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 during a career and are critical in discovering pertinent information leading to a correct diagnosis. The interview also grants therapeutic power; it is used to establish a relationship with the patient and afford empathy and reassurance. Depending on the purpose of the interview, the goals of the patient and the medical professional may be very different. 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 potential diseases. Developing skills to incorporate the patient into the diagnostic and therapeutic plan of action will improve the patient’s desire to follow through and accomplish measurable and obtainable goals.

As an interview is conducted, one must understand and decipher 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 will potentially lead to 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. The possibility exists that some patient concerns or symptoms will not be expressed directly and must be noted by an astute interviewer. For example, topical avoidance or an abrupt change of flow in conversation may be observed. The development of a nonjudgmental interviewing style will likely improve the patient’s disclosure of concerns. Patients rarely express their symptoms in an organized manner; therefore, it will benefit the interviewer to ask open or directional questions that can assist the patient in communicating 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 passing of 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 immediate demands of the patient. In the emergency room, this may include an assessment of the patient’s airway, breathing, and circulation. In other situations, the interviewee may require an aspect of comfort, 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 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, and focused questions allow the interviewer to obtain important details with yes or no answers in a more time-efficient manner. Too many focus questions may potentially cause one to feel a sense of interrogation. 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 allow the patient to share their concerns, and the interviewer can show 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 will express anxiety, anger, helplessness, or other emotions. Recognizing the patient’s emotions are valid and offering reassurance may build a meaningful relationship.[1]

During the interview, meaningful questions inquired positively will reduce defensiveness from the patient. Often this can be accomplished by suggesting or sharing a common behavior associated with the actions of the patient. 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 conclusion of the physical exam, it is then appropriate to discuss with the patient findings in the physical exam as well as the next course of action. This includes informing the patient of labs and imaging required for further information regarding the patient’s illness, as well as medications and intravenous (IV) fluids that will 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 admission to the hospital or going home and returning for a follow-up appointment at a designated time. Inpatient setting 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 will provide the patient with important information regarding their illness and build rapport in hopes the patient will become increasingly involved in their health.

Life-long learning and practice of the medical interview will 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 dialogue while incorporating other aspects of 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 provide constructive criticism to enhance interview skills. Due to the importance of the interview aspect of an appointment, simulated patient encounters have become part of the licensing exams for physicians as well as other health professionals.

Veterans, as well as inexperienced interviewers, perform many common mistakes during the medical interview. As described above, these mistakes lead to a decrease in the patient’s trust in the interviewer and may lead to more medical errors. Often mistakes are made when interviewers have an emotional detachment from the patient or when there are perceived or real-time constraints. Avoiding the following common mistakes will provide improved medical care.

Common Interview Mistakes

• Too many focused questions
• Ignoring the patient’s emotions
• Arriving at 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 to patient’s comfort, no relationship building
• No open-ended questions
• Interruptions to the interview process[2]

Clinical Significance

There are many ways in which effective patient communication can improve clinical outcomes and safety for patients.

Effective patient communication is essential when identifying the necessary labs, procedures, and imaging required to diagnose a patient's condition. This initial communication also assists in the development of a differential diagnosis on which medical treatment is based. The quality of medical treatment is largely based upon the initial patient interaction. Furthermore, a positive patient relationship improves patient outcomes including the ability to return to work promptly and increased functionality after treatment.

Effective patient communication generates an increase in positive outcomes. These positive outcomes may include but are not limited to improved compliance with medical plans, patient self-regulation of diet and medications, and improvement in patient's 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 desired outcomes for the patient. It improves the patient’s understanding of what their outcomes are likely to be with medical treatment and adherence to that treatment. This form of medical decision-making is more successful with positive patient communication developed in the initial interview. Overall, this style of communication improves the satisfaction of the treatment and the opinion of the healthcare professional.

Improving patient communication also increases trust for the healthcare provider and may allow patients to consider all their options while making thoughtful decisions regarding treatment. 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, the lab or imaging may not 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 also 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 for collecting data. This is especially true for qualitative research regarding patient experience. Research interviews have unique challenges. Scientists studying research interviews recommend new interviewers be supervised by those with extensive experience. Also, an essential requirement is for new researchers is to perform practice interviews with opportunities for feedback regarding interview skills. These pilot interviews will 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 to “yes” in yes or no questions, where 4- and 5-year-olds exhibited a “no” answer bias. The bias diminishes significantly after 5 years of age, 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-interview (interview 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 for the research question to be answered effectively and completely. This should be taken seriously to optimize the results of the research project. Depending on the research question, interviews require many of the same skills as medical interviews, for example, developing rapport and mixing open-ended questions with focus questions. Furthermore, developing an open mind and active listening is important for researchers to conduct effective research interviews.

Clearly, research types of inquiry 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 and third-party council set up 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 is required to be secured for interviewed students because information may be sensitive.  Interviewees must provide signed written consent when they are involved 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 more prepared than the interviewer, and they should be able to ask pertinent questions that demonstrate they have seriously looked into the position and organization with an intent to be a contributing member of that organization.

These types of interviews are much like academic assessments; they are staged events. Therefore, adequate preparation will greatly improve the likelihood of a successful interview. Preparation includes understanding the organization, understanding one’s self, appearing interested, and practicing clear explanations.

It is imperative an interviewee study the organization for which they want to work. The internet allows anyone to research an organization, job requirements, and the interview committee efficiently. Expressing an understanding of the organization during the interview will display 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 in that organization, and the organization does possess a fear 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?
• Is this person liked?
• 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 will 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 will understanding oneself lead to the desired job, but it will compel a person to be very powerful in "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 by the interviewing organization, this is far overshadowed by the necessity for the interviewee 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 a very important aspect. Often, these questions involve the person executing the interview. For example, “What is your experience working at this organization?"

Furthermore, the interviewee may seek information regarding qualities in employees of the organization. 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 display interest in the organization by taking effective notes during the interview; this will assist them to remember different aspects of each organization over time. After the interview, the candidate should pursue the job with personal emails, phone calls, and letters to express continued interest.

Dressing professionally will convey 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. Some other quick tips for interview etiquette include arriving at the appointment early, 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 unique characteristics the interviewee provides that will benefit co-workers and the organization. Practice providing examples that effectively illustrate these unique traits and how they were beneficial in the past. Be patient in answering interview questions knowing that one 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 time in a resume, leaving a job, and challenges one has overcome positively.[8]

In addition to verbal practice, one must also consider nonverbal communication 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 five-year plan?”
• “What are your goals?”
• “What kind of salary, benefits, and hours are you expecting?”

Note questions organizations should avoid. These include questions containing information regarding nationality, ancestry, religion, family situation, military service, among others.

Interviewing is a process. It is likely 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 interviews experienced, the higher the likelihood of being hired, matched, or accepted becomes for an individual. Focusing on the process of interviewing, along with research and practice will deliver 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 of situations can indeed lead to better patient treatment and eventually building trust in the healthcare team itself.