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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: Jane Givens, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Mar 2020. | This topic last updated: Oct 16, 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 services in an accountable and cost-effective fashion. A 2010
estimate suggested that, in the United States for example, approximately 30 percent of
health care costs, or more than $700 billion per year, is wasted, is 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, etc.

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 thought you might faint," etc) (table 4).

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 too" can be reassuring to an anxious or angry patient and turn a difficult encounter into a
productive one.

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 happen.

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 new "way of doing business" by many leading academic and
community hospitals. Referred to as "patient- and family-centered care," this approach brings
thoughtful patients and 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 conversations in medical visits and for greater attention to psychosocial issues and
affect-loaded problems. The ultimate challenge is not a cognitive one, but a behavioral one: to
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 in medical decision-making. Many older patients prefer the clinician to hold
most of the authority, while younger patients are apt to want to play an active role in shaping
diagnostic and therapeutic plans [27]. No rules hold, however, so the operative value needs to
be one of respecting each individual's preference for the extent to 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 making.

● 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 [40,41].

A second valuable resource is the American Balint Society [42], which continues the work of Dr.
Michael Balint and his wife, Enid. The Balints began their work in England during the first half of
the 20th century. They developed discussion groups (now called Balint Groups) 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.

SUMMARY AND RECOMMENDATIONS

● 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' above.)

● 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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es Press Inc, Madison, Connecticut 1964.

Topic 2754 Version 27.0

GRAPHICS

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

The clinician's tasks during a patient visit

Get the visit off to a good start

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 of the medical interview

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

Objectives

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

Objectives

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

Objectives

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

Verbal skills applying to data gathering

Strategy Rationale Examples

Joint agenda setting Negotiates priorities together; "We agree that A is important. I want to be sure
shares control we 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 Seeks patient's entire agenda; "What else has concerned you lately?" "Are you
"what else?" minimizes "oh, by the way" worried about anything else?" "Should we
questions 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
ended questions allows patient to use judgment problems should we consider today?" "Tell me
(and careful, about problems to emphasize; about A." "You say that B is bothering you - tell
uninterrupted often is most efficient way to hear me about it."
listening to the story
story)

Facilitation Encourages patient to tell story in "Tell me more about that." "Uh-huh, go on."
open-ended fashion; conveys Attentive silence, urges patient to continue;
sense that clinician wishes to hear echo patient's last few words: "It hurt when you
and understand took a 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 "You were well until..." "I'd like to summarize
that he/she has been heard; my understanding of the problem and have you
invites further clarification be sure I 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 applying to all functions of medical interview

Strategy Rationale Examples

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

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

Calm, Conveys readiness to listen Comfortable interpersonal distance; patient and

attentive, open clinician at eye level (consider implications of
posture vertical distance on patient's comfort); clinician
leans slightly forward, relaxed

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

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

Clinician Subliminal enhancement of Clinician's posture echoes patient's posture;

"matches" relationship clinician's voice tone, pace, and vocabulary
some of the matches patient's; clinician's gestures subtly echo
patient's patient's
behaviors

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 patient-centered EMR use
EMR: electronic medical record.

Data from: ​
1. LEVEL section reprinted from The Permanente Journal, Vol 8 (issue 4), Mann WR, Slaboch J,
Computers in the exam room—friend or foe?, pages 49-51, Copyright © 2004, with
permission from The Permanente Press. www.thepermanentejournal.org.
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.

Graphic 109194 Version 1.0

Verbal relationship building skills

Strategy
Description Examples
(PEARLS)

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

Empathy Show understanding; put "That sounds hard." "You look upset." "You seem
feelings 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 "I appreciate your courage/decision/action." "You have
and behaviors worked hard on this."

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

and choices 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.

Graphic 64050 Version 4.0

Patient education skills

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

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

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

Expectations Inquire about the patient's "What do you see happening when you look to the
expectations of future outcomes. future?" "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
ideas tried and what ideas he/she has have 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 happens, then you should..."
possible problems.

