CONTINUOUS MEDICAL EDUCATION AND QUALITY DEVELOPMENT
The patient-centred interview: the key to
biopsychosocial diagnosis and treatment
Pekka Larivaara, Jorma Kiuttu and Anja Taanila
Department of Public Health Science and General Practice, University of Oulu, Oulu, Finland.
Scand J Prim Health Care 2001;19:8– 13. ISSN 0281-3432
The article reports on some ideas and experiences gained from a
holistic approach to working with patients and introduces a view-
point that includes opinions on how postmodernism, the biopsycho-
social model and a patient-centred interviewing style can change
traditional, biomedical-oriented medicine. During the past 10 years,
we have been instructing medical students in the use of this pa-
tient-centred interviewing model and have trained experienced gen-
eral practitioners (GPs) in adopting it in 2-year family-oriented
continuing medical education courses. We believe that doctors and
other health care providers, particularly in primary care settings,
need a comprehensive concept of human health and illness, and
that skill in patient-centred interviewing is the product of a deep
learning process. In conclusion, we have learned that a successful
Medicine in the Western world has for long been
based on natural sciences, and teaching at medical
schools has been mainly disease-oriented. The
biomedical treatment model is deeply connected with
modernistic thinking of human beings and illnesses.
Modernism refers to a Western philosophical tradi-
tion that views knowledge as objective and Ž xed (1).
Knower and knowledge are independent, and lan-
guage is a representation of objective truth and real-
ity. Doctors are authorities as decision-makers and
patients are in a deferential position. Typically, in
this conŽ guration, doctors are the culturally deŽ ned
experts who have empowering knowledge that is of-
ten private and unavailable to a patient (2).
The emergence of a postmodern discourse in the
human sciences is challenging the modernistic per-
spective of how we see and think about the world and
our experiences in it. Postmodernism is an umbrella
term referring not to an era but to a philosophical
perspective that includes an ideological critique of the
foundation of medical and social thinking – a contin-
ual questioning and re-examination of the familiar
(2). From a postmodern perspective, everything is
open to criticism. The doctor’s knowledge, diagnosis
and treatment plans are not ‘‘objective truths’’ any
more. Postmodernism favours the idea that a knower
participates in creating the world he or she lives in,
observes and knows. In that paradigm, both the
doctor and the patient are equal knowers who, by
communicating together, create shared expertise (3).
Scand J Prim Health Care 2001; 19
patient-centred interview helps the GP to better understand the
patient and helps to explain the data that the patient presents.
Patient-centred orientation and interviewing also change the com-
munication between doctor and patient in a direction which sup-
ports the patient’s and his/ her family members’ own resources in
the healing process.
Key words: patient-centred interview, doctor– patient communica-
tion, biopsychosocial approach, postmodernism, consultations, gen-
eral practice, medical education.
Pekka LariØaara, Family and Community Medicine, Department
of Public Health Science and General Practice, UniØ ersity of
Oulu, P.O. Box 5000, FIN-90014 UniØ ersity of Oulu, Finland.
E-mail: plariØaa@cc.oulu.Ž
In Europe, Michael Balint (4) was one of the Ž rst
pioneers with a postmodern perspective to medicine.
He started analysing the communication between
doctor and patient as long ago as the 1950s. Since
then, many doctors and researchers have made a
close study of the details of this communication
process (3,5 – 7). Today, American medicine is also in
the midst of a professional evolution driven by re-fo-
cusing medicine’s regard for the patient’s point of
view (8). The biomedical model was concretely chal-
lenged there by George Engel (9), who addressed the
psychosocial aspect of medicine and formulated a
biopsychosocial diagnosis and treatment model in the
1970s. On the basis of the work of these pioneers
during the last three decades, a patient-centred inter-
viewing and treatment model has been created (10 –
13), and medical education has gradually taken a
patient-centred and learner-centred turn (14).
