EDITORIALS Talking to Patients DURING THE LATE 1960S and 1970s, medicine, and internal m e d i c i n e in particular, displayed considerable enthusiasm for the possibilities afforded b y advances in clinical chemistry, hematology, microbiology, and xrays to detect disease early or in a p r e s y m p t o m a t i c phase. 1 Multiphasic, automated testing as either an alternative or an adjunct to screening, admission, or annual examinations was v i e w e d as a potentially important advance for i m p r o v i n g the p u b l i c ' s and individual health.2.3 That enthusiasm was d a m p e n e d b y a series of large-scale trials involving a m b u l a t o r y or hospitalized patients showing either no benefit, increased use of hospital days and days out of work, or an o v e r w h e l m i n g n u m b e r of incidental or clinically irrelevant findings and diagnoses as a result of multiphasic screening. 3"6 Eventually, with the leadership of groups such as the Canadian Task Force on the Periodic Health Examination, T M consensus d o c u m e n t s based on rigorous rules of evidence w e r e d e v e l o p e d to describe h o w diagnostic tests c o u l d be applied selectively to symptom-free groups of patients w i t h reasonable e x p e c t a t i o n that the net result w o u l d benefit patients. Meanwhile, w i t h o u t the fanfare that usually acc o m p a n i e s the latest advances in medical technology, a quiet grassroots m o v e m e n t has d e v e l o p e d keen interest in w h a t general internists do most w i t h their patients - - t a l k and c o m m u n i c a t e . The successful teaching and collaborative research efforts by m e m b e r s of the SGIM Task Force on Doctor and Patient are n o t e w o r t h y examples of academic interest and a c c o m p l i s h m e n t . Inpatient and outpatient satisfaction surveys typically find that patients have the lowest level of satisfaction w i t h the a m o u n t of time spent talking w i t h their physicians c o m p a r e d with other areas of physician p e r f o r m a n c e . Sick patients or those with chronic diseases, in particular, consistently wish to spend m o r e time talking w i t h their doctors, it This edition of the Journal contains two papers that focus o u r attention on the medical interview as a diagnostic strategy. Nardone et al. 12 describe a m o d e l based on literature r e v i e w and the authors' " c o l l e c t i v e e x p e r i e n c e as clinicians and teachers." The m o d e l rightly assumes that nonverbal assessment is an important source of information from the interview. It also emphasizes the iterative process of medical diagnosis w h e r e b y clinicians constantly entertain, test, and refine diagnostic hypotheses, typically turning to the physical examination and laboratory tests to confirm or e x c l u d e possible diagnoses. 13 Most diagnostic information is obtained from the 464
interview. Experienced clinicians rely on c o m p o n e n t s of the bedside examination to formulate hypotheses. The iterative process can p r o c e e d rapidly as information from the interview is integrated into the working hypothesis; further questioning and physical examination provide confirmation. By contrast, w h e n the patient is referred for laboratory testing, the clinician typically faces delays in the iterative process. The t h r e e - c o m p o n e n t m o d e l (nonverbal, verbal, and cognitive assessment) and five heuristics are correctly described as focal points for teaching and for " f u r t h e r scientific study." The authors call for m o r e focus on "data-based inquiries" rather than the descriptive, theoretical, and p h i l o s o p h i c discussions p u b l i s h e d in the past. t2 The p a p e r by Mitchell et al. TM is m o r e discrete, describing the diagnostic yield of a c a r d i o p u l m o n a r y and gastrointestinal systems r e v i e w using 12 questions on medicine inpatients w i t h o u t k n o w n c a r d i o p u l m o nary or gastrointestinal disease. After screening 550 admissions, the authors a p p l i e d their c a r d i o p u l m o n a r y and gastrointestinal systems r e v i e w to 98 patients w i t h no k n o w n c a r d i o p u l m o n a r y disease and 207 with no k n o w n gastrointestinal disease and report a yield of 26 n e w diagnoses in 25 patients. Two diagnoses m one a surgically resectable rectal carcinoma and the other premalignant colonic p o l y p s - - w e r e classified as being of definite benefit to the patients, 20 of likely benefit, and four of no benefit. The authors c o n c l u d e that these two systems reviews are likely to be cost-effective c o m p a r e d with other a c c e p t e d medical practices (such as treatment of mild hypertension), since costs w e r e estimated at only $45,900 in total charges and 137 hours of clinician time. Both studies contain information of interest to clinicians w h o are trying to i m p r o v e the value of the t i m e w e spend talking to patients. As essentially descriptive pieces of scholarship, they are best viewed, however, as preliminary studies. They are similar to the early descriptions of the theoretical value of laboratory testing in the diagnosis of p r e s y m p t o m a t i c disease and the descriptive studies of diagnostic yield based on admission laboratory testing.l Both the Canadian Task Force and the U.S. Preventive Services Task Force 15 include history taking w h i l e acknowledging the n e e d for rigorous research, as " t h e r e are no guidelines for the content of the interview." We believe studies of the medical interview n e e d also to focus on " p a t i e n t - c e n t e r e d " o u t c o m e s . As with screening and laboratory testing for case finding, w e need to k n o w w h a t helps patients feel better, get better,