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

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

Graphic 63604 Version 5.0

Clinical behaviors that enhance the outcomes of medical care

Cognitive
Negotiating priorities and expectations

Giving an explanation

Bringing a patient to a crossroads

Making suggestions

Educating the patient

Giving a prognosis

Affective
Conveying empathy

Encouraging emotional expression

Giving encouragement

Offering hope

Touching

Facilitating self-forgiveness

Giving reassurance

Behavioral
Emphasizing patient's active role

Praising desired behaviors

Suggesting alternative behaviors

Attending to adherence

Social
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 behaviors

Getting the Finding out Talking about Following up on

visit off to a what the problem/what to problem and
good start problem is do about it treatment

Professionalism Appearance Preparation by Clear/complete Providing access and

clinician explanations coverage

Carry-over from Limit Clinician knows Following through

previous patients interruptions limitations

Respect Punctuality Listens and Involves patient in Involves patient in

understands treatment management

Treats like an equal Explains exam Honesty Conscious of financial

situations

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

seriously home

Relaxed Concerned about Encourages questions Checks on what

atmosphere daily life patient should be
doing

Graphic 52737 Version 2.0

Approach to effective clinical communication

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
quickly atmosphere
• Convey knowledge of patient's history by commenting
on prior visit or problem • Allows faster
access to real reason
• Attend to patient's comfort
for visit
• Make a social comment or ask a nonmedical question to
• Increases
put patient at ease
diagnostic accuracy
• Adapt own language, pace, and posture in response to
• Requires less work
patient
• Minimizes "Oh, by
Elicit • Start with open-ended questions: the way..." at the
patient's end of visit
- "What would you like help with today?" OR,
concerns • Facilitates
- "I understand that you're here for... Could you tell me
negotiating an
more about that?"
agenda
- "What else?"
• Decreases
• Speak directly with patient when using an interpreter potential for conflict

Plan the • Repeat concerns back to check understanding

visit with
• Let patient know what to expect: "How about if we start
the patient with 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 concerns
specific been thinking about this visit, how were you hoping I • Reveals use of
requests could help?" alternative
Explore the • Check context: "How has the illness affected your daily treatments or
impact on activities/work/family?" requests for tests
the • Improves
patient's diagnosis of
life depression and
anxiety

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

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

of your might be feeling
own
• Take a brief break if necessary
reactions

Invest in the Deliver • Frame diagnosis in terms of patient's original concerns • Increases potential
end diagnostic for collaboration
• Test patient's comprehension
information
• Influences health
Provide • Explain rationale for tests and treatments outcomes
education • Improves
• Review possible side effects and expected course of
recovery adherence

• Recommend lifestyle changes • Reduces return

calls and visits
• Provide written materials and refer to other sources
• Encourages self
Involve • Discuss treatment goals care
patient in • Explore options, listening for the patient's preferences
making
decisions • 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

the visit have?"
• 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.

Graphic 69929 Version 3.0

Areas of knowledge, skills and values that support the patient-practitioner
relationship

Area Knowledge Skills Values

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

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

Patient Role of family, culture, Recognize patient's Appreciation of the patient as a

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

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

Graphic 71179 Version 2.0

The struggle to stay centered on values in the profession of medicine

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.

Graphic 81986 Version 5.0

Techniques for improving our approach to patients

Make some quiet time to reflect on satisfying and unsatisfying visits. What 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.

Graphic 70370 Version 3.0

Contributor Disclosures
Jeannette M Shorey, II, MD Nothing to disclose John J Spollen, III, MD Nothing to disclose Mark D
Aronson, MD Nothing to disclose Jane Givens, MD Consultant/Advisory Boards (Partner): CVS
Health/CVS Omnicare [Pharmaceutical management of formulary decision-making].

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 UpToDate standards of evidence.

Conflict of interest policy