Objectives

1. To review the importance of communication as a core clinical skill for pulmonary and critical care physicians.
2. To define the three-function model for medical interviewing.
3. To describe ways to gather information using a patient-centered approach.
4. To identify ways to build rapport with patients during the medical interview.
5. To identify ways to communicate meaningful information to patients and to provide effective patient education.

Key words

building rapport; communication; gathering data; giving information; patient education; verbal and nonverbal skills

Communication is a core clinical skill for pulmonary and critical care physicians. Like skills of thoracentesis, bronchoscopy, and endotracheal intubation, communication skills are learned and practiced and can be improved upon.

Physicians use skills to communicate with patients and families on a daily basis. Effective communication with patients leads to improved outcomes for both physicians and patients. Physicians identify their patients’ problems more accurately¹ and physician well-being is improved.² Patients are more satisfied with their care and are more likely to adhere to treatment recommendations.³

Ineffective communication may lead to increased malpractice claims. The communication problems most frequently identified in malpractice claims were inadequate explanation of information relating to diagnosis or treatment^4,5 and patients feeling deserted or devalued by physicians.⁵

Until recently, medical education paid little attention to ensuring that physicians had adequate training in communication skills. Now, communication is a core competency under the new Accreditation Council for Graduate Medical Education requirements. Recertification by the American Board of Internal Medicine, using the continuous professional development program self-evaluation process, includes a module on patient and peer assessment of communication skills. The American Board of Medical Specialties is piloting a study to assess physician-patient communication skills as part of the Maintenance of Certification program.

The Medical Interview

It is estimated that during a 20-year career, an average physician conducts between 160,000 and 200,000 medical interviews.⁶ One study determined that in patients admitted to the hospital with dyspnea, the primary diagnosis was established from the medical interview alone in 74% of the cases.⁷ Traditional medical interviewing has been taught from a structured biomedical model with focus on the chief complaint followed by the history of the present illness, past medical and surgical history, family history, and social history. This traditional approach ignores the importance of conversation, relationship, and dialogue.

Because no two patients are the same, and individual patients can experience the same disease differently, it is important to consider a functional rather than structural approach to medical interviewing. Bird and Cohen-Cole⁸ developed a “three-function model” for medical interviewing, describing the skills of gathering data, building rapport, and giving information.

Gathering Data

Gathering accurate data about the person and the disease process help to create an effective physician-patient relationship.

Physicians are quick to interrupt patients during a medical interview. One study documented that physicians redirected patients after 22 s of the patient talking.⁹ Physicians often fear that, left uninterrupted, patients may speak for long periods of time, affecting the overall time for the appointment. In fact, the mean spontaneous talking time of patients in an outpatient internal medicine clinic was 92 s.¹⁰ Interrupting or redirecting a patient may result in obtaining incomplete information and may cause the patient to feel that the physician is not listening.

Patients referred to a pulmonary and critical care physician may or may not understand the reason for the referral. It is not possible to know what the patient understands about the reason for the appointment without directly asking.

Physician: “Tell me your understanding of the reason for this appointment.” Or “I received a letter from your doctor about this appointment and would like to know what questions or concerns you have for me today.”

Patient: “My doctor told me my X-ray was abnormal. She ordered a CT scan and suggested that I see you.” Or “My doctor told me I have a new nodule on my X-ray and she said that the CT scan suggests this might be cancer.”

The responses to this initial question vary and will be an important starting point for the medical interview.