JOURNALOFGENERALINTERNALMEDICINE, Volume 7 (July/August), 1992
or maintain good health. " O u t c o m e s clinical research" can e x p l o r e these issues. The patient-centered app r o a c h to the interview involves patients and puts their concerns u p front. 16 O u t c o m e s research is p r o b a b l y even m o r e challenging w h e n dealing with a subject as c o m p l e x as the value of the medical interview. 17, 18 So-called intermediate outcomes, such as patient satisfaction, compliance, diagnostic efficiency, accuracy and cost, will p r o b a b l y n e e d to be assessed alongside the m o r e traditional e n d p o i n t outcomes, w h i c h measure patient well-being, function, and survival. Studies will n e e d to be p l a n n e d w i t h precision so that they have a reasonable chance of detecting true differences or proving no difference with statistical certainty. Ideally, diagnostic techniques will be well enough d e v e l o p e d and described so that they can be studied u n d e r e x p e r i m e n t a l or quasi-experimental conditions with c o m p a r i s o n groups. Given the track record and academic domain of general internal medicine, academic internists are ideally suited to play leading roles in the d e v e l o p m e n t and assessment of i m p r o v e d diagnostic interviewing techniques. O u r patients clearly want to c o m m u n i c a t e m o r e effectively with their physicians w h i l e at the same time enjoying advances in traditional medical technology. Indeed, lack of effective c o m m u n i c a t i o n is probably the most c o m m o n c o m p l a i n t in the technologic marvels w e call " a c a d e m i c medical centers." As academics, w e should b o t h show our professional comm i t m e n t to m e e t i n g patient desires for better d o c t o r patient c o m m u n i c a t i o n and address our analytic skills to d e v e l o p i n g i m p r o v e d and proven interviewing techniques. A recent consensus statement 19 outlines current k n o w l e d g e and key areas for future research in this area. Perhaps s o m e d a y there will be enough good analytic research to allow the equivalent of the Canadian Task Force on the Periodic Health Examination or the U.S. Preventive Services Task Force to p r o d u c e periodic consensus d o c u m e n t s on the c o m p o n e n t s of the interv i e w as well as on effective medical interviewing techniques. ERIC B. LARSON, MD, MPH, Professor of -
-
Medicine, University of Washington School of Medi-
465
cine, Seattle, WA, and MARYRAMSBOTTOM-LUCIER, MD, MPH, Assistant Professor of Medicine, University of Kentucky, Lexington, KY REFERENCES 1. Breslow L. A historical review of multiphasic screening. Prev Med. 1973;2:177-96. 2. Anonymous. Admission multiphasic screening. Lancet. 1976; 2:1229-30. 3. Bates B, Yellin JA. The yield of multiphasic screening. JAMA. 1972;222:74-8. 4. Olsen DM, Kane RL, Protor BA. A controlled trial of multiphasic screening. N Engl J Med. 1967;294:925-30. 5. LeonardJV, Clayton BE, ColleyJRT. Use of biochemical profiles in a children's hospital: results of two controlled trials. BMJ. 1975;2:662-5. 6. Bradwell AR, Carmalt MHB, Whitehead, TP. Explaining the unexpected abnormal results of biochemical profile screening. Lancet. 1974;2:1071-4. 7. Canadian Task Force on the Period Health Examination. Task force report: the periodic health examination. Can Med AssocJ. 1979;121:1193-259. 8. The periodic health exam: 1984 update. Can Med Assoc J. 1984;130:1278-85. 9. The periodic health exam: 1986 update. Can Med Assoc J. 1986;134:721-9. 10. The periodic health examination: 1988update. CanMedAssocJ. 1988;138:617-26. 11. Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Faro Pract. 1991 ;32:175-81. 12. Nardone DA, Johnson GK, Faryna A, Coulehan JL, Parrino TA. A model for the diagnostic medical interview: nonverbal, verbal, and cognitive assessments. J Gen Intern Med. 1992; 7:437-42. 13. Elstein AS, Shulman LS, Spraflea SA. Medical problem solving: an analysis of clinical reasoning. Cambridge, MA: Harvard University Press, 1978. 14. Mitchell TL, Tornelli JL, Fisher TD, Blackwell TA, Moorman JR: Yield of the screening review of systems: a study on a general medical service. J Gen Intern Med. 1992;7:393-7. 15. U.S. Preventive Services Task Force. Guide to clinical preventive services: an assessment of the effectivenessof 169 interventions. Baltimore: Williams & Wilkins, 1989. 16. Smith RC, Hoppe RB. The patient's story: integrating the patient and physician-centered approaches to interviewing. Ann Intern Med. 1991;115:470-7. 17. Inui TS, Carter WB, Kukull WA, Haigh VH. Outcome-based doctor-patient interaction analysis. I. Comparison of techniques. Med Care. 1982;20:535-49. 18. Carter WB, Inui TS, Kukull WA, Haigh VH. Outcome-based doctor-patient interaction analysis. II. Identifying effective provider and patient behavior. Med Care. 1982;20:550-66. 19. Simpson M, Buckman R, Stewart M, et al. Doctor-patient communication: the Toronto consensus statement. BMJ. 1991; 303(6814):1385-7.
