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Approach to the patient

Authors: Jeannette M Shorey, II, MD, John J Spollen, III, MD

Section Editor: Mark D Aronson, MD
Deputy Editor: Judith A Melin, MA, MD, FACP

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2018. | This topic last updated: Jun 15, 2018.

INTRODUCTION — People seek medical services for many different reasons. Medical care for acute or chronic
conditions is the principal reason, but patients also request clinicians' advice about maintaining their health, good
nutrition, exercise programs, and other strategies to prevent disease. Near the end of life, patients may seek
clinicians' advice on withdrawing from cure-oriented interventions, emphasizing the need for comfort and control
of symptoms instead. Finally, people come to clinicians for their role as "social managers," seeking assistance in
accessing social goods and services (eg, disability benefits, housing benefits, workers' compensation,
"permission" to return to work, and clearance to participate in athletic activities). Responding to such diverse
needs and requests is a substantial challenge.

As we consider the approach to the "patient," we will focus upon the knowledge, skills, and values that foster
effective professional connections with the people who enter clinicians' offices seeking care, some of whom may
be sick patients. This topic provides an overview of the approach to the patient, for the satisfaction of the patient
and the clinician.

ESSENTIAL TASKS OF THE CONTEMPORARY CLINICIAN — There are six essential tasks of the
contemporary clinician (table 1).

● Knowledge base and personal strategies to keep up – Today's clinicians have at their disposal a vast
and rapidly-growing body of biomedical and psychosocial knowledge. The understanding and appropriate
application of this knowledge is a foundation for effective medical care. Two principal tasks of clinicians are
to master the knowledge pertinent to their field of medicine and to develop personal strategies to learn
continuously and manage the enormous body of information that will continue to evolve throughout their
careers [1].

● Connecting with patients – The appropriate application of biomedical and psychosocial knowledge
requires a contextual understanding of each individual who seeks medical care. This in turn requires the
ability to communicate effectively with each patient, mindful of the importance of the person's cultural
background. Unfortunately, improvements in communication between clinicians and patients, which would
require designated time prioritized to effectively interview patients and understand their needs, has not kept
pace with technological advances in medicine [2]. Clinicians must build and sustain trustworthy relationships
in order to hear and grasp patient concerns, elicit their requests, negotiate diagnostic and treatment
strategies, teach them about their health or illness, check on adherence to treatment plans, and assess the
outcomes of interventions. Thus, the third principal task of clinicians is to heed the admonition of E.M.
Forster: "always connect" [3].
● Maximizing cost-effectiveness – Societies can rightly demand that the medical profession provide its
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potentially avoidable, and would not negatively affect quality of care if eliminated [4]. Numerous
organizational models of health care delivery aim to take advantage of economies of scale and integration.
Many provide great opportunities to improve the health of individuals and of populations by better
coordination of all aspects of medical care and by assessing and responding to each individual's health
risks. The need for connection between patient and a specific clinician remains strong, whatever the
organizational structure of care delivery. In one study of patients receiving primary care among 13 practices,
the most important determinant of whether a patient received appropriate preventive health measures was
whether they were connected to a specific clinician rather than to just a clinic [5].

● Understanding the system – Clinicians must understand the "systems" in which and with which they
practice medicine; practice in ways that demonstrate accountability for both the quality and the cost of the
care they provide; and teach their patients how to use these systems effectively (table 1). These three
essential tasks are new competencies for clinicians. Clinicians have been slow to recognize the importance
of understanding the structures, forces, incentives, and dynamic equilibria of the organizations in which they
work. Systems thinking is central to the provision of high-quality care by large networks of providers. It
involves philosophical appreciation that clinicians do not work alone for their patients, but rather in teams. It
also requires procedural knowledge of "how to get things done in this system" and a capacity to collaborate
with other stakeholders to bring about systems change where there are impediments to effective care.

Effective systems thinking about medical care requires understanding the human, technological, and
financial resources available within the system and an ethic surrounding resource distribution. Inherent in
ethical systems of health care delivery is accountability both for the quality of the care delivered to
individuals and for the cost of the care, assuring appropriate distribution of resources to all persons within
the population served by the system. Any system is only as strong as its weakest component (technological,
informational, financial, or human). Hence, good systems thinking also appreciates that the functioning and
the outputs of the system must be continuously monitored and improved.

A crucial component of the health care system is the people who work in it. Changes in health care delivery
are increasing the importance of interprofessional communication and collaboration. Clinicians join allied
health providers (eg, nurses, pharmacists, clinician assistants, occupational and physical therapists, social
workers, case managers, medical assistants, clinical support staff) and administrators on teams to assure
that services are tailored to meet individual health care needs effectively and efficiently. This requires that
everyone on the team appreciates each other's roles, abilities, and limitations, that everyone appreciates the
extent of resources available to care for the patient, and that good mechanisms of communication effectively
link team members. Good communications are enhanced when team members create real professional
relationships that extend well beyond the exchange of order forms and consultation reports. The size and
complexity of teams will vary with the needs of different patient populations and practice sites. Some may be
"virtual teams," connected electronically. It is probable that even on these teams, effectiveness and
accountability is greatly enhanced when personal relationships lie behind the electronic exchanges.

