Interview Techniques

Issues of Concern

Medical professionals consider a medical history of greater diagnostic value than the physical exam or laboratory results/investigations. Patient interviews are the most common evaluation tool in clinical medicine, with medical professionals performing hundreds of thousands of them during a career, and are critical for discovering pertinent information that leads to a correct diagnosis. The interview also grants therapeutic power; it is used to establish a relationship with the patient and to afford empathy and reassurance. Depending on the purpose of the interview, the goals of the patient and the medical professional may differ significantly. Patients tend to be interested in airing their problems in front of a respected professional, and interviewers are looking for causes and/or potential solutions for the patient.

Two types of patient interviews are common: the problem-oriented interview and the health promotion interview. The problem-oriented interview addresses the patient’s current and past health concerns. The health promotion interview assesses risk factors and decreases the potential for diseases. Developing skills to involve the patient in the diagnostic and therapeutic plan improves the patient’s willingness to follow through and achieve measurable, attainable goals.

As an interview is conducted, one must distinguish between the content of what the patient is describing and their emotional and personal insight. The content includes a chronology, onset, description, intensity, exacerbating factors, remitting factors, associated symptoms, social history, medical history, allergies, surgical history, hospitalizations, family medical history, current medications, and other conditions. This information may guide a diagnostic path for the patient. Furthermore, another aspect of the patient interview is recognizing how the patient expresses information while analyzing meaning through both verbal and nonverbal communication. This includes facial expressions, posture, gestures, behaviors, and emotional reactions. Some patient concerns or symptoms may not be expressed directly and must be noted by an astute interviewer. For example, topical avoidance or an abrupt change in conversational flow may be observed. The development of a nonjudgmental interviewing style is likely to improve the patient’s disclosure of concerns. Patients rarely present their symptoms in an organized manner; therefore, it is beneficial for the interviewer to ask open or directional questions that help the patient communicate necessary information during the discussion.

Skills for building relationships with patients include:

• Active listening: Interest in the patient without judgment
• Empathy: An emotional state of communication and understanding
• Concern: Caring for the unique patient

Demonstrate knowledge and understanding by asking pertinent questions during the interview. Showing empathy may be a simple comment, such as “that sounds like a very difficult time,” when the history of a father's passing from heart disease at a young age is shared. When appropriate, a reassuring touch or moment of silence may also strengthen relationships with patients. The first step in the interview includes a formal introduction. Second, look for the patient's immediate needs. In the emergency room, this may include assessing the patient’s airway, breathing, and circulation. In other situations, the interviewee may require something to be comfortable, possibly a glass of water. Patient interviews are best conducted in private without distractions. Emotions must be assessed promptly in the interview process due to the possibility that one may confuse the history with embellishments and defensiveness.

As the interviewer, it is important to keep the interview flowing productively and positively. At the beginning of the interview, express time allocation to assist the patient in prioritizing their concerns. This also empowers the patient to feel in control of their concerns and the discussion. Furthermore, mix open-ended questions with focus questions. Open-ended questions may allow the patient to express their thoughts and feelings, while focused questions allow the interviewer to obtain important details with yes-or-no answers more efficiently. Too many focus questions may cause one to feel interrogated. Although more efficient at times, a very high number of focus questions may cost the interviewer rapport with the patient.

The first question posed in the interview is often open-ended. For example, “What is the main reason you seek medical assistance today?” This provides an opportunity for the interviewer to invite the patient to share their concerns and to show that he or she is actively listening. This includes listening without judgment and displaying concern for the patient during communication. Typically, patients do not often express their main complaint right away. Therefore, as the patient concludes their thoughts, an interviewer may find success by inquiring further, “Is there anything else you would like to share at this time?” Some patients express anxiety, anger, helplessness, or other emotions. Recognizing the patient’s emotions as valid and offering reassurance may build a meaningful relationship.[1]

During the interview, meaningful, positive questions reduce the patient's defensiveness. Often, this can be accomplished by suggesting or sharing a common behavior associated with the patient's actions. For example, the interviewer may convey the commonality for people to consume alcohol when under stress. It then becomes acceptable to inquire if this is also occurring with the patient. The patient may feel a sense of trust and therefore share pertinent information.

