Starting the interview Research has shown the importance of listening to patients' opening statements without interruption. Doctors often ask about the first issue mentioned by their patients, yet this may not be what is concerning them most. Once a doctor has interrupted, patients rarely introduce new issues. If uninterrupted, most patients stop talking within 60 seconds, often well before. The doctor can then ask if a patient has any further concerns, summarise what the patient has just said, or propose an agenda—“I wonder if I could start by asking you some more questions about your headaches, then we need to discuss the worries that your son has been causing you.” Responding to patients' “cues” Verbal cues State your observation—“You say that recently you have been feeling fed-up and irritable” Repeat the patient's own words—“Not well since your mother died” Seek clarification—“What do you mean when you say you always feel tired?” Non-verbal cues Comment on your observation—“I can hear tears in your voice” Ask a question—“I wonder if that upsets you more than you like to admit?” Detecting and responding to emotional issues Even when their problems are psychological or social, patients usually present with physical symptoms. They are also likely to give verbal or non-verbal cues. Verbal cues are words or phrases that hint at psychological or social problems. Non-verbal cues include changes in posture, eye contact, and tone of voice that reflect emotional distress. Aspects of interview style that aid assessment of patients' emotional problems Early in the interview Make good eye contact Clarify presenting complaint Use directive questions for physical complaints Begin with open ended questions, moving to closed questions later Interview style Make empathic comments Pick up verbal cues Pick up non-verbal cues Do not read notes while taking patient's history Deal with over-talkativeness Ask more questions about the history of the emotional problem It is important to notice and respond to cues at the time they are offered by patients. Failure to do so may inhibit patients from further disclosures and limit the consultation to discussion of physical symptoms. Conversely, physical symptoms must be taken seriously and adequately evaluated. Several of the skills of active listening are valuable in discussing physical, psychological, and social issues with patients. These skills have been clearly shown to be linked to recognition of emotional problems when used by general practitioners. Active listening skills Open ended questions—Questions that cannot be answered in one word require patient to expand Open-to-closed cones—Move towards closed questions at the end of a section of the consultation Checking—Repeat back to patient to ensure that you have understood Facilitation—Encourage patient both verbally (“Go on”) and non-verbally (nodding) Legitimising patient's feelings—“This is clearly worrying you a great deal,” followed by, “You have an awful lot to cope with,” or, “I think most people would feel the same way” Surveying the field—Repeated signals that further details are wanted: “Is there anything else?” Empathic comments—“This is clearly worrying you a great deal” Offering support—“I am worried about you, and I want to know how I can help you best with this problem” Negotiating priorities—If there are several problems draw up a list and negotiate which to deal with first Summarising—Check what was reported and use as a link to next part of interview. This helps to develop a shared understanding of the problems and to control flow of interview if there is too much information Think family When interviewing an individual Ask how family members view the problem Ask about impact of the problem on family function Discuss implications of management plan for the family When a family member comes in with patient Acknowledge relative's presence Check that patient is comfortable with relative's presence Clarify reasons for relative coming Ask for relative's observations and opinions of the problem Solicit relative's help in treatment if appropriate If patient is an adolescent accompanied by an adult always spend part of consultation without the adult present Never take sides Eliciting a patient's explanatory model When people consult a doctor, they do so with explanatory ideas about their problems and with anxieties and concerns that reflect these ideas. They are also likely to have hopes and expectations concerning the care that they will receive. It is important not to make assumptions about patients' health beliefs, concerns, and expectations but to elicit these as a basis for providing information and negotiating a management plan. People's health beliefs and behaviours develop and are sustained within families, and families are deeply affected by the illness of a family member. “Thinking family” can help to avoid difficult and frustrating interactions with family members. Further reading Cole SA, Bird J . The medical interview: the three function approach. St Louis, MO: Harcourt Health Sciences, 2000 Gask L, Morriss R, Goldberg D . Reattribution: managing somatic presentation of emotional distress. 2nd ed. Manchester: University of Manchester, 2000. (Teaching videotape available from Nick.Jordan@man.ac.uk) Usherwood T . Understanding the consultation. Milton Keynes: Open University Press, 1999