1. Interviewing techniques
Fahad Alosaimi
MBBS, SSC-Psych
Consultation liaison psychiatrist
King Saud University

2. Introduction One supreme skill of any physician is active listening.
Physicians should monitor :
1)the content of the interaction (what patient and doctor say to each other)
2)the process (what patient and doctor may not say but clearly convey in many other ways).
Physicians who are sensitive to the effects of history, culture, environment, and psychology on the doctor–patient relationship work with patients who are multifaceted people, not mere disease syndromes.
Engel's concept of the biopsychosocial model was a 1971
Edward Suchman described five stages of illness behavior: the symptom experience stage, in which a decision is made that something is wrong; the assumption of the sick role stage, in which a decision is made that a person is sick and needs professional care; the medical care contact stage, in which a decision is made to seek professional care; the dependent-patient role stage, in which a decision is made to transfer control to the doctor and to follow prescribed treatment; and the recovery or rehabilitation stage, in which a decision is made to give up the patient role.
Models of the doctor–patient relationship include the active-passive model, the teacher–student (or parent–child, guidance–cooperation) model, the mutual participation model, and the friendship (or socially intimate) model.
The active-passive model implies a patient's complete passivity and a physician's taking control. In this model patients assume virtually no responsibility for their own care and take no part in treatment. The model is appropriate when patients are unconscious, immobilized, or delirious.
In the teacher–student model the physician's dominance is assumed and emphasized. The role of the physician is paternalistic and controlling; the role of the patient is essentially one of dependence and acceptance. This model is often observed during a patient's recovery from surgery.
The mutual participation model implies equality between doctor and patient; both participants require and depend on each other's input. The need for a doctor–patient relationship based on a model of mutual, active participation is most obvious in the treatment of such chronic illnesses as renal failure and diabetes, in which a patient's knowledge and acceptance of treatment ramifications are critical to the success of the treatment. The model may also be effective when patients have conditions such as pneumonia.
The friendship model of the doctor–patient relationship is generally considered dysfunctional if not unethical. It most often reflects a primary, underlying psychological problem in the physician, who may have an emotional need to turn the patient's care into a relationship of mutual sharing of personal information and love. The model often involves indeterminate perpetuation of the relationship rather than an appropriate ending and a blurring of boundaries between professionalism and intimacy.

3. Introduction Models of the doctor–patient relationship include:
the active-passive model,
the teacher–student (or parent–child, guidance–cooperation) model,
the mutual participation model,
the friendship (or socially intimate) model.
The more that doctors understand themselves, the more secure they feel, and the better able they are to modify destructive attitudes.
Increased flexibility leads to a responsiveness to the subtle interplay between doctor and patient and also assumes a certain tolerance for the uncertainty present in any clinical situation with any patient.
Gaining conscious insight into the relationship between physicians and patients requires constant evaluation. The more that doctors understand themselves, the more secure they feel, and the better able they are to modify destructive attitudes. Doctors must empathize with patients, but not to the point of assuming their patients' burdens or unrealistically fantasizing that only they can be the patients' saviors. They should be able to leave behind their patients' problems when away from the office or the hospital and should not use their patients as substitutes for an intimacy or relationship that may be missing in their personal lives. Otherwise they are handicapped in their efforts to help sick people, who need sympathy and understanding, not sentimentality and overinvolvement.
A medical student insisted on questioning a patient about her relationship with her 23-year-old son. The playback of a tape-recorded interview revealed that the patient wanted to talk about her problems with her husband. When the supervising doctor later interviewed the patient, she said: "The medical student was a nice fellow, but I could see that he was having trouble with his mother. It made me understand my own son more.“
Physicians are prone to some defensiveness, partly with good reason; many innocent doctors have been sued, attacked, and even killed because they did not give some patients the satisfaction they desired. Consequently, physicians may assume a defensive attitude toward all patients. Although such rigidity may create the image of thoroughness and efficiency, it is frequently inappropriate. Increased flexibility leads to a responsiveness to the subtle interplay between doctor and patient and also assumes a certain tolerance for the uncertainty present in any clinical situation with any patient. Physicians must learn to accept that, as much as they may wish to control everything in a patient's care, this wish can never be fully realized. In some situations a disease cannot be controlled, and death cannot be prevented, no matter how conscientious, competent, or caring a physician is. Physicians must also avoid sidestepping issues that they find difficult to deal with because of their own sensitivities, prejudices, or peculiarities, especially when these issues are important to a patient.
A medical student insisted on questioning a patient about her relationship with her 23-year-old son. The playback of a tape-recorded interview revealed that the patient wanted to talk about her problems with her husband. When the supervising doctor later interviewed the patient, she said: "The medical student was a nice fellow, but I could see that he was having trouble with his mother. It made me understand my own son more."