At the conclusion of the patient interview, an appropriate transition statement to begin the physical exam may be, “Is there anything else that you would like to share with me before I start the physical examination?” This statement serves 2 purposes. First, it elicits any additional information the patient deems necessary, and second, it signals a transition to the physical exam. Upon completion of the physical exam, it is appropriate to discuss the findings with the patient, as well as the next course of action. This includes informing the patient of the labs and imaging required to obtain further information about the illness, as well as the medications and intravenous fluids to be administered to treat the patient. Lastly, before concluding the interview, it is important to discuss the probable follow-up plan and further treatment. In the outpatient setting, this may include hospital admission, going home, and returning for a follow-up appointment at a designated time. Inpatient settings may include admission to the hospital, discharge, and follow-up with a physician in the outpatient setting, or discussion of further testing and examinations for a final resolution. The final phase of communication in the interview process provides the patient with important information about their illness and builds rapport, with the goal of increasing the patient's involvement in their health.

Lifelong learning and practice in medical interviewing improve one’s ability to reach patients in a more understanding and caring manner. Research provides evidence that even novice medical interviewers can be taught to be more effective in the interview process. Furthermore, studies confirm that as students begin interviewing, they benefit from a set of interview questions while incorporating other positive interview skills, as explained above. As students progress in their careers, they can adopt a more open-ended interview method. Simulated patient encounters have become an aspect of education and examinations in health professional schools. These patient encounters are recorded, and proctors provide feedback regarding the student’s performance during the encounter. It is perfectly acceptable to ask a more experienced interviewer to review your patient interviews and offer constructive feedback to enhance your interview skills. Due to the importance of the interview component of an appointment, simulated patient encounters have become part of licensing exams for physicians and other health professionals.

Veterans, as well as inexperienced interviewers, often make common mistakes during medical interviews. As described above, these mistakes decrease the patient’s trust in the interviewer and may lead to additional medical errors. Often, mistakes occur when interviewers are emotionally detached from the patient or when there are perceived or real-time constraints. Avoiding the following common mistakes provides improved medical care.

Common Interview Mistakes

• Too many focused questions
• Ignoring the patient’s emotions
• Arriving at a diagnosis or shortening the differential too early in the interview process
• Refusing to return to the patient for further information or clarifications
• No introductions, no regard for the patient’s comfort, no relationship building
• No open-ended questions
• Interruptions to the interview process [2]

Clinical Significance

There are many ways effective patient communication can improve clinical outcomes and patient safety. It is essential when identifying the labs, procedures, and imaging required to diagnose a patient's condition. This initial communication also assists in developing a differential diagnosis on which medical treatment is based. The quality of medical treatment is largely based on the initial patient interaction. Furthermore, a positive patient relationship improves patient outcomes, including the ability to return to work promptly and greater functional recovery after treatment.

Effective patient communication leads to improved outcomes. These positive outcomes may include, but are not limited to, improved compliance with medical plans, patient self-regulation of diet and medications, and improved coping mechanisms. These outcomes improve the patient's functional status after treatment. For example, chronic diseases are especially impacted by improved patient relationships and communication due to the complex nature of chronic diseases and extensive treatment.

Joint medical decision-making occurs when a patient and healthcare professional discuss treatment options and the patient's desired outcomes. It improves the patient’s understanding of their likely outcomes with medical treatment and adherence to it. This form of medical decision-making is more successful when positive patient communication is established during the initial interview. Overall, this communication style improves satisfaction with the treatment and opinions of the healthcare professional.