In this paper, we Ž rst try to clarify the key elements
and theoretical differences of the doctor-centred and
patient-centred interviews. The patient-centred inter-
viewing model formulated by us is based on the
literature, our previous study outcomes and our
teaching, supervision and clinical experiences. Sec-
ondly, we introduce an illustrative patient case that
helps readers to understand how these two interview-
ing styles differ from each other and how a doctor’s
patient-centred interviewing and attitude offer an op-
portunity to formulate a biopsychosocial diagnosis
for the starting point of a comprehensive treatment
plan.

THE DOCTOR-CENTRED INTERVIEW
A doctor-centred attitude and interview is appropri-
ate in acute clinical situations when there is imminent
danger to the patient’s life and when very rapid
action is needed, e.g. in emergency clinics. The goal
of the doctor-centred interview is to make a clinical
symptom or disease diagnosis based on an authorita-
tive, modernistic and biomedical approach. The doc-
tor leads the conversation and interrupts the patient’s
story shortly (15) by starting to present a sequence of
closed questions (11). The doctor makes decisions
about what information and knowledge is necessary
and important.
With the exception of these few acute clinical in-
stances, especially in primary care settings, the doc-
tor-centred interview has several disadvantages: the
patient’s own expectations, views of the symptoms,
concerns, fears and other feelings are not fully elic-
ited. Even his or her real reasons for coming to the
physician may be ignored (15). The patient readily
begins to believe that his or her ideas are not impor-
tant while planning the treatment. He or she may
become passive and lose conŽ dence in his or her own
strengths. Then symptoms and a feeling of illness
often increase, resulting in heavy use of medical care
(16).
THE PATIENT-CENTRED INTERVIEW
The essence of the patient-centred method is that the
doctor tries to enter the patient’s world and tries to
get a holistic picture of the patient. This includes
information from all the levels of the biopsychosocial
model: cell-organ level, psychological-individual level,
and family-community level (9). The goal is also to
reach shared expertise with the patient (3). Further-
more, in the patient-centred treatment model the
physician has to support the patient’s autonomy
(2,3,5,11,12), i.e. the personal authority and compe-
tence of the patient fully and responsibly to take a
central role in his or her health and illness
management.
Key elements of the patient-centred encounter
In this decade, a growing consensus has emerged on
deŽ ning some key elements of the patient-centred
encounter (11). These include: (i) assessing the full
spectrum of patient concerns, (ii) getting to the heart
of the problem, (iii) delivering diagnostic informa-
tion, (iv) developing treatment plans, and (v) educat-
ing and motivating patients.
Gathering data
Everyone agrees that a doctor has to be able to
gather data accurately if s:he is to understand a
The patient-centred inter×iew 9
patient’s problem and to assess the full spectrum of
the patient’s concerns. It has been estimated that
two-thirds of diagnoses can still be made by the
history alone, despite the technological innovations
of modern medicine (11). However, taking a good
history is not easy. Doctors seem not to be good
listeners, and often interrupt their patients within the
Ž rst 18 seconds of the encounter (15). Therefore, in
many cases, patients’ reasons for coming to the doc-
tors are not fully elicited.
A good interview should begin with a patient-led
storytelling process in which the patient has in uence
over the selection of the headlines and details of the
story told. Skilled interviewers convey warmth and
attention by their forward posture, eye contact and
expressive face, gesture and tone (11,12). Their ques-
tions are single and to begin with open-ended, con-
trary to the closed ones used in the doctor-centred
interview: ‘‘What can I do for you today? ’’ Questions
invite the patient to describe their problems by using
their own vocabulary and personal experience of the
symptoms: ‘‘Tell me some more – whate×er you feel is
important? ’’ By allowing the patient the opportunity
to describe his or her own complaints, the skilled
doctor can more efŽ ciently develop diagnostic hy-
potheses and recognise patterns that are relevant for
that particular patient’s problems.
