* THE INFORMED PATIENT
* SEPTEMBER 21, 2005
Teaching Doctors How to Interview
Programs Offer Strategies For Quickly Getting to Heart Of Patients’ Problems, Fears
*
By LAURA LANDRO
As doctors cram more appointments into their busy day, they are under growing pressure to become more skilled at the art of the “medical interview.”
Medical researchers and educators are increasingly focusing on programs that train doctors to become expert in ferreting out all of their patients’ most pressing concerns, symptoms and fears. At a conference next month in Chicago on communication in health care, sponsored by Northwestern University and the American Academy on Physician and Patient, for example, experts will present a number of models on how to foster better interviewing skills with patients, including those from different racial and ethnic backgrounds.
One model getting attention was developed by health-plan giant Kaiser Permanente in the past 16 years to train thousands of physicians to quickly get to the heart of their patients’ medical problems. Known as the “Four Habits” model, the Kaiser program offers up a set of interview techniques doctors can use — but also provides a good road map for patients who want to get the most out of their doctor’s visit.
Kaiser’s program includes workshops that train its staff doctors in four major habits or skills: quickly creating a rapport with patients; drawing out and prioritizing their concerns; exploring the problem from the patient’s perspective; and showing empathy to set the stage for getting the patient engaged in joint decision making about treatment. In the workshops, actors pose as patients and audience volunteers play the roles of difficult patients while faculty members demonstrate useful communication strategies.
“The idea is to give some structure to these brief but intense interactions when time is always an issue, so we can find out everything we need to know,” says Terry Stein, the director of clinician-patient communication for Oakland, Calif.-based Kaiser.
Since, on average, a doctor conducts 120,000 to 160,000 interviews over a lifetime, even modest improvements can greatly affect treatment, outcomes and the cost of care, studies by Dr. Stein and others show. But if doctors fail to get at the full spectrum of concerns in the beginning of the encounter and to assess their importance from the patient’s point of view, there is likely to be more premature testing, misplaced empathy and support, and the emergence of hidden concerns at the end of the visit.
Kaiser includes eight questions doctors should ask to help patients explain their own illness, such as what they call the problem, why they think it started when it did, what difficulties it causes and what they fear most about it.
Doctors who have taken the training, says Dr. Stein, “sometimes can make small changes in how they interact with patients and they find their job becomes more satisfying.”
That was the case for Ann Eastman, a Kaiser physician who was trained in the Four Habits model and uses it in her obstetrics and gynecology practice in Oakland. “It’s the best way to get at the patient’s real reason for a visit, which sometimes never surfaces because a patient doesn’t know how to say something, and the doctor hasn’t built the trust for her to feel it’s OK to try,” Dr. Eastman says.
Recently, Dr. Eastman says, she saw a new patient complaining of vague abdominal distress in an urgent care visit; her Four Habits training taught her to “sit back and try to find out from her what she thought the reason was, show empathy and be open to her emotions.” What finally came out, Dr. Eastman says, is that the patient had an abusive spouse. She advises patients “to make sure your doctor really understands how a problem is affecting your whole life, because health issues don’t occur in a vacuum — life, stress and our environment affect our health.”
[The Four Habits]
Dr. Eastman, who teaches the Four Habits model to residents, adds, “Creating a welcoming, trusting atmosphere may not come naturally to all doctors, but it can be learned.” In her own practice, “I am less stressed out myself because I’m finding out what’s going on and developing more trust.”
Ceda Floyd, a 52-year-old retired city clerk who is a patient of Dr. Eastman’s, says the OB/GYN’s interviewing style has made her comfortable talking about things she might not share with a close family member, especially because Dr. Eastman is sensitive, direct and easy to understand, translating medical jargon into plain English and explaining the consequences of various treatment options even in brief visits.
“You don’t need to be with the doctor for an hour,” Ms. Floyd says. “You can have a full meeting in 10 minutes if you don’t judge by the amount of time but by what was accomplished in the time you spent.”
