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September, 2016

Orthopedic Clinical Examination: Optimizing interviews with clients


This is an excerpt from Orthopedic Clinical Examination With Web Resource by Michael Reiman.

Effective Communication in the Client Interview

Eliciting a good history and therefore conducting an organized and fruitful client interview and history requires several skills, not the least of which are organizational and communication abilities. Effective communication on the part of the clinician when interviewing a client requires several skills. The clinician must be able to not only ask appropriate questions but also listen to the client, ask followup questions based on information the client shares, redirect the line of questioning dependent on this information, and so on.

During consultation, the client must be considered the most valuable source of information. Many clinicians take control during the examination process, not allowing the client to express the reasoning for seeking care. Beckman and colleagues found that in 69% of visits, physicians interrupted client’s statements and directed questions toward a specific concern. In another study, physicians redirected clients during their opening statement after a mean of 23.1 seconds. Clients allowed to complete their opening statement required an average of only 6 seconds longer to state their primary concerns. Many clients will not divulge additional relevant information after being interrupted.

The fact that a client interview can be done more or less effectively is demonstrated by the fact that essential diagnostic information can be uncovered from the client interview. One’s efficiency in communication can be improved through training. It is unlikely that any future technological advances will negate the need and value of compassionate and empathetic two-way communication between clinician and client. The published literature also expresses belief in the essential role of communication: "It has long been recognized that difficulties in the effective delivery of health care can arise from problems in communication between patient and provider rather than from any failing in the technical aspects of medical care. Improvements in provider-patient communication can have beneficial effects on health outcomes." Professional conversation between clients and clinicians shapes diagnosis, initiates therapy, and establishes a caring relationship.

The development and improvement of communication and clinical reasoning skills leads to the clinician "developing an accurate clinical hypothesis, developing an examination and intervention approach to meet the individual’s cultural, communication, anatomic, and physiologic needs and abilities, recognizing patient symptoms and signs that necessitate communication with other health care providers, and participating in the decision-making process regarding the selection of appropriate diagnostic testing."

Despite these facts, many health care providers have poor communication skills and perform inadequate client interviews. Many times failure to take a sufficient medical history with proper client communication can lead to mistakes that have clinical and economic consequences. In fact, many complaints about health care providers are not about the medical care provided but in regard to poor or insufficient communication. A complex relationship exists between clients’ opinions of physician communication and physicians’ malpractice history. Clinicians must learn to adapt and tailor their communication styles to each individual client due to variations that exist in clients’ intellectual and emotional needs. Clinicians must also develop an understanding of each individual client’s desired communication needs.

Communication in primary care physicians is also a significant variable in malpractice claims. Physicians without such claims educated patients on what to expect during their visit, laughed and demonstrated humor, spent more time with patients during routine visits, and sought and facilitated the expression of the patient’s opinions, values, and beliefs. For a successful and humanistic encounter at an office visit, the clinician needs to be sure that the client’s key concerns have been directly and specifically solicited and addressed. To be effective, the clinician must gain an understanding of the client’s perspective on their illness. The whole client must be evaluated because a plethora of conditions may present with manifestations similar to musculoskeletal conditions. Furthermore, client concerns can be wide ranging. Client values, cultures, gender, and preferences need to be taken into consideration.

Clinician skill, rapport, and health-related communication behaviors are key elements of a client interview. Clients are more likely than clinicians to report behaviors demonstrating thoroughness in routine examinations as essential to a quality office visit, such as spending enough time with them, engaging them, and treating them with courtesy and respect. The degree to which these activities are successful depends, in large part, on the communication and interpersonal skills of the clinician.

Certain observable history-taking behaviors are evident between good and poor diagnosticians. Furthermore, these behaviors are evident during the first 3 minutes of the encounter. Behaviors characteristic of good diagnosticians are thoroughness of inquiry about the chief complaint, asking questions in close proximity within a line of reasoning, clarifying or verifying information provided by the client, and summarizing the information at hand. Characteristic behaviors of bad diagnosticians are repeating questions unnecessarily, changing the topic before completing a line of inquiry, inquiring about systems, and inquiring about past history.

A positive working relationship between clinician and client has a positive effect on treatment outcomes, although further research is needed to determine the strength of the relationship. Poor communication, though, can leave clients with an undefined understanding of their diagnosis, prognosis, future management plans, and the therapeutic intent of treatment.

Communicating with a client is a must in order to set up an effective therapeutic alliance. The approach taken is important. Physical therapists tend to apply a paternalistic approach even though clients prefer to share decisions or provide their opinions about treatment options.

The communication relationship with the client encompasses many aspects, including verbal and nonverbal communication, a client-centered interview, the use of empathy, active listening, facilitation, summarization, clarification, and reflection skills. Each of these aspects has specific considerations that the clinician must take into account when engaging in the therapeutic relationship with the client.

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