Interviewing and the Health History PDF

Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] outcomes, decrease symptoms, improve...

Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] outcomes, decrease symptoms, improve functional status, reduce litigation, and TOPIC OVERVIEW decrease errors The interview is also the most commonly A. INTRODUCTION performed clinical intervention B. DIFFERENT KINDS OF HEALTH Interviewing is both a skill and an art HISTORIES Skilled interviewing is both patient-centered C. THE FUNDAMENTALS OF SKILLED and clinician-centered INTERVIEWING The clinician must focus on the patient to elicit a. Active Listening the full story of the patient’s symptoms, but the b. Empathic Response clinician must also interpret key information to c. Guided Questioning: Options for reach an assessment and plan Expanding and Clarifying the Patient-centered interviews “recognize the Patient’s Story importance of patients’ expressions of d. Nonverbal Communication personal concerns, feelings, and emotions” e. Validation and evoke “the personal context of the f. Reassurance patient’s symptoms and disease.” g. Partnering Experts have defined patient-centered h. Summarization interviewing as “following the patient’s lead to i. Transitions understand their thoughts, ideas, concerns j. Empowering the Patient and requests, without adding additional D. THE SEQUENCE AND CONTEXT OF information from the clinician’s perspective.” INTERVIEW In the more symptom-focused, a. Preparation clinician-centered approach, the clinician b. The Sequence of the Interview “takes charge of the interaction to meet her or c. The Cultural Context of the his own need to acquire the symptoms, their Interview details, and other data that will help her or him E. ADVANCE INTERVIEWING identify a disease,” which can bypass the a. Interviewing The Challenging personal dimensions of the illness Patient Evidence suggests that the patient is best b. Sensitive Topics served by integrating these interviewing styles, F. ETHICS AND PROFESSIONALISM leading to a more complete picture of the G. REFERENCES patient’s illness and allowing clinicians to more fully convey the caring attributes of “respect, empathy, humility and sensitivity.” INTRODUCTION Interviewing process The health history interview is a generates the patient’s story is fluid conversation with a purpose and draws on numerous relational the primary goals of the patient interview are skills to respond effectively to patient to listen and to improve the well-being of cues, feelings, and concerns the patient through a trusting and supportive The interview is more than just a relationship series of questions; it requires a highly Relating effectively with patients is among refined sensitivity to the patient’s the most valued skills of clinical care feelings and behavioral cues For the patient, “a feeling of connectedness. should be “open-ended,” drawing on.. of being deeply heard and under- stood... a range of techniques to cue patients is the very heart of healing.” to tell their stories—active listening, For the clinician, this deeper relationship guided questioning, nonverbal enriches the rewards of patient care affirmation, empathic responses, High-quality patient–clinician communication validation, reassurance, and has also been shown to improve patient partnering PAGE 1 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] Health history format For patients seeking care for ongoing or provides an important framework for chronic problems, focusing the patient’s organizing the patient’s story into self-management, response to treatment, various categories pertinent to the functional capacity, and quality of life is most patient’s present, past, and family appropriate health Patients frequently schedule health structured framework for organizing maintenance visits with the more focused patient information in written or verbal goals of keeping up screening examinations or form discussing concerns about smoking, weight focuses your attention on the specific loss, or sexual behavior kinds of information you need to A specialist may need a more comprehensive obtain, facilitates clinical reasoning, history to evaluate problem with numerous and standardizes communication to possible causes other health care providers involved in the patient’s care The Past Medical History, the Family History, Personal and Social History, and Review of Systems give shape and depth to the patient’s story. The Personal and Social History is an opportunity for the clinician to see the patient as a person and gain deeper understanding of the patient’s outlook and background Learning about the patient’s life circumstances, emotional health, perception of health care, health behaviors, and access to and utilization of health care strengthens your therapeutic alliance and improves health outcomes Make every effort to limit the “clinician-centered,” closed-ended “yes-no” questions to the Review of Systems. DIFFERENT KINDS OF HEALTH HISTORIES The scope and detail of the history depends THE FUNDAMENTALS OF SKILLED on the patient’s needs and concerns, your INTERVIEWING goals for the encounter, and the clinical setting (inpatient or outpatient, the amount of time available, primary care or subspecialty). Comprehensive Health History for new patients Focused or problem-oriented history for patients seeking care for specific concerns, for example, cough or painful urination, a more limited interview tailored to that specific problem may be indicated PAGE 2 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] Your goal is to facilitate full communication, in A ACTIVE LISTENING the patient’s own words, without interruption Lies at the heart of the patient interview Guided questions show your sustained It means closely attending to what the patient interest in the patient’s feelings and deepest is communicating, connecting to the patient’s disclosures emotional state, and using verbal and They help you avoid