By the end of Step I, students agree that the patients’ complaints about the doctor–patient relationship cannot be dismissed as rare or trivial. This conclusion is the point of departure for Step II, during which students are asked to propose ways to reduce patient dissatisfaction. Commonly, students participate enthusiastically in this discussion and on their own suggest sensible solutions to most of the problems.

For example, to reduce the likelihood of the complaint that: “The doctor did not understand me,” students suggest summarizing the patient’s concerns at least once toward the end of the interview. To reduce the likelihood of the complaint that: “The doctor did not let me ask questions,” students suggest asking at least once: “Is there anything that you want to tell me/want to know/did not understand?” To reduce the likelihood of a complaint that the doctor was impolite, students suggest treating patients with respect. To reduce the likelihood of the complaint that: “The doctor did not meet my expectations/was inconsiderate of my feelings,” students agree with the tutor’s suggestion that a doctor should ask: “Of all your problems, which is the one that worries you most?” (Table 5.2). Unlike the first half of the previous step, when the tutor only recorded the students’ input, in this step, she/he would offer suggestions, whether by verbal descriptions of various types of physician behavior, which may reduce the frequency of patient complaints, or by role-playing, for example, demonstrating nonverbal expressions of interest, respect, and concern.

By allowing students to set their own pace, they commonly identify the very same objectives that the tutor has in mind, although in somewhat different order. Some students may be concerned about the suggestion to listen to a patient’s narrative for more than the reported 18-s average (“How much more?”) and inquire how to interrupt talkative patients. The tutor would respond that such decisions are a trade-off between the patient’s need to be heard out and the doctor’s time constraints. On the one hand, the longer the interview, the better the doctor’s chances of obtaining insight into the patient’s concerns; indeed, the duration of the doctor–patient encounter has been found to be associated with increased patient and doctor satisfaction, fewer malpractice claims, and reduced prescription rates, requests for ancillary testing and referral to specialists [11]. On the other hand, at some point, time constraints force a doctor to take control of the interview. Students are advised to interrupt the patient’s narrative after 1–3 min by asking an open question such as, “You mentioned chest pain. I would like to hear more about that.”

The objective of Step III is to show how the solutions proposed in Step II are put into practice. To accomplish this, the tutor interviews two patients for about 15 min each. Live demonstrations with real patients are used because they appear to command more attention than videotaped patient interviews or those of simulated patients. Students are told that the two interviews will be conducted using different approaches; that it is not the tutor’s intention to emphasize the advantages or disadvantages of either approach; that the tutor will not commit deliberate interviewing errors; and that during both interviews, the tutor will attempt to convey respect for the patient, to sustain an unhurried and relaxed atmosphere, to transmit a willingness to listen to patients sharing personal problems, and to end the interview with a summary of the patient’s complaints. Students are asked to identify the differences between the two interviews; look for the errors that will inevitably occur; and comment on these differences and errors during the discussion following the demonstrations.

Almost always, the interviewed patients are aware of the students’ presence only during the first 30 s, and thereafter are not distracted by the audience. The first interview is “patient centered.” Its main feature is listening to the patient’s spontaneous narrative, and if necessary, sustaining it by echoing the patient’s last words. The tutor permits the patient to control the interview and encourages him/her to talk about his/her disease and personal problems by asking general open questions such as: “Is there anything else that has been bothering you?” Only after the patient appears to have completed his/her narrative, does the tutor ask specific open-ended questions such as: “Ms …, you mentioned a pain in the stomach. I’d like to hear more about it,” and closed questions such as: “Did you have heartburn?”

The second interview is “disease centered.” It begins with the tutor asking a series of questions about the patient’s age, marital status, and profession, and proceeds with the tutor interrupting the patient by asking questions as soon as she/he mentions a symptom. The tutor controls the interview, which consists mostly of a sequence of closed questions related to the patient’s symptoms and the results of previous examinations.

After the demonstrations, students compare the interviewing techniques and explore their advantages and weaknesses. Students may suggest that the disease-centered approach focused on symptoms while the patient-centered interview was more conductive for gaining insight into the patient’s concerns. Some students may submit that the disease-centered interview provided information in a logical sequence (i.e., one consistent with the manner in which the doctor views the patient’s disease), but it precluded expressions of empathy. The patient-centered interview avoided these disadvantages. On the other hand, apart from taking more time, it demanded that the doctor make mental notes of issues to be elucidated in closed questions at the end of the interview .