THE THREE DIMENSIONS OF A
• Frederic W. Platt, MD
• James Hardee, MD
• Jim Binder, MD
• Paul Haidet, MD
• AACH October 17,
1st Qtr 2nd Q tr 3rd Qtr 4th Qtr
• Clinical Interviews seem too chaotic to
describe in a rational fashion. Structures
that have been useful in the past including
a progression from open-ended inquiry
towards closed ended, often labeled as
“patient centered” vs. “doctor centered” do
not seem to do justice to the complexity of
the clinical conversations being described.
Even fragments of interviews
are tough to classify.
Analysis of short segments can be difficult and
confusing, much as longer interview transcripts
Consider these scraps of clinical conversations:
• Clinician: You have to quit smoking. If
you continue you will have a twenty-fold
increase in the likelihood of developing
• Patient: I know all that. But when I quit
before, I was such a bear that all my
friends at work told me to go back to
• WHAT’S GOING ON?
• Clinician: Do you have chest pain?
Trouble breathing? Fever?
• Patient: No, no fever.
• Patient: I thought it might be West Nile
• Clinician: Sounds scary.
• Patient: It was. But then the big change
was when I started sinking.
• Clinician: Sinking?
• Patient: Yes, I swim half a mile about
three times a week. And Friday I couldn’t
float. I sank.
• Clinician: Let’s get down to business; the
nurse says your knees are bothering you.
• Patient: Well, yeah, but mostly …
• Clinician: (interrupting) Slip out of your
trousers and we’ll take a look.
Finally Scrap #5:
• Clinician: You mentioned trouble in your
• Patient: Yeah, my left knee, just when I
walk downstairs or down a hill. It clicks
and sometimes it hurts.
• Clinician: I see.
What is going on? How to analyze
• We find a three-dimensional analysis
helpful. We can consider first our goals
(“our” meaning both patient and clinician),
then the topics of our scrutiny, and finally
the tools we might use in our
Goals of the interview
• What does the patient want to achieve?
• What does the clinician want?
The patient’s goals
• Being heard and understood (common
complaint: “My doctor doesn’t listen and
• Having our opinions and values counted.
• Having the clinical expertise of the doctor
employed to ferret out diagnoses and pick
treatments that will alleviate our suffering.
• What else?
The clinician’s goals.
• 1. Rapport and trust building; creating a
• 2. Data retrieval. Understanding the
patient’s symptoms, saga of medical care,
and feelings, ideas, and values.
• 3. Forward moving steps: Patient
education, behavior modification; enlisting
the patient in his own health behavior;
Involving and recruiting others; Future
medical attention. J. Bird, S. Cohen Cole
The Clinician’s goals: another
• 1. Fostering the relationship
• 2. Gathering data
• 3. Providing information (education,
• 4. Decision making.
• 5. Behavior modification.
• 6. Responding to the patient’s values,
ideas, and emotions.
– De Haas and Bensing 2009
The data base
• What are we interested in? What do we
include in a thorough data base? Is there
room for the person of the patient?
Topics for our scrutiny.
• Who is this patient? The person of the
patient. Work, activities, relationships.
• Key symptoms and their development.
• Other current active medical problems:
symptoms, history, treatments.
• Social situation and relationship issues.
• Health related behaviors: alcohol, tobacco,
drugs, allergies auto behavior, family and
Topics to attend to (Continued)
• Health promotion activities: medical
screening, exercise, diet pattern, …
• Mental state and personality.
• Past medical history and events.
• Review of systems.
• Ideas and concerns. Explanatory model.
• Current feelings and underlying values.
The clinician’s tools
• What really goes on?
• What does the clinician say and do? We
must not get trapped in considering only
what the clinician SHOULD say or do.
This is descriptive, not prescriptive.
The Clinician’s conversational
tools and techniques.
• Closed questions, answerable with a
“yes,” a “no,” or a number.
• Invitations to tell a story.
• Listening, accompanied by non-verbal
• Listening while focus is elsewhere.
• Urging specific behaviors or changes in
Clinician’s conversational tools.
• Reception devices: “I see,” “OK,” “Gosh!,”
“Wow!,” “Sounds good,” “That’s awful,” …
• Nonverbal behaviors including eye-contact
or its lack, touch, nods, head shakes,
body posture, and wordless sounds.
(hmmm, ah, …)
Clinician’s conversational tools
• Summarization, echo, reflection, empathy
• Gentle commands
• Harsh orders
• Requests for permission to enter a tender
subject or explain.
• Warnings and threats.
Fragment analysis in three
• Case 1: Doctor’s tools: warning, even
• Topic: patient’s cigarette smoking, an item
from “Harmful Behaviors.”
• Clinician’s goal: behavior change.
Patient’s goal: maintain productive
relationships with his social network. (n.b.
“denial” = difference in cost-benefit
• Clinician tool: series of narrow-ended
questions (most pervasive in our observed
• Topic: current symptoms.
• Goal: data acquisition. Patient’s goal
invisible and likely given up already.
• Topic: patient’s symptoms and ideas (EM)
• Clinician’s goal: data retrieval but includes
patient ideas as well as symptoms.
• Patient’s goal: to voice her own ideas and tell
her story and be heard and understood.
• Clinician’s technique: empathic response; open-
ended inquiry. Curiosity and a willingness to
Case #4 and #5
• Clinician’s tool: appears to be an invitation
but then focuses on a second-hand
datum. Disregard of patient’s effort to
• Target topic: symptom and location.
• In case #5 the clinician gently returns the
patient to a previously mentioned
symptom and gets further patient
Consider two Emergency
• Clinician: I’m Dr. Jones. What seems to
be the trouble? What brings you to us
today? (This doctor did not look at his
patient, did not offer a handshake, and
seemed focused on the chart.)
• Patient: I think I might have that H1N1 flu.
• Clinician: Why do you think that?
• Patient: Mostly it’s my wife’s idea.
#7. A different beginning.
• Clinician: (sitting down facing the patient
and offering a handshake) Hello, I’m Dr.
Jones. Are you Mr. January?
• Patient: Yes, that’s me, doctor.
• Clinician: OK, well how about starting by
telling me a little about yourself and what
sort of trouble you’ve been having.
• Patient: OK, doctor. I’m Jim January. I’m
a plumber but I haven’t been working for a
week because of this cough and the fever
I’ve got. My wife thinks I might have that
• Clinician: I see. Cough and fever. And
Another approach to patient #1?
• Clinician: I know we’ve talked about your
breathing trouble and your cough but now
I wonder if we might talk some about your
• Patient: I know, doc, it’s part of the
problem. I watched that 20-20 program
about cigarettes and I don’t want to end up
with lung cancer.
• Clinician: So tell me more about the
Case #1a. Continued.
• Patient: I’ve been doing it since I was 15.
I smoke about a pack a day and I’ve tried
to quit a couple of times but I get so cross
and irritable that people tell me to go back
• Clinician: So you’ve tried to quit but it
• Patient: Exactly!
What of multiple interviewees?
e.g. Pediatrics or Geriatrics.
• Invitations may work well with parents.
Less effectively with young patients who
may limit their responses.
• Consider offering the patient a chance to
talk when he/she is ready.
What works best?
• Avoid rapport-diminishing techniques.
• The trap of closed questions.
• Somewhere in there, discover the person
of the patient.
• Three dimensions to consider: goals,
topics, and techniques.
• Time provides a fourth dimension.
Relationships stretch over time.
Thanks, now tell us:
• What other goals, topics, techniques fit in
with your work?
• What works best for you?
• What further dimensions need to be
• What else?