● Educating and supporting patients in the optimal use of the system – Responsible stewardship for
health care resources in large health care delivery systems is not simply a matter of producing services at
the least cost. Stewardship requires that human relationships be highly valued in all choices. It is within
individual human relationships that patients can feel sufficient safety and trust to disclose their fears,
symptoms, concerns, and preferences about their health. Creating these relationships, wherein patients feel
heard, acknowledged, and understood, can be healing in itself. Furthermore, individual relationships foster
professional satisfaction and pride for members of the health care team. All relationships matter, including
clinician-patient, patient-unit secretary, primary care clinician-subspecialty consultant, patient-case manager,
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Clinicians must recognize the importance of managing the care of patients within a system so as to
maximize quality and cost-effectiveness of the care delivered to their patients. A substantial portion of a
patient's confidence in his/her clinician will depend upon the clinician's skill and capacity to access and
unfold the best aspects of the system for the patient.

The trust forged in the initial clinician-patient relationship is often the key to a patient's willingness to
participate in, and benefit from, care provided by members of a clinical team other than the clinician.
Willingness to forego unnecessary and costly medical services is only present within a trusting clinician-
patient relationship. In the final analysis, all systems of care are founded upon the capacity of the clinician to
establish and sustain an effective relationship, first created in the context of a clinical visit.

The clinician has numerous tasks during the patient visit (table 2). This extensive work needs to be accomplished
with every patient but fortunately not on every visit. The abstract list comes to life when it is appreciated as the
work performed in a skillfully guided conversation, or series of conversations, between two people within a
professional relationship. It is colored by the feelings and life experiences of both parties [6]. The methods
applied must be tailored to the situation at hand, differing somewhat in the emergency department, consultant's
office, and primary care office. In all settings, however, there are some consistent truths about medical
encounters: all people are anxious to some extent when they come to see a clinician; all people desire and
deserve to be treated with respect; all people want to be heard and understood by their clinicians; and almost all
people expect to be professionally touched by their clinicians.

FUNCTIONS OF THE MEDICAL INTERVIEW — The medical interview is the medium through which the
patient’s needs and requests are made known, the human connections are established, and almost all the work
of doctoring is conducted. Many diagnoses can be made based on the patient’s history alone [7].

Three functions of the medical interview have been identified (table 3) [8,9]:

● Data-gathering

● Relationship-building

● Patient education

The three functions of the interview are interwoven throughout the dialogue of the clinician and patient.

Data-gathering — Data-gathering enables the clinician to establish a diagnosis or recommend further diagnostic
procedures, suggest courses of treatment, and predict the nature of the illness. The tasks of this function are to:

● Acquire the appropriate knowledge base of diseases and disorders

● Acquire the knowledge base of psychosocial issues that contribute to the patient's illness behavior

● Bring the data that have been elicited into focus

● Generate and test multiple hypotheses during the course of the interview

The verbal skills that facilitate accomplishing these tasks include asking open-ended questions (and waiting for
the answers); active listening; making facilitative utterances ("uh-huh, tell me more… yes… go on…"); making
orienting remarks ("I will ask you about x, and then we will do y…"); asking focusing questions when needed
("Where was the pain? What made it worse?"); eliciting and prioritizing the patient's agenda for the visit ("What
should we be certain to get done today?"); checking for understanding; and summarizing what the clinician has
heard ("Let me be sure I have this right. You felt fine until you started shoveling snow, then you felt dizzy and
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The nonverbal skills that facilitate good data collection start with "clearing the clinician's mental and physical
slate" before entering the room with the patient. Important and often neglected nonverbal skills also include being
aware of and consciously shaping how the clinician's appearance, body language, voice qualities (eg, tone,
volume, pace), and the spatial arrangements of furniture and people in the room affect the interactions (table 5).
As health care providers increasingly use electronic medical records (EMRs), they must master the skills needed
to use the computer to assist effective data-gathering and -sharing and the skills needed to avoid allowing the
computer to become a barrier between the patient and the provider (figure 1).

Relationship-building — Relationship-building seeks to ensure the patient's willingness to provide diagnostic

and other important information, to relieve the patient's physical and psychosocial distress, to ensure the
patient's willingness to accept the treatment plan or a process of negotiation, and to ensure both the patient's
and clinician's satisfaction with work well-done. The tasks of this function are to:

● Define the nature of the relationship

● Communicate professional expertise

● Communicate interest, respect, support, and empathy

● Recognize and resolve various relational barriers to patient/clinician communication

● Elicit the patient's perspective

The skills of effective relationship building are both verbal and nonverbal. The power and importance of
nonverbal communication cannot be overstated. Consider, for example, the effect of nonverbal empathy when
the clinician gently touches the shoulder of the newly widowed woman. All behavior is communication. Patients
are reading nonverbal messages from clinicians consciously or unconsciously throughout each visit [10]. Does
the clinician lean towards or away from the patient? Is there appropriate eye contact and head nodding to
indicate listening? The clinician and patient assess whether the unspoken messages match the words. When
they match, the veracity of the words is likely. A mismatch suggests need for some explicit checking (eg, patient
says "OK, I'll fill the prescription" but looks absently out the window). The skillful clinician is consciously
monitoring and controlling his/her own nonverbal messages to the patient while reading the nonverbal
communication from the patient.

The skillful clinician is also evaluating his/her own thoughts and emotions and how these affect verbal and
nonverbal responses to the patient and even influence clinical judgment. Is a growing sense of irritation in the
clinician during an interview related to actions of the patient, or unrelated issues (eg, that second cup of coffee,
air conditioning problems, or a disagreement at home the previous night?). Awareness of the effects of our own
mental processes on our relationships with patients is often referred to as "mindful practice" and has been
described as "cultivation of the observing self in the midst of the complexity and chaos of everyday work" [11].
Through mindful practice, clinicians improve their attention and ability to sense subtleties, reduce bias and
premature categorization, and enhance openness to new ideas and actions.

