Communication Techniques

(Interviews
• The health history interview is a conversation
with a purpose
• The primary goal of the clinician–patient
interview is to improve the well-being of the
patient
The purpose of conversation with a patient
is threefold:
✓to establish a trusting and supportive
relationship,
✓to gather information, and to offer information.
✓To establish a supportive interaction that
enhances the therapeutic process of patient
care.
• The interviewing process differs
significantly from taking history.
The interviewing process actually
generates these pieces of information
and is more fluid.
➢ It requires knowledge of the
information needed to obtained
Getting Ready: The Approach to the
Interview
Interviewing patients to obtain a health
history needs planning as:
1. Take Time for Self-Reflection.
• Clinicians, encounter a wide variety of
people, each one of whom is unique.
✓Self-reflection is a continual part of
professional development in clinical work.
It is one of the most rewarding aspects of
providing patient care.
2. Review of the Chart.
• Before seeing the patient, review his or her
medical record, or chart.
• Its purpose is to gather information and to
develop ideas about what to explore with the
patient.
• Look closely at the identifying data and past
diagnoses and treatments;
• Do not let the chart prevent you from
developing new approaches or ideas.
3. Setting Goals for the Interview.
Consciously or not, one send messages through
words and behavior; Be sensitive to those messages
and manage them.
➢Posture, gestures, eye contact, and tone of voice
can all express interest, attention, acceptance, and
understanding.
➢The skilled interviewer is calm and unhurried,
even when time is limited.
➢Don’t express reactions that betray disapproval,
embarrassment, impatience, or boredom block.
4. Improve the Environment.
• Make the setting as private and comfortable
as possible.
• Taking Notes. write down much of what you
learn during the interview.
▪ Do not, however, let note-taking distract you
from patient.
▪ Maintain good eye contact, and whenever the
patient is talking about sensitive or disturbing
material, put down your pen.
THE SEQUENCE OF THE INTERVIEW
• Greet the patient and establishing rapport

• Invite the patient’s story

• Establish the agenda for the interview
• Expand and clarify the patient’s story; generating and testing
diagnostic hypotheses
• Create a shared understanding of the problem(s)
• Negotiate a plan (includes further evaluation, treatment, and
patient education)

• Plan for follow-up and closing the interview.

Greeting the patient and establishing rapport
• Greet the patient by name and introduce yourself, giving your
name.
• If possible, shake hands with the patient. If this is the first
contact, explain your role, including status as a student and
how you will be involved in the patient’s care
• In the hospital, after greeting the patient, ask how the patient
is feeling and look for signs of discomfort.
• Arrange the bed to make the patient more comfortable
• Consider the best way to arrange the room and how far to be
from the patient. Consider cultural background and individual
taste influence preferences about interpersonal space.
• Give the patient undivided attention.
• Spend enough time on small talk to put the patient at ease.
Inviting the Patient’s Story
• Pursue the patient’s reason for seeking health care,
or chief complaint. Begin with open-ended
questions are:
✓“What concerns bring you here today?” or “How
can I help you?” . These questions encourage the
patient to express any possible concerns
✓Don’t’ restrict the patient to a limited and minimally
informative “yes” or “no” answer. Listen to the
patient’s answers without interrupting.
✓After giving the patient the opportunity to respond
fully, inquire again of “anything else?”
✓Lead the patient back several times to additional
concerns
✓ Some patients may want only BP check or
routine examination, without having a specific
complaint or problem. Others physical
examination but feel uncomfortable bringing
up an underlying concern.
• In all these situations, start with the patient’s
story. Helpful open-ended questions are “Was
there a specific health concern that prompted
you to schedule this appointment?” and “what
made you decide to come in for health care
now? It is important to follow the patient’s
leads
 Good interviewing techniques

