Communication Skills For Patient-Centered Care
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORGVO L U M E 87-A · N U M B E R 3 · M A RC H 2005COMMUNICATION SKILLS FORP A T I E N T -C E N T E RE D C A RECommunication Skills forPatient-Centered CareRESEARCH-BASED, EASILY LEARNED TECHNIQUES FOR MEDICAL INTERVIEWSTHAT BENEFIT ORTHOPAEDIC SURGEONS AND THEIR PATIENTSBY JOHN R. TONGUE, MD, HOWARD R. EPPS, MD, AND LAURA L. FORESE, MDAn Instructional Course Lecture, American Academy of Orthopaedic SurgeonsBetter physician-patient communication is linked to increased patientsatisfaction and patient adherence tomedication and treatment regimens aswell as to improved clinical outcomes1-4.Practicing orthopaedic surgeons havereceived limited formal education inthe communication skills necessary forpatient-centered care; yet, we performover 100,000 medical interviews during our careers5. Patient-centered careinvolves treating patients as partners,involving them in decision-making,and enlisting their sense of responsibility for their care while respecting theirindividual values and concerns6,7. Wehave tended to focus mainly on thetechnical aspects of our care-giving8.We do not seem to be very goodcommunicators9,10. In 1998, the American Academy of Orthopaedic Surgeons(AAOS) conducted an extensive national survey to which 807 patients and700 orthopaedic surgeons responded11.The patients and surgeons were askedto rate orthopaedic surgeons with useof the same categories. Patients ratedtechnical skills as important (“hightech”) but valued communication skillsequally (“high-touch”)12 (Table I). According to this survey, 75% of the orthopaedic surgeons believed that theycommunicated satisfactorily with theirpatients, but only 21% of the orthopaedic patients reported satisfactorycommunication with their physicians.This gap was most evident in categoriessuch as listening and caring and timespent with the patient9. Our most common deficiency in our daily interviewswith patients remains a failure to demonstrate an empathic response13.We can all learn to communicatebetter. During the past twenty years, effective tools for teaching and assessingphysician communication skills havebeen developed. Communication skillsare being taught in medical schools andresidency programs2,8,14-16. Beginningwith the class of 2005, the United StatesMedical Licensing Examination will require medical students to pass a clinicalskills-assessment examination byinterviewing standardized patients atdesignated national testing centers17.Furthermore, the Accreditation Councilfor Graduate Medical Education andthe American Board of Medical Specialties now link assessment of communication skills to accreditation ofresidency programs and to maintenanceof certification for practicing physicians, respectively18,19. Busy orthopaedicsurgeons must continue to build communication skills to deal with the challenges of shifting patient expectations,language and cultural barriers, increasingly complex medical treatments, andconstraints from managed care.Good communication skillsimprove medical care and reducelawsuits20. Skillful interviews improvediagnostic accuracy by gathering a superior quantity and quality of data2.Physicians with adept communicationskills establish rapport with their patients and consequentially improve thepatients’ compliance with treatment.Effective interviews also improve patient outcomes, reduce medical errors,and make the specialty of orthopaedicsurgery more enjoyable15,21,22.Malpractice suits often are the results of differences in expectations between the patient and the physician.Beckman et al. reviewed depositionsfrom sixty-seven malpractice claims andreported both the preponderance andthe types of communication problemsdescribed in these depositions23 (TableII). Good communication helps physicians to understand patient expectations,thereby reducing liability exposure.Improving OurCommunication SkillsEducational ProgramsImproving communication skills, likeimproving operating skills, is best done
