1 - The Patient-Doctor Relationship | Kaplan and Sadocks Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry

Authors: Sadock, Benjamin James; Sadock, Virginia Alcott

Title: Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th Edition

> Table of Contents > 1 - The Patient Doctor Relationship

The Patient Doctor Relationship

The quality of patient doctor or patient therapist relationship is crucial to the practice of medicine and psychiatry. The capacity to develop an effective relationship requires a solid appreciation of the complexities of human behavior and a rigorous education in the techniques of talking and listening to people. To diagnose, manage, and treat an ill person, doctors and therapists must learn to listen. They need the skills of active listening, which means listening both to what they and the patient are saying and to the undercurrents of the unspoken feelings between them (Fig. 1-1). A physician who monitors both the content of the interaction (what the patient and the doctor actually say) and the process (what the patient or the doctor mean to say) realizes that communication between two people occurs on several levels at once: what the person believes about himself or herself; what he or she wants others to believe about them; and finally who the person really is.

An effective relationship is characterized by good rapport. Rapport is the spontaneous, conscious feeling of harmonious responsiveness that promotes the development of a constructive therapeutic alliance. It implies an understanding and trust between the doctor and the patient. Frequently, the doctor is the only person to whom the patients can talk about things that they cannot tell anyone else. Most patients trust their doctors to keep secrets, and this confidence must not be betrayed. Patients who feel that someone knows them, understands them, and accepts them find that a source of strength. In his essay, Caring for the Patient Francis Peabody, M.D. (1881 1927), a talented teacher and clinician (Fig. 1-2), wrote:

The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy, and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.

Establishing Rapport

Ekkehard Othmer and Sieglinde Othmer defined the development of rapport as encompassing six strategies: (1) putting patients and interviewers at ease; (2) finding patients' pain and expressing compassion; (3) evaluating patients' insight and becoming an ally; (4) showing expertise; (5) establishing authority as physicians and therapists; and (6) balancing the roles of empathic listener, expert, and authority. As part of a strategy for increasing rapport, they developed a checklist (Table 1-1) that enables interviewers to recognize problems and refine their skills in establishing rapport.

In one survey of 700 patients, patients substantially agreed that many physicians do not have the time or inclination to listen and consider their feelings, that physicians do not have enough knowledge of the emotional problems and socioeconomic background of their families, and that physicians increase their fear by giving explanations in technical language.

Evaluating the pressures in patients' early lives helps psychiatrists better understand patients. Emotional reactions, healthy or unhealthy, are the result of a constant interplay of biological, sociological, and psychological forces. Each stress leaves behind a trace of its influence and continues to manifest itself throughout life in proportion to the intensity of its effects and the susceptibility of the human being involved. Past and current stresses should be determined to the fullest extent possible.

Empathy

Empathy is a way of increasing rapport. It is an essential characteristic of psychiatrists, but it is not a universal human capacity. An incapacity for normal understanding of what other people are feeling appears to be central to certain personality disturbances, such as antisocial and narcissistic personality disorders. Although empathy probably cannot be created, it can be focused and deepened through training, observation, and self-reflection. It manifests in clinical work in a variety of ways. An empathic psychiatrist may anticipate what is felt before it is spoken and can often help patients articulate what they are feeling. Nonverbal cues, such as body posture and facial expression, are noted. Patients' reactions to the psychiatrist can be understood and clarified.

Patients sometimes say, How can you understand me if you haven't gone through what I'm going through? Clinical psychiatry, however, is predicated on the belief that it is not necessary to have other people's literal experiences to understand them. The shared experience of being human is often sufficient. Whether in an initial diagnostic setting or in ongoing therapy, patients draw comfort from knowing that psychiatrists are not mystified by their suffering.

Transference

Transference is generally defined as the set of expectations, beliefs, and emotional responses that a patient brings to the patient doctor relationship. They are based not necessarily on who the doctor is or how the doctor acts in reality but, rather, on repeated experiences the patient has had with other important authority figures throughout life.

Transferential Attitudes

The patient's attitude toward the physician is apt to be a repetition of the attitude he or she has had toward authority figures. The patient's attitude can range from one of realistic basic trust, with an expectation that the doctor has

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the patient's best interest at heart, through one of overidealization and even eroticized fantasy to one of basic mistrust, with an expectation that the doctor will be contemptuous and potentially abusive.

FIGURE 1-1 The active listening described in the text is illustrated by the therapist's expression of concern for what the patient is experiencing. The psychiatrist Harry Stack Sullivan referred to the therapist as a participant observer in the patient's life. (Courtesy of Corbis).

Role of the Psychiatrist versus the Nonpsychiatric Physician

In many respects, the role of a psychiatrist differs from that of a nonpsychiatric physician, yet many patients expect the same from the psychiatrist as they do from other physicians. If they expect a doctor to take action, give advice, and prescribe medication to cure an illness, they may well expect the same interaction with a psychiatrist and be disappointed or angry if it does not occur. Transferential reactions can be strongest with psychiatrists for a number of reasons. For example, in intensive insight-oriented psychotherapy the encouragement of transference feelings is an integral part of treatment. In some types of therapy, a psychiatrist is more or less neutral. The more neutral or less known the psychiatrist is, the more a patient's transferential fantasies and concerns are mobilized and projected onto the doctor. Once the fantasies are stimulated and projected, the psychiatrist can help patients gain insight into how those fantasies and concerns affect all the important relationships in their lives. Although a nonpsychiatrist does not use or even need to understand transference attitudes in that intensive way, a solid understanding of the power and the manifestations of transference is necessary for optimal treatment results in any patient doctor relationship.

FIGURE 1-2 Francis W. Peabody, M.D. (1881 1927). (Courtesy of the National Library of Medicine.)

The doctor's words and deeds have a power far beyond the commonplace because of his or her unique authority and the patient's dependence on the doctor. How a particular physician behaves has a direct bearing on the patient's emotional and even physical reactions.