The appropriate use of language is also a crucial aspect of relationship building. Both what is said and how it is
said are important. Verbal relationship building skills include statements of partnership, empathy, apology,
respect, legitimation, and support (PEARLS) (table 6). Empathy is most easily conveyed by the use of reflection.
Communication of understanding of emotion through reflective statements such as "that was tough for you" or
even "gosh!" can deepen the therapeutic relationship and improve patient satisfaction [12]. Legitimation refers to
voicing acceptance or validation of the emotions or reactions of the patient [13]. A simple "I'd be upset by that
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Patient education — Patient education seeks to ensure the patient's understanding of the illness, to suggest
diagnostic procedures and treatment possibilities, to foster consensus between clinician and patient, and to
create a firm foundation for informed consent, improved coping mechanisms, and the promotion of healthy
lifestyle change. Providing appropriate patient education to foster consensus and allow full informed consent is
one way that clinicians show respect for their patients [14].

The tasks of this function are to:

● Determine the areas of differences (potential conflict) between the clinician and patient, and promote
negotiation to resolve the differences

● Communicate about the diagnostic significance of the problem(s)

● Recommend the appropriate diagnostic procedures and treatment, including appropriate preventive
measures and lifestyle changes

● Enhance coping ability by understanding and working with the social and psychosocial consequences of the
disease and treatment

The skills of patient education involve asking questions to discover what the patient knows about the illness, how
s/he feels about it, what s/he believes about it, what meanings s/he attaches to it, and what s/he expects to
happen because of the illness and/or its treatment. The two keys to successful patient education are the use of
comprehensible language and avoidance of "too much, too soon, too fast."

The skillful clinician's questions probe the patient's "need to know" in each of these areas. S/he then calibrates
responses in both content and tone to exactly what the patient wants to know. If the clinician senses resistance
to learning about something that is important from her/his perspective, this resistance must be explored.
Invariably, such an exploration will uncover important patient concerns, fears, prior adverse experience, or
serious misunderstanding of what the clinician is saying. In summary, the content of effective patient education
rests upon the clinician's knowledge, but that is not enough. Its implementation requires an open, trusting
clinician-patient relationship. Patient education is best accomplished in a true conversation between clinician and
patient, not through a clinician monologue (table 7).

EFFECTIVE CLINICIAN STRATEGIES — Four general categories of clinician behaviors lead to effective patient
care (table 8) [15,16]:

● Cognitive strategies (knowledge-related)

● Affective strategies (emotion-related)

● Behavioral change strategies

● Social strategies (invoking group mechanisms beyond the individual)

Cognitive strategies — The effective clinician negotiates patient priorities and expectations explicitly at the
beginning of the relationship, as well as at subsequent critical junctures of decision making. S/he gives a
complete explanation of the patient's condition and treatment options, encouraging questions that expand the
patient's understanding. Through this dialogue, the clinician brings the patient to a "decision crossroads" at which
s/he is ready to make informed choices about treatment. The clinician also educates the patient about difficulties
s/he might have with her/his condition or its management, and offers a prognosis of what may be expected to
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Cognitive strategies that the cost-conscious clinician employs prior to recommending specific diagnostic testing
or treatments include asking the questions: Why order this test or treatment? What makes it appropriate and
cost-effective in this patient's care? What will I do with the test results? Will the test results affect my
management of this patient's care? [17].

Affective strategies — The effective clinician conveys his/her genuine empathy for the patient in many ways.
These include facilitating full expression of the emotional content of the patient's experience, providing
encouragement and reassurance when needed and suitable, touching the patient appropriately; and taking
actions that sustain hope. The clinician also facilitates patient self-forgiveness, in anticipation of or after failure in
the face of a challenge.

Behavioral change strategies — The effective clinician discovers a patient's readiness to change any particular
unhealthy behavior. One group has described stages of behavior change as precontemplation, contemplation,
preparation, action, and then either maintenance of the new, healthier behavior or relapse into the old, unhealthy
behavior [18]. Understanding the patient's readiness to change and then matching the clinician's strategy to that
stage may lead to successful change efforts.

Patients in precontemplation may need to hear clearly from the clinician that the behavior is likely to have
unhealthy consequences. Others may be aware of the consequences but need a supportive and nonjudgmental
atmosphere in which to wrestle with their ambivalence about behavior change.

Patients in contemplation often need help from the clinician to explore the pros and cons of continuing versus
stopping the unhealthy behavior. Exploring the pros of the unhealthy behavior (eg "What do you like about
smoking?") as an initial step can often reduce defensiveness and open conversation. Reviewing past attempts at
change may be helpful. Emphasis should be placed on past successes ("You were able to quit for an entire
week!"), leading to increased self-efficacy and hope.

Patients in preparation may need the clinician's help in planning a specific behavior change strategy, and
patients in action may benefit from the prescription of specific treatments that can support the change (eg,
alternative nicotine delivery systems to aid in smoking cessation). The clinician must explain clearly the goals of
any specific treatment and the means of achieving them, emphasizing the benefits and necessity of the patient's
active participation in the program of care. S/he provides regular, positive feedback for patient adherence to the
program and, when needed, suggests alternative courses if the original path proves impossible.

Motivational Interviewing is a patient counseling method for encouraging behavioral changes to improve health
outcomes [19]. While motivational interviewing is most associated with substance use disorders (see
"Motivational interviewing for substance use disorders"), and is often used in counseling patients regarding
alcohol and tobacco use, meta-analyses have indicated effectiveness in medical care settings for a range of
important outcome measures including blood pressure [20], cholesterol level, sedentary behavior, body weight,
HIV viral load, patient confidence, intention to change, engagement in treatment, and even death rate [21].
Combining the active ingredients of a supportive relationship and a conversation that promotes positive change
statements, motivational interviewing may be a useful strategy for a number of common problems.