However, very often the patient’s story includes
ambiguity and jargon, in which case the doctor has to
interrupt (not too early during the interview) and to
present some clarifying comments: ‘‘I’m not clear
about that – tell me again’’ or ‘‘Let me see if I’×e
understood that correctly …’’ or ‘‘Let me check to see
if I understand what you ha×e told me so far.’’ Check-
ing (11) gives an important message to the patient,
including reassurance about the doctor’s active listen-
ing and interest in gaining an accurate understanding
of the problem.
At the end of the interview, the patient-centred
interviewer often explicitly introduces the summary
and invites the patient’s comment, not just medical
but also social and emotional issues are included.
Summarising also demonstrates that the doctor has
been attentive (3,11,12).
Responding to patients’ emotions
All experiences of symptoms and illness produce
many emotions in patients and their families. In
order to get to the heart of the patient’s problems, the
doctor must somehow perceive these emotions and
respond to them either verbally or non-verbally. The
manner in which the doctor responds to the patient’s
emotions will, to a large extent, determine the quality
of the overall doctor – patient relationship. Even a
competent technical procedure may be felt unsuccess-
Scand J Prim Health Care 2001; 19
10 P. Lari×aara et al.
ful by a patient if the doctor is not supportive and
emotionally available (16).
The empathic doctor encourages the patient to
describe his:her feelings about the illness and treat-
ment. S:he has a small packet of tissues on the table
of the consulting room for tearful patients. It helps
the patient if the doctor states that an emotion is
recognised and accepted. ‘‘This must be ×ery hard for
you. Now I understand your situation better.’’
Respect and personal support
The patient-centred doctor acknowledges and appre-
ciates the patient’s efforts to cope with his:her symp-
toms and problems. Respectful comments add a great
deal to improving the relationship. Sometimes it is
good to move closer to the patient, even to touch and
use warm tones while speaking. Once in a while,
limited self-disclosure is appropriate and supportive
(11): ‘‘When my mother had symptoms like yours some
years ago, she and I felt upset like you do now.’’
Patient-centred doctors are also honest to patients
and their family members (17). They tell them what is
possible to manage in the ‘here and now’ and what
issues are outside their knowledge. ‘‘I want to help
you in any way I can. Please, let me know what you
expect me to do to help.’’
Diagnosis, treatment plans, education and moti×ating
The Ž nal function of the patient-centred interview
concerns a kind of summary of the information from
the doctor to the patient. This is a special part of the
communication process to which more attention
should be paid, because, even when patients become
fully informed, only 22– 72% of doctors’ recommen-
dations are followed (14). Many doctors are frus-
trated, and often ask: ‘‘How can we get the patient to
understand and remember the diagnostic information
and advice?’’ There are at least six steps in the
affective process of educating a patient about his or
her illness (11): (i) establish the patient’s perception
of the problem, (ii) provide a basic diagnosis, (iii)
respond to the patient’s feelings about the diagnosis,
(iv) check the patient’s knowledge of the illness, (v)
provide details of the diagnosis, and (vi) check the
patient’s understanding of the problem.
In this phase of the interview, it is therefore impor-
tant Ž rst to elicit the patient’s ideas about the cause
of the main symptom. ‘‘What do you think might be
causing your problem or illness? ’’ At this moment,
patients very often reveal their fears about some
particular illness or severe disease. Patients are also
often fearful and very anxious in listening to the
doctor’s diagnostic information, especially if the in-
formation includes some bad news. Therefore this
information and any instructions need to be brief and
Scand J Prim Health Care 2001; 19
succinct. Every now and then the patient’s response is
only non-verbal. The patient may be silent or may
look sad, or anxious.
When making treatment plans it is also important
for the doctor to give due attention to the patient’s
motivation. However, even experienced doctors know
that one of the most difŽ cult tasks is to motivate a
patient into making changes in their lifestyle. There
are at least seven steps in a basic motivational se-
quence that the doctor can use to help motivate
patients to adhere to treatment plans (18): (i) check
adherence carefully; (ii) diagnose speciŽ c adherence
problems; (iii) respond to emotions and offer sup-
port, partnership and respect; (iv) elicit a statement of
commitment; (v) negotiate solutions; (vi) obtain an
afŽ rmation of intent and follow-up; and (vii) rein-
force the patient’s own strengths (empowerment).
