Table Of ContentFrontiers of Primary Care
Series Editor: Mack Lipkin, Jr.
Frontiers of Primary Care
Series Editor: Mack Lipkin, Jr.
Editorial Board
Charles Bridges-Webb
Sydney, Australia
Thomas Delbanco
Boston, Massachusetts, USA
Sheldon Greenfield
Boston, Massachusetts, USA
Henk Lamberts
Amsterdam, The Netherlands
Robert Pantell
San Francisco, California, USA
Burton Singer
New Haven, Connecticut, USA
Robert Taylor
Portland, Oregon, USA
Kerr L. White
Stanardsville, Virginia, USA
Maurice Wood
Richmond, Virginia, USA
Mack Lipkin, Jf. Samuel M. Putnam
Aaron Lazare
Editors
The Medical Interview
Clinical Care, Education, and Research
J. Gregory Carroll Richard M. Frankel
Associate Editors
Allen Keller Terri Klein P. Kay Williams
Assistant Editors
Springer-Verlag
New York Berlin Heidelberg London Paris
Tokyo Hong Kong Barcelona Budapest
Mack Lipkin, Jr., M.D., Department of Medicine, Division of Primary Care,
New York University Medical Center, 550 First Avenue, New York, NY 10016, and
American Academy on Physician and Patient, 550 First Avenue,
New York, NY 10016, USA
Samuel M. Putnam, M.D., East Boston Neighborhood Health Center,
10 Grove Street, East Boston, MA 02128, USA
Aaron Lazare, M.D., University of Massachusetts Medical Center,
55 Lake Avenue North, Worcester, MA 01655, USA
With 5 Illustrations
Library of Congress Cataloging-in-Publication Data
Lipkin, Mack, 1943-
The medical interview/Mack Lipkin, Jr., Samuel M. Putnam, Aaron
Lazare.
p. cm.
Includes bibliographical references and index.
ISBN-13: 978-1-4612-7559-6 e-ISBN-13: 978-1-4612-2488-4
DOl: 10.1007/978-1-4612-2488-4
1. Medical history taking. I. Putnam, Samuel M. II. Lazare,
Aaron,1936- . III. Title.
[DNLM: 1. Medical History Taking-methods. 2. Physician-Patient
Relations. WB 290 L764m 1994]
RC65.L57 1994
616.07'51-dc20
DNLMIDLC
for Library of Congress 94-6511
Printed on acid-free paper.
© 1995 Mack Lipkin, Jr., M.D.
Softcover reprint of the hardcover 1s t edition 1995
All rights reserved. This work may not be translated or copied in whole or in part without
the written permission of Dr. Lipkin or his designee (N.Y.U. Medical Center, 550 First
Avenue, New York, NY 10016, USA), except for brief excerpts in connection with reviews
or scholarly analysis. Use in connection with any form of information storage and retrieval,
electronic adaptation, computer software, or by similar or dissimilar methodology now
known or hereafter developed is forbidden without written permission.
The use of general descriptive names, trade names, trademarks, etc., in this publication,
even if the former are not especially identified, is not to be taken as a sign that such
names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly
be used freely by anyone.
While the advice and information in this book are believed to be true and accurate at the
date of going to press, neither the authors nor the editors nor the publisher can accept any
legal responsibility for any errors or omissions that may be made. The publisher makes no
warranty, express or implied, with respect to the material contained herein.
Production coordinated by Chernow Editorial Services, Inc., and managed by Natalie
Johnson; manufacturing supervised by Jeffrey Taub.
Typeset by Asco Trade Typesetting Ltd., Hong Kong.
98765 432 1
This book is dedicated to clinicians of all disciplines who are committed to
learning and teaching themselves and their students how to form more effec
tive relationships with patients. As individuals, they have labored long and
hard, often in isolation, to teach the medical interview. As a group, as
sembled in the American Academy on Physician and Patient, they have
provided the inspiration for this book. Many who read this book will
recognize ideas that they helped to nourish. We acknowledge with appre
ciation each person who feels a special sense of ownership.