questions that nonverbal skills to encourage the patient to prestructure or even shut down the patient’s expand on his or her feelings and concerns responses Allows you to relate to those concerns at A series of “yes-no” questions makes the multiple levels of the patient’s experience patient feel more restricted and passive, Focus on what the patient is telling you,both leading to significant loss of detail. Instead, verbally non verbally use guided questioning to absorb the patient’s full story Use guided questioning to absorb the B EMPATHIC RESPONSE patient’s full story Vital to patient rapport and healing Empathy C1 Moving from Open-Ended to Focused capacity to identify with the patient and Questions feel the patient’s pain as your own, then respond in a supportive manner Your questions should flow from general to “requires a willingness to suffer some specific of the patient’s pain in the sharing of Start with the most general questions like, suffering that is vital to healing.” “How can I help?” or “What brings you in As patients talk with you, they may convey, in today?” their words or facial expressions, feelings they Then move to still open, but more focused, have not consciously acknowledged questions like, “Can you tell me more about To express empathy, you must first recognize what happened when you took the medicine?” the patient’s feelings, then actively move Then pose closed questions like, “Did the toward and elicit emotional content new medicine cause any problems?” Your empathic responses will deepen mutual Begin with a truly open-ended question that trust does not prefigure an answer Sometimes a patient’s response may not A possible sequence might be: correspond to your initial assumptions “Tell me about your chest discomfort.” It is better to ask the patient to expand or (Pause) clarify a point than assume you understand “What else?” (Pause) Empathy may also be nonverbal—placing your “Where did you feel it?” (Pause) hand on the patient’s arm or offering tissues “Show me.” when the patient is crying “Anywhere else?” (Pause) Once the patient has shared these feelings, “Did it travel anywhere?” (Pause) reply with understanding and acceptance “To which arm?” Your responses may be as simple as: “I cannot Avoid leading questions that already contain imagine how hard this must be for you” or an answer or suggested response like: “That sounds upsetting” or “You must be “Has your pain been improving?” feeling sad.” “You don’t have any blood in your For a response to be empathic, it must convey stools, do you?” that you feel what the patient is feeling “Is your pain like a pressure?” Adopt the more neutral “Please describe your pain.” GUIDED QUESTIONING: OPTIONS FOR C EXPANDING AND CLARIFYING THE PATIENT’S STORY C2 Questioning That Elicits a Graded PAGE 3 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] Response C5 Echoing Ask questions that require a graded response Simply repeating the patient’s last words rather than a yes-no answer Encourages the patient to elaborate on details “How many steps can you climb and feelings. before you get short of breath?” Demonstrates careful listening and a subtle connection with the patient by using the same words C2 Asking a Series of Questions, One at a Example: Time Patient: “The pain got worse and Be sure to ask one question at a time began to spread.” (Pause) “Any tuberculosis, pleurisy, asthma, bronchitis, Response: “Spread?” (Pause) pneumonia?” may prompt “No” out of sheer Patient: “Yes, it went to my shoulder confusion and down my left arm to the fingers. It Try “Do you have any of the following was so bad that I thought I was going problems?” to die.” (Pause) Be sure to pause and establish eye contact Response: “Going to die?” as you list each problem. Patient: “Yes, it was just like the pain my father had when he had his heart attack, and I was afraid the same thing C3 Offering Multiple Choices for Answers was happening to me.” Sometimes, patients need help describing This reflective technique helped to reveal not their symptoms only the location and severity of the pain but To minimize bias, offer multiple-choice also its meaning to the patient answers: It did not bias the story or interrupt the “Which of the following words best patient’s train of thought describes your pain: aching, sharp, pressing, burning, shooting, or D NONVERBAL COMMUNICATION something else?” Almost any specific question can contrast two Both clinicians and patients continuously possible answers display nonverbal communication that “Do you bring up any phlegm with your provides important clues to our underlying cough, or is it dry?” feelings Being sensitive to nonverbal cues allows you to “read the patient” more effectively and send C4 Clarifying What the Patient Means messages of your own Sometimes the patient’s history is difficult to Pay close attention to eye contact, facial understand expression, posture, head position and It is better to acknowledge confusion than to movement such as shaking or nodding, act like the story makes sense interpersonal distance, and placement of the To understand what the patient means, you arms or legs—crossed, neutral, or open need to request clarification Be aware that some forms of nonverbal “Tell me exactly what you mean by communication are universal, but many are ‘the flu” culturally bound “You said you were behaving just like Just as mirroring your posture shows the your mother. What did you mean?” patient’s sense of connection, matching your Taking time for clarification reassures the position to the patient’s can transmit increased patient that you want to understand his or her rapport story and builds your therapeutic relationship You can also mirror the patient’s paralanguage, or qualities of speech, such as pacing, tone, and volume PAGE 4 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] Moving closer or making physical contact like placing your hand on the patient’s shoulder G PARTNERING conveys empathy and can