This editorial focuses on a review carried out by a multidisciplinary group of authors and recently published in Psychotherapy and Psychosomatics [1]. This is not surprising given that mental health clinicians and researchers have been among the leaders in the art and science of clinical interviewing. At the same time, Fava et al. [1] present findings and recommendations that are transdisciplinary and applicable across most clinical settings. Certainly, there are important variations and accommodations distinct to different types of providers. For example, I am a general internist, and my perspectives are inevitably informed by encounters in the primary care setting. Nonetheless, interviewing is an essential skill universally required for effective and patient-centered care. Attaining proficiency warrants the same degree of training and practice as do sophisticated medical procedures. Furthermore, the return on investment in terms of clinical value, health care expenditures, and customer satisfaction equals or surpasses many other clinical tasks and activities.

Many practitioners would agree with the assertion by Fava et al. [1] that “interviewing deserves more attention in educational training and more space in clinical encounters.” Related concepts include history-taking and provider-patient communication [2‒4]. Benefits of effective clinical interviewing include establishing a therapeutic bond/relationship; identifying the patient’s health concerns and priorities; and gathering information to inform diagnosis, estimate prognosis, and guide treatment decisions. This would seem sufficient to convince providers, patients, and payers of the preeminent role of interviewing in clinical encounters. Instead, clinical interviewing often travels third class in the modern health care train.

Several factors contribute to the devaluation of clinical interviewing. First and foremost is reimbursement. Health care expenditures are disproportionately allocated to procedures, tests, and care delivered in the hospital, emergency room, and other high-cost settings [4, 5]. In contrast, time spent talking with the patient is felt to be worth much less and reimbursed accordingly. A consequence is the much lower payments for primary care and mental health services for which conversations and dialogue rather than procedures and tests are the focal point of many visits. Because the dollars received per minute are far less for nonprocedural encounters, this leads to squeezing many more visits into a typical day where 10–20 min is the typical time allowed for a patient encounter. Moreover, non-interviewing tasks compete for this limited time, such as navigating an increased amount of information available in the electronic health record, onerous documentation requirements, actions required by preventive services and disease-specific guidelines, refilling multiple medications, and dividing time between the patient and the computer [1, 6]. Within the span of a single decade (2005–2016), face-to-face time between the patient and provider dropped dramatically from 55% to 27% of office time, while the time required for EHR and desk time tripled [3, 7, 8].

However, low reimbursement and limited time are not the only impediments to clinical interviewing. In contrast to objective findings from tests, physical examination, and clinician observation, data derived directly from patients is labeled as subjective, a term that connotes “soft,” less valid information than the “hard” data obtained independent of the patient [9]. Importantly, more than half of outpatient visits are prompted by physical or psychological symptoms for which 75% of diagnoses are derived predominantly from the patient’s history (i.e., the clinical interview) [4]. Kudos to the authors when they write that “in a reimbursement system, clinical interview should become the best paid procedure, since it is an extraordinary investigative technique that is ‘the most clinically sophisticated procedure of medicine’” [1].

The first few minutes are the opportune time to introduce the patient voice into the agenda of a time-limited office encounter. In a classic study, Beckman and Frankel found that in only 17 (23%) of 74 primary care visits, the patient was provided the opportunity to complete his or her opening statement of concerns [10]. The authors noted: “In 51 (69%) of the visits, the physician interrupted the patient's statement and directed questions toward a specific concern; in only 1 of these 51 visits was the patient afforded the opportunity to complete the opening statement… Interruption occurred, on average, 18 s after the patient began to speak, a surprisingly short time, particularly for new visits. No completed statement of concerns took more than 150 s.” Clinicians often overestimate how long the patient’s opening gambit will last; a minute or two of listening by the clinician may have a high diagnostic and therapeutic payoff.

