History-Taking and Interview Techniques and the Physician-Patient Relationship

The sophisticated scientific discoveries and dramatic technological innovations of the past few decades have substantially altered the manner in which diseases are diagnosed and managed. In this era of technological, “modern” medicine, however, one of the primary principles of compassionate care – listening to the patient – is often overshadowed by the results of imaging studies and laboratory tests. Productivity demands, shorter hospitalizations with more frequent physician team handoffs, among other factors, provide challenges and barriers to making a connection with patients. The importance of physician communication skills within the paradigm of the physician–patient relationship is not a new concept. Sir William Osler once remarked, “The good physician treats the disease; the great physician treats the patient who has the disease”.¹ The emerging body of literature on quality and safety in medical care has demonstrated an unequivocal benefit of good communication on improved outcomes and clear associations of communication deficiencies with medical error and negative patient experiences.² Therefore, effective communication in medicine is of paramount importance for providers and patients.   

In the 1960s, Engle developed the concept of the “biopsychosocial model” of patient care to incorporate the broader psychological and social context of the patient into an understanding of their overall health.³ Since that time, numerous partnership models for physician–patient communication have been developed. The Institute of Medicine popularized the concept of “patient-centered care”.⁴ In educational materials, the American College of Obstetricians and Gynecologists endorse the GATHER and RESPECT models^{5, 6} for improved communication. While the acronyms, wording, and phrasing may differ slightly between organizations and models, a unified concept has emerged: namely, that quality medical care requires a combination of comprehensive scientific knowledge and sophisticated communication skills.   

This review focuses on the development of effective communication strategies and patient-centered interviewing techniques that may facilitate successful physician–patient relationships and improve medical care provided by the obstetrician-gynecologist. 

The medical interview remains the most common task performed by physicians. Clinicians perform, on average, over 200,000 interviews during their career.⁷ Obtaining a history and performing the patient interview is the principal skill in medicine and represents the primary vehicle for eliciting relevant personal or symptom information about patients. In fact, studies have demonstrated that interviewing generates the clinical data necessary for diagnoses more often than physical examination and laboratory studies combined.^{8, 9, 10} Communication during interviews represents the primary mechanism for conveying information about treatment and prevention to patients. Importantly, interviewing is the primary determinant of the physician–patient relationship, which impacts the therapeutic potential of any clinical encounter. Communication skills are so important to providing compassionate, quality care that the Accreditation Council for Graduate Medical Education (ACGME) identified interpersonal and communication skills as one of six primary areas, critical to any residency training program, necessary to demonstrate competence.¹¹

Historically, physicians were trained in “clinician-centered” interviewing and were taught to understand patient symptoms and complaints in a biomedical model of health.^{12, 13} A biomedical model of care contextualizes patients strictly by disease. While responsible for many of the great successes and advances in medicine, this approach fails to incorporate other psychological or social factors that may be primary determinants of health for patients. “Clinician-centered” interviewing represents the bedside counterpart to this biomedical model of health care. In “clinician-centered” interviewing, the clinician dictates the interaction to meet his or her own needs – eliciting symptoms and other data to facilitate making a diagnosis. While scientific and focused, this style of interviewing involves many closed-ended questions and fails to allow patients to express personal concerns. Patients do not have the opportunity to lead the encounter, which often precludes the development of a psychosocial history that may impact the care for a particular patient. Current medical literature highlights the deficiencies of the clinician-centered approach. A study of physician interviewing demonstrated that physicians failed to allow their patients to complete their opening statement of symptoms and concerns in 69% of visits and interrupted patients after a mean time of 18 seconds.¹⁴ Another study reported that isolated clinician-centered interviewing techniques revealed only 6% of primary problems of psychosocial origin.¹⁵  

As a result, “patient-centered” interviewing within a biopsychosocial model of care has evolved as a response to the inadequacies of the aforementioned method and model. The biopsychosocial model integrates the biological, psychological, and social dimensions of the individual.³ This model combines a scientific and humanistic approach, whereby an individual with the disease deserves as much attention as the disease itself. The patient brings to the table factors that impact health outcomes, from presentation and treatment to compliance and complications. In a biopsychosocial model of health, the centerpiece of the clinical encounter is an integrated interview approach driven by “patient-centered” interviewing techniques. In patient-centered interviewing, clinicians allow patients to lead and direct the conversation. Patients are encouraged to express what they feel is important, including personal concerns and emotions, which provide an individual context for their symptoms and disease. This approach validates the notion that patients are experts in their own symptomatology, while physicians are skilled in the translation of patient complaints into diagnoses and recommendations for treatment.^{12, 16, 17, 18, 19, 20, 21} This approach also facilitates patient autonomy and a feeling of responsibility for one’s care. When integrated with traditional interviewing techniques, a patient-centered approach to interviewing has been associated with higher patient satisfaction, improved compliance and outcomes in the management of chronic diseases such as hypertension and diabetes, and decreased malpractice suits.^{22, 23} Importantly, patient-centered interviewing should complement traditional clinician-centered interviewing, not replace it. 

Integrated medical interviewing, which includes both clinician- and patient-centered approaches, serves as the backbone for most clinical encounters. Assuming non-urgent symptoms or concerns are not present, the patient-centered portion of the interview generally precedes the clinician-centered portion. This approach validates the importance of a patient’s concerns and allows the patient to develop comfort with the provider as he/she leads the conversation. In an integrated interview of a new patient, the following information is obtained, generally in order:¹² chief complaint, history of present illness, past medical history, past surgical history, past obstetric and gynecologic history, family history, social history (may include spiritual issues that impact care), other health issues/behaviors/hazards, review of systems.