Social strategies — In all of these activities, when appropriate, the effective clinician employs social group
strategies to improve health outcomes. These include obtaining permission from the patient to inform and involve
family members in the patient's care, as well as collaboration with appropriate community organizations. The
clinician explicitly creates coherent teamwork for patient care, sharing information about his/her own care
activities with other members of the health professions team.
The first decades of the 21st century are seeing social strategies to improve health and healthcare adopted as a
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family members into the administrative
decision-making practices of hospitals and office practices. Patients and family members offer their insights into
how health care delivery can be made more "user-friendly" and efficient. The four core concepts of patient- and
family-centered care are [22]:

● Dignity and Respect – Listen to and honor patient and family perspectives and choices

● Information Sharing – Communicate and share complete information with patients and families in ways that
are affirming and useful

● Participation – Patients and families are encouraged and supported in participating in care and decision
making at the level they choose

● Collaboration – Patients, families, and health care practitioners and leaders collaborate in policy and
program development, implementation and evaluation, facility design, and professional education as well as
in delivery of care

The potential for patient- and family-centered care to improve patient safety and satisfaction, the cost of care,
and provider satisfaction is substantial and is becoming an important research topic.

DESIRABLE CLINICIAN BEHAVIORS — Patients' descriptions of desirable clinician behaviors can be grouped
into three major dimensions (table 9) [23,24]:

● Behaviors expected of clinicians because they are professionals

● Clinician behaviors understood by patients to be respectful

● Clinician behaviors understood by patients to be supportive

Patients expect clinicians to groom and dress appropriately, minimize frustrations from prior visits with other
patients that carry over into subsequent visits, be punctual, treat them like an equal, engage in the courteous
behaviors expected among equals (eg, shaking hands, calling patients by the names they prefer, sitting down
with them, etc), and engage in activities that establish a relaxed atmosphere in spite of patients' anxiety. These
help to get the visit off to the right start.

Clinicians should prepare in advance for the visit, minimize interruptions during the visit (eg, unnecessary phone
use), listen actively and seek to understand fully the patient's illness history, explain elements of the physical
examination as it proceeds, take all the patient's complaints seriously even if they are not medically plausible,
and express concern for the effects of the illness in the patient's daily life. Critical professional behaviors when
talking about a diagnosis and its possible therapy include clear and complete explanations of the problem and
treatment, and the clinician's knowing his/her own limitations, referring when necessary for consultation.

Respectful clinician behaviors when talking about a problem and its treatment include involving the patient in
making treatment choices and being honest under all circumstances. Supportive actions on the part of the
clinician include taking time to talk no matter how busy and encouraging patient and family questions. In follow-
up activities, the clinician provides the patient with ready access to care, including cross-coverage when s/he is
away, and follows through on all promises made to the patient. The respectful clinician involves the patient in
management and is conscious of the financial implications of the patient's illness. Finally, the supportive clinician
remains active in helping patients throughout the process by connecting them with additional resources, being
available between appointments, and, when possible and appropriate, checking on them at home.
The overarching task for clinicians is to appreciate and act upon patient preferences for better integrated
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one: stay in close touch with the clinician's own
humanity, no matter how harried the day, and to connect with the patient. The growing prevalence of burnout
among physicians may add difficulty to being emotionally present in the moment with patients [25]. When
burnout is recognized as a problem, specific interventions, especially those that are organizationally directed,
have shown important benefits [26].

This behavioral task of making a good connection with each patient must be realistically considered within the
context of time-limited office and hospital visits. Research demonstrates that expressly attending to affect-loaded
problems can in fact improve efficiency as well as improve patient and provider satisfaction [27]. Approaches that
have been proven to save time include allowing patients to offer and finish their opening statements, negotiating
a consensually prioritized agenda for the visit, responding to patients' reactions and concerns with empathy, and
offering patients orientation to the events of the visit [28].

The "Four Habits Approach" to clinical communication provides a useful and well-validated summary of clinician
behaviors during a medical visit that have proven to be effective for both the patient and clinician (table 10) [29].

PROFESSIONAL VALUES — Dr. Francis W. Peabody's often-quoted address on "The Care of the Patient"
speaks eloquently to the value of clinicians' respect for humanity and the value of the clinician-patient
relationship to treatment itself. "The significance of the intimate personal relationship between clinician and
patient cannot be too strongly emphasized, for in an extraordinarily large number of cases both the diagnosis
and the treatment are directly dependent on it. One of the essential qualities of the clinician is interest in
humanity, for the secret of the care of the patient is caring for the patient" [30,31]. Carl Rogers studied and taught
about the beneficial outcomes for learning and health that result from approaching a learner/patient with
unconditional positive regard [32].

The American Board of Internal Medicine has placed increasing importance on humanistic qualities as it
considers candidates for its examination. It requires program directors to evaluate residents' personal integrity
and their respect and compassion for patients. The Pew-Fetzer Task Force on Advancing Psychosocial Health
Education carefully considers areas of knowledge, skills, and values that support effective patient-practitioner
relationships (table 11) [33]. They emphasize the following values: importance of self-awareness, self-care, and
self-growth; appreciation of the patient's life story and the meaning of the health-illness condition; respect for the
patient's dignity, uniqueness, and integrity (mind-body-spirit unity); respect for self-determination; respect for a
person's own power and self-healing processes; and the importance of being open and nonjudgmental.