We also dedicate this book to our families with love and gratitude for their
love, support, and acceptance of the long effort this book has required. We
thank you Anna Rose and Ellen; Donka, Aleisha, and Laura; Louise and
Robert, Jackie, David, Sam, Sarah, Hien, Thomas and Naomi.
Series Preface
Primary care medicine is the new frontier in medicine. Every nation in
the world has recognized the necessity to deliver personal and primary
care to its people. This includes first-contact care, care based in a posi
tive and caring personal relationship, care by a single healthcare pro
vider for the majority of the patient's problems, coordination of all care
by the patient's personal provider, advocacy for the patient by the pro
vider, the provision of preventive care and psychosocial care, as well as
care for episodes of acute and chronic illness. These facets of care work
most effectively when they are embedded in a coherent integrated
approach.
The support for primary care derives from several significant trends.
First, technologically based care costs have rocketed beyond reason or
availability, occurring in the face of exploding populations and diminish
ing real resources in many parts of the world, even in the wealthier
nations. Simultaneously, the primary care disciplines-general internal
medicine and pediatrics and family medicine-have matured significantly.
They have become viable alternatives to the specialty approach to care
with its potential dehumanization, coordination problems, and increased
cost. The primary care disciplines have begun to create new sets of intel
lectual tools and new educational approaches to support their new para
digm of biopsychosocial care, including clinical epidemiology that exam
ines the efficacy, effectiveness, and efficiency of everyday real-world care;
clinical decision making that is beginning to find ways to improve the
rational basis for common clinical choice; the medical interview, which is
in this volume coming under critical study as the major medium of care;
problem-based learning and community-oriented medical education that
enable efficient learning of the greatest relevance and with increased
satisfaction for learner and teacher; and the philosophic and empiric
study of ethical aspects of care.
Several major questions have emerged in the new disciplines. Who is to
do primary care? What do these practitioners need to know? How can
the needed content, skills, and attitudes be best taught? Who is to teach
VB
viii Series Preface
these new practitioners, and what skills do the practitioners need? Per
sons interested in these questions include primary care professionals,
teachers, and researchers in primary medicine.
Frontiers of Primary Care plans to help meet the needs of these over
lapping groups, reporting fundamental and applied research findings in
clinically relevant, readable ways. It will provide information to teachers
of primary medicine about necessary content areas such as alcoholism or
the medical interview. It will teach teachers about new teaching ap
proaches and methods and include some books teachers may choose to
use as texts. Finally, it will publish new conceptual work about the basis
of the field and the shifting paradigm of care.
This volume is the first type of contribution to the series. It is an impor
tant introduction for health care teachers, practitioners, and those pre
paring for such roles concerning the doctor/patient relationship and the
medical interview. It is the first empirically based, scholarly reference
text in this new field. The data and approaches give us hope for the
future humanism and relevance of health care.
Mack Lipkin, Jr., M.D.
Series Editor
Preface
Medical interviewing is a core clinical skill. It is the medium of doctor/
patient communication and relationship, the most important single
source of diagnostic data, the means through which we elicit the patient's
partnership and participation in the processes of care. An average gen
eralist during a 40-year professional life may conduct between 160,000
and 200,000 interviews!
It is not clear what the early history of the medical interview con
tains-data available are scanty and indirect. Most of what is available
consists of practitioner recall of the content or themes of encounters.
Only during and after World War II did recordings begin to be taken
that can be reviewed for study and scientific description. A few authors
attempted to describe their own approach to interviewing and to obtain
ing the desired content of an encounter between practitioner and patient.
In the 1960s, videotaping became significantly more convenient and
affordable. Barbara Korsch videotaped the encounters between pediatri
cians and their patients in an emergency room in Los Angeles. Her ana
lysis of these interactions led to the description of communication gaps.