4. Goals for psychiatric interview:
Determining the nature the problem.
To establish a relationship with the patient.
To provide feedback and formulate a treatment plan.

5. Content versus Process of the interview
Every interview has three main components:
the beginning
the interview itself
the closing of the interview.

6. Major tips for interview
introduce yourself
greet the patient by name
arrange for a private comfortable setting
appropriately tell the purpose of the interview
put the patient at ease
be supportive, attentive, non judgmental and encouraging.
Avoid excessive note-taking
observe the patient’s nonverbal behavior.

7. THE PSYCHIATRIC HISTORY
 It is the chronological story of the patient’s life from birth to present.
It includes information about who the patient is, his problem (bio psycho-social aspects) and its possible causes and available support.
Information elicited both from the patient and from one or more informants.
The mental status examination
*patient’s feelings, thoughts, perception and behavior during the interview.

8. THE PSYCHIATRIC HISTORY
Identification data
Referral Source
Chief Complaint
History of present illness
Family history
Personal history
Medical history
Past Psychiatric history
Personality traits

9. Identification of the Patient:
Name, age, sex, marital status, occupation, education, nationality, residency and religion.
Referral Source:
Brief statement of how the patient came to the clinic and the expectations of the consultation.
Chief Complaint:
Exactly why the patient came to the psychiatrist, preferably in the patient’s own words (a verbatim statement).
History of Present Illness:
Chronological background of the psychiatric problem: nature, onset, course, severity, duration, effects on the patient (social life, job, family…), review of the relevant problems, symptoms not mentioned by the patient (e.g. sleep, appetite, …), and treatment taken so far (nature and effect).
Note if the chief complaint differs significantly from the reports of those who accompany the patient (other informants).

10. Family History:
Mother and father: current age (if died mention age and cause of death, and patient’s age at that time), relationship with each other and with the patient.
Siblings: list, in order of age, brothers and sisters, education, occupation, marital status, major illnesses and relationship with the patient.
Ask about mental illnesses in second-degree relatives (grand parents, uncles, aunts, nephews, & nieces). 
Family history is important in psychiatry for several reasons:
Events happening currently to a family member may act as a stressor to the patient.
Family atmosphere has an effect on the patient’s psychological condition.
Some psychiatric disorders are familial and have an important genetic contribution.

11. Personal History: Birth & Early development: developmental School
School
Occupations
Puberty & Adolescence:
Marital history.
Current social situation:
Tobacco and substance abuse.
legal (forensic) problems.
(Relatives may be a source of information). Personal history helps in constructing a brief biography of the patient that forms a background against which you understand the presenting complaints and predict future behaviour.
-Birth: any known obstetric or prenatal difficulties?.
-Early development: developmental milestones (motor and language), early childhood attitudes and relationships with parents, siblings and others, any emotional or behavioural difficulties,
-School: age at starting and end of school life, approximate academic ability, specific difficulties, attitudes and relationships with teachers and pupils and highest grade attained.
-Occupations: age at starting work, jobs held, reasons for change, satisfaction in work, relationships with workmates and with supervisors.
-Puberty: age at onset, knowledge, attitude and practice of sex.
-Adolescence: attitude to growing up, to peers, to family and authority figures, and emotional or behavioural problems.
-Marital history: age at marriage, relationships within the marriage, number of children and attitude toward them.
-Current social situation: social environment and social relationships, financial circumstances and social difficulties.
-Tobacco and substance abuse, and legal (forensic) problems.