One patient repeatedly had high blood pressure readings when examined by a physician he considered cold, aloof, and stern. He had normal blood pressure readings, however, when seen by a doctor he regarded as warm, understanding, and sympathetic.

Countertransference

Just as the patient brings transferential attitudes to the patient doctor relationship, doctors themselves often have countertransferential reactions to their patients. Countertransference can take the form of negative feelings that are disruptive to the patient doctor relationship, but it can also encompass disproportionately positive, idealizing, or even eroticized reactions to patients. Just as patients have expectations for physicians for example, competence, lack of exploitation,

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objectivity, comfort, and relief physicians often have unconscious or unspoken expectations of patients. Most commonly, patients are thought of as good patients if their expressed severity of symptoms correlates with an overtly diagnosable biological disorder, if they are compliant with treatment, if they are emotionally controlled, and if they are grateful. If those expectations are not met, the patient may be disapproved of and experienced as unlikable, unworkable, or bad.

Table 1-1 Checklist for Clinicians

		Yes	No	N/A
The following checklist allows clinicians to rate their skills in establishing and maintaining rapport. It helps them detect and eliminate weaknesses in interviews that failed in some significant way. Each item is rated yes, no, or not applicable.
1.	I put the patient at ease.
2.	I recognized the patient's state of mind.
3.	I addressed the patient's distress.
4.	I helped the patient warm up.
5.	I helped the patient overcome suspiciousness.
6.	I curbed the patient's intrusiveness.
7.	I stimulated the patient's verbal production.
8.	I curbed the patient's rambling.
9.	I understood the patient's suffering.
10.	I expressed empathy for the patient's suffering.
11.	I tuned in on the patient's affect.
12.	I addressed the patient's affect.
13.	I became aware of the patient's level of insight.
14.	I assumed the patient's view of the disorder.
15.	I had a clear perception of the overt and the therapeutic goals of treatment.
16.	I stated the overt goal of treatment to the patient.
17.	I communicated to the patient that I am familiar with the illness.
18.	My questions convinced the patient that I am familiar with the symptoms of the disorder.
19.	I let the patient know that he or she is not alone with the illness.
20.	I expressed my intent to help the patient.
21.	The patient recognized my expertise.
22.	The patient respected my authority.
23.	The patient appeared fully cooperative.
24.	I recognized the patient's attitude toward the illness.
25.	The patient viewed the illness with distance.
26.	The patient presented as a sympathy-craving sufferer.
27.	The patient presented as a very important patient.
28.	The patient competed with me for authority.
29.	The patient was submissive.
30.	I adjusted my role to the patient's role.
31.	The patient thanked me and made another appointment.
Reprinted with permission from Othmer E, Othmer SC. The Clinical Interview Using DSM-IV. Washington, DC: American Psychiatric Press; 1994.

Disliking a Patient

A physician who actively dislikes a patient is apt to be ineffective in dealing with him or her. Emotion breeds counteremotion. For example, if the physician is hostile, the patient becomes hostile; the physician then becomes even angrier than before, and the relationship deteriorates rapidly. If the physician can rise above such emotions and handle a difficult patient with equanimity, the interpersonal relationship may shift from one of mutual overt antagonism to one of at least increased acceptance and grudging respect. Rising above such emotions involves being able to step back from the intense countertransferential reactions and dispassionately explore why the patient is reacting to the doctor in such an apparently self-defeating way. The patient needs the doctor, and hostility ensures that the needed help will occur in a less effective context. If the doctor can understand that the patient's antagonism is in some ways defensive or self-protective and most likely reflects transferential fears of disrespect, abuse, and disappointment, the doctor may be less angry and more empathic than otherwise.

Doctors who have strong unconscious needs to be all-knowing and all-powerful may have particular problems with certain types of patients. These patients may be difficult for most physicians to handle, but if the physician is as aware as possible of his or her own needs, capabilities, and limitations the patients will not be threatening. Such patients include the following: those who repeatedly appear to defeat attempts to help themselves (for example, patients with severe heart disease who continue to smoke or drink); those who are perceived as uncooperative (for example, patients who question or refuse treatment); those who request a second opinion; those who fail to recover in response to treatment; those who use physical or somatic complaints to mask emotional problems (for example, patients with somatization disorder, pain disorder, hypochondriasis, or factitious disorders); those with chronic cognitive disorders (for example, patients with dementia of the Alzheimer's type); and patients who represent a professional failure and, thus, are a threat to the physician's identity and self-esteem (for example, those who are dying or in chronic pain).

Sexuality and the Physician

Physicians are bound to like some patients more than others. However, if the physician feels a strong attraction to a patient and is tempted to act on the attraction, stepping back and assessing the situation are essential. In some medical specialties in which the patient doctor relationship is not particularly intimate or intense, the prohibition against romantic involvement with patients may not be strong.

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In other specialties, however, especially psychiatry, the ethical and even legal prohibition is important. The doctor is a powerful figure in the United States culture and may trigger many unconscious fantasies of being rescued, taken care of, and loved. Doctors themselves may have their own unconscious fantasies of being and needing to be all-powerful, rescuing, and loving. Those fantasies are inherently unrealistic and are inevitably disappointed. The disappointments, if realized in a romantic relationship between the doctor and the patient, can be destructive, especially for the patient. Patient therapist sex is discussed further in Chapter 59.

Another aspect of sexuality as it pertains to countertransference issues relates to asking patients about sexual issues and obtaining a sexual history. A reluctance to do so may reflect the physician's own anxiety about sexuality or even an unconscious attraction toward the patient. Moreover, the omission of those questions generally tells patients that the doctor is uncomfortable with the subject, thus leading to an inhibition about discussing any number of other sensitive subjects.