This list may be focused or truncated in patients already familiar to the provider. The chief complaint and history of present illness provide information on the most pertinent symptom bothering a patient as well as the historical and personal context in which the symptoms occur. This portion of the history is best developed using a patient-centered interviewing approach. The latter portions of the interview, from past medical history through review of systems, are most appropriately developed using clinician-centered techniques. Additionally, should pertinent personal issues arise during the latter part of the interview where a clinician-centered approach predominates, providers may need to return to a patient-centered approach to elicit more information. Therefore, providers may need to toggle between techniques within the context of an interview.  

Numerous interviewing skills facilitate a patient-centered approach to clinical encounters. These skills include open-ended questioning, non-verbal communication skills such as purposeful silence or non-verbal encouragement, attentive listening, and summarizing or paraphrasing. Effective patient–physician communication and shared decision-making require the incorporation of these techniques into everyday practice. Smith and colleagues have published extensively regarding the interviewing skills in patient-centered encounters.^{12, 16, 17} Additionally, they proposed a “Five-Step” model to synthesize patient-centered facilitating skills into sequential steps that can be adopted to any clinical encounter (Table 1).^{12, 24}

Table 1. The five step model   

Data from Smith RC.  Patient-centered interviewing: an evidence-based method, 2nd edn. Philadelphia (PA): Lippincott Williams & Wilkins; 2002.  

Table adapted from Committee Opinion #492, Effective Patient-Physician Communication, American College of Obstetricians and Gynecologists, May 2011.    

Smith and colleagues developed and conducted an intensive training program in the five step model, which validated this model within the clinical context of a primary care residency training program.¹⁶ Utilizing this system facilitates the clinician’s understanding of the patient’s point of view and allows clinicians to incorporate the social and emotional context of each individual patient into management and treatment plans.   

Additional qualities that impact provider communication skills include comfort, acceptance, responsiveness, and empathy.²⁴ Caring physicians with effective communication skills have the ability to address difficult topics without apprehension, to accept diverse patient attitudes without intolerance, and to display patience and compassion in all situations. While these qualities are central to caring communication and effective patient–physician relationships, they also facilitate cultural competence in medicine. Numerous studies have demonstrated a significant impact of race and/or gender on care, with discrepancies negatively impacting minorities and women. The Institute of Medicine, Joint Hospital Commission, and National Quality Forum have all issued new standards and measures in cross-cultural communication and cultural competence to improve health care quality for the diverse population in the United States.^{25, 26, 27} Effective communication across cultural barriers is of utmost importance for providers given that patient populations are highly diverse. 

Effective communication and strong patient–physician relationships, while central to all fields of medicine, are of particular importance in obstetrics and gynecology given the sensitive and intimate nature of commonly addressed clinical concerns. While some women feel comfortable discussing the menstrual cycle, genital concerns, contraception, sexuality, or abuse, others may find discussions on these topics inappropriate or embarrassing. Therefore, an obstetrician-gynecologist must establish a comfortable environment and welcoming interviewing technique to facilitate the care of their patients.   

Ideally, a gynecologic history should be obtained in a relaxed, private setting with a patient fully clothed. Under usual circumstances, the interview should occur alone. However, patients may request the presence of parent, spouse or loved one for the interview. This accommodation should be made after verifying that she is comfortable addressing personal questions with an observer in the room. Otherwise, a loved one may be present for part of the interview and, subsequently, a provider may request to speak with the patient alone for a brief period of time before the physical exam to address more personal questions or concerns.   

During the interview, providers must continually assess the patient’s comfort level and make adjustments to their questioning and technique to facilitate the history. For example, a reserved patient who may be uncomfortable answering a direct question about sexual activity may respond to an open-ended question about contraception. Other topics in the gynecologic history, such as vulvar or vaginal symptoms, pelvic relaxation, and pregnancy history may also serve as transitions for exploring the sexual history further with patients. Occasionally, a complete gynecologic history will only be obtained over multiple visits, as some patients will provide more detailed information about their emotional, social, or sexual history only as they become more comfortable with their provider.   

Additionally, remaining non-judgmental during the interview process is imperative; making assumptions regarding a patient’s sexual orientation or sexual activity represents unethical behavior that may have a substantial negative impact on outcomes (such as failing to perform sexually transmitted infection testing and missing the opportunity to diagnose HIV). Ultimately, providers must always remember the sensitive and intimate nature of the gynecologic history. Therefore, the adoption of a comfortable, patient, tolerant, and accommodating interview technique and style is particularly important. 

The integrated medical interview, which incorporates both patient- and clinician-centered techniques, serves as the principal instrument for obtaining a comprehensive history from patients. This approach not only facilitates a broader patient history by incorporating social and emotional aspects of health, but also serves to improve the patient–physician relationship. The five step model proposed by Smith and colleagues represents a tool for the incorporation of patient-centered techniques into clinical practice. Patient-centered techniques are of critical importance to practitioners in obstetrics and gynecology given the intimate and emotional nature of the clinical subject matter and exam. Therefore, providers must develop an empathetic, accepting, and comfortable interview technique and communication style.   

The importance of patient–physician relationships and strong communication skills as a foundation for quality medical care is clear. Ultimately, improving patient–physician communication requires time – time to listen to patients in the office or at the bedside, time to teach and train professionals at all levels in the basics of patient-centered, empathetic communication skills, and time to study the impact of improved communication of quality improvement. Medical student and resident curricula rarely contain devoted or structured education in communication skills.²⁸ Feedback regarding communication is not routinely provided to trainees. Moving forward, the development of effective communication skills must become a centerpiece in medical education. The medical community must make a commitment excellence in communication – improvements in health care quality, patient satisfaction, and patient outcomes depend on the advancement of provider communication skills.