When a patient-centered approach to the interview is used, patients will provide information—both medical and psychosocial—that they consider important.¹¹ The key questions to ask in a patient-centered approach (Table 1) are as follows: (1) Who is the patient? This may include learning about the patient in the context of work, family, and hobbies. Knowing that a patient works as a baker will be important when evaluating new symptoms of asthma. (2) What does the patient want from the physician? What specific questions does the patient have today? This could range from a recertification for oxygen and a prescription for refills of an inhaler to an extensive evaluation of shortness of breath, chest pain, cough, weakness, and recurrent pneumonias. (3) How does the patient experience illness? How has the illness affected the patient’s relationships and ability to function? A young woman with primary pulmonary hypertension may no longer be able to care for her children. A salesman with severe COPD may not be able to travel or play golf as a result of his dyspnea. (4) What are the patient’s ideas about the illness? What is his or her understanding of the cause and treatment? A grandmother with bronchiectasis may be worried about visiting her grandchildren for fear of spreading an infection to them. A truck driver with undiagnosed obstructive sleep apnea may think that the reason he is falling asleep driving is because he is working too much. A banker with idiopathic pulmonary fibrosis may have searched the Internet and wishes to discuss treatment options. (5) What are the patient’s main feelings about the illness (with special attention to fear, distrust, anger, sadness and ambivalence)? A 55-year-old current cigarette smoker with a new diagnosis of metastatic lung cancer may experience anger and fear about the diagnosis and ambivalence about quitting smoking.

Table 1. Five Key Questions To Ask in a Patient-Centered Interview*

Gathering information through open-ended questions allows patients to tell the story of their illness in their own way.

Patient:“My cough started several weeks ago in church when I was singing.”

Patient: “I first noted shortness of breath and chest pain when I was carrying groceries from the car on Saturday.”

The physician can use both verbal and nonverbal skills to demonstrate active listening. Active listening skills include using facilitative statements such as “Tell me more...” or “Hmm...” or “I see...” to demonstrate that the physician is listening and wants to know more. Nonverbal skills include maintaining good eye contact, mirroring facial expressions, and physically turning to face the patient or leaning toward the patient. After the patient has finished telling his or her story, the physician can seek clarity by asking for additional information.

Physician: “What makes your cough worse?”

Physician: “What other activities cause you to have chest pain?”

Once the patient provides additional information, it is helpful to check back with the patient and summarize to ensure an accurate understanding. Using questions such as “Is that correct?” or “Did I miss anything?” or “Is there anything I left out?” can be helpful towards that end.

Physician: “I have heard you say that although you remember the cough starting in church, it is worse when you lay down at night and is associated with feelings of heartburn. Is that correct?”

Physician: “I’d like to summarize my understanding of your symptoms so we both can be sure that I have understood them correctlyº Your chest pain and shortness of breath occur with the exertion of carrying groceries, walking up a flight of stairs, and get better when you rest. Is that correct?”

The patient has the opportunity to confirm that the information is accurate or to add to the information until it is accurate.

Gathering data can be facilitated using the phrase “What else?” or “Anything else?” This can be used to elicit the patient’s entire list of concerns and helps to prevent important concerns from going unspoken or being brought up unexpectedly later.

Physician: “We have talked about your inhalers and the correct amount of oxygen for you to use. Is there anything else that you are concerned about?”

Patient: “I have been coughing up some blood over the last 2 weeks.”

Physician: “What else?”

Patient: “I have noticed a new pain in my left shoulder and am concerned about some weight loss.”

Physician: “Anything else?”

Patient: “No, that’s it.”

Once all of the issues have been identified, the physician and patient can negotiate the priorities together to allow for shared decision making. It may not be feasible to cover all items in a single visit. The physician may have some important items to cover that are not yet known to the patient.

Physician: “I’m concerned about the hemoptysis and the shoulder pain. I also hear that you are concerned about weight loss. I would suggest proceeding with a chest X-ray today and a bronchoscopy tomorrow. I also suggest you keep track of your weight and start a diet diary.”

Building Rapport

The medical interview is a time to build rapport and to develop a relationship with your patient. The intensity and duration of the relationship may differ depending on the patient and the clinical situation. You may have a brief, periodic relationship with a 25-year-old marathon runner with mild, intermittent asthma and an intense, more extended relationship with a 65-year-old man who has malignant mesothelioma, along with his wife and children.

Statements of partnership, empathy, apology, respect, legitimation, and support (PEARLS)¹² can help to build rapport.