Self-Monitoring of Countertransference Feelings

Countertransference feelings do not always have to be perceived in negative terms. They also have the potential, if recognized and analyzed, to help the doctor better understand the patient who has stimulated the feelings. For instance, if a doctor feels bored and restless when with a particular patient and has ascertained that the boredom is not secondary to his or her own preoccupations, the doctor may surmise that the patient is speaking about trivial or insignificant concerns to avoid real and potentially disturbing concerns.

Physicians as Patients

A special example of countertransference issues occurs when the patient being treated is a physician. Problems that can arise in that situation include an expectation that the physician-patient will take care of his or her own medications and treatment and the treating physician's fear of criticism of his or her skills or competence. Physicians are notoriously poor patients, most likely because physicians are trained to be in control of medical situations and to be the masters of the patient doctor relationship. For a physician, being a patient may mean giving up control, becoming dependent, and appearing vulnerable and frightened behaviors that most physicians are professionally trained to suppress. Physician-patients may be reluctant to become what they perceive as burdens to overworked colleagues, or they may be embarrassed to ask pertinent questions for fear of appearing ignorant or incompetent. Physician-patients may stimulate fear in the treating physicians who see themselves in the patient, an attitude that can lead to denial and avoidance on the part of the treating physician.

Models of Interaction Between Doctor and Patient

The interactions between a doctor and patient the questions a patient asks, the way in which news is conveyed and treatment recommendations are made can take different shapes. It is helpful in thinking about the relationship to formulate models of interaction. These are fluid concepts, however. A talented, sensitive physician will have different approaches with different patients and indeed may have different approaches with the same patient as time and medical circumstances vary.

The paternalistic model. In a paternalistic relationship between the doctor and patient, it is assumed that the doctor knows best. He or she will prescribe treatment, and the patient is expected to comply without questioning. Moreover, the doctor may decide to withhold information when it is believed to be in the patient's best interests. In this model, also called the autocratic model, the physician asks most of the questions and generally dominates the interview.

Circumstances arise in which a paternalistic approach is desirable. In emergency situations the doctor needs to take control and make potentially life-saving decisions without long deliberation. In addition, some patients feel overwhelmed by their illness and are comforted by a doctor who can take charge. In general, however, the paternalistic approach risks a clash of values. A paternalistic obstetrician, for example, might insist on spinal anesthesia for delivery when the patient wants to experience natural childbirth.
The informative model. The doctor in this model dispenses information. All available data are freely given, but the choice is left wholly up to the patient. For example, doctors may quote 5-year survival statistics for various treatments of breast cancer and expect women to make up their own minds without suggestion or interference from them. This model may be appropriate for certain one-time consultations where no established relationship exists and the patient will be returning to the regular care of a known physician. At other times, the informative model places the patient in an unrealistically autonomous role and leaves him or her feeling the doctor is cold and uncaring.
The interpretive model. Doctors who have come to know their patients better and understand something of the circumstances of their lives, their families, their values, and their hopes and aspirations, are better able to make recommendations that take into account the unique characteristics of an individual patient. A sense of shared decision-making is established as the doctor presents and discusses alternatives, with the patient's participation, to find the one that is best for that particular person. The doctor in this model does not abrogate the responsibility for making decisions, but is flexible, and is willing to consider question and alternative suggestions.
The deliberative model. The physician in this model acts as a friend or counselor to the patient, not just by presenting information, but in actively advocating a particular course of action. The deliberative approach is commonly used by doctors hoping to modify injurious behavior, for example, in trying to get their patients to stop smoking or lose weight.

These models are only guides for thinking about the doctor patient relationship. One is not intrinsically superior to any other, and a physician may use all four approaches with a patient during a single visit. Difficulties are most likely to arise not from the use of one or another of the models, but with the physician who is rigidly fixed in one approach and cannot switch strategies, even when indicated and desirable. The models do not, moreover, describe the presence or absence of interpersonal warmth. It is entirely possible for patients to see a paternalistic or autocratic physician as personable, caring, and concerned. In fact, a common image of the small town or country doctor in the early part of the 20th century was a man (seldom a woman) totally committed to the welfare of his patients, who would come in the middle of the night and sit at the bedside holding the patient's hand, who would be invited to Sunday dinner, and who expected his instructions to be followed exactly and without question.

Illness Behavior

The term illness behavior describes patients' reactions to the experience of being sick. Aspects of illness behavior have sometimes been termed the sick role, the role that society ascribes to people when they are ill. The sick role can include being excused from responsibilities and the expectation of wanting to

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obtain help to get well. Illness behavior and the sick role are affected by people's previous experiences with illness and by their cultural beliefs about disease. The influence of culture on reporting and manifestation of symptoms must be evaluated. For some disorders, this varies little among cultures, whereas for others, the cultural mores may strongly shape the way the patient presents the condition. The relation of illness to family processes, class status, and ethnic identity is also important. The attitudes of peoples and cultures about dependency and helplessness greatly influence whether and how a person asks for help, as do such psychological factors as personality type and the personal meaning the person attributes to being ill. Some people experience illness as overwhelming loss; others see in the same illness a challenge they must overcome or a punishment they deserve. Table 1-2 lists essential areas to be addressed in assessing illness behavior and helpful questions for making the assessment.

Table 1-2 Assessment of Individual Illness Behavior

Prior illness episodes, especially illnesses of standard severity (childbirth, renal stones, surgery)
Cultural degree of stoicism
Cultural beliefs concerning the specific problem
Personal meaning of or beliefs about the specific problem
Particular questions to ask to elicit the patient's explanatory model:

What do you call your problem? What name does it have?
What do you think caused your problem?
Why do you think it started when it did?
What does your sickness do to you?
What do you fear most about your sickness?
What are the chief problems that your sickness has caused you?
What are the most important results you hope to receive from treatment?
What have you done so far to treat your illness?

Courtesy of Mack Lipkin, Jr., M.D.