interview. Experienced clinicians rely on c o m p o n e n t s of the bedside examination to formulate hypotheses. The iterative process can p r o c e e d rapidly as information from the interview is integrated into the working hypothesis; further questioning and physical examination provide confirmation. By contrast, w h e n the patient is referred for laboratory testing, the clinician typically faces delays in the iterative process. The t h r e e - c o m p o n e n t m o d e l (nonverbal, verbal, and cognitive assessment) and five heuristics are correctly described as focal points for teaching and for " f u r t h e r scientific study." The authors call for m o r e focus on "data-based inquiries" rather than the descriptive, theoretical, and p h i l o s o p h i c discussions p u b l i s h e d in the past. t2 The p a p e r by Mitchell et al. TM is m o r e discrete, describing the diagnostic yield of a c a r d i o p u l m o n a r y and gastrointestinal systems r e v i e w using 12 questions on medicine inpatients w i t h o u t k n o w n c a r d i o p u l m o nary or gastrointestinal disease. After screening 550 admissions, the authors a p p l i e d their c a r d i o p u l m o n a r y and gastrointestinal systems r e v i e w to 98 patients w i t h no k n o w n c a r d i o p u l m o n a r y disease and 207 with no k n o w n gastrointestinal disease and report a yield of 26 n e w diagnoses in 25 patients. Two diagnoses m one a surgically resectable rectal carcinoma and the other premalignant colonic p o l y p s - - w e r e classified as being of definite benefit to the patients, 20 of likely benefit, and four of no benefit. The authors c o n c l u d e that these two systems reviews are likely to be cost-effective c o m p a r e d with other a c c e p t e d medical practices (such as treatment of mild hypertension), since costs w e r e estimated at only $45,900 in total charges and 137 hours of clinician time. Both studies contain information of interest to clinicians w h o are trying to i m p r o v e the value of the t i m e w e spend talking to patients. As essentially descriptive pieces of scholarship, they are best viewed, however, as preliminary studies. They are similar to the early descriptions of the theoretical value of laboratory testing in the diagnosis of p r e s y m p t o m a t i c disease and the descriptive studies of diagnostic yield based on admission laboratory testing.l Both the Canadian Task Force and the U.S. Preventive Services Task Force 15 include history taking w h i l e acknowledging the n e e d for rigorous research, as " t h e r e are no guidelines for the content of the interview." We believe studies of the medical interview n e e d also to focus on " p a t i e n t - c e n t e r e d " o u t c o m e s . As with screening and laboratory testing for case finding, w e need to k n o w w h a t helps patients feel better, get better,
JOURNALOFGENERALINTERNALMEDICINE, Volume 7 (July/August), 1992
or maintain good health. " O u t c o m e s clinical research" can e x p l o r e these issues. The patient-centered app r o a c h to the interview involves patients and puts their concerns u p front. 16 O u t c o m e s research is p r o b a b l y even m o r e challenging w h e n dealing with a subject as c o m p l e x as the value of the medical interview. 17, 18 So-called intermediate outcomes, such as patient satisfaction, compliance, diagnostic efficiency, accuracy and cost, will p r o b a b l y n e e d to be assessed alongside the m o r e traditional e n d p o i n t outcomes, w h i c h measure patient well-being, function, and survival. Studies will n e e d to be p l a n n e d w i t h precision so that they have a reasonable chance of detecting true differences or proving no difference with statistical certainty. Ideally, diagnostic techniques will be well enough d e v e l o p e d and described so that they can be studied u n d e r e x p e r i m e n t a l or quasi-experimental conditions with c o