❑using verbal and nonverbal cues that prompt

patients to recount their stories spontaneously.
❑listening actively and
❑Making use of continuers, especially at the
outset as nodding
Establishing the Agenda for the Interview.
• The clinician often approaches the interview with
specific goals in mind.
• The patient also has specific questions and
concerns. It is important to identify all these issues
at the beginning of the encounter.
• Doing so allows you to use the time available
effectively and ensure address all the patient’s
issues.
Expanding and Clarifying the Health History
(the Patient’s Perspective). Guide the patient
into elaborating areas of the health history
that seem most significant. For the clinician,
each symptom has attributes that must be
clarified, including context, associations, and
chronology, particularly for complaints of pain
 The Techniques of Skilled Interviewing
❑Active listening
❑ Adaptive questioning
❑ Nonverbal communication
❑ Facilitation
❑ Echoing
❑ Empathic responses
❑ Validation
❑ Reassurance
❑ Summarization
❑ Highlighting transitions
1. Active Listening. Underlying all these
specific techniques is this practice
Active listening is the process of fully attending
to what the patient is communicating, being
aware of the patient’s emotional state, and
using verbal and nonverbal skills to encourage
the speaker to continue and expand.
• It takes practice; It is easy to drift into thinking
about next question or the differential
diagnosis.
2. Adaptive Questioning. There are several ways to
ask questions that add detail to the patient’s story yet
facilitate the flow of the interview.
Adaptive Questioning: Options For Clarifying The
Patient’s Story
• Directed Questioning—from general to specific
• Questioning to elicit a graded response
• Asking a series of questions, one at a time
• Offering multiple choices for answers
• Clarifying what the patient means
• Directed questioning is useful for drawing the
patient’s attention to specific areas of the history.
principles of directed questioning; to be
effective:
✓ should proceed from the general to the specific.
✓Should not be leading questions that call for a
“yes” or “no” answer.
3. Nonverbal Communication.
• It does not involve speech, occurs continuously and provides
important clues to feelings and emotions.
• Becoming more sensitive to nonverbal messages allows you to
both “read the patient” more effectively and to send messages of
your own.
• Pay close attention to eye contact, facial expression, posture,
head position and movement. To match your position to the
patient’s can be a sign of increasing rapport.
• Moving closer can convey empathy or help the patient gain
control of feelings.
• Mirror the patient’s paralanguage, or qualities of speech such as
pacing, tone, and volume, to increase rapport.
4. Facilitation;

• Used when, by posture, actions, or words, you encourage the

patient to say more but do not specify the topic.

• Pausing with a nod of the head or remaining silent, yet

attentive and relaxed, is a cue for the patient to continue.

• Leaning forward, making eye contact, and using continuers

make story flow

5. Echoing:

• Simple repetition of the patient’s words encourages the patient

to express both factual details and feelings.
6. Empathic Responses.
• Conveying empathy is part of establishing and
strengthening rapport with patients.
• To empathize with patient first; identify his or her
feelings. When you sense important but unexpressed
feelings from the patient’s face, voice, words, or behavior,
inquire about them rather than assume how the patient
feels.
• Simply ask “How did you feel about that?”
• Unless you let patients know that you are interested in
feelings as well as in facts, you may miss important
insights.
• Once you identify the feelings, respond with understanding and
acceptance.
• Empathy may be nonverbal.
7. Validation.
• It helps the patient feel that such emotions are legitimate and
understandable.
8. Reassurance. When you are talking with patients who are
anxious or upset: The first step to effective reassurance is:
✓ identify and accept the patient’s feelings without offering
reassurance at that moment.
✓ Doing so promotes a feeling of security.
✓ The actual reassurance comes after completing the interview,
the physical examination, and perhaps some laboratory studies.

✓ At that point, interpret for the patient what you think is

happening and deal openly with the real concerns.

9. Summarization.

➢ its giving a capsule summary of the patient’s story in the

course of the interview can serve several different functions:

➢ It indicates to the patient that you have been listening

carefully.

➢ It can also identify what one know and what is not known.
➢ Use summarization at different points in the interview to

structure the visit, especially at times of transition

➢ This technique also allows the clinician, to organize clinical

reasoning and to convey thinking to the patient, which making

relationship more collaborative.

10. Highlighting Transitions. Patients have many

reasons to feel worried and vulnerable.

✓ To put them more at ease, tell them when changing

directions during the interview.

✓ This gives patients a greater sense of control

Adapting Interviewing Techniques to different
patients:
a. Silent Patient.
• Novice interviewers may be uncomfortable with periods
of silence and feel obligated to keep the conversation
going.
• Patients frequently fall silent for short periods; to collect
thoughts, remember details, or decide whether to trust one
with certain information.
• The period of silence usually feels much longer to the
clinician than it does to the patient.
• Appear attentive and appropriate; give brief
encouragement to continue
• Watch the patient closely for nonverbal cues, or , patients with
depression or dementia may lose their usual spontaneity of
expression, give short answers to questions, then quickly become
silent afterwards; one may need to shift your inquiry to the
symptoms of depression or begin an exploratory mental status
examination
• At times, silence may be the patient’s response to how you are
asking questions. If so, you may need to ask the patient directly,
“You seem very quiet. Have I done something to upset you?”
• For natural laconic patients; accept and try asking them for
suggestions about other sources to help gather more information.
• With the patient’s permission, talking with family members or
friends may be of value.
b. The Talkative Patient.
• Give the patient free rein for the first 5 or 10 minutes and
listen closely to the conversation.
• Does the patient seem obsessively detailed or unduly
anxious? Is there a flight of ideas or disorganized thought
process that suggests a psychosis or confabulation?
• Try to focus on what seems most important to the patient.
• Show your interest by asking questions in those areas.
Interrupt if you must, but courteously.
• Remember that part of your task is to structure the interview.
• It is acceptable to be directive and set limits when necessary.
• A brief summary may help you change the subject yet
validate any concerns
• Follow up on summarized concern.