help the patient When building rapport with patients, express gain control of upsetting feelings your commitment to an ongoing relationship The first step to using this important technique Make patients feel that no matter what is to notice nonverbal behaviors and bring happens, you will continue to provide their them to conscious level care. Even as a student, especially in a hospital E VALIDATION setting, this support can make a big difference Another way to affirm the patient is to validate the legitimacy of his or her emotional H SUMMARIZATION experience Giving a capsule summary of the patient’s “Your accident must have been very story during the course of the interview serves scary. Car accidents are always several purposes unsettling because they remind us It communicates that you have been listening how vulnerable we are. Perhaps that carefully explains why you still feel upset” It identifies what you know and what you don’t know F REASSURANCE “Now, let me make sure that I have the full story. You said you’ve had a cough When patients are anxious or upset, it is for 3 days, that it’s especially bad at tempting to provide reassurance night, and that you have started to “Don’t worry. Everything is going to be bring up yellow phlegm. You have not all right.” had a fever or felt short of breath, but Although this is common in social interactions, you do feel congested, with difficulty for clinicians, such comments may be breathing through your nose.” premature and counterproductive Following with an attentive pause, or asking Depending on the actual situation,they may “Anything else?” lets the patient add other even be misleading and block further information and corrects any disclosure misunderstandings The patient may sense that you are You can use summarization at different points uncomfortable handling anxiety or fail to in the interview to structure the visit, especially appreciate the depth of the distress at times of transition The first step to effective reassurance is simply It also allows you to organize your clinical identifying and acknowledging the patient’s reasoning and convey your thinking to the feelings patient, making the relationship more “You seem upset today.” collaborative This promotes a feeling of connection. Meaningful reassurance comes later, after you have completed the interview, the physical I TRANSITION examination, and perhaps some laboratory To put patients more at ease, tell them when tests you are changing directions during the At that point, you can explain what you think is interview happening and deal openly with any concerns. Transitions help prepare patients for what Reassurance is more appropriate when the comes next patient feels that problems have been fully As you move through the history and on to the understood and are being addressed physical examination, orient the patient with brief transitional phrases “Now I’d like to ask some questions about your past health.” PAGE 5 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] Make clear what the patient should expect or Prepare for the interview by reviewing the do next record and setting goals for the interview “Before we move on to reviewing all ahead your medications, was there anything Check your appearance else about past health problems?” Make sure the patient is comfortable and the “Now I would like to examine you. I will environment is conducive to the very personal step out for a few minutes. Please information soon to be shared undress and put on this gown.” Each interview has its own rhythm and sequence The interview has important societal J EMPOWERING THE PATIENT dimensions The clinician–patient relationship is inherently Reflect on any biases you have that color your unequal reactions to the patient and the therapeutic Patients have many reasons to feel alliance you need to create vulnerable. They may be in pain or worried about A PREPARATION a symptom They may feel overwhelmed by even Interviewing patients requires planning scheduling a visit, a task you might take for granted Differences of gender, ethnicity, race, or A1 REVIEWING THE CLINICAL RECORD socioeconomic status contribute to the Before seeing the patient, review the clinical power asymmetry of the relationship record Ultimately, however, patients are responsible This provides important background for their own care information and suggests areas you need to When you empower patients to ask questions, explore express their concerns, and probe your Review identifying data such as age, gender, recommendations, they are most likely to address, and insurance adopt your advice, make lifestyle changes, or Look at the problem list and the patient’s take medications as prescribed medications and allergies Even though the clinical record usually contains past diagnoses and treatments, you need to make your own assessment based on what you learn from the visit ahead The clinical record is compiled from many observers. Data may be incomplete or even disagree with what the patient tells you. Correcting discrepancies in the record is important for the patient’s care A2 SETTING GOALS FOR THE INTERVIEW THE SEQUENCE AND CONTEXT OF THE INTERVIEW Before you talk with the patient, clarify your goals for the interview As a student, your primary purpose may be to complete a comprehensive history required for your rotation As a practicing clinician, your goals can range from assessing a new concern, to treatment follow-up, to completing forms PAGE 6 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] The clinician must balance these Importance of Privacy and Comfort provider-centered goals with patient-centered ○ Ensuring a private and comfortable goals, weighing multiple agendas arising from environment for the interview the needs of the patient, the patient’s family, ○ Addressing challenges in different settings and health care agencies and facilities (e.g., two-bedrooms, busy emergency Taking a few minutes to think about your goals