This means that the doctor has to create with the
patient an atmosphere in which it is possible to
discuss all problems regarding non-adherence openly.
When patients describe their difŽ culties in trying to
follow advice, the doctor should indicate an under-
standing of the problem. ‘‘I understand that this is
difŽ cult for you. I ha×e seen the same kind of
difŽ culties in se×eral other patients.’’ As the problems
have been clariŽ ed, it is easier for the doctor and the
patient to develop a plan together to address them.
When the patient has successfully accomplished even
a small part of the plan, the doctor must respect this
issue and praise the patient. ‘‘I am ×ery impressed that
you ha×e succeeded in cutting down smoking so much.’’
Motivational efforts usually arouse many emotions
in the patients. These can include for example sad-
ness, anger, humiliation or enjoyment and happiness.
Responding to all the patient’s emotions fosters a
relationship and can result in better health outcomes.
AN ILLUSTRATIVE CASE
The following example, based on recent experience in
a health care centre, illustrates the differences be-
tween the doctor-centred and the patient-centred in-
terview. The details have been changed so that the
patient cannot be identiŽ ed and conversations are
presented as abridged versions. A 46-year-old female
patient was Ž rst interviewed by a young GP with no
special training in patient-centred interviewing. After
this, an experienced GP, who had received special
training in a biopsychosocial approach and in pa-
tient-centred and family-oriented interviewing, met
with the patient and performed a patient-centred
interview without seeing the previous one. Both inter-
views were videotaped, transcribed and analysed.

Doctor-centred inter×iew
Doctor: How are you today?
Patient: I have had stomach-aches. It is an old trou-
ble and it has bothered me, perhaps, four years. It is
a kind of sense of burning here (pointing to the pit of
the stomach). There must be something.
Doctor: Hmm. Let us look at it.
Patient: Now it bothers me all the time. It is a terrible
pain.
Doctor: How long you have suffered from it? (The
doctor starts to dominate the inter×iew.)
Patient: For a long time, but during the last two
weeks it has been especially serious. I feel that it has
been even difŽ cult to walk, my legs do not bear me,
and it is troublesome to see in my way.
Doctor: Was it the pain which made walking so
difŽ cult? (A closed question)
Patient: Perhaps, yes. I don’t know. (The doctor
doesn’t react to the patient’s ×ague answer)
Doctor: Can you eat anything?
Patient: Yes, but I think that fatty food makes the
aches worse. When I ate grilled sausages at our
summer place, the trouble began. (No attention to the
patient’s suggestion about her life situation)
Doctor: Have you lost any weight? (A close question)
Patient: I don’t think so. I have had some pills and
they have helped a bit.
Then they discuss the pills for a while. The patient
says that a gastroscopy was performed about four
years previously and that the doctor recommended a
repeat procedure in a year.
Doctor: Is the pain either during the night and day or
at what time? (A closed question)
Patient: It is, perhaps, less difŽ cult in the night.
Doctor: Have you seen any blood in your stools? Any
nausea or vomiting? (A closed question)
Patient: No.
Doctor: Well, let us look at your stomach.
Then the doctor performed a physical examination
and recommended some laboratory tests and sug-
gested a further gastroscopy. Psychosocial issues were
not elicited.
Patient-centred inter×iew
Doctor: Hello, what can I do for you?
Patient: I have had stomach-aches for about two
weeks or even longer. It is a sense of burning here
(pointing to the pit of the stomach). There must be
something. It is difŽ cult to sit and when walking I
feel myself too weak. It has been a very difŽ cult
situation during the last few days. (Feeling)
Doctor: Hmm. I understand. So two terrible weeks.
(Empathy, facilitating beha×iour)
Patient: Yes, it has been bad, perhaps, since I ate
some fatty sausages at my summer place.