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORGVO L U M E 87-A · N U M B E R 3 · M A RC H 2005COMMUNICATION SKILLS FORP A T I E N T -C E N T E RE D C A RETABLE I Discrepancies Between AAOS Members’ Self-Assessment and Patients’Perceptions of Orthopaedic Care12Physician’s Perception:I Believe PatientsView Me As:Patient’s PerceptionHighly trained70%64%Having successful results64%53%Being caring and compassionate71%37%Spending time with patients71%36%Providing valuable service65%35%with an organized educational program. Although written material is useful in improving patient-physiciancommunication, behavioral change ismore likely to occur in a workshop9.The AAOS partnered with the Bayer Institute for Health Care Communication (BIHCC) in 2001 to form theAAOS Communication Skills MentorsProgram (CSMP)24. This initiative combines a successful educational model,the “4Es” (engage, empathize, educate,enlist), with jointly developed orthopaedic-specific video vignettes (Fig. 1).Twenty-five orthopaedic surgeonstrained as mentors teach interactiveworkshops as part of the CSMP. Writtencomments and follow-up questionnaires confirm the workshop participant’s interest and ability to successfullyincorporate new communication skillstechniques.The Bayer educational model, orthe “4Es,” defines the critical communication tasks to engage, empathize, educate, and enlist the patient which areconsidered to be of equal importance tothe biomedical tasks, or the “2Fs,” offinding the problem (diagnosis) andfixing the problem (treatment). TheBIHCC has fifteen years of experienceteaching the science behind the art ofmedicine and has trained more than90,000 clinician participants25-27. Engagement establishes an interpersonalconnection that sets the stage for thepatient-physician interaction. Engagement draws the patient in. Empathydemonstrates the physician’s understanding of and concern about the patient’s thoughts and feelings. Thepatient is seen, heard, and understoodby the physician. Education delivers in-formation to the patient. The patientlearns something. Enlistment extendsan offer to the patient to actively participate in decision-making. Enlistmentacknowledges that the patient controlsmuch of what can happen in his or herhealth-care treatment plan28.Techniques forPatient-Centered InterviewsFirst impressions are important29,30.You should be neatly dressed and wellgroomed. You should clear yourthoughts and smile to provide a pleasant introduction for the patient. Afterknocking, enter the room with a deliberate but not rushed pace. Smile, make eyecontact, and speak in a calm, pleasant,consistent tone of voice. All attentionshould be on the patient. When introducing yourself, start with a salutation(good morning/afternoon/evening).The patient should be addressed as Mr.,Ms., Madame, Señorita, etc. Check thepronunciation of the patient’s name, ifnecessary. Even in an emergency, introductions are important.You should be cautious aboutasking patients “How are you today?”Although this is more of a greeting thana question in the United States, it canput ill or injured patients in the awkward position of responding that theyare “fine” just before relating their storyand/or medical problem. With the initial introduction, say “Welcome” or“Good to see you” while maintainingeye contact and offering a handshake,when such a greeting is culturally appropriate. You should sit approximately 2 to 4 ft (0.6 to 1.2 m) from thepatient. If the patient continues to lookyou over in an attempt to estimate yourpace and the warmth of the initialgreeting, you should try a normalizingstatement such as “How do you like thishot/cold/wet weather?” You should notstand while the patient is seated duringthe medical interview.Ask: “How can I help you today?”Six simple, powerful words. Openended questions allow the patient theopportunity to define the conversation.Although it is hard to do, you shouldwait until the patient finishes speaking.It takes most patients two minutes totell their story and explain why they areseeing you; however, the average physician interrupts the patient within eighteen to twenty-three seconds. Avoid thispitfall. If you listen for two minutes thepatient will tell you 80% of what youneed to know2. Nodding, reflective facial expressions, and continued eyecontact all signal your attention to andconcern for the patient. Physiciansshould look at the patient while listening; notes should be written duringpauses in the conversation.When the patient says, for example, “I’m here because my shoulderhurts,” you should respond by saying“Fine, tell me all about it” with an uplifting, pleasant tone of voice indicatinginterest and concern. If you say, “TellTABLE II Contribution of Communication Breakdowns to Malpractice Risks*23Patient mentioning poor relationship as reason for claim71%Patient felt deserted32%Patient felt devalued29%Patient felt information was delivered poorly26%Patient felt there was a lack of understanding by the clinician13%*The decision to litigate is most often associated with perceived lack of caring and/or collaboration in health care delivery.
