Interviewing habits that may discourage patients from sharing their concerns include: (a) writing up the patient history during interviewing, (b) focusing on the chief complaint too early in the interview, and, possibly also, (c) performing a complete system review by asking a series of closed questions.

A doctor may write up a history while the patient speaks or postpone the write-up to after the interview. The advantage of the former is that it reassures the doctor of accuracy, of not omitting relevant details, and provides a feeling of using time efficiently. Yet, patients may fail to disclose their concerns when faced with a doctor who is recording their words. Furthermore, writing while interviewing prevents eye contact, observation of a patient’s body language, and detection of nonverbal clues. Recording the history while the patient is talking also forces the doctor to control the interview: rather than listen to the patient’s narrative, the doctor must conduct the interview in the sequence of the standard recorded history—i.e., chief complaint , present illness , past, social, occupation/environmental and family history, and system review—which inevitably results in a disease-centered interviewing style.

The tendency to write up histories during patient interviewing has increased since the introduction of electronic health records . Many physicians tend to exhibit “screen-driven” behaviors of information gathering, asking questions as they appear on the screen rather than following the patient’s narrative [16]. As physicians spend more time interacting with the computer, they have less time available to interact with the patient. Indeed, patients seeing residents using computers have reported loss of eye contact and less time for discussing psychosocial issues [17] .

The main drawback of recording the history while the patient is speaking is that it requires doctors to identify the chief complaint (e.g., “pain in the chest”) early in the interview because it appears at the beginning of the standard recorded history. This prompts an immediate search for additional symptoms by asking closed questions (e.g., “Did the pain radiate to the arm?”) and this, in turn, explains the observation that doctors interrupt the patient’s narrative within seconds [18]. Moreover, in many cases, the patient’s chief complaint or main concern emerges only later in the doctor–patient encounter, and a premature definition may be misleading to the doctor’s diagnostic reasoning .

It is generally agreed that the interview should end with a review of systems consisting of a series of closed questions aimed at ascertaining the presence or absence of specific symptoms . The review of systems has two purposes. First, it teaches students to associate symptoms with various organ systems. Second, it may uncover symptoms that patients failed to mention in their narratives. The advantage of performing a complete review of systems is supported by studies indicating that it led to new diagnoses for 5 [19], 7 [20], and 11 % [21] of new patients. On the other hand, a complete review of systems may provide irrelevant information and impede the diagnostic process. Additionally, novices may perform the systems review as a substitute for listening to a patient’s narrative, creating an atmosphere of detachment and formality that is detrimental to expressions of respect and empathy.

To sum up: to encourage patients to share concerns, students should: listen to the patient’s history, watch for verbal and nonverbal expressions of feelings; if necessary, inquire about the patient’s sources of distress, verbally summarize the patient’s story, reach an agreement with the patient on defining the chief complaint and main concerns, and only then write up the history using the sequence of the standard record. Students should be advised to avoid: extensive note-taking while the patient is speaking, focusing on the chief complaint early in the interview, and asking a rapid succession of closed questions. Teaching students to perform a systems review may be given lower priority. They should be told that in cases of time constraints, listening to and encouraging the patient’s narrative is more likely to be informative than a closed-question interrogation. In these cases, the systems review may be replaced by open questions such as, “Is there something else that has been bothering you?” Performance of a complete systems review may be restricted to doctor–patient encounters that have no time constraints and patients who are unresponsive to a doctor’s attempt to sustain their spontaneous narratives.

Effort should be made to elicit a patient’s concerns also when using interpreters to overcome situational barriers to communication, such as deafness or lingual mismatch. In such cases, communication could be further improved if the doctor (a) talks directly to the patient, addresses her/him in the second person, and maintains eye contact with the patient, not with the interpreter; (b) instructs the interpreter to translate the patient’s comments as completely as possible; (c) watches the patient while s/he talks and responds to nonverbal cues; and (d) verifies understanding by periodically summarizing his/her perception of the problem for back-translation and confirmation by the patient [22, 23]. A failure to abide by these rules results in a doctor–interpreter, rather than a doctor–patient, dialogue and may breed misunderstanding.