Avoiding tension in the medical interview

A physician has just received the thyroid-stimulating hormone test results for a female patient, Julie, which reveal uncontrolled hypothyroidism. He suspects that she has stopped taking the levothyroxine she was prescribed and wants to inform her of the importance of restarting treatment. Table 1 provides an analysis of a telephone call from the physician to the patient, conducted at the end of a long day.

In this confrontation-type telephone interview, the physician misses several opportunities to change the course of the discussion. The patient “wins” and wants to confirm her win before following the physician’s advice—on her terms. The danger here is that the relationship of trust can deteriorate to such an extent during the confrontation that the patient will not follow the physician’s advice (in this case, restart her treatment).

Certainly, external factors affecting the telephone call (eg, end-of-day fatigue) can make for a difficult conversation. The physician could have, in this case, postponed the call to a more favourable time (without compromising Julie’s health), in order to reduce the risk of confrontation.

If the physician is already involved in a conversation during which the patient questions his medical expertise, such as in the example provided, he can manage the interaction in the following more satisfactory ways: First, by explicitly recognizing the existence of a new problem and its effect on the patient’s daily life; second, by giving his professional opinion regarding the possible relationship between the medication and the arm pain; third, by discussing the poor control of thyroid function associated with stopping levothyroxine; and fourth, by suggesting reintroduction of the medication at a dose that the patient was previously able to tolerate, while documenting the medication-pain association in the meantime. With this approach, the physician stays on track by identifying solutions, avoiding confrontation, and minimizing tension in the interaction. He maintains his therapeutic relationship with the patient and helps maintain her commitment to the care process.

It is unfortunate that extraneous and emotional aspects of a conversation often take away from the therapeutic objective.1 Only by examining and understanding our interactions can we get the necessary perspective to redirect the discussion so that it is in the best interest of the patient’s health.

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