Communication Skills: Patient Interview Tips

Prepared by:
John Tongue, MD
Chair, AAOS Communications Skills Project Team

  • The Greeting
    • Entering the exam room:
      Professional attire, clear your thoughts, smile before opening the door, knock, enter with a deliberate pace, not rushed. The patient will size you up in the next 5 seconds.

  • Welcoming Statement
    • Good morning/afternoon/evening! Smiling, eye contact, calm, pleasant, appropriate, consistent voice tone, focused attention, not rushed.
    • Mr/Ms-------------? (check pronunciation), I'm Doctor----------. Even in an emergency room, introductions are important. I prefer the 'Doctor' naming to first names.
    • "Welcome." or "Good to see you." Combine handshake with eye contact.
    • Sit down two to four feet across from the patient, maintaining eye contact at the same level.
    • If the patient is still 'looking you over' and estimating your pace and the warmth of your greeting, try a simple, normalizing comment as you sit down and lean toward them saying:
      "How were the roads this afternoon?" or "How do you like this hot/cold/wet weather?"

    Pitfalls: "How are you today?" - in the U.S., this is a greeting, not a question, that can put the ill/injured person in the awkward position of saying they are "fine" just before telling you their story/problem(s). Do not stand while the patient is seated during the interview.

  • The Patient's Story
    • Lean forward, maintain eye contact, smile and inquire:
      "How can I help you today?" Six simple, powerful, empowering words.
    • Open-ended questions allow the patient the opportunity to define the conversation.
    • Lean forward and wait until the patient finishes speaking -- this is hard to do.
    • Inhale information, without trying to organize it.
    • It takes most patients two minutes to state their story: why they are seeing you, yet the average medical doctor interrupts the patient within 18 to 23 seconds.
    • At this time in the evolution of managed care, many patients expect to be interrupted or have little time to tell their story. They may simply respond to your open ended questions with a single sentence, answer and stop. "I'm here because my right shoulder hurts." Try responding with:
      "Fine. Tell me about it!" Usually the patient will now tell their 'story'.
    • Most orthopedic patients have two or more musculoskeletal complaints they wish to discuss and it's better to get them out on the table early in order to prioritize the time and negotiate the agenda for this visit.
    • Listen to the patient's exact/key phrases/words---you will often be able to repeat them later to demonstrate your understanding, listening ability, and caring.
    • You have the opportunity to facilitate the 'telling of the story' with nodding, facial expression, and voice inflections, or just repeating a key phrase.
      Pitfalls:"What seems to be the problem today?" Patients sometimes react defensively to this question; 'That's what you're supposed to tell me' may be their thought. Or... "Tell me about your shoulder pain." Open-ended, but may give the impression that you are interested in a body part, not the patient. Also, implies only one complaint can be discussed.

    • Next: question the patient's own story - not your first interpretation of their orthopedic condition:
    • Be as curious about the person as you are about their medical problem.
    • Avoid interrupting with how/what/when/where questions at this time, resisting the urge to jump into an orthopaedic 'fix it' mode.
    • Don't write and listen at the same time. Alternate. Look at the patient when listening.
    • Try one of these:
      "I'm curious about...", "Tell me more about..." -or- "That must have been?(very painful/frightening/frustrating)"
    • Name their expressed, or nonverbal emotion. Acknowledge stressful situations. Acknowledging the patient's emotions and values helps them see you as someone who values them as an individual--- not "the sore shoulder in room #3".
    • Surgeons use empathic statements rarely for fear of: 1) getting into a long discussion (when just the opposite is true: patients will appreciate the empathy and NOT head off on their life story), or 2) the surgeon is not comfortable relating the patient's emotions (just when a little human kindness could make this patient your best advocate).

  • Negotiate an agenda
    • Reflect on your understanding of the patient's story by summarizing what you have heard. Repeat some of the patient's own words. Normalize feelings. Tell something from your life if it will help the patient's well being.
    • Explain the necessary additional information and/or tests that will be done now. Orient patient to this process, and limit the scope of this day's evaluation if necessary. Offer to reschedule time for complete consideration of secondary complaints if necessary.
    • Orienting statements show consideration and respect. For example, after completing the history and initial physical exam, briefly explain what is next by saying:
      "With your permission, we can now take x-rays of your shoulder for more information." (Patient agrees). "Wait here for a few minutes. The technician will take the pictures here in this office. Then I'll show you the films and discuss them with you shortly. Thank you."

  • Educate
    • After completing the history and physical exam, ask the patient what they know.
    • Explain your thoughts with clear, direct words that suit to the patient's style, values.
    • Use analogies and simple drawings to give the patient perspective, and reduce the chances that they are not understanding your terms at all. Remember that patients normally will forget 50% of what you say the minute they leave the office. Patient information brochures can be effective supplements for the patient after leaving your office.
    • Humor is important, but it can cause misunderstandings--- if you are heard as being patronizing or arrogant.
    • Orthopedic surgeons are good educators, and use appropriate words with few exceptions. Make sure to interact with the patient during any discussion to check understanding. Truly encourage questions and discussion:
      "What questions do you have?"
      "Is there anything else you've been wondering about?"

    Pitfalls:"Do you have any questions?" This is sometimes said with a hurried glance, a low 'I sure hope not' tone of voice, even with a 'no' nodding of the physician's head.

  • Enlist the patient as a partner:
    • Patients come with a self-diagnosis; so after presenting your professional opinion, always ask:
      "How does this fit with what you've been thinking?"
    • This one question can prevent more misunderstandings than all other questions. The patient may still have a very different agenda than you realize, or may have a deep concern they have been holding back that will now pop out.
    • Discuss the treatment regimen in simple terms; emphasizing benefits, explaining potential obstacles, and offering a specific time frame. Offer goals tied to future results that put the patient in control. Write it down if it will improve adherence, and schedule a follow up to monitor progress. Then say:
      "When you return, I'll ask you if you are better. And if you are better, I'll ask you how much! ---10%, 50%, 90%. So be thinking about this until I see you then."
    • This positive request helps the patient join in evaluating their own course, and helps motivate them to be accountable to the treatment program.

  • Closing
    • End by reviewing the diagnosis, treatment, and prognosis.
    • With a sincere, uplifting voice tone, say good-bye and express an expectation for a positive outcome --- while shaking hands and maintaining eye contact.

    This outline of the Orthopaedic Patient Encounter was developed based upon my interviews with over 100,000 orthopaedic patients as well as the Institute for Healthcare Communications' "Clinician-Patient Communication Course."

  • John R. Tongue, M.D.
    Clinical Associate Professor, Oregon Health Sciences University
    Past Chair, AAOS Board of Councilors
    Faculty, The Institute for Healthcare Communication.
    6485 S.W. Borland Rd., Suite A
    Tualatin, Oregon 97062

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