Psychiatric versus Medical-Surgical Interviews

Mack Lipkin, Jr., described three functions of medical interviews: to assess the nature of the problem, to develop and maintain a therapeutic relationship, and to communicate information and implement a treatment plan (Table 1-3). These functions are exactly the same in psychiatric and surgical interviews. Also universal are the predominant coping mechanisms used in illness, both adaptive and maladaptive. These mechanisms include such reactions as anxiety, depression, regression, denial, anger, and dependency (Table 1-4). Physicians must anticipate, recognize, and address such reactions if treatment and intervention are to be effective.

Psychiatric interviews have two major technical goals: (1) recognition of the psychological determinants of behavior and (2) symptom classification. These goals are reflected in two styles of interviewing: the insight-oriented, or psychodynamic, style and the symptom-oriented, or descriptive, style. Insight-oriented interviewing attempts to elicit unconscious conflicts, anxieties, and defenses. The symptom-oriented approach emphasizes the classification of patients' complaints and dysfunctions as defined by specific diagnostic categories. The approaches are not mutually exclusive and, in fact, can be compatible. A diagnosis can be described as precisely as possible by eliciting such details as symptoms, course of illness, and family history and by understanding a patient's personality, developmental history, and unconscious conflicts.

Psychiatric patients often contend with stresses and pressures that differ from those of patients who do not have a psychiatric disorder. These stresses include the stigma attached to being a psychiatric patient (it is more acceptable to have a medical or surgical problem than a mental problem); communication difficulty because of disorders of thinking; oddities of behavior; and impairments of insight and judgment that might make compliance with treatment difficult. Because psychiatric patients often find it difficult to describe fully what is going on in their lives, physicians must be prepared to obtain information from other sources. Family members, friends, and spouses can provide critical data such as previous psychiatric history, responses to medication, and precipitating stresses that patients may not be able to describe themselves.

Psychiatric patients may not be able to tolerate a traditional interview format, especially in the acute stages of a disorder. For instance, a patient who has increased agitation or depression may not be able to sit for 30 to 45 minutes of discussion or questioning. In such cases, physicians must be prepared to conduct multiple brief interactions over time, for as long as the patient is able, stopping and returning when the patient appears able to tolerate more.

Studies show that about 60 percent of all patients with mental disorders visit a nonpsychiatric physician during any 6-month period and that patients with mental disorders are twice as likely to visit a primary care physician as are other patients. Nonpsychiatric physicians should be knowledgeable about the special problems of psychiatric patients and the specific techniques used to treat them.

Biopsychosocial Model

In 1977, George Engel at the University of Rochester, published a seminal paper that described the biopsychosocial model of disease, which stressed an integrated systems approach to human behavior and disease. The biopsychosocial model is derived from general systems theory. The biological system emphasizes the anatomical, structural, and molecular substrate of disease and its effects on the patient's biological functioning; the psychological system emphasizes the effects of psychodynamic factors, motivation, and personality on the experience of illness and the reaction to it; and the social system emphasizes cultural, environmental, and familial influences on the expression and the experience of illness. Engel postulated that each system affects, and is affected by, every other system. Engel's model does not assert that medical illness is a direct result of a person's psychological or sociocultural makeup but, rather, encourages a comprehensive understanding of disease and treatment.

A dramatic example of Engel's conception of the biopsychosocial model was a 1971 study of the relation between sudden death and psychological factors. After investigating 170 sudden deaths over about 6 years, he observed that serious illness or even death can be associated with psychological stress or trauma. Among the potential triggering events Engel listed are the following: the death of a close friend, grief, anniversary reactions, loss of self-esteem, personal danger or threat and the letdown after the threat has passed, and reunion or triumphs.

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Table 1-3 Three Functions of the Medical Interview

Functions	Objectives	Skills
I. Determining the nature of the problem	To enable the clinician to establish a diagnosis or recommend further diagnostic procedures, suggest a course of treatment, and predict the nature of the illness	Knowledge base of diseases, disorders, problems, and clinical hypotheses from multiple conceptual domains: biomedical, sociocultural, psychodynamic, and behavioral Ability to elicit data for the above conceptual domains (encouraging the patient to tell his or her story: organizing the flow of the interview, the form of questions, the characterization of symptoms, the mental status examination) Ability to perceive data from multiple sources (history, mental status examination, physician's subjective response to the patient, nonverbal cues, listening at multiple levels) Hypothesis generation and testing Developing a therapeutic relationship (function II)
II. Developing and maintaining a therapeutic relationship	The patient's willingness to provide diagnostic information Relief of physical and psychological distress Willingness to accept a treatment plan or a process of negotiation Patient satisfaction Physician satisfaction	Defining the nature of the relationship Allowing the patient to tell his or her story Hearing, bearing, and tolerating the patient's expression of painful feelings Appropriate and genuine interest, empathy, support, and cognitive understanding Attending to common patient concerns over embarrassment, shame, and humiliation Eliciting the patient's perspective Determining the nature of the problem Communicating information and recommending treatment (function III)
III. Communicating information and implementing a treatment plan	Patient's understanding of the illness Patient's understanding of the suggested diagnostic procedures Patient's understanding of the treatment possibilities Consensus between physician and patient about the above items 1 to 3 Informed consent Improve coping mechanisms Lifestyle changes	Determining the nature of the problem (function I) Developing a therapeutic relationship (function II) Establishing the differences in perspective between physician and patient Educational strategies Clinical negotiations for conflict resolution
Reprinted with permission from Lazare A, Bird J, Lipkin M Jr, Putnam S. Three functions of the medical interview: An integrative conceptual framework. In: Lipkin Jr M, Putnam S, Lazare A, eds. The Medical Interview. New York: Springer; 1989:103.

The patient doctor relationship is a critical component of the biopsychosocial model. Physicians must have both a working knowledge of the patient's medical status and be familiar with how the patient's individual psychology and sociocultural milieu affect the medical condition.

