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Medical interviews are of two basic types: the problem-oriented and the health promotion interviews ( Levinson, 1987). The Problem-Oriented and the Health Promotion Interviews At its best, the interview becomes a dialogue between two people driven toward a common goal. For most physicians, the most difficult aspect of interviewing patients is maintaining a balance between the patient's and the physician's agenda between actively directing the encounter and facilitating the patient's spontaneous report of history. During the interview the patient's need to have his or her story heard and suffering understood is balanced by the physician's need to know and understand as much as possible about the patient and his or her problems ( Engel, 1988).
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The patient enters the interview seeking relief from the discomforts and uncertainties of illness, while the physician actively conducts the interview in order to clarify the patient's problems and derive diagnostic and therapeutic plans for the patient's benefit. Its direction reflects the respective needs of both participants-patient and physician. Fundamentally, the medical interview is a purposeful conversation undertaken with a set of goals and priorities clearly maintained in the physician's mind. It is the sense of direction that distinguishes the medical interview from the casual conversations of most social encounters. The student may wonder how the medical interview differs from other conversations and why special skills are required. The therapeutic alliance forged during the clinical encounter provides the foundation for ongoing patient care and education. As the medium through which a positive relationship is established between the doctor and the patient, an empathic, patient-centered interview can bolster the patient's sense of self-esteem and lessen the feelings of helplessness that often accompany an episode of illness. The diagnostic utility of the interview is complemented by its therapeutic power. Clinical hypotheses generated during the interview provide the basis for a cost-effective utilization of the clinical laboratory and other diagnostic modalities. An accurate history also provides focus to the physical examination, making it more productive and time efficient.
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The clinical adage that about two-thirds of diagnoses can be made on the basis of the history alone has retained its validity despite the technological advances of the modern hospital.
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Most clinicians rate the patient's medical history as having greater diagnostic value than either the physical examination or results of laboratory investigations ( Rich, 1987). As clinicians, we do in fact spend a great deal of our time talking with patients. No amount of reading can replace the experience of actually talking with patients, especially if the student's interviews can be observed and critiqued. The discussion will focus on the problem-oriented diagnostic interview, but the health promotion interview and interviews during follow-up visits will also be mentioned.īefore reading this chapter, the student should keep in mind that interviewing is a practical skill that can only be learned through doing. It will outline the knowledge, attitudes, and skills that lead to effective interviewing. It provides a guide to conducting initial interviews and making sense of what happens. This chapter will demonstrate the validity of interviewing as a clinical science based on critical observation and analysis of the patient without diminishing its excitement as a clinical activity. Perhaps the most compelling is that labeling it an "art" removes interviewing from the realm of critical appraisal and suggests that there is something magical or mysterious about interviewing that cannot be described or taught. There are many reasons to dispute this distinction. Interviewing is often considered part of the "art" in contrast to the "science" of medicine. The analytical skills of diagnostic reasoning must be balanced with the interpersonal skills needed to establish rapport with the patient and facilitate communication. The demands made on the physician are both intellectual and emotional. However, interviewing is also one of the most difficult clinical skills to master. The medical interview is the practicing physician's most versatile diagnostic and therapeutic tool.