Suddenly, tools were developed for the systematic study of our most fun
damental clinical tool. Since Korsch, we have seen snowballing quantities
of research and scholarship concerning the medical interview and related
skills. There now exists an increasingly robust literature on the medical
interview that includes more than 7,000 titles. There is a raft of introduc
tory texts. There is a quarterly newsletter, Medical Encounter.
This book was undertaken to draw together some of the wealth of re
search and scholarship concerning the medical interview over the last 25
years and in so doing provide some structure to the large domain of
knowledge concerning the medical interview and related skills. To our
knowledge, this has not been undertaken previously with such a large
scope-most of the existing textbooks are focused at beginning clinical
students.
We have attempted to coalesce the findings and progress of the 1970s
through the early 1990s into readable segments. Although it is all of in-
ix
x Preface
terest to us, we recognize that readers may prefer to emphasize reading
of selected parts. A teacher might look to the education segment (part
VI). The researcher or persons considering entering research might find
part VIII a useful introduction to the concepts currently under scientific
scrutiny. We hope that clinicians at every stage will find use in the clinical
sections of the book, which provide a framework for the interview (part I),
the structure and process of the interview (part II), the context of the inter
view (part III) and special situations and types of interviews (part IV).
The book begins with general aspects of the interview, focuses then on
specific situations and types of interviews, and then covers ethics, teach
ing, evaluation, research, and resources. In the process of writing, we
asked authors to relate their discussion to the three-function model of the
interview, presented here by Lazare, Putnam, and Lipkin but originated
by Bird and Cohen-Cole. Our hope is that use of the three-function
model will assist in reading, remembering, and teaching.
The impetus for this book arose in the work of the Task Force on the
Doctor and Patient of the Society of General Internal Medicine. The Task
Force was founded in 1978 to pursue research, education, and faculty de
velopment of generalists in the medical interview and related skills. It has
involved internists, family practitioners, pediatricians, psychiatrists, social
scientists, and psychologists, other physicians, nurses, and social workers.
Over time, the Task Force developed highly successful faculty develop
ment courses using an innovative model created by Dr. Lipkin and
started a newsletter now reaching 1,500 readers, Medical Encounter,
edited by Dennis Novack. The Task Force did collaborative research,
held annual research symposia, and supported those in or considering
this area of learning and teaching. Because the demand for the courses
was so high, the Task Force in 1990 obtained federal funding for training
facilitators, directed by Craig Kaplan. This has now become a national
fellowship allowing persons at several stages of development to find
guided evolution as scholars and teachers of the medical interview. In
1992, the Task Force became the American Academy on Physician and
Patient, a national academy dedicated to furthering work in this field
and welcoming persons from diverse disciplines, including especially
pediatrics, family medicine, internal medicine, psychiatry, psychology,
and social sciences.
In 1982 the Task Force created a curriculum committee, headed by
Rudy Napodano. This committee defined a core curriculum (see Lipkin,
Quill, and Napodano, 1984) and noted the lack of generally available re
sources for clinicians, teachers, and researchers. Hence the committee
called for creation of this book. The vision of those involved in the ori
gins of this work is much appreciated. Certain individuals have played
key roles in bringing this book to press. Foremost are our associate edi
tors: J. Gregory Carroll and Richard M. Frankel; our assistant editors Allen
Keller, Terri Klein, and P. Kay Williams. They have our deep gratitude.
Preface xi
P. Kay Williams and Terri Klein patiently managed administrative aspects
of the gestation. Of course, the authors have worked intensely hard,
been very patient with our editorial whims, and been generously giving
of thought and effort. We are most grateful to them. Participants in
American Academy on Physician and Patient courses have regularly
given invaluable feedback about the appropriateness of our choices for
content as well as specific feedback about particular chapters.
Finally, our editors at Springer-Verlag have been our champions and
advocates throughout this process. We thank them, especially Esther
Gumpert and Laura Gillan. Natalie Johnson and Kathy Jackson have
been of great help during production.
Mack Lipkin, Jr.
New York, NY
Samuel M. Putnam
Boston, MA
Aaron Lazare
Worcester, MA