• Finally, do not show your impatience. If there is no more

time, explain the need for a second meeting.

c. The Anxious Patient.

Anxiety is a frequent and normal reaction to sickness,

treatment, and the health care system itself.

• For some patients, anxiety is a filter for all their perceptions

and reactions; for others it may be part of illness.

• Watch for nonverbal and verbal cues.

• They fall silent, others try to cover their feelings with
words, busily avoiding their own basic problems.

• When you detect anxiety, reflect impression back to

the patient and encourage him or her to talk about any
underlying concerns.

• Don’t transmit individual anxieties about completing

the interview
d. The Crying Patient.
• Crying signals strong emotions, ranging from sadness to anger
or frustration.

• Allow the patient to cry for that’s therapeutic, as is quiet

acceptance of the patient’s distress or pain

• Offer a tissue and wait for the patient to recover. Make

supportive remark & most patients will soon be
composed and resume story.

• Other than in acute grief or loss, it is unusual for crying to

escalate and become uncontrollable.
.
e. The Confusing Patient.
• The patients with multiple symptoms.

• They seem to have every symptom asked about

• Although they may have multiple medical illnesses, a somatization

disorder is more likely.

• Focus on the meaning or function of the symptom and guide the interview
into a psychosocial assessment

• The history is vague; difficult to understand, ideas are poorly

related to one another, and language is hard to follow.

• Though you word your questions carefully, you cannot seem to get
clear answers.
• The patient’s manner of relating seem peculiar, distant,
aloof, or inappropriate. Patients may describe symptoms
in bizarre terms
• Perhaps there is a mental status change e.g. psychosis
or delirium, a mental illness as schizophrenia, or a
neurologic disorder; watch for delirium in acutely ill or
intoxicated patients and for dementia in the elderly.
• These patients give histories that are inconsistent and
cannot provide a clear chronology about what has
happened.
• When you suspect a psychiatric or neurologic disorder,
Shift to the mental status examination, focus level of
consciousness, orientation, and memory.
f. Angry or Disruptive Patient.
• More often, patients displace their anger onto the clinician as a
reflection of their pain.
• Accept angry feelings from patients and allow them to express
emotions without getting angry in return. Beware of joining
such patients in their hostility toward another provider, facility
when you sympathize
• The complex nature of our health care system can seem very
unsupportive when one isn’t well.”
• After the patient has calmed down, find steps that will avert
such situations in the future.
• Some angry patients become hostile and disruptive.
• Keep your posture relaxed and nonthreatening and your

hands loosely open. At first, do not try to lower their

voices or stop if they are cursing you or the staff.

• Listen carefully and try to understand what they are

saying. Once you have established rapport, gently suggest

moving to a different location that is not upsetting to

other patients or families.

g. The Patient With a Language Barrier.

• When patient speaks a different language, make

effort to find an interpreter who is a neutral objective

person familiar with both languages and cultures.

• Beware of using family members or friends

h. The Patient With Impaired Vision.
• When meeting with a blind patient, shake hands to establish
contact and explain who you are and why you are there.

• If the room is unfamiliar, orient the patient to the surroundings

and report if anyone else is present.