Many years ago, I read an essay (I cannot recall the exact source) in which a clinician wrote something like Stop talking. I am trying to listen. He was using auscultation to listen to the patient’s heart sounds. But the patient was trying to tell him something, and the clinician belatedly realized that pausing to hear what the patient was saying might have been more informative than persisting with the stethoscope. This anecdote exemplifies how the subjective may outstrip the objective in terms of information gathering, prioritizing, and therapeutic relationship. Indeed, beyond auscultation, clinicians need to remind themselves to stop talking and try listening. This can substantially reduce the likelihood of missing important items on the patient’s agenda or leaving unmet patient expectations on the table following the visit [11, 12].

Location matters. As Fava et al. [1] note, “The initial interview may have different characteristics as to whether it occurs in general practice/internal medicine or in a specialty setting. In the latter case, the initial interview may be restricted to the system that is of primary concern (e.g., cardiovascular)…” [1]. Medical and surgical specialists typically can be more laser-focused in one area of health. Although mental health professionals often have competing demands of their own, the interview is their stethoscope, and conversation is the predominant laboratory test. Paradoxically, primary care clinicians assume the broad and holistic mantle of caring for the whole patient but as a consequence are at greatest risk of competing demands squeezing out interview time.

Reframing the clinical interview as a longitudinal rather than cross-sectional process may enhance both its diagnostic and therapeutic value. Historically, the “find it and fix it” intent of medical and surgical providers to mitigate a patient’s problem(s) in one or a few visits contrasts sharply with the mental health clinician’s listening and problem-solving over a series of visits. Whereas adequate reimbursement for longer office visits is one way of providing sufficient time for clinical interviewing, a complementary approach is to extend interviewing over several or more visits for single complex problems or multiple health concerns [13].

One challenge in many primary care practices is the large size of patient panels that can inhibit earlier and more frequent follow-up visits with individual patients. Another is patient expectations inculcated by modern health care for simple clearcut solutions, an impatience for resolution of physical and mental ailments. This is the “repairman” paradigm. If our refrigerator is not working, we want the repairman to come and fix it today and not return repeatedly over time. While appropriate for some acute illnesses, this urgency is misdirected when it comes to the numerous chronic conditions that now populate a large part of clinical practice. This urgency can drive excessive and premature diagnostic testing. Follow-up may be preferable to work-up, both to complete the clinical interviewing process and to sort out self-limited from more persistent problems. Reflecting on ambulatory care some years ago, I wrote: “A single visit may sometimes accomplish a single task. Relieve a present ailment. Construct a problem list. Examine the patient. Perform a procedure. Counsel, educate, immunize, or proffer prophylaxis. These sundry tasks may mandate separate visits. An analyst is not expected to effect immediate psychic healing. Patient care is more than a 1-day job [13].

Finally, there are related movements that can further inform and enrich our perspectives on clinical interviewing. One example includes clinimetrics for which foundational work was initiated by Alvan Feinstein more than 5 decades ago and further investigated by the authors over the years [14]. Although a scientifically valid approach of measuring patient-reported outcomes is central to clinimetrics, a general underlying principle is the importance of patient-derived data. The biopsychosocial model originating with George Engel in the 1960s and elaborated in research and practice by the authors and others is also heavily dependent upon the clinical interview [15, 16]. Sharing decision-making is a third paradigm aligned with interviewing [17].

The clinical interview precedes technology-driven health care by millennia. An unhurried conversation with the patient seems antiquarian and devoid of the allure that emanates from laboratory testing, imaging machines, diagnostic and therapeutic procedures, and precision medicine [18]. Certainly, a Luddite agenda to wreck the machines of modern medicine would be retrograde and unwarranted. At the same time, restoring the primacy of the clinical interview and preserving it as a fundamental instrument in the doctor’s black bag can proceed pari passu with the modern tools that complement rather than replace provider-patient dialogue. It would be tragic to relegate taking a careful and compassionate medical history to the history books.

Prof. Kurt Kroenke has no conflicts of interest to declare.

Prof. Kurt Kroenke has no funding to declare.

Prof. Kurt Kroenke conceived and wrote the entire manuscript.

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