Derived from Lipkin M, Frankel RM, Beckman HB, et al. Performing the interview. In: Lipkin M, Putnam SM, Lazare A, eds. The medical interview: clinical care, education, and research. New York: Springer-Verlag, 1995:65–82.
discussions with physicians are more dialogue than lecture. In addition, when patients feel they have some room for negotiation, they tend to retain more information regarding health care recommendations. The concept of collaborative planning between patients and physicians is embraced as a more effective alliance than the previous model in which physicians issued orders (22). The patient thus becomes more vested in the process of determining health care choices. For example, decisions about the risks and benefits of menopausal hormone therapy must be discussed in the context of an individual’s health and family history as well as her personal beliefs and goals. The woman decides whether the potential benefits outweigh the potential risks, and she is the one to determine whether or not to use such therapy. Whereas most women prefer shared decision making in the face of uncertainty, with an evidence-based discussion of her risks and benefits, others want a more directive approach (23). The physician’s challenge is to be able to personalize the interaction and communication.
There is evidence that when patients are heard and understood, they become more vocal and inquisitive and their health improves (9). Participation facilitates investment and empowerment. Good communication is essential to the maintenance of a relationship between the patient and physician that will foster ongoing care. Health maintenance, therefore, can be linked directly to the inﬂuence of positive interactions between the physician and patient. Women who are comfortable with their physician may be more likely to raise issues or concerns and convey information about potential health risks and be more receptive to the physician’s recommendations. This degree of rapport may promote the effectiveness of health interventions, including behavior modification. It helps ensure that patients return for regular care because they feel the physician is genuinely interested in their welfare and they have confidence in the quality of the treatment and guidance they receive.
When patients are ill, they feel vulnerable, physically and psychologically exposed, and powerless. The physician, by virtue of his or her knowledge and status, has power that can be intimidating. It is essential that the physician be aware of this disparity so the “balance of power” does not shift too far away from the patient. Shifting it back from the physician to the patient may help improve outcomes (1,20,21). Physicians’ behaviors can suggest that they are not respectful of the patient. Such actions as failing to maintain scheduled appointment times, routinely holding substantive discussions when the patient is undressed, or speaking to her from a standing position while she is lying down or in the lithotomy position can emphasize the imbalance of power in the relationship.
In assessing the effects of the patient–physician interaction on the outcome of chronic illness, three characteristics associated with better health care outcomes were identified (21): 1.
An empathetic physician and a high level of patient involvement in the interview.
2.
Expression of emotion by both patient and physician.
3.
Provision of information by the physician in response to the patient’s inquiries.
Among patients with diabetes, these characteristics resulted in improved diastolic blood pressure and reduction of hemoglobin A1c. The best responses were achieved when an empathetic physician provided as much information and clarification as possible, responded to the patients’ questions openly and honestly, and expressed a full range of emotions, including humor. Responses improved when the relationship was not dominated by the physician (21).