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORGVO L U M E 87-A · N U M B E R 3 · M A RC H 2005COMMUNICATION SKILLS FORP A T I E N T -C E N T E RE D C A REFig. 1The “4Es” define the communication tasks, combined with traditionally taught biomedical tasks, that are necessary for complete clinical care25.me about your shoulder pain,” you riskconveying the impression that you areinterested only in a body part and thatonly that one complaint can be considered. Continue to avoid a transition toclosed questions of what/how/when/where to gather more information. Instead, the next few questions shouldflesh out the patient’s story, not the interpretation of the orthopaedic condition. Helpful statements might include“I’m curious about . . .” or “Tell memore about . . . .”A source of frustration frequentlymentioned by participants duringCSMP workshops is the unmentionedproblem that arises at the end of thevisit. These “hidden agendas” may forcethe physician to extend the visit anddisrupt the schedule or risk angeringthe patient by leaving the problemunaddressed31. Because orthopaedic patients often have multiple complaints, itis very important to identify them and,if necessary, to prioritize them (“Is thereanything else?”). When secondary concerns cannot be adequately addressedduring an office visit, the physicianshould explain in terms that are centered on the patient’s best interests(“We did not schedule enough time toadequately address these other problems today, but we can schedule another appointment for you.”).Familiarizing the patient with the pro-cess and the need for additional information and/or tests also reduces thepatient’s anxiety and expresses your respect for the patient. Humor can be animportant method of presenting a physician’s style and confidence as well as oflightening and refreshing an otherwiseoverly serious conversation. However,humor can cause misunderstandingsand possibly result in patients judgingphysician behavior as being patronizing or arrogant.Acknowledging the patient’semotions and values demonstrates thatyou recognize their individuality. Statements such as: “That must have been(painful/frightening/frustrating)” arecrucial to establish rapport. Orthopaedic surgeons rarely use empatheticstatements. We tend to be uncomfortable relating to our patients’ emotions.Remember that a little human kindnesscould make that patient your best advocate. As Terry Canale said in his AAOSVice-Presidential Address: “The patientwill never care how much you know,until they know how much you care.”32You should reflect your understanding of the patient’s story by summarizing what you heard. Some of thepatient’s words should be repeated.Feelings should be normalized (for example, “Many people feel that way.”). Itmay help to briefly share a story fromyour own life that relates to the patient’scondition as long as the attention remains focused on the patient.After completing the history andphysical examination, say, “Tell me whatyou understand about this problem” or“So what have you been thinking aboutthis condition?” This saves time becausephysician-dominated visits often include information that does not addresswhat is on the patient’s mind3,31.You should explain your thoughtswith clear direct words, avoiding jargonand reflecting the patient’s style andvalues. Pause to check for comprehension during what might otherwise become misunderstood as a physicianmonologue, even when patients arenodding and appear to be following every word. Patients normally forget halfof what is said within minutes of leaving our offices. Pamphlets and informational brochures can supplement, butnot replace, effective communication.Asking questions, in an uplifting tone ofvoice, such as: “What questions do youhave?” and “Is there something elseyou’ve been wondering about?” encourages patient responses, while authoritative voice tones may be perceived bypatients as indicating the end of aninterrogation.After assessing the patient’s understanding of the possible diagnosis andtreatments, you should always ask,“How does this fit with what you’ve been
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORGVO L U M E 87-A · N U M B E R 3 · M A RC H 2005thinking?” This one question can avoidmisunderstandings and may reveal thatthe patient has a different agenda that heor she has been hesitant to share. Treatment options should be discussed toexplain benefits, anticipate potential obstacles and risks, and offer a specifictime-frame for reevaluation and results.You should offer goals tied to future results that put the patient in control; it isoften helpful to write them down.Scheduled follow-up examinations help to motivate and monitorprogress. Patients should have ownership of their treatment program, whichshould include feedback measures tohelp keep them motivated. Ask the patient: “How important do you think it isto do these things?” and “How confident are you that you can do thesethings?” These two questions often uncover unknown barriers or motivatorsand provide opportunities to tailor thetreatment plan. An effective tool for improving future follow-up communication is to say: “When you return, I’ll askyou if you are better. And if you are better, I’ll ask you how much better 10%,50%, 90%? So be thinking about