BOOK REVIEW

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Field Guide to the Difficult Patient Interview, 2nd ed. By Frederic W. Platt and Geoffrey H. Gordon. Philadelphia, PA: Lippincott Williams & Wilkins ; 2004 . 297 pages $32.95 .

“Dr. S, I'm leading a family meeting for one of our inpatients later today and need a few pointers. Can you help?” asked a resident who had paged. “Sure, just give me a few moments and I'll get back to you,” I replied, knowing that the current edition of the Field Guide to the Difficult Patient Interview was close at hand. Needless to say, my subsequent dialogue and rare feat of brilliance with the resident were due largely to Drs. Platt and Gordon's wise words in chapter 35, “Talking with Families of Seriously Ill Patients.”

Health communication is rapidly maturing as an essential discipline in medical education. New testing standards at the graduate level and new competencies at the postgraduate level attest to the recognition of interviewing as a core clinical skill. Medical students and residents now receive formal communications training, and must demonstrate their ability to communicate successfully in videotaped encounters with standardized patients. For many of us whose training predated this sea change, how might we keep pace with the burgeoning knowledge in this field, and how can we assimilate new techniques to help improve our clinical interactions?

The second edition of the Field Guide to the Difficult Patient Interview offers just such an opportunity. The book is a delightful, thoughtful, and pragmatic presentation of best practices in the medical interview. General internists Platt and Gordon, who have woven their distinguished careers around the teaching of medical interviewing, write with the wisdom and confidence of master clinicians. Building on the successful first edition (1999), the authors expanded the new version from 198 to 297 pages, adding 13 chapters and updating others. The new edition includes chapters on current flashpoints in health communication, including empathy, self-awareness, hope, shared decision making, disclosing unexpected outcomes and errors, clinician-to-clinician communication, and coaching communication skills.

This handbook-sized volume is divided into 8 sections containing 48 chapters. Written in modified outline form, the text is formatted into “five P's”: problem, principles, procedures, pitfalls, and concludes with a pearl. Examples of physician-patient dialogue are generously interspersed in each chapter. The authors make a point of providing key interviewing phrases, enabling the text to be a “how to say it” guide. An ample and current selected readings list is found at the end of each chapter. The text format works very well and offers the options of reading the book from beginning to end, or using it as a quick reference guide. Each chapter can be digested in a few minutes, which makes this a great bookshelf resource for those hectic clinical or teaching days.

In the opening discussion of basic interview technique, the authors advocate for a relationship-centered approach. Instead of viewing the patient encounter as a series of discrete content areas to cover, Platt and Gordon recommend attending to the setting and imminent interpersonal exchange first. “Begin with the personal,” state the authors, [as] “devoting a bit of time … to this social history will establish a connection and … a perspective from which to understand the patient's problems.”

Although not possible in a brief review to mention all of the topics covered in this expansive text, several are noteworthy. The fourth section, entitled, The Clinical Attitude, offers novel and refreshing topics, including Curiosity, “OK” and “Wow”—the Short Words, Self-awareness, and Hope. In Self-awareness, Platt and Gordon encourage the reader to practice contemplation while engaged in a clinical encounter. This includes monitoring our feelings, values, and prior experience, which can influence our responses and behavior with patients. Anger, impatience, fear, sadness—feelings commonly aroused in a physician's typical workday, require pausing for a moment of awareness. “Reflection sharpens our focus on the patient,” the authors conclude.

The subsequent sections address difficult relationships and specific clinical situations, such as chronic pain and somatizing patients. Two outstanding chapters in this section are Being with a Dying Patient, and Talking with Families of Seriously Ill Patients. Here Platt and Gordon suggest a useful, empiric framework to guide us when we might otherwise struggle for the right thing to say or do. For example, in “Being with a Dying Patient,” they write: “The hardest action for many of us is no action, just being present. We have to recognize that being there is an activity that requires effort.”

In coaching the aforementioned resident in leading a family meeting, the chapter on this topic offered a series of step-by-step procedures which are as easy to follow as they are to teach. The book's final two sections focus on risk behaviors such as sex and violence, and on special situations, ranging from the patient bearing literature, to disclosing medical errors.

The second edition of the Field Guide to the Difficult Patient Interview is a resounding success, and will meet the needs of both experienced and beginning internists in teaching and practice roles. However, a few weaknesses bear noting. Although a reading list is included in each chapter, a lack of footnotes at times creates ambiguity as to what may be an author's opinion versus what is supported by literature or clinical evidence. Although the authors did cover a large number of communications topics, a few were underrepresented: health literacy, racial and ethnic disparities, gender differences, and the patient with psychiatric illness.

Other important texts in this field include: The Medical Interview: Clinical Care, Education, and Research, 1995, edited by Lipkin, Putnam, and Lazare; The Medical Interview: The Three-function Approach, second edition, 2000, by Steven Cohen and Julian Bird; and Patient-centered Interviewing: An Evidence-based Method, second edition, 2002, by Robert C. Smith. While the Platt and Gordon book is better suited to function as a handbook for practicing physicians and residents, by comparison, the Lipkin et al. text is a weightier tome offering a foundational resource for communications educators and researchers. The Cohen/Bird and Smith texts focus on details of interview structure and method, and are ideally crafted for medical school and residency communications courses. The next generation of learning resources are likely to be web based and equally exciting, offering multimedia demonstrations of interview technique (oral communication with W. Clark, managing editor of doc.com, a web-based communications resource currently under construction).

In this new edition of the Field Guide, Platt and Gordon clearly and succinctly present the conceptual framework and language that can help us practice or teach our way through the most challenging patient-physician encounters. As aptly noted by Dennis Novack in the book's foreword, this work may indeed “reflect the coming of age of education physician-patient communication.”

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