The patient-centred inter×iew 11
Doctor: I see. Did you have a party there? (Facilitat-
ing beha×iour)
Patient: No, not anything special, I was there only
with my friend. We sometimes eat some grilled food
after sauna. (Life situation)
Doctor: You mentioned your friend. (Facilitating
beha×iour)
Patient: Yes, I am engaged to him.
Doctor: Yes, and… (In×iting her to continue)
Then she describes that she has been divorced for
about 2 years. The marriage had lasted 20 years. She
has two adult daughters who have already moved out
of the home.
Doctor: So, your life situation has changed a lot
recently. (Facilitating beha×iour)
Patient: Yes and my father died of cancer a year ago
and one of my friends passed away just recently with
breast cancer. (Feeling)
Doctor: You must have had a hard time. (Empathy
and support)
Her eyes are Ž lled with tears and the doctor gives
her a tissue. She dries away her tears and then tells
how her father died. However, not until her friend
died did she remember that a gastroscopy had been
performed on her about 4 years previously and that a
follow-up was recommended in a year but she never
went there.
Patient: I have been thinking that it may be stress
behind my stomach-aches. My stomach has always
been a bit sensitive. Now, I should get married and
trust in my new friend. I should also sell my house
and my daughters don’t like this idea. I am faced
with very difŽ cult decisions and I have been thinking
about that all the time. (Feeling)
Doctor: I understand, and these changes in your life
situation may affect your stomach. (Empathy, starting
to consult about diagnosis and treatment plan)
After negotiation they jointly agree that a gas-
troscopy should be performed soon. She believes that
she does not need any further medication right now.
(Shared understanding and treatment plan). The con-
sultation Ž nishes with the following discussion:
Doctor: Do you have any other comments or ques-
tions? Have we discussed all the topics and concerns
you were thinking about before the visit? (Checking)
Patient: Yes, thank you for your help. I hope it is
only stress. However, very often it seems that there is
something extra there (pointing at the stomach ). Actu-
ally, I believe that when I have solved my problems
and made the important decisions, my distress will
ease off and my stomach will be better. But they are
such difŽ cult decisions. I don’t want to make the
same mistakes that I did with my ex-husband, and
just recently when my anger towards him has disap-
peared I have started to miss him and my daugh-
ters… (She has difŽ culty Ž nishing her story).
Scand J Prim Health Care 2001; 19
12 P. Lari×aara et al.
Doctor: Yes, I understand. Well, I think we have to
end this consultation, but I would like to see you
soon after the gastroscopy. It seems to me that
despite all your aches and problems, you are strong
enough to make the right decisions. (Empowering).
The doctor-centred patient’s encounter was typi-
cally biomedically oriented. The doctor listened to the
patient’s story for only a few moments and while
hearing the patient mentioning the stomach-ache and
pointed at her stomach, she started leading the con-
versation. The doctor’s questions were mostly closed
and she only paid attention to symptoms and physi-
cal examination. Psychosocial issues were ignored
and therefore no picture was received of the patient’s
life situation. After the gastroscopy the patient might
have got the answer that nothing serious could be
found. The patient might have been relieved, but
probably her symptoms would have continued with-
out her being able to connect them to her life stress.
She might then have re-visited the doctor and the
physical examinations and biochemical tests would
have been continued. Based on our experience (16)
this kind of process may be the iatrogenic starting
point for heavy consumption of medical services.
In reality, 2 weeks later, another patient-centred
consultation took place. A gastroscopist did not Ž nd
anything abnormal in her stomach. Most of the time
the patient wanted to talk about her life situation.
She had not yet made all the decisions, but she
seemed to feel relieved. The doctor felt that it was
important to listen to her, to be empathic and to
avoid giving direct advice. He believed that by em-
powering the patient she would manage to solve her
life problems herself. In addition, the doctor told her
that now it was easy to understand her having symp-
toms like these in that kind of stressful life situation.