thisuntil I see you then.” This suggestioninvites patients to actively monitor andprepare to discuss their progress and todemonstrate their level of adherence attheir follow-up visit33.You should conclude each interview by reviewing the diagnosis, treatment, and prognosis. With a sincere,uplifting tone, physicians should saygood-bye and, while shaking hands andmaintaining eye contact, deliberatelystate the expectation of a positive outcome. Expressing hope leaves the patient with a lasting positive impression.Communicating Adverse OutcomesWhen a patient has had an adverse outcome or has sustained an injury as a result of a medical error, the physician’sreaction is often defensive, resulting inthe patient not being fully informed.There are, however, persuasive arguments for complete disclosure34. Informing patients allows them to makeappropriate plans for subsequenttreatment35. An uninformed patientmay not cooperate with necessary cor-COMMUNICATION SKILLS FORP A T I E N T -C E N T E RE D C A RErective measures. Disclosure also prevents the patient from worrying aboutthe etiology of an event. For example, apatient who is informed that unexpected bleeding is due to anticoagulantswill not worry that he or she has a gastrointestinal tumor36.Patients prefer full disclosure oferrors. In a study of 1500 randomly selected members of a large health maintenance organization, patients who hadreceived full disclosure were less likelyto change physicians and had greatersatisfaction37. Trust in their physicianincreased, and they had a more positiveemotional response. In some cases, disclosure decreased the risk of legal action. A positive response was notguaranteed, however; it was dependenton the clinical outcome and the detailsof the error38.In another study, investigatorsassessed the attitudes of 149 randomlychosen adults about medical errors39.Patients were more likely to commence litigation following moderateand severe errors if there had been nodisclosure.The Ethics Committees of theAmerican Academy of OrthopaedicSurgeons, the American College of Surgeons, and the American Medical Association believe that the physician has aduty to inform the patient about anyadverse event or error. Also, the JointCommission on Accreditation ofHealthcare Organizations (JCAHO) requires physicians in accredited hospitalsto inform a patient when results oftreatment differ substantially from theanticipated outcomes40.There are specific techniques thatare useful in communicating adverseevents41. Discussing the incident withmembers of the patient’s health-careteam and other staff members can easethe burden and help to prepare an appropriate response42. Consider whoshould be present and who shouldbreak the news. Patients and their families may suffer not only from an adverse incident, but also when theincident is handled insensitively or inadequately. Conversely, when staffmembers acknowledge the damage andtake corrective actions, the overall im-pact on patients can be greatlyreduced43. Include important familymembers and try to have both parentspresent if the patient is a minor. Eliminate possible interruptions like pagersand cellular phones. The exact contentof the disclosure and the order in whichfacts will be given should be carefullyconsidered. All pertinent data and testresults should be readily available44-47.Use a quiet room with privacy.Avoid barriers like desks and tables between you and the patient. A substantialportion of communication is nonverbal. Make eye contact, and speak withan even tone of voice. The discussionshould not appear hurried, and youshould try to remain calm.Provide ample time. The discussion should not occur between surgicalcases or five minutes before officehours. Reschedule other commitmentsin order to properly organize and address the communication needs relatedto the unexpected event in the sameway that you would prepare for emergency surgery. The content of the initialdiscussion may be less important thanthe circumstances of the delivery. Somesuggest that touching the patient byholding hands or providing a hug canbe very reassuring to carefully selectedpatients. However, such gestures are notappropriate in every situation, and thephysician should judge each situationcarefully45-48.Direct, clear statements are important, as are their delivery, particularly the tone of voice. You may want tostart by saying, “I am afraid I have somebad news.” Communicate in a mannerthat is open, compassionate, and timely.Give an accurate, clear-cut statementwith nondefensive explanations of whathas happened. Speak in short statements, frequently stopping to inquirewhether the patient or family membersunderstand. Avoid slipping into thecomfort zone of technical descriptionsand medical jargon.Do not assign blame, and avoidoffering initial beliefs or subjectiveopinions of possible causes of the event.The cause of the error may not be understood or apparent until a thoroughinvestigation has been completed. Many