12. Past Psychiatric History Personality Traits:
Medical History
Past Psychiatric History
Personality Traits: 
Attitude to self (self-appraisal, performance, satisfaction, past achievements and failures, future..)
Moral and religious attitudes and standards.
Prevailing mood and emotions.
Reaction to stress (ability to tolerate frustration and disappointments, pattern of coping strategies).
Personal interests, habits, hobbies and leisure activities.
Interpersonal relationships.
Medical History:
All major illnesses should be listed (nature, extent, dates, treatment, outcome, and patient’s reaction and attitude). Women should be asked about menstrual (and, if appropriate, about menopausal) difficulties.
Past Psychiatric History:
Any previous psychiatric illness (nature, extent, dates, treatment, outcome and patient’s reaction and attitude).
Personality Traits:
It is important to obtain adequate information (from a variety of sources) about the patient’s characteristic traits that distinguish him as an individual. The patient’s personality usually interacts with his illness and should be separated from episodes of illness. Elicit information about the following:
Attitude to self (self-appraisal, performance, satisfaction, past achievements and failures, future..)
Moral and religious attitudes and standards.
Prevailing mood and emotions.
Reaction to stress (ability to tolerate frustration and disappointments, pattern of coping strategies).
Personal interests, habits, hobbies and leisure activities.
Interpersonal relationships.

13. The Mental State ExaminationJ:\KKUH\MENTAL STATE EXAMINATION.ppt
Appearance,Behaviour &Attitude
Speech
Mood & Affect
Thoughts
Perception
Cognitive functions and consciousness
Consciousness level
attention
concentration
orientation(time, place, person)
memory
Abstract thinking
Visuospatial ability
Language and reading.
Judgment
Insight