Improving patient communication also increases trust in the healthcare provider and may enable patients to consider all their options when making thoughtful treatment decisions. One such example is a "wait and see" recommendation. This is when a patient may forego an expensive procedure or imaging study and await improvement. Over time, lab or imaging tests may no longer be necessary. This recommendation is less likely to be successful without mutual trust between the healthcare provider and the patient. Also, a patient who trusts their interviewer is more likely to communicate private and personal information regarding themselves and their lifestyle. This may lead to improved treatment and outcomes.[2]

Other Issues

Research Interviews

Medical research investigators use interviews to collect data. This is especially true for qualitative research regarding patient experience. Research interviews have unique challenges. Scientists studying research interviews recommend that new interviewers be supervised by those with extensive experience. Also, an essential requirement for new researchers is to perform practice interviews with opportunities for feedback regarding interview skills. These pilot interviews assist new researchers and avoid misunderstandings and assumptions during their initial research interviews.[3] It is also important to avoid interviewing bias. One example of an interview bias occurs when interviewing young subjects. Children at 2 years old consistently display a bias toward “yes” in yes-or-no questions, whereas 4- and 5-year-olds exhibit a “no” answer bias. The bias diminishes significantly after age 5, as long as the question is comprehensible to the child.[4] Another example of an interview bias involves sensitive questions regarding sexual behaviors. These biases were reduced with audio-computer-assisted self-interviews (completed over a computer interface) compared to face-to-face interviews.[5] Finally, interview bias occurs when interviewers choose their study subjects. This bias can be reduced with strict sampling protocols, consistently trained interviewers, and checking responses to ensure interviewers are sampling similar groups.[6]

A unique aspect of research interviewing is selecting the most suitable individuals to interview to answer the research question effectively and completely. This should be taken seriously to optimize the research project's results. Depending on the research question, interviews require many of the same skills as medical interviews, such as developing rapport and mixing open-ended questions with focused questions. Furthermore, developing an open mind and active listening is important for researchers to conduct effective research interviews. Clearly, research inquiry types differ from medical interviews. For example, researchers are not trying to pinpoint the shortest differential diagnosis. Often, researchers are searching for diverse pieces of information or the consensus of a group or subset of individuals.

A unique aspect of research interviews involves ethical issues. Thus, the questions in a research study must be approved by a separate, third-party council established to review all aspects of research projects.  One ethical issue includes extracting information without harming the people participating in the study. Another ethical issue includes the exploitation of interviewees. If the interview questions are likely to cause emotional or mental harm to those interviewed, counseling must be provided after the questioning. Anonymity must be ensured for interviewed students because the information may be sensitive.  Interviewees must provide signed written consent when participating in a research study. The last step in the research interview is analyzing the information obtained. This involves specialized statistical skills often completed by professionals with expertise in this area.[7]

Job Interviews

Unlike patient and research interviews, job, residency, and academic institution interviews are competitive. The candidate should be better prepared than the interviewer and able to ask pertinent questions that demonstrate they have seriously researched the position and organization and intend to be a contributing member of that organization. These types of interviews are much like academic assessments; they are staged events. Therefore, adequate preparation greatly improves the likelihood of a successful interview. Preparation includes understanding the organization, understanding one’s self, appearing interested, and practicing clear explanations.

It is imperative that an interviewee study the organization for which they want to work. The internet allows anyone to efficiently research an organization, job requirements, and the interview committee. Expressing an understanding of the organization during the interview displays dedication and interest, as the interviewee may tailor their explanations regarding a proposal to fulfill the specific position. This may allow for a more productive interview. Ultimately, the interviewer is seeking someone to fulfill a need within that organization, and the organization is wary of making a hiring misstep. The interviewer uses questions to minimize that risk. Four main questions must be asked and answered during an interview. The questions include:

• Can this person do the job?
• Does this person like?
• Is this person risky in some way?
• Will the salary be sufficient?