In addition to the above observations, we would highlight the importance of ascribing value to several other
features of clinician-patient interactions:

● Clinical curiosity

● Attention to decision-making preferences

● Attention to cultural issues

● Attention to accountability

● Attention to professionalism

Clinical curiosity — Respectful curiosity about the person in front of you and about medicine brings energy,
vitality, salience, and meaningfulness to medical visits. It is healthy for the encounter and critically important to
the sustenance of the clinician's dedication to his/her work.
Explicit attention to decision-making preferences — Patients vary in the degree to which they want to share
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which decision-making is shared, and the operative behavior must be to check explicitly about that preference.

Attention to cultural issues — We have alluded to the importance of knowledge about cultural differences
between patients and clinicians. For this knowledge to be of real use, to effect medical outcomes of care, the
clinician must move beyond cognition of cultural differences to truly valuing and respecting the beliefs of each
patient to whom s/he provides care. (See "Cross-cultural care and communication".)

Attention to accountability — Much of medical training inculcates clinicians with a strong sense of
responsibility. "The buck stops here" is a feeling well known by every intern. While this can greatly benefit
patients when the clinician is personally executing every aspect of care, that is now rarely the case. It is not an
effective point of view when the clinician is part of a team. Clinician arrogance about "who knows best" is
unfortunately another well-known phenomenon. The clinician must hold responsibility for his/her part in the
team's work but must also appreciate each team member's role and skills. All team members are responsible for
respectful collaboration in the work and participation in a system that monitors outcomes of care and provides
clear and timely feedback about each team member's performance.

Attention to professionalism — Effective interactions between each clinician and patient depend, at their core,
on mutual trust. Survey data show that the levels of trust and respect that were formerly extended to the
profession of medicine have substantially eroded over the past 40 years [34,35]. Societal skepticism about the
trustworthiness of medicine has many legitimate sources and is a cause for concern.

What can we do to restore the public's trust in our chosen profession? While there is no straightforward solution,
we can begin by being aware of this challenging situation and mindful of the foundational values that can guide
our behavior with each patient we approach (figure 2).

● We must learn to use and balance our values when navigating particularly difficult situations with patients
(eg, breaking bad news, withholding an unnecessary and costly technology/test).

● We must openly reveal to our patients (and students) the basis for the professional judgments we are

● We must actively take patients' preferences into consideration and be prepared to change our opinions
when new information becomes available, including the basis for patients' opinions.

Only by making this "juggling act" explicit will we regain trust and avoid perpetuating some of the most damaging
situations of all, ones in which we contribute to racial, ethnic, and other disparities through our implicit processes
of stereotyping and misperceptions [36].

CONTINUOUS LEARNING — As Hippocrates observed, art is long and life is short. No one of us truly "masters"
skillful approaches to all patients in all situations. We mature, grow in our professional experience, and hope to
improve our capacity for this most fundamental of clinical tasks. Several additional techniques can support our
continued learning in this domain (table 12) [37-39].

There are two other special resources available to help us enhance our approaches to patients. The Academy on
Communication in Healthcare (formerly the American Academy on Physician and Patient) is an organization of
health care providers committed to enriching the practice and teaching of medicine by improving the clinician-
patient relationship through educational programs, research, scholarly publications, and teaching resources
A second valuable resource is the American Balint Society [42], which continues the work of Dr. George Balint
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wherein clinicians present their patients' stories to each
other (maintaining appropriate patient confidentiality) and then discuss aspects of the clinician-patient
interactions that seem meaningful or puzzling. The goals of the discussion are increased understanding of the
patient's perception of his/her situation and increased personal awareness for the clinician, the consequences of
which are a better understanding of how to work effectively with the patient [43].

We owe it to our patients and ourselves to continue to reflect and improve our interactions.


● Clinicians must recognize the importance of managing the care of patients within a system so as to
maximize quality and cost-effectiveness of the care delivered to their patients. A substantial portion of a
patient's confidence in his/her clinician will depend upon the clinician's skill and capacity to access and
unfold the best aspects of the system for the patient. (See 'Essential tasks of the contemporary clinician'

● The medical interview has three functions: data-gathering, relationship-building, and patient education.
Nonverbal communication is an important component of the interview. Attention to one's mental processes
during an interview (mindful practice) improves understanding of the patient, reduces bias, and can enhance
clinical judgment. (See 'Functions of the medical interview' above.)

● Effective patient care involves four strategic elements that can be categorized as cognitive, affective,
behavioral, and social. Cognitive strategies encourage dialogue that expands patients' understanding of their
condition and allows informed medical decisions. Affective strategies convey empathy and facilitate patient
self-forgiveness. Behavioral change strategies target a patient's readiness to seek treatment or alter
behaviors. Motivational Interviewing is a particularly effective counseling method for behavior change. Social
strategies involve the patient's family or community in collaborating with the patient to improve health
outcomes. (See 'Effective clinician strategies' above.)

● The "Four Habits Approach" to clinical communication provides a useful and well-validated summary of
clinician behaviors during a medical visit that have proven to be effective for both the patient and clinician
(table 10). (See 'Desirable clinician behaviors' above.)

● The patient-practitioner relationship is enhanced by a number of clinician attributes, including respect for
patient dignity and self-determination, clinical curiosity, attention to decision-making preferences and cultural
issues, accountability, and professionalism. (See 'Professional values' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Thomas Inui, MD, who
contributed to an earlier version of this topic review.

Use of UpToDate is subject to the Subscription and License Agreement.