Partnership involves joint problem solving and nonabandonment. It is a reminder that the physician and patient are partners committed to preventing illness, treating disease, and managing symptoms.

Empathy is the ability to understand the patient’s perspective and feelings. Empathy allows the patient to feel respected and validated. Clinical empathy involves responding to the patient’s feelings. Articulating empathy needs to be done in a way that ensures authenticity. Empathic responses to patient statements that express emotion typically involve naming the emotion. “It sounds like you are sad,” “I can see that you are angry,” or “I can imagine that this might make you feel afraid.”¹³

Apology, when used appropriately, can strengthen rapport. If a patient develops a procedural complication such as pneumothorax after central line placement and requires a chest tube, it would be appropriate to discuss this by saying, “I’m very sorry that this happened.”¹³ If an error occurs, it is important to apologize as soon as the error is realized. Not doing so may jeopardize trust. “I’m sorry that the wrong blood test was ordered. I will request that you not be charged for this.” It is important to realize that sometimes the words “I’m sorry” are misinterpreted to imply that an error has occurred when one has not. Statements such as “I’m sorry that your advanced-stage lung cancer was not diagnosed earlier” may be well-meaning, yet may imply that an error occurred in the context of the diagnosis. Alternatively, phrases such as “I wish we had more effective treatments for your advanced-stage lung cancer” articulate an empathic response without possible misinterpretation.

Respect involves acknowledging a patient’s behaviors, choices, and values. “You have worked hard on quitting smoking.” Or “I appreciate the time you have taken to discuss your advance directives with your wife and children.”

Legitimation is a way of normalizing and validating the patient’s feelings. “Anyone would be confused by this situation. We discussed a lot of information regarding the results of your open lung biopsy and it’s normal to feel overwhelmed right now.”

Offering support in an ongoing fashion helps the patient realize that he or she is not alone. “I’ll help you to understand the meaning of cryptogenic organizing pneumonia and be available for any questions that you have.”

It is important to resist the temptation to focus on biomedical details when responding to emotion. Building a relationship helps the patient to feel safe and to trust the physician, leading to a healthier approach to dealing with illness. Avoid prematurely giving reassurance. Generally speaking, phrases such as “don’t worry,” or “everything will be all right,” or “you’ll be fine” may not be true, and may dismiss the patient’s feelings and concerns.

Giving Information

Physicians give information and educate patients every day. Patients may receive information about a condition from their primary-care physician, the Internet, magazines, family members, and friends. Not all of the information they receive may be accurate. In order to help patients understand their symptoms and diagnoses, physicians need to give information that is meaningful to each individual patient. Physicians need to ask what the patient already knows, what he or she wants to know, and what questions he or she has. When giving information, it is essential for physicians to speak in terms that the patient understands.¹⁴

Physician: “Tell me what you know about sarcoidosis.”

Patient: “My family doctor told me a little bit about it and I found a lot of information on the Internet. It’s scary that it could involve my lungs, brain, liver, and eyes.”

Physician: “I can imagine that reading all that information on the Internet may cause you to feel scared. Sarcoidosis is a condition that causes inflammation of cells resulting in granulomas that can involve many different organs. The only evidence of sarcoidosis that you have right now is some enlargement of the lymph glands in your chest. At this time these are not causing any symptoms and do not require any treatment.”

Patients easily can feel overloaded with new or biomedical information. It is helpful to provide small amounts of information and to check frequently for understanding. Providing accurate and understandable information to patients can help to promote behavior change (as in smoking cessation), ensure patients’ understanding of a complex diagnosis (as in pulmonary lymphangioleiomyomatosis), improve compliance with medications (as in inhaler usage for COPD), and promote shared decision making.

Summary

Communication is a core clinical skill that pulmonary and critical care physicians use on a daily basis. Like other skills, it is learned and practiced and can be improved on. Effective communication leads to improved outcomes for both physicians and patients. When communicating with patients, physicians should trust their own instincts and not rely on scripted phrases if those do not genuinely reflect their own feelings.

References

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