• Remember to use words whenever respond to such patients,

because postures and gestures are unseen

• Encourage visually impaired patients to wear glasses, if

available, to ease communication
i. The Patient With Limited Intelligence.
• Patients of moderately limited intelligence can usually give
adequate histories.
• If unsure about the patient’s level of intelligence, make a smooth
transition to the mental status examination and assess simple:
calculations, vocabulary, memory, and abstract thinking
• For patients with severe mental retardation, obtain the history from
the family or caregivers
• Establish rapport, make eye contact, and engage in simple
conversation.
• As with children, avoid “talking down” or condescending behavior.
j. The Poor Historian.
• Some patients are totally unable to give their own
histories due to: age, dementia; find a third person who
can give you the story.
• For patients who are mentally competent, obtain their
consent before talking about their health with others.
• Assure patients for confidentiality, and clarify what
can be shared.
• Even if patients can communicate only by facial
expressions or gestures, maintain confidentiality and
elicit their input.
• It is possible to divide the interview into 2; with the
patient alone and the other with both
The basic principles of interviewing apply to
your conversations with relatives or friends.
✓Find a private place to talk.
✓Introduce yourself, state your purpose, inquire
how they are feeling under the circumstances,
and recognize and acknowledge their concerns.
✓As you listen to their versions of the history, be
alert to the quality of their relationship with the
patient.
✓It may color their credibility or give you
helpful ideas for planning the patient’s care.
k. The Patient With Personal Problems.
• Patients may ask you for advice
personal problems other than health
care.
• Let the patient talk through the problem
with you is usually much more valuable
and therapeutic than giving any answer
Cultural Competence.
• Developing the ability to interact and
communicate effectively with patients from
many backgrounds is a lifelong professional
goal.
• The following examples illustrate how
communication barriers, cultural differences,
and unconscious biases can influence patient
care.
Ethical Considerations
Ethics are a set of principles that have been created through
reflection and discussion to guide our behavior.

Ethical principles

a. Nonmaleficence or primum non nocere is commonly stated

as “First, do no harm.”

• In interview, to give information that is incorrect or not really

related to the patient’s problem can do harm.

• Avoiding relevant topics or creating barriers to open

communication can also do harm
Beneficence : the clinician needs to “do good” for the

patient.

Autonomy reminds us that patients have the right to

determine what is in their own best interest.

Confidentiality obligation not to tell others what we

learn from our patients.

Interviewing Patients of Different Ages

a. Talking With Children:

• they are usually are accompanied by a parent or caregiver.

• Even when adolescents are alone, they are often seeking health

care at the request of their parents.

• When interviewing a child, you need to consider the needs and

perspectives of both the child and the caregivers.

Establishing Rapport.
• Begin the interview by greeting and establishing rapport
with each person present. Refer to the infant or child by
name
• Clarify the role or relationship of all the adults and
children.
• To establish rapport, the key is to meet children on their
own level.
• Use your personal experiences with children to guide
how you interact in a health care setting.
• Maintain eye contact at their level participating in playful
engagement, and talking about what interests them
• Spend time at the beginning of the interview to calm
down and connect with an anxious child or crying infant
to put both the child and the caregiver at ease.
b. Talking With Adolescents.
• Adolescents, like most other people, usually respond positively to
anyone who demonstrates a genuine interest in them.
• It’s important to show interest early and then sustain the connection if
communication is to be effective.
• They are more likely to open up when the interview is focused on them
rather than on their problems.
• In contrast to most other interviews, start with specific directed
questions to build trust and rapport and start the conversation.
• Using silence in an attempt to get adolescents to talk or asking about
feelings directly is usually not a good idea;
• use summarization and transitional statements to explain what to do
during the physical examination.
• Once you have established rapport, return to more open-ended
questions.
• At that point, make sure to ask what concerns or questions the
adolescent may have.
• Remember also that adolescents’ behavior is related to their
developmental stage
• Issues of confidentiality are important in adolescence.
• Explain to both parents and adolescents that the best health
care allows adolescents some degree of independence and
confidentiality.
• Before the parent leaves the room, get any relevant medical
history from the parent, Also discuss the need for
confidentiality.
• Explain that the purpose of confidentiality is to improve health
care, not to keep secrets.
• However, never make confidentiality unlimited. Always state
explicitly that you may need to act on information that makes
you concerned about safety.
• The goal is to help adolescents bring their concerns or
questions to their parents.
c. Talking With Aging Patients.
At the other end of the life cycle, aging patients also have
special needs and concerns.
• Their hearing and vision may be impaired, their
responses and explanations may be slow or lengthy, and
they may have chronic illnesses with associated
disabilities.
• Elderly people may not report their symptoms. Some may
be afraid or embarrassed; others may be to avoid the
medical expenses or the discomforts of diagnosis and
treatment.
• They may think their symptoms are merely part of aging,
or they may simply have forgotten about them.
• They may be inhibited by fears of losing their
independence.
• As you proceed with interview, give elderly patients time
to respond to questions.
• Speak slowly and clearly but do not shout or raise your
voice.
• A comfortable room, free of distractions and noise, is
helpful.
• Remember that visual cues may be important, ensure that
your face is well lit. If they wear glasses, make sure they
put them on.
• Learn to recognize and avoid stereotypes that block your
appreciation of each individual patient.
• Find out how patients see themselves and their situation,
as well as each patient’s unique priorities, goals, and
patterns for handling problems. This knowledge will help
collaborate on treatment plans.