The next step in the job interview process includes 2 aspects of self-analysis. First, an interviewee must discover their unique qualities, which is likely the most important skill. This includes, but is not limited to, life experiences, awards received, and academic grades. Second, each unique experience and its qualities must translate into characteristics that benefit the organization and fulfill the job requirement. For example, if one possesses high grades or awards, they may be known as a “hard worker.” Not only does understanding oneself lead to the desired job, but it also makes a person very effective at "selling themselves" during an interview. Also, consider appropriateness for a job as well as weaknesses in the interviewing process. Although some recruitment is involved in the interview process conducted by the interviewing organization, this is far overshadowed by the interviewee's need to answer the 4 questions above appropriately.

Interest in the job and organization is the next essential step in the interview process. Personal phone calls and confirmation emails before the interview display interest in an organization. During the interview, research goes a long way; however, prepared, well-thought-out questions based on the organization are also very important. Often, these questions involve the interviewer. For example, “What is your experience working at this organization?" Furthermore, the interviewee may seek information about the organization's employee qualities. For example, “Can you describe your ideal candidate?” A worthy closing question that also expresses your interest is, “What do I need to do to get this job?” Interviewees may demonstrate interest in the organization by taking effective notes during the interview; this helps them remember different aspects of each organization over time. After the interview, the candidate should follow up on the job with personal emails, phone calls, and letters to express continued interest.

Dressing professionally conveys commitment and interest in a program. Business suits or conservative colors are recommended. Often, it is better to be overdressed than underdressed in these situations. Other quick tips for interview etiquette include arriving early and respecting the interviewer's time. Also, turning off cell phones during the interview is essential. To set oneself apart from other interview candidates, answer all follow-up phone calls and emails promptly.

Successful interviewees practice interview questions extensively before the interview. Textbooks are readily available online and provide many likely interview questions. Remember, the most valuable questions are those related to the 4 main questions listed above. A question one should be prepared to answer is, “Why should the organization take you over another candidate?” These questions should be answered with a strong understanding of the interviewee's unique characteristics that benefit co-workers and the organization. Practice providing examples that effectively illustrate these unique traits and their benefits in the past. Be patient in answering interview questions, knowing that 1 small mistake can cost you an opportunity, for example, saying something negative about another person or a previous organization with which the candidate was affiliated. Also, it is wise to be prepared to explain any gaps in a resume, leaving a job, and challenges one has overcome.[8] In addition to verbal practice, one must also consider nonverbal communication, such as mannerisms. This includes posture, eye contact, voice volume, and use of time while communicating interest in the job. With practice, all these traits may provide a positive interview experience.

Sample Questions

• ”Exactly, what are you looking for in a job?”
• “Tell me about your last job.”
• “What was the most difficult part?”
• “What was your greatest accomplishment?”
• “Why did you apply here?”
• “How do you work with others?”
• “Who has been the hardest person to work with at your previous jobs?”
• “How do you take criticism?”
• “How do you handle change?”
• “What makes you different from other candidates?”
• “Talk about a time of failure.”
• “How does this job fit in your 5-year plan?”
• “What are your goals?”
• “What kind of salary, benefits, and hours are you expecting?”

Note the questions organizations should avoid. These include questions about nationality, ancestry, religion, family situation, and military service, among others. Interviewing is a process. It is likely that a person must interview for multiple positions before they receive a job offer and acceptance. There are many factors a candidate cannot control; therefore, the more interview experience an individual has, the higher the likelihood of being hired, matched, or accepted. Focusing on the interviewing process, along with research and practice, yields positive results.[9][10]

Enhancing Healthcare Team Outcomes

Learning how to conduct a medical interview is a basic skill required of all clinical providers. Patients often present with complex scenarios and may have underlying apprehensions, preconceptions, or biases towards the medical profession. It is important for the healthcare provider to navigate these emotions with care and respect to improve patient interactions and outcomes. A well-conducted medical interview in the most difficult situations can indeed lead to better patient care and, eventually, build trust in the healthcare team.