m p a r i s o n groups. Given the track record and academic domain of general internal medicine, academic internists are ideally suited to play leading roles in the d e v e l o p m e n t and assessment of i m p r o v e d diagnostic interviewing techniques. O u r patients clearly want to c o m m u n i c a t e m o r e effectively with their physicians w h i l e at the same time enjoying advances in traditional medical technology. Indeed, lack of effective c o m m u n i c a t i o n is probably the most c o m m o n c o m p l a i n t in the technologic marvels w e call " a c a d e m i c medical centers." As academics, w e should b o t h show our professional comm i t m e n t to m e e t i n g patient desires for better d o c t o r patient c o m m u n i c a t i o n and address our analytic skills to d e v e l o p i n g i m p r o v e d and proven interviewing techniques. A recent consensus statement 19 outlines current k n o w l e d g e and key areas for future research in this area. Perhaps s o m e d a y there will be enough good analytic research to allow the equivalent of the Canadian Task Force on the Periodic Health Examination or the U.S. Preventive Services Task Force to p r o d u c e periodic consensus d o c u m e n t s on the c o m p o n e n t s of the interv i e w as well as on effective medical interviewing techniques. ERIC B. LARSON, MD, MPH, Professor of -
-
Medicine, University of Washington School of Medi-
465
cine, Seattle, WA, and MARYRAMSBOTTOM-LUCIER, MD, MPH, Assistant Professor of Medicine, University of Kentucky, Lexington, KY REFERENCES 1. Breslow L. A historical review of multiphasic screening. Prev Med. 1973;2:177-96. 2. Anonymous. Admission multiphasic screening. Lancet. 1976; 2:1229-30. 3. Bates B, Yellin JA. The yield of multiphasic screening. JAMA. 1972;222:74-8. 4. Olsen DM, Kane RL, Protor BA. A controlled trial of multiphasic screening. N Engl J Med. 1967;294:925-30. 5. LeonardJV, Clayton BE, ColleyJRT. Use of biochemical profiles in a children's hospital: results of two controlled trials. BMJ. 1975;2:662-5. 6. Bradwell AR, Carmalt MHB, Whitehead, TP. Explaining the unexpected abnormal results of biochemical profile screening. Lancet. 1974;2:1071-4. 7. Canadian Task Force on the Period Health Examination. Task force report: the periodic health examination. Can Med AssocJ. 1979;121:1193-259. 8. The periodic health exam: 1984 update. Can Med Assoc J. 1984;130:1278-85. 9. The periodic health exam: 1986 update. Can Med Assoc J. 1986;134:721-9. 10. The periodic health examination: 1988update. CanMedAssocJ. 1988;138:617-26. 11. Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Faro Pract. 1991 ;32:175-81. 12. Nardone DA, Johnson GK, Faryna A, Coulehan JL, Parrino TA. A model for the diagnostic medical interview: nonverbal, verbal, and cognitive assessments. J Gen Intern Med. 1992; 7:437-42. 13. Elstein AS, Shulman LS, Spraflea SA. Medical problem solving: an analysis of clinical reasoning. Cambridge, MA: Harvard University Press, 1978. 14. Mitchell TL, Tornelli JL, Fisher TD, Blackwell TA, Moorman JR: Yield of the screening review of systems: a study on a general medical service. J Gen Intern Med. 1992;7:393-7. 15. U.S. Preventive Services Task Force. Guide to clinical preventive services: an assessment of the effectivenessof 169 interventions. Baltimore: Williams & Wilkins, 1989. 16. Smith RC, Hoppe RB. The patient's story: integrating the patient and physician-centered approaches to interviewing. Ann Intern Med. 1991;115:470-7. 17. Inui TS, Carter WB, Kukull WA, Haigh VH. Outcome-based doctor-patient interaction analysis. I. Comparison of techniques. Med Care. 1982;20:535-49. 18. Carter WB, Inui TS, Kukull WA, Haigh VH. Outcome-based doctor-patient interaction analysis. II. Identifying effective provider and patient behavior. Med Care. 1982;20:550-66. 19. Simpson M, Buckman R, Stewart M, et al. Doctor-patient communication: the Toronto consensus statement. BMJ. 1991; 303(6814):1385-7.