Table 1-4 Predictable Reactions to Illness

Intrapsychic	Clinical
Lowered self image loss grief	Anxiety or depression
Threat to homeostasis fear	Denial or anxiety
Failure of (self) care helplessness, hopelessness	Depression Bargaining and blaming
Sense of loss of control shame (guilt)	Regression Isolation Dependency Anger Acceptance
Courtesy of Mack Lipkin, Jr, M.D.

Spirituality

The role of spirituality and religion in sickness and health has gained ascendancy in recent years, with some suggesting that it become part of the biopsychosocial model. Some evidence suggests that strong religious beliefs, spiritual yearnings, prayer, and devotional acts have positive influences on a person's mental and physical health. These issues are better attended to by theologians than by physicians; however, doctors need to be aware of spirituality in their patients' lives and sensitive to their patients' religious beliefs. In some instances, beliefs can impede medical care, such as the refusal of some religious groups to accept blood transfusions. In most cases, however, when treating patients with strong religious beliefs, the wise physician will welcome the collaboration of the pastoral counselor.

Interviewing Effectively

One of the physician's most important tools is the ability to interview effectively. Through a skilled interview, physicians can gather the data necessary to understand and treat patients

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and, in the process, to increase patients' understanding of, and compliance with, the physicians' advice.

Many factors influence both the content and the process of interviews. Patients' personalities and character styles significantly influence reactions as well as the emotional context in which interviews unfold. Various clinical situations including whether patients are seen on a general hospital ward, on a psychiatric ward, in an emergency room, or as outpatients shape the questions asked and the recommendations offered. Technical factors such as telephone interruptions, the use of an interpreter, note taking, and the patient's illness itself whether in an acute stage or in remission influence the content and process of the interview. Interviewers' styles, experiences, and theoretical orientations also have a significant impact. Even the timing of interjections such as uh huh can influence when patients speak and what they do or do not say as they unconsciously try to follow the subtle leads and cues provided by the doctor.

Beginning the Interview

How a physician begins an interview provides a powerful first impression to patients, which can affect the way the remainder of the interview proceeds. Patients are often anxious on first encounters with physicians and feel both vulnerable and intimidated. A physician who can establish rapport quickly, put the patient at ease, and show respect is well on the way to conducting a productive exchange of information. This exchange is critical to making a correct diagnosis and to establishing treatment goals.

Physicians should initially make sure that they know a patient's name and that the patient knows the physician's name. Physicians should introduce themselves to other people who have come with the patient and should find out if the patient wants another person present during the initial interview. The request for the presence of another person should be granted, but the physician should also attempt to speak with patients privately to determine if there is anything that they want the doctor to know but would be reluctant to say in front of someone else.

Patients have a right to know the position and professional status of persons involved in their care. For example, medical students should introduce themselves as such and not as doctors, and physicians should make it clear whether they are consultants (called in by another physician to see the patient), are covering for another physician, or are involved in the interview to teach students rather than to treat the patient.

After the introductions and other initial assessments have been made, useful and appropriate opening remarks are as follows: Can you tell me about the troubles that bring you in today? or Tell me about the problems you have been having. Following up with a second one such as What other problems have you been experiencing? often elicits information that patients were reluctant to give initially. It also indicates to the patient that the doctor is interested in hearing as much as a patient wants to say.

A less directive approach is to ask a patient Where shall we start? or Where would you prefer to begin? If a patient has been referred by another doctor for consultation, the initial remarks can indicate that the consulting doctor already knows something about the patient. For instance, the consulting doctor might say, Your doctor has told me something about what has been troubling you but I'd like to hear from you in your own words what you've been experiencing.

Most patients do not speak freely unless they have privacy and are sure that their conversations cannot be overheard. Physicians who have attended to such factors as privacy, quiet, and a lack of interruptions before the interview convey to patients that what they say is important and worthy of serious consideration.

Sometimes a patient will appear frightened at the beginning of an interview and may not want to answer questions. If this seems to be the case, the physician may comment on this impression directly in a gentle and supportive way and encourage the patient to talk about his or her feelings about the interview itself. Acknowledging a patient's anxiety is the first step in understanding and reducing it. An example of what could be said is I notice that you seem to be feeling anxious about talking with me. Is there anything I can do or any questions I can answer that will make it easier? or I know it can be frightening to talk to a doctor, especially one you've never met before, but I'd like to make it as comfortable for you as possible. Is there anything you can put your finger on that's making it tough for you to talk with me?

Another important initial question is Why now? A physician should be clear about why a patient has chosen that particular time to ask for help. The reason may be as simple as that it was the first available appointment hour. Very often, however, people seek out doctors as the result of particular events that have increased stress. These stressful events may be thought of as precipitants, and they often contribute significantly to patients' current problems. Examples of stressful precipitants include real or symbolic losses, such as deaths or separations; milestone events (for example, birthdays or anniversaries); and physical changes, such as the presence or intensification of symptoms.

The Interview Proper

In the interview proper, physicians discover in detail what is troubling patients. They must do so in a systematic way that facilitates the identification of relevant problems in the context of an ongoing empathic working alliance with patients.

The content of an interview is literally what is said between doctor and patient: the topics discussed, the subjects mentioned. The process of the interview is what occurs nonverbally between doctor and patient, that is, what is happening in the interview beneath the surface. Process involves feelings and reactions that are unacknowledged or unconscious. Patients may use body language to express feelings they cannot express verbally, for example, a clenched fist or nervous tearing at a tissue by a patient with an apparently calm outward demeanor. Patients may shift the interview away from an anxiety-provoking subject onto a neutral topic without realizing that they are doing so. Patients may return again and again to a particular topic, regardless of what direction the interview appears to be taking. Trivial remarks and apparently casual asides can reveal serious underlying concerns, for example, Oh, by the way, a neighbor of mine tells me that he knows someone with the same symptoms as my son, and that person has cancer.