14. Six strategies to develop rapport
putting patients and interviewers at ease.
finding patients' pain and expressing compassion.
evaluating patients' insight and becoming an ally
showing expertise
establishing authority as physicians and therapists
balancing the roles of empathic listener, expert, and authority.
Othmer and Othmer
Transference. Transference is generally defined as the set of expectations, beliefs, and emotional responses that a patient brings to the doctor–patient relationship. Transference reflects not necessarily who a doctor is or how a doctor acts in reality but, rather, what persistent experiences a patient has had with other important authority figures throughout life.
TRANSFERENTIAL ATTITUDES. A patient's attitude toward a physician is apt to be a repetition of the attitude he or she has had toward authority figures. The attitude may range from one of realistic basic trust, with an expectation that the doctor has the patient's best interests at heart, through one of overidealization and even eroticized fantasy, to one of basic mistrust, with an expectation that the doctor will be contemptuous and potentially abusive. A patient may expect a doctor to do something—for example, to prescribe medication or to perform surgery—and can accept a doctor's care as sufficient and competent only if these actions occur. Inherent in this attitude is a patient's role as a passive recipient in relation to a doctor's role as an active bestower of help. A doctor has different expectations. Another patient may be active and expect to participate fully in treatment and, correspondingly, feels at odds with a doctor who does not want patient participation.
PSYCHIATRIST VERSUS NONPSYCHIATRIST. In many respects the role of psychiatrists is different from that of nonpsychiatric physicians, and yet many patients expect the same from a psychiatrist as they do from other physicians. When they expect a doctor to take action, give advice, and prescribe medication to cure an illness, they may well expect the same interaction with a psychiatrist and may be disappointed or angry when their expectations are not fulfilled. For many reasons, transference reactions may be strongest with psychiatrists. For example, in intensive insight-oriented psychotherapy, the encouragement of transference feelings is an integral part of treatment. In some types of therapy, a psychiatrist is more or less neutral. The more neutral or less known a psychiatrist is, the more a patient's transferential fantasies and concerns are mobilized and projected onto the doctor. Once fantasies are stimulated and projected, psychiatrists can help patients gain insight into how these fantasies and concerns affect all the important relationships in their lives.
Although a nonpsychiatrist does not use or even need to understand transference attitudes in this intensive way, a solid understanding of the power and manifestations of transference is necessary for optimal treatment results in any doctor–patient relationship. Physicians' words and deeds have a power far beyond the commonplace because of their unique authority and patients' dependence on them. How a particular physician behaves and interacts has a direct bearing on a patient's emotional and even physical reactions. One patient repeatedly had high blood pressure readings when examined by a physician the patient considered cold, aloof, and stern but had normal blood pressure readings when seen by a doctor the patient regarded as warm, understanding, and sympathetic.
Countertransference. Just as patients bring transferential attitudes to doctor–patient relationships, doctors themselves often have countertransferential reactions to their patients. Countertransference may take the form of negative feelings that are disruptive to the doctor–patient relationship but may also encompass disproportionately positive, idealizing, or even eroticized reactions. Just as patients have expectations—such as competence, lack of exploitation, objectivity, comfort, and relief—physicians often have unconscious or unspoken expectations of patients. Most commonly, physicians think of patients as good when their expressed severity of symptoms correlates with an overtly diagnosable biological disorder, when they are compliant and generally do not challenge the treatment, when they are emotionally controlled, and when they are grateful. If these expectations are not met, physicians may blame patients and experience them as unlikable, untreatable, or bad.
DISLIKE. A psychiatrist who actively dislikes a patient is apt to be ineffective in dealing with him or her. Emotion breeds counteremotion. For example, if a physician is hostile, the patient becomes hostile; the physician then becomes even angrier than before, and the relationship deteriorates rapidly. If a physician can rise above such emotions and handle a resentful patient with equanimity, the interpersonal relationship may shift from one of mutual overt antagonism to one of at least increased acceptance and grudging respect. Rising above such emotions involves being able to step back from the intense countertransferential reactions and to dispassionately explore why a patient reacts to the doctor in such an apparently self-defeating way. After all, patients need doctors, and hostility ensures that the needed help does not occur. If the doctor can understand that a patient's antagonism is in some ways defensive or self-protective and most likely reflects transferential fears of disrespect, abuse, and disappointment, the doctor may be less angry and more empathic than otherwise.
Psychiatrists with strong unconscious needs to be all knowing and all powerful may have particular problems with certain types of patients: those who appear to repeatedly defeat attempts to help them (for example, patients with severe heart disease who continue to smoke or drink); those who are perceived as uncooperative (for example, patients who question or refuse treatment); those who request a second opinion; those who fail to recover in response to treatment; those who use physical or somatic complaints to mask emotional problems (for example, patients with somatization disorder, pain disorder, hypochondriasis, or factitious disorders); those with chronic cognitive disorders (for example, patients with dementia of the Alzheimer's type); and those who are dying or in chronic pain (for example, patients who represent a professional failure and are, thus, a threat to a physician's identity and self-esteem). These patients may be difficult for most physicians to deal with, but if a physician is as aware as possible of his or her own needs, capabilities, and limitations, the patients will not be threatening.
SEXUALITY. Psychiatrists are bound to like some patients more than others, but if a physician feels a strong attraction to a patient and is tempted to act on the attraction, stepping back and dispassionately assessing the situation is essential. In some medical specialties in which the doctor–patient relationship is not particularly intimate or intense, the prohibition against romantic involvement with patients may not be strong. In other specialties, however, especially psychiatry, the ethical and even legal prohibitions are important. Physicians are powerful figures in this country's culture and may trigger many unconscious fantasies of being rescued, taken care of, and loved. Doctors themselves may have their own unconscious fantasies of being, and needing to be, all powerful, rescuing, and lovable. These fantasies are not only inherently unrealistic and dehumanizing but are inevitably disappointed. The disappointments, if realized in a romantic relationship between a doctor and a patient, can be destructive, especially for the patient. (Sexual relationships between patients and therapists are discussed further in Chapter 56.)
Another aspect of sexuality as it pertains to countertransference issues relates to asking patients about sexual issues and to obtaining a sexual history. A reluctance to do so may reflect a physician's own anxiety about sexuality or even an unconscious attraction toward a patient. Moreover, the omission of these questions generally tells patients that a doctor is uncomfortable with the subject and thus leads to an inhibition about discussing any number of other sensitive subjects.
NEED TO SELF-MONITOR. Countertransference feelings need not always be perceived in negative terms. They also have the potential, if recognized and analyzed, to help psychiatrists better understand patients who have stimulated the feelings. For instance, if a doctor feels bored and restless when with a particular patient and has ascertained that the boredom is not secondary to his or her own preoccupations, the doctor may surmise that the patient is speaking about trivial or insignificant concerns to avoid real and potentially disturbing concerns.
PHYSICIAN PATIENTS. A special example of countertransference issues, which applies to psychiatrists and nonpsychiatrists alike, occurs when the patient being treated is a physician. Problems that can arise for the treating physician in this situation include the expectation that a physician-patient can take care of his or her own medications and treatment and the fear that the patient will criticize the treating doctor's skills or competence. Ill physicians are notoriously poor patients, most likely because they are trained to be in control of medical situations and to be the masters in the doctor–patient relationship. For a physician, being a patient may mean giving up control, becoming dependent, and appearing vulnerable and frightened—tendencies that most physicians are professionally trained to suppress. Physician-patients may be reluctant to become what they perceive as burdens to overworked colleagues, or they may be embarrassed to ask pertinent questions for fear of appearing ignorant or incompetent. Physician-patients may stimulate fear in the treating physicians who see themselves in the patient, an attitude that can lead to denial and avoidance on the part of the treating physician.