DISCUSSION
Communication is both the most common and the
most important procedure used by doctors to diag-
nose and treat illness. It is probably also the single
most important factor in uencing patient satisfaction
and patients’ ratings of their doctors’ performance.
Furthermore, good communication is now seen as a
right by patients, and therefore criteria for compe-
tence in communication have been developed for
doctors (10). The medical interview is part of a
communicative process and the most essential clinical
tool available to health practitioners (11). The devel-
opment of high-quality, low-cost audio and video
recordings has made possible the observation and
analysis of a range of encounters (14).
Traditionally, teaching in medical schools has been
mainly biomedically oriented and the qualifying doc-
Scand J Prim Health Care 2001; 19
tors have in most cases adopted a doctor-centred way
of working with their clients (16). The doctor-centred
attitude and interview is appropriate in hospital
emergency rooms when there is an imminent danger
to the patient’s life and when very rapid action is
needed. In these situations the goal of the interview is
to make a quick clinical symptom, trauma or disease
diagnosis. However, on many other clinical occasions
the doctor-centred interview has several disadvan-
tages and the patient’s real reasons for coming to the
physician may be ignored (6,9,13,15).
Until now, consultations have often been assessed
as mostly doctor-centred (3,16,19). Doctors almost
always do most of the talking. Furthermore, most
interviews focus solely on biomedical issues (20). The
situation becomes more difŽ cult because patients sel-
dom verbalise their emotions directly and sponta-
neously. They tend to offer clues instead, and if
invited to elaborate they may then express their emo-
tional concern directly. In addition, although more
and better information is usually obtained in a given
time using patient-centred techniques (4 – 6,11,14),
many doctors still believe that using patient-centred
interviewing techniques is time-consuming and
inefŽ cient.
Postmodernism (2), the biopsychosocial diagnostic
and treatment model (6,9), including patient-centred
working style (5,11,13) may provide current medicine
with revolutionary ideas and challenge the tradi-
tional, authoritarian doctor-centred treatment model.
Recent studies have shown that patients are most
satisŽ ed by interviews that encourage them to talk
also about psychosocial issues in an atmosphere not
dominated by the doctor (21,22). On the contrary,
when doctors only ask questions about biomedical
topics, this has been shown to relate negatively to
patient satisfaction. An additional beneŽ t of the pa-
tient-centred treatment model is that this approach is
more satisfying for the doctor, too (11,21); the en-
hancement of the therapeutic relationship works both
ways.
Based on our own studies and experiences, we
believe that a doctor-centred working style may be
the cause of ‘doctor-shopping’ behaviour (16,21,
23,24). The authoritarian, purely biomedical orienta-
tion of the health care system may in this way
iatrogenically increase patients’ feelings of illness and
produce heavy usage of medical care. If the patient’s
stories are not listened to and understood by the
doctor, and their concerns and fears are not elicited,
they begin to think that their ideas and opinions are
not important at all in the treatment process. Their
often basically holistic idea of an illness disappears;
they become biomedically oriented and somehow
start to trust only medical tests and procedures. We

have often observed that heavy users of medical care,
and their families, have almost totally lost their own
strengths (16). We believe that by using patient-cen-
tred interviewing and a biopsychosocial approach,
the doctor can get a better outcome and save on
health care costs.
A central theme of this article is the message that
doctors and other health care providers, particularly
in primary care settings, need a comprehensive con-
cept of human health and illness, and that skill in
interviewing is essentially a product of professional
learning, rather than an innate ability that some
possess from birth, but others lack. In Finland, and
we believe in many other countries, too, we really
need biopsychosocial thinking and clinical models
today, when primary care is moving towards the
‘personal doctor’ system. This change should be
taken into account in the education of new doctors.
The professional identity, the way of thinking and
working develop during the education process, and so
it is important that teaching in medical schools is
based on the biopsychosocial model (9).
ACKNOWLEDGEMENTS
We are indebted to Dr. Peter Pritchard, honorary
secretary of UK-Nordic Medical Educational Trust
for reading the manuscript and for assisting us in
working it up in its present form.
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