Shirah Vollmer MD

The Musings of Dr. Vollmer

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.

4 Responses to “The Initial Interview: Structured or Open Ended?”

  1. Eleanor said

    I can clearly visualize my initial meeting with my psychoanalyst today as tho it were yesterday, even though was many many years ago. My first comment was “well what should I talk about” and the answer i got was a short and simple ….”whatever bugs you the most”. This left the conversation wide open for me to take the lead and of course what bugged me the most was my immense struggles, psychic pain and confusion with my then 10 year old daughter that had been born with spina bifida and had to live will significant physical disabilities. Of course the conversation branched out from this starting point. So, yes I would vote for an open ended initial approach. This gave me some sense of control and let me rant! 😉

    • Yes, Eleanor, the freedom to “rant” to express yourself on your own terms is, to quote Yalom, “the gift of therapy”. This is something we need to hold on to tightly and not let EMR take that away. Thanks.

  2. Shelly said

    I can imagine the EMR is structured by insurance companies which want to get the facts down on paper and don’t deal with the non-tangibles like dreams. They have alot of ground they need to cover (symptoms, length of time of symptoms, family members with similar symptoms, medications, physical issues, etc…) and they want it documented. There goes the “art” of psychiatry which you so want to protect. But what is the answer to the question you posed? How do you open up your first sessions with your patients? “What brings you in today?” “How can I help you?” “Tell me about yourself?”

    • Billing is structured in the United States in which the more the physician demonstrates complexity the more the insurance will pay and so many EMR systems are built to maximize payment. As to how I open a session with a new patient, that depends on the phone call or email which precedes the appointment. It is not one size fits all, but one of my favorite ways of opening a relationship is to invite the patient to tell me their story, that is, to tell me the context in which they entered and developed in the world. Creating context is lost in our modern world of symptom management. If EMRs can provide an opportunity to document the patient’s life then it can be enormously useful to future clinicians. In that way, I am excited to digitize records, but at the same time, privacy is a major concern and is sacrificed in our digital age. Thanks, as always.

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