15. Techniques Bay attention to both content & process.
Open-ended question versus Closed-ended questions.
REFLECTION. In the technique of reflection, a doctor repeats to a patient in a supportive manner something that the patient has said.
FACILITATION. Doctors help patients continue in the interview by providing both verbal and nonverbal cues.
SILENCE.
The early part of the interview is generally the most open ended, in that physicians allow patients to speak as much as possible in their own words. A closed-ended question or directive question is one that asks for specific information and that allows a patient few options in answering. Too many closed-ended questions, especially in the early part of an interview, can lead to a restriction of patients' responses. Sometimes, directive questions are necessary to obtain important data, but when they are used too often, a patient may think that information is to be given only in response to direct questioning by the doctor. An example of an open-ended question is, "Can you tell me more about that?" A closed-ended question, if a patient has stated that he or she has been feeling depressed, might be, "Your mother died recently, didn't she?" This question can be answered only by a yes or no, and the mother's death may or may not be the reason the patient is depressed. More information is likely to be obtained if the doctor responds with, "Tell me more about what you're feeling and what you think may be causing it."
Closed-ended questions, however, can be effective in generating specific and quick responses about a clearly delineated topic. Closed-ended questions have been shown to be effective in eliciting information about the absence of certain symptoms (for example, auditory hallucinations and suicidal ideation). Closed-ended questions have also been found to be effective in assessing such factors as the frequency, the severity, and the duration of symptoms
REFLECTION. In the technique of reflection, a doctor repeats to a patient in a supportive manner something that the patient has said. The purpose of reflection is twofold: to assure the doctor that he or she has correctly understood what the patient is trying to say and to let the patient know that the doctor is perceiving what is being said. It is an empathic response meant to allow the patient to know that the doctor is both listening to the patient's concerns and understanding them. For example, if a patient is speaking about fears of dying and the effects of talking about these fears with his or her family, the doctor may say, "It seems that you are concerned with becoming a burden to your family." This reflection is not an exact repetition of what the patient has said but, rather, a paraphrase that indicates that the doctor has perceived what the patient is trying to say.
FACILITATION. Doctors help patients continue in the interview by providing both verbal and nonverbal cues that encourage patients to keep talking. Nodding the head, leaning forward in the chair, and saying, "Yes, and then ¼ ?" or "Uh-huh, go on," are all examples of facilitation.
SILENCE. Silence can be used in many ways in normal conversations, even to indicate disapproval or disinterest. In the doctor–patient relationship, however, silence may be constructive and in certain situations may allow patients to contemplate, to cry, or just to sit in an accepting, supportive environment where the doctor makes it clear that not every moment must be filled with talk.

