The Initial Interview: Structured or Open Ended?
Posted by Dr. Vollmer on May 4, 2015
When meeting a patient for the first time, in an outpatient setting, should the interview be structured or open-ended, meaning should the doctor have a list of questions, or should the patient determine the flow of conversation? Physicians are taught to have more closed-ended questions in an effort to get through a lot of “material.” Psychoanalysts are more curious how the patient constructs his/her narrative. Being in both camps, a physician and a psychoanalyst, I tilt towards being curious about how the patient creates an impression of himself. Does he start with where he is born, his siblings, his parents, or the “here and now” issues, as Dr. Yalom labels the current complaints. Yet, medical training fights against narratives as the pressure towards electronic medical records, corresponding to billing pressures, forces the physician to ask very specific and limited questions. This aspect of EMR (electronic medical records) is yet another unintended consequence in that EMR changes how the physician obtains a history and in so doing, the narrative is short-changed. This has been my fear for some time, but chatting with newly minted physicians, my fears are confirmed. The art of listening to narratives, like reading books, or watching movies, is diminishing in this time of monetizing clicks for billing purposes. Can we bring back this narrative, the opportunity for the patient to speak in ways which convey his subjectivity, his vulnerabilities, transmitted through changing eye contact, switched subjects and tone of voice. Dreams too, are another avenue of rich exploration, lost to the physician struggling to make sure he/she does all the right boxes on the EMR. A utilization review person will poke them if a box is not checked, but if they fail to ask about the nature of the patient’s dreams, there is no immediate consequence. My rant persists. The loss of the patient narrative, listening to how the patient wants the physician to hear his life story, is tremendous, both for patients and for physician satisfaction.