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORGVO L U M E 87-A · N U M B E R 3 · M A RC H 2005medical errors result from poor communication among team members.Criticisms of the health-care team maydetract from caring for the patient.Disclosure of an adverse eventcauses stress for the patient and thefamily. Expect and acknowledge emotional responses. Complex, even severereactions of fear, anger, mistrust, andhopelessness are common. An apologywithout assigning blame is acceptableand does not denote an admission of liability. “We are sorry that this happenedto you” demonstrates concern withoutblame. The focus should remain on thedisease, not the health-care provider49.Prepare to receive the patient’semotional outpouring of fear, anger,disappointment, and mistrust. Toleratesilence as emotions are gradually understood and then expressed. Reflectand acknowledge emotions that you seeas well as those that are stated. Listenfor concerns that can be clarified andvalues that can be confirmed. Offer tolisten to family members who could notparticipate in the initial disclosure.At the end of the discussion, youshould summarize an explicit, proactiveplan for the care and support of the patient. The patient’s understanding andacceptance of the plan should be evaluated and improved if necessary. Writingdown a list of instructions for the patientcan be helpful. Document thoroughlythe details of the discussion. Adverseevents and bad outcomes profoundly affect the physician as well as the patient42.After the discussion, the physicianshould take time to regroup before moving on to the next task. Follow-up afterthe discussion is critical. Subsequenttests and consultations should be completed expeditiously. The progress of thecare plan should be reviewed directlywith the patient. As care continues, thepatient’s emotions may shift, and suchchanges should be acknowledged and respected. You should remain hopeful forthe patient and the family.Culturally Diverse PopulationsNearly twenty years ago, in The SilentWorld of Doctor and Patient, Jay Katzfirst articulated his premise that effective communication between physi-COMMUNICATION SKILLS FORP A T I E N T -C E N T E RE D C A REcians and patients builds essentialmutual trust and facilitates medical decision-making14. Yet even Katz couldnot anticipate the magnitude of language and cultural barriers that challenge efforts to improve effectivecommunication. More than twentymillion people living in the UnitedStates are not proficient in English.Linguistic minorities report worse carethan ethnic or racial minorities50. Atthe same time, cultural conflicts oftenlead to misunderstandings and distrust, which adversely affect patientoutcomes16,51.The Language DivideEnglish is not the primary language of agrowing number of patients in theUnited States. The number of immigrants has nearly tripled since 1970,increasing from 9.6 to twenty-sixmillion52. These patients have been described as having limited English proficiency. The scope of the language divideis qualitative as well as quantitative.When an interpreter is necessary, introduce the interpreter to the patient. During the medical interview, you shouldrelate to the patient, not the interpreter.Speak to the patient as if they understand. Make certain that the patient isresponding to your questions throughthe interpreter, and do not allow the interpreter to answer without the patient’sresponse. Any effort by the physician tospeak even a few words of the patient’slanguage will be appreciated53. Patientsusing interpreters require more physician time than do those who are proficient in English50. They also requiremore visits54. Decision-making may bemore cautious and expensive whennon-English-speaking patients aretreated in the absence of a bilingualphysician or a professional interpreter55.The Office of Civil Rights (OCR)of the United States Department ofHealth and Human Services has issueda final “policy guidance” (i.e., regulation) that requires physicians who receive reimbursement from Medicaid orState Children’s Health Insurance Programs to provide competent translation services when they are requested bypatients who claim limited Englishproficiency56. According to the regulation, any reimbursement for medicalservices provided to Medicaid patients(and, if applicable, patients covered byMedicare Part A) constitutes “federal financial assistance” to the physician under provisions of Title VI of the CivilRights Act of 1964.Physicians can comply by retaining employees who are fluent in English and a second language to performthe translation services, by using thetelephonic services offered by MultiLing(www.multiling.com, accessed 1/20/05), or by contracting with professionaltranslators. In some communities, volunteer translators for certain languagesmay be an alternative. The OCRstrongly suggests that it is inappropriatefor family members to play the role oftranslator between the patient and physician and other medical office staff forreasons of confidentiality. The practiceis acceptable if the patient offers oragrees to use a family member or friendto translate but not when the patient requests an independent translator. Therule also specifically bars physiciansfrom discriminating against patientswith limited English proficiency by refusing to see them or discharging themfrom their practices.Because these regulations makeno provision to pay the considerablecost of translators, several specialtymedical associations and nearly fortystates have signed letters in opposition,recommending that physicians be exempted from these OCR regulationsand that translators be allowed to directly bill third-party carriers or patients for their services. There is also theconcern that these costs will reduce patient access to physicians.The Cultural DivideThe American Medical Association’sCultural Competence Compendium defines a culture as “any group of peoplewho share experiences, language, andvalues that permit them to communicate knowledge not shared by thoseoutside the culture.”57 Medical culturalcompetence refers to the effective communication of a diagnosis and treatment plans in a manner that is