Specific Techniques

Table 1-5 lists some common interview techniques. Others are discussed below with examples.

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Table 1-5 Common Interview Techniques

Establish rapport as early in the interview as possible.
Determine the patient's chief complaint.
Use the chief complaint to develop a provisional differential diagnosis.
Rule the various diagnostic possibilities out or in by using focused and detailed questions.
Follow up on vague or obscure replies with enough persistence to accurately determine the answer to the question.
Let the patient talk freely enough to observe how tightly the thoughts are connected.
Use a mixture of open-ended and closed-ended questions.
Don't be afraid to ask about topics that you or the patient may find difficult or embarrassing.
Ask about suicidal thoughts.
Give the patient a chance to ask questions at the end of the interview.
Conclude the initial interview by conveying a sense of confidence and, if possible, of hope.

Reprinted with permission from Andreasen NC, Black DW. Introduction Textbook of Psychiatry. Washington, DC: American Psychiatric Association, 1991.

Open-Ended Versus Closed-Ended Questions

Interviewing any patient involves a fine balance between allowing the patient's story to unfold at will and obtaining the necessary data for diagnosis and treatment. Most experts agree that an ideal interview begins with broad, open-ended questioning, continues by becoming specific, and closes with detailed direct questioning.

An example of an open-ended question is Can you tell me more about that? A closed-ended question would be How long have you been taking the medication? Closed-ended questions can be effective in generating specific and quick responses about a clearly delineated topic. Closed-ended questions have also been found effective in assessing such factors as the presence or absence, frequency, severity, and duration of symptoms. Table 1-6 summarizes some of the pros and cons of open- and closed-ended questions.

Reflection

In the technique of reflection, a doctor repeats to a patient, in a supportive manner, something that the patient has said. The goal of reflection is twofold: to assure the doctor that he or she has correctly understood what the patient is trying to say and to let the patient know that the doctor is perceiving what is being said. The response is meant to let the patient know that the doctor is both listening to the patient's concerns and understanding them. For example, if a patient is speaking about fears of dying and the effects of talking about these fears with his or her family, the doctor might say, It seems that you are concerned with becoming a burden to your family. This reflection is not an exact repetition of what the patient has said, but rather a paraphrase that indicates the doctor has perceived the essential meaning.

Table 1-6 Pros and Cons of Open-Ended and Closed-Ended Questions

Aspect	Broad, Open-Ended Questions	Narrow, Closed-Ended Questions
Genuineness	High They produce spontaneous formulations.	Low They lead the patient.
Reliability	Low They may lead to nonreproducible answers.	High Narrow focus, but they may suggest answers.
Precision	Low Intent of question is vague.	High Intent of question is clear.
Time efficiency	Low Circumstantial elaborations.	High May invite yes or no answers.
Completeness of diagnostic coverage	Low Patient selects topic.	High Interviewer selects topic.
Acceptance by patient	Varies Most patients prefer expressing themselves freely; others feel guarded and insecure.	Varies Some patients enjoy clear-cut checks; others hate to be pressed into a yes or no format.
Reprinted with permission from Othmer E, Othmer SC. The Clinical Interview Using DSM-IV. Washington, DC: American Psychiatric Press; 1994.

Facilitation

Doctors help patients continue in the interview by providing both verbal and nonverbal cues that encourage patients to keep talking. Nodding one's head, leaning forward in the chair, and saying, Yes, and then ? or Uh-huh, go on, are all examples of facilitation.

Silence

Silence can be used in many ways in normal conversations, even to indicate disapproval or disinterest. In the doctor patient relationship, however, silence can be constructive and, in certain situations, allow patients to contemplate, to cry, or just to sit in an accepting, supportive environment in which the doctor makes it clear that not every moment must be filled with talk.

Confrontation

The technique of confrontation is meant to point out to a patient something to which the doctor thinks the patient is not paying attention, is missing, or is in some way denying. The confrontation is meant to help patients face whatever needs to be faced in a direct but respectful way. For example, a patient who has just made a suicidal gesture but is telling the doctor that it was not serious may be confronted with the following statement: What you have done may not have killed you, but it's telling me that you are in serious trouble right now and that you need help so that you don't try suicide again.

Clarification

In clarification, doctors attempt to get details from patients about what they have already said. For example, a doctor may say, You are feeling depressed. When do you feel most depressed?

Interpretation

The technique of interpretation is most often used when a doctor states something about a patient's behavior or thinking of which the patient may not be aware. The technique requires the doctor's careful listening for underlying themes and patterns in the patient's story. Interpretations usually help clarify interrelationships that the patient may not see. It is a sophisticated technique and should generally be used only after the doctor has established some rapport with the patient and has a reasonably good idea of what some interrelationships are. For example, a doctor may say, When you talk about how angry you are that your family has not been supportive, I think you're also telling me how worried you are that I won't be there for you either. What do you think?

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Summation

Periodically during the interview, a doctor can take a moment and briefly summarize what a patient has said thus far. Doing so assures both the patient and doctor that the doctor has heard the same information that the patient has actually conveyed. For example, the doctor may say, OK, I just want to make sure that I've got everything right up to this point.

Explanation

Doctors explain treatment plans to patients in easily understandable language and allow patients to respond and ask questions. For example, a doctor may say, It is essential that you come into the hospital now because of the seriousness of your condition. You will be admitted tonight through the emergency room, and I will be there to make all the arrangements. You will be given a small dose of medication that will make you sleepy. The medication is called lorazepam, and the dose you will be getting is 0.25 mg. I will see you again first thing in the morning, and we'll go over all the procedures that will be required before anything else happens. Now, what are your questions? I know you must have some. Note that when prescribing medication, the patient should be advised of common adverse effects.

