Sot. Sci. Med. Vol. 36, No. 12. pp. 1597-1604, 1993 0277.9536/93 $6.00 + 0.00 Prinkd in Great Britain. All rights reserved Copyright (‘. 1993 Pergamon Press Ltd VERBAL EXCHANGES IN MEDICAL INTERVIEWS: IMPLICATIONS AND INNOVATIONS* SAMUEL M. PUTNAM’ and WILLIAM B. STILES* ‘East Boston Neighborhood Health Center, Boston, MA 02128, U.S.A. and 2Department of Psychology, Miami University, Oxford, OH 45056, U.S.A. Abstract-Medical interviews (consultations) are composed of zyxwvutsrqponmlkjihgfedcbaZYXWVUTSR verbal exchanges, complementary categories of speech by patients and clinicians that tend to occur together. Patients and clinicians employ a joint repertoire of exchanges to accomplish their goals in the encounter. The seven principal exchanges are called Exposition, Closed Question, Checking, Direction, Inquiry, Explanation, and Instruc- tion/Contracts. We discuss how the verbal exchange structure contributes to understanding the confluence of patients’ and clinicians’ goals and expectations. clinicians’ hypothetico-deductive method of reasoning during interviews, and establishing the patient-clinician relationship. We conclude by considering new exchanges that might make medical interviewing more effective and humane. Key word.r-medical interview, medical consultation, verbal interaction, patient-clinician relationship In a previous paper, we described a conceptual framework for the verbal interaction between patients and clinicians during medical interviews (consultations) that serves as a bridge between specific observable verbal behaviors and the tasks and goals that clinicians and patients hope to accomplish during their encounter [l]. Our intention in develop- ing the concept is to help organize the literature on medical interviewing, stimulate research, and suggest how employing specific skills might improve clinical effectiveness [2]. In this paper, we review the concept of the verbal exchange structure and give an example of each principal exchange. Then, we discuss how the verbal exchange structure describes; (a) the confluence of the goal and expectations of patients and clinicians in medical encounters; (b) the hypothetico-deductive method of reasoning that clinicians apply in gather- ing data; and (c) the process of establishing the patient-clinician relationship. We conclude by con- sidering new exchanges that might be added to the repertoire of patients and clinicians to improve the medical interview. THEVERBALEXCHANGESTRUCTURE Verbal exchanges, as we define them, consist of complementary categories of speech that tend to occur together. For example, clinician questions and patient yes/no answers form one kind of exchange, while clinician instructions and patient agreements to comply form another. Together they make up the verbal exchange structure of the medical interview. *This paper is a sequel to “Verbal exchanges in medical interviews: concepts and measurement” published in Social Science & Medicine 35, 347-355, 1992. We identified the verbal exchange in studies that we and other investigators conducted on medical inter- views in varied populations. In these studies we first coded patient and clinician ‘utterances’ (sentences, independent clauses) into categories and then used factor analysis to identify categories that tended to be used together within each segment of the interview (medical history, physical examination, or con- clusion) [3-61. We did not identify the exchanges through the categories’ temporal sequence or proxim- ity. Instead, we hypothesized that when verbal behav- iors were initiated by one party, the other party would respond with complementary behaviors at some point in that interview segment. Using this strategy we identified seven common exchanges, which together account for most clinician and patient talk in medical interviews [I]. Although grouping the speech categories into ex- changes was based on a statistical association, the functions implicit in the verbal behaviors (e.g. clini- cian questions serving the function of eliciting specific patient information) suggested that the utterances were linked with each other to accomplish specific tasks within the interview. Using a computer pro- gramming analogy, a verbal exchange can be con- sidered as a subroutine [7]. It performs a particular function that the operators (patient or clinician) can call upon whenever that function is required during the interview. Briefly, in E.uposiGon exchanges, patients describe their illnesses and circumstances in their own words while clinicians show attentiveness (e.g. by acknowl- edgements such as “mm-hm”). Exposition occurs in all segments of the interview, but it is especially prominent in the medical history segment. Clinicians may use Exposition exchanges to identify presenting problems. gather background information, and give 1597