THE JOUR NAL OF BONE & JOINT SURGER Y · JBJS.ORGVO L U M E 87-A · N U M B E R 3 · M A RC H 2005COMMUNICATION SKILLS FORP A T I E N T -C E N T E RE D C A RETABLE III Six Realities of “Cultural Programming”*Culture is not obviousWe all feel our own culture is bestWe misinterpret the actions of others if we do not understand their interpretationsof their own observationsWe may not know when we are offending othersAwareness of differences and possible barriers improves our chances for successful interactionsUnderstanding our own “software” or value system is a crucial step in providing culturally competent care*Adapted, with permission, from: Gardenswartz L, Rowe A. Managing diversity in healthcare manual: proven tools and activities for leaders and trainers. San Francisco: JosseyBass; 1999.acceptable to patients from differentcultural backgrounds58.Each of us reflects individual cultural values as well as the culture ofmedicine. We need to be aware of ourown culture, belief systems, and valuesbecause they affect our interactionswith patients59. Cross-cultural communication is a critical skill for physiciansand other health-care workers if we areto reduce disparities in both access andoutcomes of medical care. To avoidmisunderstandings, Gardenswartz andRowe recommended that physiciansconsider six “realities of cultural programming”60 (Table III). Problem areasarising from misunderstandings incross-cultural communication includethose related to authority, physical contact, communication styles, gender, sexuality, and family61.We can reduce these misunderstandings by being more aware of possible cultural barriers62. For example, incultures where status is inheritedrather than earned, the position ofother decision-makers in the familymust be acknowledged. Also, values related to privacy, including feelings ofmodesty and shame, could make itmore difficult to obtain necessary information even after initial efforts tobuild a trusting relationship.Ethnicity-specific information foruse in the treatment of several differentdisease states is available from a series ofbooklets entitled A Provider’s Handbook on Culturally Competent Care fromKaiser Permanente63. Sections in each ofthese handbooks are devoted to majordiseases and areas of special clinical focus. There are no specific references tomusculoskeletal conditions.OverviewGood communication between physicians and patients is the bedrock ofquality medical care. Essential communications cannot be delegated28,64. Theimportance of communication skillseducation has recently been fully recognized, leading to requirements of documented teaching in orthopaedicresidency programs as well as assessments within the proposed maintenance-of-certification process65,66.We can all improve our performance of the most common procedurein orthopaedic surgery the medicalinterview. Recognizing communicationskills as a new focus of medical education, the AAOS has successfullydeveloped and implemented a Communication Skills Mentoring Program,which includes interactive, highly ratedworkshops. This AAOS program provides residents and practicing orthopaedic surgeons with easily learnedtechniques that sharpen their professional communication skills. More information, including the CSMPmentors and workshop schedules, isavailable at www.aaos.org.John R. Tongue, MDOrthopedic and Fracture Surgery,6485 S.W. Borland Road, Suite A, Tualatin,OR 97062. E-mail address for J.R. Tongue:jtongue.md@verizon.netHoward R. Epps, MDFondren Orthopedic Group, 7401 South MainStreet, Houston, TX 77030Laura L. Forese, MDNew York-Presbyterian Hospital, 161 FortWashington Avenue, New York, NY 10032The authors did not receive grants or outsidefunding in support of their research or preparation of this manuscript. They did not receivepayments or other benefits or a commitmentor agreement to provide such benefits from acommercial entity. No commercial entity paidor directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable ornonprofit organization with which the authorsare affiliated or associated.Printed with permission of the AmericanAcademy of Orthopaedic Surgeons. A modifiedversion of this article, as well as other lecturespresented at the Academy’s Annual Meeting, isavailable in Instructional Course Lectures,Volume 54. The complete volume can be ordered online at www.aaos.org, or by callin
THE JOURNAL OF BONE & JOINT SURGERY · JBJS.ORG VOLUME 87-A · NUMBER 3 · MARCH 2005 COMMUNICATION SKILLS FOR PATIENT-CENTERED CARE Communication Skills for Patient-Centered Care RESEARCH-BASED, EASILY LEARNED TECHNIQUES FOR MEDICAL INTERVIEWS THAT BENEFIT ORTHOPAEDIC SURGEONS AND THEIR
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