Transition

The technique of transition allows doctors to convey the idea that sufficient information has been obtained on one subject; the doctor's words encourage patients to continue on to another subject. For example, a doctor may say, You've given me a good sense of that particular time in your life. Perhaps now you could tell me a bit more about an even earlier time in your life.

Self-Revelation

Limited, discreet self-disclosure by physicians may be useful in certain situations if physicians feel at ease and can communicate a sense of self-comfort. Conveying this sense may involve answering a patient's questions about whether a physician is married and where he or she comes from. A doctor who practices self-revelation excessively, however, is using a patient to gratify unfulfilled needs in his or her own life and is abusing the role of physician. If a doctor thinks that a piece of information will help a particular patient be more comfortable, the doctor can decide to be self-revealing. The decision depends on whether the information will further a patient's care or if it will provide nothing useful. Even if the doctor decides that self-revelation is not warranted, he or she should be careful not to make the patient feel embarrassed for asking a question. For example, the doctor may say, I will be happy to tell you whether or not I am married, but first let's talk a little about why it is important for you to know that. If we talk about it, I'll have a bit more information about who you are and what your concerns are regarding me and my involvement in your care. Do not take patients' questions at face value alone. Many questions, especially personal ones, convey not just natural curiosity but also hidden concerns about the doctor that should not be ignored.

Positive Reinforcement

The technique of positive reinforcement allows patients to feel comfortable telling a doctor anything, even about such things as noncompliance with treatment. Encouraging a patient to feel that the doctor is not upset by whatever the patient has to say facilitates an open exchange. For example, a doctor might say, I appreciate your telling me that you have stopped taking your medication. Can you tell me what the problem was? An experienced psychiatrist, in response to patients who were afraid of revealing shocking material in the initial interview, may respond in the following manner: After all these years in practice I don't think I have heard anything that could shock me. The implied acceptance of all things human usually puts patients at ease.

Reassurance

Truthful reassurance of a patient can lead to increased trust and compliance and can be experienced as an empathic response of a concerned physician. False reassurance, however, is essentially lying to a patient and can badly impair the patient's trust and compliance. False reassurance is often given from a desire to make a patient feel better, but once a patient knows that a doctor has not told the truth, the patient is unlikely to accept or believe truthful reassurance. In an example of false reassurance, a patient with a terminal illness asks, Am I going to be all right, Doctor? and the doctor responds, Of course you're going to be all right. Everything's fine. An example of truthful reassurance is I'm going to do everything possible to make you comfortable, and part of being comfortable is for you to know as much as I know about what is going on with you. We both know that what you have is serious. I'd like to know exactly what you think is happening to you and to clarify any questions you have. The patient may then be able to talk openly about his or her fear of dying.

Advice

In many situations it is not only acceptable but desirable for doctors to give patients advice. To be effective and to be perceived as empathic rather than inappropriate or intrusive, the advice should be given only after patients are allowed to talk freely about their problems so that physicians have an adequate information base from which to make suggestions. At times, after a doctor has listened carefully to a patient, it becomes clear that the patient does not, in fact, want advice as much as an objective, caring, nonjudgmental ear. Giving advice too quickly can lead a patient to feel that the doctor is not really listening but, rather, is responding, either out of anxiety or from the belief that the doctor inherently knows better than the patient what should be done in a particular situation. In an example of advice given too quickly, a patient says, I can't take this medication. It's bothering me, and the physician responds, Fine. I think you should stop taking it, and I'll prescribe something different. A more appropriate response is I'm sorry to hear that. Tell me what about the medication has been bothering you, and I'll have a better idea what we should do to make you more comfortable. In another example, the patient says, I've really been feeling down lately, and the doctor replies, Well in that case, I think it's important that you go out and do some things that are fun, such as going to a movie or taking a walk in the park. In this case, a more appropriate and helpful response could be Tell me more about what you mean by feeling down .

Ending the Interview

Physicians want patients to leave an interview feeling understood and respected and believing that all the pertinent and important information has been conveyed to an informed, empathic listener. To this end, doctors should give patients a chance to ask questions and should let patients know as much as possible about future plans. Doctors should thank patients for sharing the necessary information and let patients know that the information conveyed has been helpful in clarifying the next steps. Any prescription of medication should be spelled out clearly and simply, and doctors should ascertain whether patients understand the prescription and how to take it. Doctors should make another appointment or give a referral and some indication about how patients can reach help quickly if it is necessary before the next appointment.

Specific Issues in Psychiatry

Fees

Before clinicians can establish an ongoing relationship with patients, they must address certain issues. For instance, they must openly discuss payment of fees. Discussing these issues and any other questions about fees from the beginning of the relationship can minimize misunderstanding later. Most patients have medical insurance through health maintenance organizations (HMOs) or Medicare. HMOs pay for doctors' visits in whole or in part, but only if the doctor is a member (or provider) in the patient's plan. Some plans (called point of service plans) offer partial payments even if the doctor is not a member (i.e., he or she is called out-of-network ). That should be clarified; otherwise, the patient may have to pay out-of-pocket, which he or she may be unwilling or unable to do.

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Confidentiality

Psychiatrists and mental health professionals should discuss the extent and limitations of confidentiality with patients, so that patients are clear about what can and cannot remain confidential. As much as physicians must legally and ethically respect patients' confidentiality, it may be wholly or partially broken in some specific situations. For example, if a patient makes clear that he or she intends to harm someone, the doctor has a responsibility to notify the intended victim. Other issues related to confidentiality include who has access to the patient's medical record, information required by insurance companies (which may be extensive), and the degree to which the patient's case will be used for teaching purposes. In all such situations, the patient must give permission for the use of medical records. (See Chapter 58 for a discussion of confidentiality.)

