Conducting a Productive Diagnostic Interview:
THE IMPORTANCE OF FOLLOWING THE PATIENT'S
ASSOCIATIONS WHILE DIRECTING THE INTERVIEW
Excerpted from Morgan WL and Engel GL: The Clinical Approach to the Patient (W.B. Saunders, 1969)
The necessity to delineate the illness and to characterize symptoms in the seven dimensions requires that the student provide direction in the interview. Encouraging the patient to speak freely continues to be the basic requirement for a productive interview, since only the patient can describe what he has been experiencing. On the other hand, he usually does not appreciate all that the interviewer needs to learn from him. In order to accomplish his task of diagnosis, the student must subtly direct the course of the interview. Far from being merely a passive listener, he indicates to the patient by his responses and questions the need for certain organization and content. The patient soon comes to appreciate that events must be dated, sequences established, and symptoms described precisely. At the same time, such direction must not be achieved at the expense of prejudicing the patient's responses or of blocking the free flow of his associations. The amount of direction needed in the interview varies with the patient. Some will wander and discuss unproductive areas in minute detail; others will gloss over important historical points, and still other patients will present a coherent story where little intervention is needed. It is most important that the student be flexible in his interview technique, learn to adapt to the patient's style of reporting, and still remain in control of the situation. The student should neither passively listen to volumes of irrelevant detail, nor should he conduct the interview in the manner of a courtroom lawyer by firing repeated questions. Obviously, much practice and experience are needed to achieve the proper balance.
The two objectives, to encourage the patient's spontaneous associations and to provide direction, are best achieved by always initiating the inquiry into each new area with open-ended (nondirective) questions and by following with progressively more specific (directive) questions until the subject is fully clarified. This means that the interviewer must have clearly in his mind what details are necessary to understand the illness yet not prematurely impose his ideas on the patient. For example, he may begin the investigation of a symptom with the request, "Tell me more about it" or "What was it like?" This allows the patient to say whatever he wishes about the symptom and to bring up his own associations, unprejudiced by the interviewer. The student, as he listens to the patient's account, is alert to omissions and ambiguities, and periodically indicates what needs to be clarified; e.g., "That was when?" What was the feeling?" Which came first?" As the patient completes his more spontaneous account, the interviewer then follows with whatever specific questions are necessary to complete the picture. In so doing, he always tries to formulate each successive question on the basis of what the patient has just said. In essence, just as is done in sustaining a conversation, the student picks up where the patient leaves off. By following the patient's lead, he avoids the disruption of the patient's train of thought and important associations emerge naturally under such conditions. When a series of direct questions are posed early in the interview, the patient may respond simply by waiting passively for the next question. Only when the interviewer is satisfied that he has obtained all the information that he needs by following the patient's associations, does he again take the initiative to change the subject and introduce a new topic. Each new area is pursued in the same manner. Thus, the interview typically consists of a series of interconnected sequences, each one of which begins with open-ended questions and progresses to increasingly more specific questions until the issues are fully defined.
Throughout the interview, the student remains attentive to the patient's spontaneous associations, even when at first they may seem to be irrelevant. The patient is allowed to digress long enough to establish whether the information is pertinent to the history. If so, he is encouraged to continue. All the while, however, the student must keep in mind what information the patient has not yet clarified, so that he can return later to ask the necessary questions at an appropriate time.
The value of pursuing the patient's associations is illustrated in the following example.
A 34-year-old man, complaining of headaches, mentioned that they seemed to get worse
toward the end of a day's work. When asked at that point what his work was, the patient described a job in a poorly-ventilated auto repair shop. Spontaneously, he began to wonder whether exhaust fumes could be responsible for the headaches. This was a plausible suggestion, since headaches are a symptom of carbon monoxide poisoning. Inquiry about working conditions, however, revealed this cause to be improbable. Asked what he did after leaving work, he said that he often procrastinated about going home, stopping at a bar to visit with his cronies. He went on to explain that he and his wife were not getting along well, so that often he was reluctant to go home. As he mentioned this, he began to wonder whether tension could have anything to do with the headaches. Further questioning about his marital situation, however, left no doubt that the headaches preceded the difficulty with his wife by several months. Asked about other circumstances when headaches occurred, he mentioned playing golf, working in his basement workshop, and romping with the children. Exploration now revealed that repeated bending over was the common denominator for all the situations in which the headache developed. This discovery suggested that a mechanical factor was important; and indeed, it turned out that the headache was due to a brain tumor.
In this example, each of the associations had to be examined in its own right. Some proved to be blind alleys in respect to the final diagnosis of brain tumor, but all yielded information important for a better understanding of the patient.
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