and tends to answer with simplicity. It is at this time that the student, perhaps subconsciously, becomes aware that the patient is not very bright nor very sophis- ticated and promptly the student begins to pro- vide leading questions or questions which allow only ‘yes’ or ‘no’ answers. Often the verbal students set up a type of multiple-choice question and answer situation, but only so that his own pace can be maintained. The tapes, however, frequently reveal that the students, at least when the patient is verbal, do tend to facilitate his information giving. They can remain silent for judicious periods and are pleasantly surprised at the continuing flow of information. The ‘power of silence’, they call it.

Interpretation and confrontation as recom- mended by Froelich and Bishop (1969) is seldom practised by the beginners and perhaps might not be expected at this level. However, non-verbal communications are noted on the tapes. Deep sighs, hesitations, dropping of the voice, and the beginning of emotional choking are discernible, and the student is reminded that he might have confronted the patient with such a situation.

Pitfalls Perhaps, as explained previously, the most com-

mon pitfall is for the student to assume what the patient meant. For instance, if the patient should say ‘my headaches are better now’, the student might assume that this area is taken care of and the headaches are gone. The patient, however, might have meant that he has gone from a severe, practically incapacitating migrainous condition to a less frequent, but still somewhat incapacitat- ing, condition. Thus the student is brought to task for having assumed something which he might have readily cleared up.

Another pitfall involves certain subject areas which the beginners might be expected to deal with poorly. It often becomes a conspicuous element on the audio tape that the patient was interested, or at least willing, to talk on certain subjects but that the student avoided this. Such areas as sex, money matters, serious complica- tions of the illness, and especially death are often skirted because of the students’ discomfort. The stress made by the supervisor is that these are areas commonly avoided in social situations but that in a professional setting there is every auth- ority and, indeed, a responsibility to take up these matters.

Finally, a most ‘interesting’ pitfall is noted when students interview post-partum patients. There seems to be the common assumption that all is well, at least if the baby is alive. For example, a student reached three-fourths into a one-hour interview before it finally dawned on him that the mother was very concerned about a 3-) pound premature son and that bcing ‘glad it was over with’ did not mean all was well.

Rapport Finally, during the tape-review session an effort is made to look at the rapport and the empathy which may have been developed during the inter- view. The student himself can often give a rather good account as to the success or failure in this area. Not infrequently rather interesting and sig- nificant incidents do come through which can be exploited by the supervisor to the benefit of the students. It is not uncommon, for instance, to note that the patient and not the student was the more understanding and accommodating. Other times both student and patient have found their interview being held under the most adverse con- ditions (ajackhammer working in the next room, or the interview being done in a small chart room where constant traffic was taking place), and

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both patient and student shared in the adversity and managed to muddle through. It is often a delight to see an older patient and a younger student strike upnot a grandparent to grandson relationship but a true affective rapport which obviously would have contributed to the treat- ment situation. This is pointed out.

Once in a while interviews lapse into a social visit and the student must be reminded of the folly of this within a professional context. It was interesting to note a student interview with an acquaintance which began on a social level but which the student definitely put into a profes- sional context, kept it there, and concluded it as such. Once the interview was over the student was then willing to deal with his acquaintance on a social level and did so.

Summary An introduction to medical interviewing can be instituted during the first semester of the fresh- man year. By orientating the content of the inter- view towards 'patienthood' the student can then carry out an interview with regular hospital patients on a professional level. The elements of the interviewing are briefly given to the students in lectures. The interviews are taped and reviewed individually or in a group situation. As an intro- ductory effort, three taped interviews seem to be sufficient.

References Froelich, R., and Bishop, M. F. (1969). Medico1 Inrerviewing:

Kahn, R. J., and Cannell. C. E. (1957). The Dynamics uf A Programmed Manual. C. V. Mosby Co: St Louis.

Ittierviewing. John Wiley and Sons: New York.