Supervision

It is both commonplace and necessary for doctors in training to receive supervision from experienced physicians. This practice is the norm in large teaching hospitals, and most patients are aware of it. When young doctors are receiving supervision from senior physicians, patients should know from the beginning. Informing patients is particularly important in psychiatry, in which the supervision of individual psychotherapy cases is a routine and established practice and in which the psychiatric resident is required to present verbatim accounts of an entire therapy session (process notes) to a senior supervisor. If a patient is curious about the level of the treating doctor's experience, the doctor or medical student should respond honestly and not mislead the patient. If the doctor is less than truthful and the patient later discovers this, the relationship between doctor and patient may become untenable.

Missed Appointments and Length of Sessions

Patients need to be informed about a doctor's policies for missed appointments and length of sessions. Psychiatrists generally see patients in regularly scheduled blocks of time ranging from 15 to 45 minutes. At the end of this time, psychiatrists expect patients to accept the fact that the session is over. Nonpsychiatric physicians may schedule somewhat differently, by putting aside 30 minutes to an hour for an initial visit and then perhaps scheduling patient visits every 15 to 20 minutes for follow-up appointments. Psychiatrists who are treating psychotic inpatients may determine that a patient cannot tolerate a lengthy session and may decide to see the patient in a series of 10-minute sessions throughout the week. Whatever the policies, patients must be made aware of them to prevent misunderstandings.

The same can be said about policies for missed appointments. Some doctors ask patients to give 24 hours' notice to avoid being billed for a missed session. Others bill for missed sessions regardless of advance notification. Still others decide on a case-by-case basis or perhaps state a 24-hour rule, but make exceptions when warranted. Some doctors state that if they receive advance notice and can fill the appointment time, they will not charge for missed sessions; others do not charge for missed appointments at all. The choice is up to the individual physician, but patients must know in advance to make an informed decision about whether to accept the doctor's policy or to choose another doctor.

Availability of Doctor

What are a doctor's obligations to be available between scheduled appointments? Is it incumbent on physicians to be available 24 hours a day? Once a patient enters into a contract to receive care from a particular physician, the doctor is responsible for having a mechanism in place for providing emergency service outside scheduled appointment times. Patients should be told what the mechanism is, whether it is an emergency phone number or a covering physician. If the physician is going to be away for a period of time, coverage by another physician is necessary, and patients must be informed how to reach the covering doctor. They should know that their doctor will be available between appointments to answer pressing questions and that extra appointments can be scheduled if necessary.

Within these general parameters, however, physicians must make their own decisions about their availability to specific patients. In some cases, doctors may have to place firm limits on availability between sessions. For instance, patients who repeatedly call at all hours with concerns that are best addressed during scheduled appointments should be respectfully but firmly discouraged from calling unnecessarily. They can be reassured that all concerns will be addressed and if insufficient time exists during the regular appointment, another appointment can be made, but they should be told that all nonemergency concerns will be postponed until the next session.

Follow-Up

Many events can disrupt the continuity of the patient doctor relationship. Some of these events are routine, such as residents ending their training and moving on to another hospital; others are out of the ordinary and thus unpredictable, for example, when physicians become ill and can no longer take care of their patients. Patients must be assured that regardless of what occurs in the course of a particular patient doctor relationship, their care will be ongoing.

A complex situation arises when physicians become ill and are unable to continue caring for patients. When they know in advance that they will have to interrupt therapy, clear arrangements for referral to other doctors can be made. Although arguments exist both for and against physicians revealing their illnesses to patients, it seems best to err on the side of truth. The information should be conveyed in as calm and nonthreatening a way as possible. The reason for telling the truth is that patients will fantasize reasons about why the doctor has stopped seeing them and may fear that something about them has made the doctor leave. Untruthfulness in this situation also encourages the view that being ill is shameful or frightening. It is not the role of patients, however, to take care of their doctors; informing patients should not carry with it any sense that a doctor's illness is a patient's burden.

Qualities of the Physician

Physicians are drawn to the field of medicine for many reasons. These include a desire to help people, to cure illness, to

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be part of a respected profession or to hold a position of authority, and to exert some control over life and death. Many people who choose to become physicians are perfectionistic, demanding of themselves, and attentive to details. These qualities can be adaptive in fact, are probably necessary but need to be balanced with healthy doses of self-knowledge, humility, humor, and kindness. William Osler, M.D. (1814 1919), physician and teacher, discussed the characteristics and quality of the physician in his book Aequanimitas, which are summarized in Table 1-7. They are ideals to be strived for, but they are rarely reached. Physicians (and other health care providers) must be tolerant about the limits on what they can realistically and honestly accomplish.

Table 1-7 Character and Qualities of the Physician*

Imperturbability	The ability to maintain extreme calm and steadiness
Presence of mind	Self-control in an emergency or embarrassing situation so that one can say or do the right thing
Clear judgment	The ability to make an informed opinion that is intelligible and free of ambiguity
Ability to endure frustration	The capacity to remain firm and deal with insecurity and dissatisfaction
Infinite patience	The unlimited ability to hear pain or trial calmly
Charity toward others	To be generous and helpful, especially toward the needy and suffering
The search for absolute truth	To investigate facts and pursue reality
Composure	Calmness of mind, bearing, and appearance
Bravery	The capacity to face or endure events with courage
Tenacity	To be persistent in attaining a goal or adhering to something valued
Idealism	Forming standards and ideals and living under their influence
Equanimity	The ability to handle stressful situations with an undisturbed, even temper
*After William Osler, M.D.

The demands on a physician can be daunting. In addition to the vast amount of knowledge and the skills required to practice medicine, the doctor must also develop the capacity of balancing compassionate concern with dispassionate objectivity, the wish to relieve pain with the ability to make painful decisions, and the desire to cure and control with an acceptance of one's human limitations. The lack of these capacities can lead a physician to feel overwhelmed and depressed. Learning to balance these interrelated aspects of the physician's role allows the doctor to cope productively within daily work that involves illness, pain, sadness, suffering, and death.

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