16. CONFRONTATION. The technique of confrontation is meant to point out to a patient something that the doctor thinks the patient is not paying attention to, is missing, or is in some way denying.
CLARIFICATION. In clarification, doctors attempt to get details from patients about what they have already said.
INTERPRETATION. The technique of interpretation is most often used when a doctor states something about a patient's behavior or thinking that a patient may not be aware of.
CONFRONTATION. The technique of confrontation is meant to point out to a patient something that the doctor thinks the patient is not paying attention to, is missing, or is in some way denying. Confrontation must be done skillfully, so that patients are not forced to become hostile and defensive. The confrontation is meant to help patients face whatever needs to be faced in a direct but respectful way. For example, a patient who has just made a suicidal gesture but is telling the doctor that it was not serious may be confronted with the statement, "What you have done may not have killed you, but it's telling me that you are in serious trouble right now and that you need help so that you don't try suicide again."
CLARIFICATION. In clarification, doctors attempt to get details from patients about what they have already said. For example, a doctor may say: "You are feeling depressed. When is it that you feel most depressed?“
INTERPRETATION. The technique of interpretation is most often used when a doctor states something about a patient's behavior or thinking that a patient may not be aware of. The technique follows on the doctor's careful listening to the underlying themes and patterns in the patient's story. Interpretations usually help clarify interrelationships that the patient may not see. The technique is a sophisticated one and should generally be used only after the doctor has established some rapport with the patient and has a reasonably good idea of what some interrelationships are. For example, a doctor may say: "When you talk about how angry you are that your family has not been supportive, I think you're also telling me how worried you are that I won't be there for you either. What do you think?"

17. SUMMATION. Periodically during the interview, a doctor can take a moment and briefly summarize what a patient has said thus far.
EXPLANATION. Doctors explain treatment plans to patients in easily understandable language and allow patients to respond and ask questions
TRANSITION. The technique of transition allows doctors to convey the idea that enough information has been obtained on one subject; the doctor's words encourage patients to continue on to another subject.
SUMMATION. Periodically during the interview, a doctor can take a moment and briefly summarize what a patient has said thus far. Doing so assures both patient and doctor that the doctor has heard the same information as the patient has actually conveyed. For example, the doctor may say, "OK, I just want to make sure that I've got everything right up to this point."
EXPLANATION. Doctors explain treatment plans to patients in easily understandable language and allow patients to respond and ask questions. For example, a doctor may say: "It is essential that you come into the hospital now because of the seriousness of your condition. You will be admitted tonight through the emergency room, and I will be there to make all the arrangements. You will be given a small dose of medication that will make you sleepy. The medication is called triazolam (Halcion), and the dose you will be getting is mg. I will see you again first thing in the morning, and we'll go over all the procedures that will be required before anything else happens. Now, what are your questions? I know you must have some."
TRANSITION. The technique of transition allows doctors to convey the idea that enough information has been obtained on one subject; the doctor's words encourage patients to continue on to another subject. For example, a doctor may say: "You've given me a good sense of that particular time in your life. It would be good now if you told me a bit more about an even earlier time in your life."