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Topic 2754 Version 25.0

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Essential tasks of the contemporary clinician

Comprehend the biomedical and psychosocial knowledge base pertinent to your field of medicine

Develop a personal strategy to learn continuously and manage the rapid changes in this information

Connect in a personal, professional manner with each patient who seeks care from you

Understand the health care delivery system in which you work, and your role in it

Act in ways that maximize the cost-effectiveness and healing influences of the health care you provide

Educate and support your patients in the optimal use of the health care system

Graphic 53207 Version 3.0

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Learn what the patient hopes to accomplish in the visit (the patient's agenda)

Elicit the patient's complaints (symptoms), concerns, and requests

Perform an appropriately focused physical examination

Mentally test diagnostic hypotheses throughout the collection of historical and examination data

Develop a differential diagnosis of the problem(s)

Plan a cost-effective workup if needed

Choose a therapeutic intervention if needed

Discuss all of this with the patient in terms that are easily understood

Check the patient's understanding

Negotiate differences of opinion the patient and doctor may have about the nature of the problem, its evaluation, and
its treatment

Assure that attention is given to disease prevention strategies appropriate to the patient's age, gender, habits, and
genetic and socioeconomic risk factors

Make plans for follow-up of the problem and its treatment

Conclude the visit

Graphic 51924 Version 3.0

Three functions
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Function 1
Data gathering: Determine and monitor the nature of the problem


Enable the clinician to establish a diagnosis or recommend further diagnostic procedures, suggest courses of
treatment and predict the nature of the illness

Function 2
Relationship building: Develop, maintain, and conclude the therapeutic relationship


Ensure patient's willingness to provide diagnostic information

Ensure relief of patient's physical and psychological distress

Ensure patient's willingness to accept the treatment plan or a process of negotiation

Ensure patient and clinician satisfaction

Function 3
Patient education: Carry out patient education and implementation of treatment plans


Ensure patient's understanding of the nature of the illness

Ensure patient's understanding of suggested diagnostic procedures

Enhance patient's understanding of the treatment possibilities

Achieve consensus between clinician and patient

Achieve informed consent

Improve coping mechanisms

Promote lifestyle change

Adapted from Lipkin M, Putnam S, Lazare A. The Medical Interview, Springer-Verlag, New York 1995.

Graphic 65802 Version 3.0

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Strategy Rationale Examples

Joint agenda setting Negotiates priorities together; shares "We agree that A is important. I want to be sure we
control also address B, and you've said you were worried
about C. I'm not certain we can cover all our
concerns today. Where should we start?"

The exhaustive "what Seeks patient's entire agenda; "What else has concerned you lately?" "Are you
else?" minimizes "oh, by the way" questions worried about anything else?" "Should we consider
anything else before we do your exam?"

Storytelling: Open- Invites patient to state the agenda; "How can I be of help to you today?" "What problems
ended questions (and allows patient to use judgment about should we consider today?" "Tell me about A." "You
careful, uninterrupted problems to emphasize; often is most say that B is bothering you - tell me about it."
listening to the story) efficient way to hear story

Facilitation Encourages patient to tell story in "Tell me more about that." "Uh-huh, go on."
open-ended fashion; conveys sense Attentive silence, urges patient to continue; echo
that clinician wishes to hear and patient's last few words: "It hurt when you took a
understand deep breath..."

Clarification Seeks specificity and clarity "Help me understand what you mean by dizziness."

Checking and Seeks to assure accurate "Let me review what I think I've heard you say."
summarizing understanding; assures patient that "You were well until..." "I'd like to summarize my
he/she has been heard; invites further understanding of the problem and have you be sure I
clarification have the story straight."

Adapted by permission from Clark W, Hewson M, Fry M, et al. American Academy on Physician and Patient (AAPP 1998), now
the American Academy on Communication in Healthcare.

Graphic 76848 Version 4.0

Nonverbal skills
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Strategy Rationale Examples

Professional Conveys confidence and expertise Well-kempt; with or without white coat, depending on
appearance expectations of majority of patient population

Comfortable Helps patient and clinician relax, conveys Appropriate temperature; no barriers to direct eye
office professionalism, and can convey sense of contact; gowns that fit; efficient organization of exam
clinician's level of organization and room; attention to modesty; minimization of
aesthetic taste interruptions

Calm, attentive, Conveys readiness to listen Comfortable interpersonal distance; patient and
open posture clinician at eye level (consider implications of vertical
distance on patient's comfort); clinician leans slightly
forward, relaxed

Eye contact Conveys focused interest on the patient; Clinician looks patient directly in the eye while talking
clinician is not distracted and listening; consider the effect of note-taking style
on the flow of the interview

Voice quality: Conveys much about clinician's tranquillity Calm versus brusque and hurried; loud/soft enough;
pitch, pace, and readiness to hear patient; respectful avoid hostile, scolding, or irritated quality
tone, volume of hearing deficits

Clinician Subliminal enhancement of relationship Clinician's posture echoes patient's posture; clinician's
"matches" some voice tone, pace, and vocabulary matches patient's;
of the patient's clinician's gestures subtly echo patient's

Doctors should be aware that many nonverbal behaviors have special cross-cultural implications.

Adapted by permission from Clark W, Hewson M, Fry M, et al. American Academy on Physician and Patient (AAPP 1998), now
the American Academy on Communication in Healthcare.

Graphic 50644 Version 3.0

Tips to enhance
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EMR: electronic medical record.
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Data from:
1. LEVEL section reprinted from The Permanente or Vol
Journal, find8 (issue
out more.
4), Mann WR, Slaboch J,
Computers in the exam room—friend or foe?, pages 49-51, Copyright © 2004, with permission
from The Permanente Press.
2. HUMAN LEVEL adaptation reproduced with permission from: Alkureishi M, Lee W, Farnan J,
Arora V. Breaking away from the iPatient to care for the real patient: implementing a patient-
centered EMR use curriculum. MedEdPORTAL Publications 2014; 10:9953.

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Description Examples

Partnership Joint problem-solving "Let's tackle this together."

Empathy Show understanding; put feelings "That sounds hard." "You look upset." "You seem
into words discouraged." "Wow!"

Apology Show concern for "faux pas," "I'm sorry I (or others) hurt/offended/annoyed you."
(compassion) hurts, bumbles

Respect Value patient's choices, traits and "I appreciate your courage/decision/action." "You have
behaviors worked hard on this."

Legitimization Normalize and validate feeling and "Anyone would be confused/sad/irritated by this situation."

Support Offer ongoing personal support "I'll stick with you as long as necessary."

Resist the powerful temptation to pursue clinical details when responding to a patient's emotion. Avoid actions that
tend to make people feel ignored or irritated, such as judging, being defensive, persistent questioning, giving
nonverbal cues of irritation, or prematurely giving information, advice, or reassurance.

Adapted by permission from Clark W, Hewson M, Fry M, et al. American Academy on Physician and Patient (AAPP 1998), now
the American Academy on Communication in Healthcare.

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Objective 1: Tell a meaningful diagnosis.
Step 1 - Ask patient his/her understanding of what the problem or situation is. Or, reflect what you've heard if patient
has already stated this.

Step 2 - Tell patient "You have... (diagnosis)" or "The diagnosis is not clear, but I'm concerned about... (list issues)."

Step 3 - Ask patient about his/her reaction.

Ask about Description Examples

Knowledge Teach patient about diagnosis. "What do you already know about this?" "What questions do
Inquire about patient's understanding you have?" "What do you want to know more about?"
of your news. Regulate quantity and
level of information.

Feelings Inquire about patient's inner state in "What's your reaction to this?" "How are you feeling about
response to the news, reflect feelings this?" "You look worried."
you see/hear (use PEARLS).

Beliefs/Meaning Inquire about patient's beliefs about "Why do you think you have high blood pressure?" "What
why he/she has the problem or what does it mean to you to hear I'm uncertain about...?"
it means.

Expectations Inquire about the patient's "What do you see happening when you look to the future?"
expectations of future outcomes. "How do you think things will go for you?"

Objective 2: Negotiate and implement a plan (again use Ask-Tell-Ask format)*

Action Description Examples

Ask - existing Find out what he/she has already "What have you tried already?" "What ideas do you have
ideas tried and what ideas he/she has about what we should do now?"
about what the plan should be.

Tell - plan Describe plan, give reasons and "I recommend... because..." "You can expect..." "If...
expectations, and forecast possible happens, then you should..."

Ask - Check patient's understanding and "How does this sound to you?" "What problems do you
understanding agreement. Inquire about obstacles. anticipate?" "Help me understand - what's holding you back?"
Problem-solve and negotiate "What would it take for you to be ready?" "Let's look together
differences. for what might work."

Rehearse Check to be sure your and your "Just to be sure we're clear, what would you tell your spouse
patient's understanding of the plan (or friend) about our plan?"
are the same.

PEARLS: partnership, empathy, apology (compassion), respect, legitimization, support.

* Caution: Patient's unspoken beliefs, fears, or lack of commitment frequently appear as defensiveness, resistance, or
reluctance. Remember, when defensiveness starts, learning stops. For treatment planning, your understanding of such fears
and beliefs is as important as your medical expertise. If you see, hear, or feel defensiveness in your patient, go back and
focus on relationship building. If you're rushed, it is better to schedule another visit than to create frustration.

Adapted by permission from Clark W, Hewson M, Fry M, et al. American Academy on Physician and Patient (AAPP 1998), now
the American Academy on Communication in Healthcare.

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Negotiating priorities and expectations

Giving an explanation

Bringing a patient to a crossroads

Making suggestions

Educating the patient

Giving a prognosis

Conveying empathy

Encouraging emotional expression

Giving encouragement

Offering hope


Facilitating self-forgiveness

Giving reassurance

Emphasizing patient's active role

Praising desired behaviors

Suggesting alternative behaviors

Attending to adherence

Using family and social supports

Using community agencies and other health care providers

Adapted from: Lipkin M, Putnam S, Lazare A. The Medical Interview. Springer-Verlag, New York 1995.

Graphic 54037 Version 3.0

Desirable clinician
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Getting the visit Finding out Talking about Following up on
off to a good what the problem/what to do problem and
start problem is about it treatment

Professionalism Appearance Preparation by Clear/complete Providing access and

clinician explanations coverage

Carry-over from Limit interruptions Clinician knows limitations Following through

previous patients

Respect Punctuality Listens and Involves patient in Involves patient in

understands treatment management

Treats like an equal Explains exam Honesty Conscious of financial


Support Courtesy Takes complaints Taking time to talk Checks on patients at

seriously home

Relaxed atmosphere Concerned about Encourages questions Checks on what patient

daily life should be doing

Graphic 52737 Version 2.0

Approach to effective
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Habit Skills Techniques and examples Payoff

Invest in the Create • Introduce self to everyone in the room • Establishes a

beginning rapport • Acknowledge patient wait time, if appropriate welcoming atmosphere
quickly • Allows faster access
• Convey knowledge of patient's history by commenting on prior
visit or problem to real reason for visit

• Attend to patient's comfort • Increases diagnostic

• Make a social comment or ask a nonmedical question to put
patient at ease • Requires less work

• Adapt own language, pace, and posture in response to patient • Minimizes "Oh, by the
way..." at the end of
Elicit • Start with open-ended questions: visit
patient's - "What would you like help with today?" OR, • Facilitates negotiating
concerns an agenda
- "I understand that you're here for... Could you tell me more
about that?" • Decreases potential
for conflict
- "What else?"
• Speak directly with patient when using an interpreter

Plan the • Repeat concerns back to check understanding

visit with • Let patient know what to expect: "How about if we start with
the patient talking more about..., then I'll do an exam, and then we'll go
over possible tests/ways to treat this? Sound OK?"
• Prioritize when necessary: "Let's make sure we talk about X
and Y. It sounds like you also want to make sure we cover Z. If
we can't get to the other concerns, let's..."