18. POSITIVE REINFORCEMENT REASSURANCE ADVICE
SELF-REVELATION. Limited, discreet self-disclosure by physicians may be useful in certain situations, and physicians should feel at ease and should communicate a sense of self-comfort.
POSITIVE REINFORCEMENT
REASSURANCE
ADVICE
SELF-REVELATION. Limited, discreet self-disclosure by physicians may be useful in certain situations, and physicians should feel at ease and should communicate a sense of self-comfort. Conveying this sense may involve answering a patient's questions about whether a physician is married and where he or she comes from. A doctor who practices self-revelation excessively, however, is using a patient to fulfill unfilled needs in his or her own life and is abusing the role of physician. If a doctor thinks that a piece of information will help a patient be more comfortable, the doctor can decide in each case whether to be self-revealing. It depends on whether the information will further a patient's care or whether it will provide nothing useful. Even if the doctor decides that self-revelation is not warranted, he or she should be careful not to make the patient feel embarrassed for asking. For example, the doctor may say: "I'm not sure whether you are really asking if I'm married. Let's talk about it a little more, so that I can understand why that information is important to you. Maybe it has more to do with some concerns you have about my commitment to your care." Or "I am married, but let's talk a little about why it was important for you to know that. If we talk about it, I'll have a bit more information about who you are and what your concerns are regarding me and my involvement in your care." Perhaps the important point here is not to take patients' questions at face value alone. Many questions, especially personal ones, convey not just natural curiosity but also hidden concerns about the doctor, which should not be ignored.
POSITIVE REINFORCEMENT. The technique of positive reinforcement allows patients to feel comfortable in telling a doctor anything, even about such things as noncompliance with treatment. By encouraging a patient to feel that the doctor is not upset by whatever the patient has to say, the doctor facilitates an open exchange. For example, a doctor may say: "I appreciate your telling me that you have stopped taking your medication. Can you tell me what the problem was with the medication? The more I know about what's going on with you, the better I'll be able to treat you in a way that you will feel comfortable with."
REASSURANCE. Truthful reassurance of a patient can lead to increased trust and compliance and can be experienced as an empathic response of a concerned physician. False reassurance, however, is essentially lying to a patient and can badly impair the patient's trust and compliance. False reassurance is often given from a desire to make a patient feel better, but once a patient knows that a doctor has not told the truth, the patient is unlikely to accept or believe truthful reassurance. In an example of false reassurance, a patient with a terminal illness asks, "Am I going to be all right, Doctor?" and the doctor responds, "Of course you'll be all right; everything is fine." In an example of truthful reassurance, the doctor responds: "I am going to do everything to make you as comfortable as possible, and part of being comfortable is for you to know as much as I know about what is going on with you. We both know that what you have is serious. I'd like to know exactly what you think is happening to you and to clarify any questions or confusion you have.“
ADVICE. In many situations it is not only acceptable but desirable for physicians to give patients advice. To be effective and to be perceived as empathic rather than as inappropriate or intrusive, the advice should be given only after patients are allowed to talk freely about their problems, so that physicians have an adequate information base from which to make suggestions. At times, after a doctor has listened carefully to a patient, it becomes clear that the patient does not, in fact, want advice as much as an objective, caring, nonjudgmental ear. Giving advice too quickly can lead a patient to feel that the doctor is not really listening but, rather, is responding either out of anxiety or from the belief that the doctor inherently knows better than the patient what should be done in a particular situation. In an example of advice given too quickly, a patient says, "I cannot take this medication; it's bothering me," and the physician responds: "Fine. I think you should stop taking it, and I'll start you on something new." A more appropriate response is the following: "I'm sorry to hear that. Tell me what about the medication is bothering you, so that I have a better idea of what we may do to make you feel more comfortable." In another example the patient says, "I've really been feeling down lately," and the doctor responds, "Well, I think in that case it would be a good idea for you to go out and really do some things that are fun, like going to the movies or walking in the park." In this case a more appropriate and helpful response is the following: "Tell me what you mean by `feeling down.' The more I know about what you're feeling, the more likely it will be that I can help."

20. Thank you