Elicit the Ask for • Assess patient's point of view: • Respects diversity
patient's patient's - "What do you think is causing your symptoms? • Allows patient to
perspective ideas provide important
- "What worries you most about this problem?"
diagnostic clues
• Ask about ideas from significant others
• Uncovers hidden
Elicit • Determine patient's goal in seeking care: "When you've been concerns
specific thinking about this visit, how were you hoping I could help?" • Reveals use of
requests alternative treatments
Explore the • Check context: "How has the illness affected your daily or requests for tests
impact on activities/work/family?" • Improves diagnosis of
the depression and anxiety

Demonstrate Be open to • Assess changes in body language and voice tone • Adds depth and
empathy patient's • Look for opportunities to use brief empathetic comments or meaning to the visit
emotions gestures • Builds trust, leading
to better diagnostic
Make at • Name a likely emotion: "That sounds really upsetting." information,
least one • Compliment patient on efforts to address problem adherence, and
empathetic outcomes
• Makes limit-setting or
Convey • Use a pause, touch, or facial expression saying "no" easier

Be aware • Use own emotional response as a clue to what patient might

of your be feeling
• Take a brief break if necessary
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Invest in the Deliver Continue
• Frame diagnosis oroffind
in terms outoriginal
patient's more.concerns • Increases potential
end diagnostic • Test patient's comprehension for collaboration
information • Influences health
Provide • Explain rationale for tests and treatments outcomes
education • Review possible side effects and expected course of recovery • Improves adherence

• Recommend lifestyle changes • Reduces return calls

and visits
• Provide written materials and refer to other sources
• Encourages self care
Involve • Discuss treatment goals
patient in • Explore options, listening for the patient's preferences
• Set limits respectfully: "I can understand how getting that
test makes sense to you. From my point of view, since the
results won't help us diagnose or treat your symptoms, I
suggest we consider this instead."
• Assess patient's ability and motivation to carry out plan

Complete • Ask for additional questions: "What questions do you have?"

the visit • Assess satisfaction: "Did you get what you needed?"
• Reassure patient of ongoing care

Reproduced with permission from: Frankel RM, Stein T. Getting the most out of the clinical encounter: The Four Habits Model.
J Med Pract Manage 2001; 16:184. Copyright ©2001 Greenbranch Publishing.
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Areas of uses
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relationship Continue or find out more.
Area Knowledge Skills Values

Self-awareness Knowledge of self Reflect on self and Importance of self-awareness, self-

Understanding self as a resource work care, self-growth
to others

Patient experience Role of family, culture, community Recognize patient's Appreciation of the patient as a
of health and in development life story and its whole person
illness Multiple components of health meaning Appreciation of the patient's life
Multiple threats and contributors to View health and story and the meaning of the
health as dimensions of one's illness as part of health-illness condition
reality human development

Developing and Understanding of threats to the Attend fully to the Respect for patient's dignity,
maintaining caring integrity of the relationship (eg, patient uniqueness, and integrity (mind-
relationships power inequalities) Accept and respond body-spirit unity)
Understanding of potential for to distress in patient Respect for self-determination
conflict and abuse and self Respect for person's own power
Respond to moral and and self-healing processes
ethical challenges
Facilitate hope, trust,
and faith

Effective Elements of effective Listen; learn Importance of being open and

communication communication Impart information nonjudgemental

Facilitate the learning

of others
Promote and accept
patient's emotions

Adapted from Tresoloni CP, Pew-Fetzer Task Force on Advancing Psychosocial Health Education, Pew Health Professions
Commission, San Francisco 1994. p. 30.

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This struggle to stay By
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profession of
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medicine Continue or find out more.

Reproduced with permission from: Inui TS. A Flag in the Wind: Educating for Professionalism in
Medicine. Association of American Medical Colleges, Washington, DC 2003. Copyright © 2003
Association of American Medical Colleges.

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Make some quiet time to reflect on satisfying or find
and unsatisfying outWhat
visits. more.
did you do, and what did the patient do that
made the difference? What life experiences influenced your behavior in that circumstance?

Observe your interactions with patients directly. Obtain permission from your patients to audiotape or videotape visits
for the purpose of self-improvement. Assure your patients about the fate of the recordings (eg, destruction after you
have studied them). We all have "blind spots" about our behaviors that the recorders can reveal to us.

Talk with trusted colleagues about challenging interactions with patients, seeking their insights and their strategies for
dealing with similar situations.

Seek feedback about your interactions with patients from colleagues who have opportunities to observe at least parts of
your clinician-patient visits. Support staff may have very useful feedback about what patients say to them about you.

When you sense an absence of rapport with a patient and cannot comprehend the source of the disconnection, put the
difficulty in the relationship nonjudgementally "on the table" for discussion with the patient.

Read the world's great literature with an ear to hearing people's stories. Many clinician-authors have contributed their
special insights into how we can hear our patients' life stories amid their "biomedical stories."

Write about your insights into the human condition - in a private journal, or for publication.

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Contributor Disclosures
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Jeannette M Shorey, II, MD Nothing to disclose or find
John out more.
J Spollen, III, MD Nothing to disclose Mark D Aronson,
MD Nothing to disclose Judith A Melin, MA, MD, FACP Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
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