departments) makes it easier to align your priorities with the Maximizing Confidentiality patient’s agenda ○ Using privacy curtains ○ Moving to more secluded areas, like empty rooms, when possible A3 REVIEWING YOUR BEHAVIOR AND Adjusting Physical Conditions APPEARANCE ○ Modifying room temperature for patient comfort ○ Emphasizing the clinician's role in ensuring Non-Verbal Communication comfort ○ Importance of observation from both patient Value of Efforts and clinician ○ Importance of taking time to improve the ○ The messages conveyed through posture, environment gestures, eye contact, and tone ○ Benefits to communication and patient comfort ○ The impact of these cues on the patient’s perception of interest, attention, acceptance, B SEQUENCE OF INTERVIEW and understanding Composure and Focus ○ Remaining calm and unhurried, even when time is limited B1 GREETING THE PATIENT AND ○ Importance of full attention to the patient ESTABLISHING RAPPORT ○ Recognizing when the patient senses preoccupation Initial Greeting and Introductions Sensitivity to Patient Reactions ○ It's essential to greet patients by name and ○ Awareness of the patient’s sensitivity to introduce yourself clearly, including your role, disapproval, embarrassment, impatience, especially if you are a student. boredom, etc. ○ This sets the tone for transparency and helps ○ Avoiding condescending or critical behaviors the patient feel informed and respected. Professionalism and Attitude ○ Reintroducing yourself in subsequent meetings ○ Importance of equanimity and “unconditional ensures that patients remember you, positive regard” reinforcing continuity and rapport. ○ Nurturing healing relationships through Respectful Addressing of Patients professionalism ○ The guidelines suggest using formal titles like Appearance and Presentation "Mr." or "Ms." unless you have explicit ○ Importance of cleanliness, neatness, permission to use first names, especially for conservative dress, and wearing a name tag adults. Avoiding overly familiar terms, such as ○ Reassuring the patient with a professional "dear," helps maintain professionalism and appearance avoids any sense of depersonalization. Building Trust ○ Keeping the patient’s perspective in mind Handling Names and Pronunciation ○ Establishing trust through non-verbal ○ Asking how to pronounce a patient’s name if communication, professionalism, and you're unsure is encouraged, reflecting cultural appearance sensitivity and respect for individual identities. ○ This small action can go a long way in making A4 ADJUSTING TO ENVIRONMENT patients feel valued. PAGE 7 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] Managing Visitors in the Room distractions like note-taking, looking at charts, ○ Acknowledging visitors and ensuring patient or scanning a computer screen should be confidentiality is crucial when others are minimized. present. ○ Asking open-ended questions like “Tell me ○ The patient should decide if visitors should about yourself” can help the patient feel seen remain during the interaction, and it's advised as an individual. to explicitly ask for the patient's comfort level in Note-Taking their presence. ○ For novice clinicians, note-taking is often Dealing with Sensitive Topics necessary, but it should not interfere with ○ For delicate matters, arranging private patient interaction. conversations with the patient alone may be ○ Experienced clinicians rely less on notes, but necessary, ensuring they feel comfortable all should prioritize maintaining eye contact discussing personal issues. and actively listening, especially during Patient Comfort sensitive topics. When using electronic ○ Attending the patient's physical and emotional records, clinicians should face the patient, comfort from the outset is crucial. maintain engagement, and glance at the ○ Simple gestures, such as helping with screen only when necessary. belongings, asking how they feel, or rearranging the environment for convenience, show attentiveness and compassion. B2 ESTABLISHING AGENDA ○ In the hospital, this could mean adjusting the Open-Ended Questions bed or waiting while the patient finishes an ○ Once rapport has been established, you are activity, demonstrating respect for their needs. ready to pursue the patient’s reason for Observing Discomfort seeking care, traditionally called the chief ○ Clinicians are encouraged to be observant for complaint. non-verbal cues of discomfort, like shifting ○ When eliciting the patient's reason for the visit, positions or facial expressions of pain. open-ended questions are emphasized as a ○ Addressing these signs promptly fosters trust way to give patients the freedom to express and reassures the patient that their comfort is their concerns. a priority. ○ Phrases like “What are your special concerns Room Arrangement today?” or “How can I help you?” allow the ○ The arrangement of the room and physical patient to raise a variety of issues, not just the proximity to the patient also impact the primary medical complaint. interaction. Identifying All Concerns Early ○ Factors such as personal space preferences, ○ Uncovering all of the patient's concerns at the cultural background, and ensuring eye contact beginning of the visit is key. are all essential to creating a positive ○ This allows both the clinician and patient to environment. prioritize which issues need immediate ○ Sitting at eye level and removing physical attention and which can be addressed later. barriers, like bed railings, demonstrates Asking questions like “Is there anything else?” respect and a desire to engage meaningfully or “Have we covered everything?” helps with the patient. ensure that nothing is missed. Lighting and Positioning ○ Identifying the full agenda protects time for the ○ Avoid settings that may make the patient feel most important issues. uncomfortable, such as sitting in front of a bright light that forces them to squint. Negotiating the Agenda ○ Lighting and positioning play a role in creating ○ Once all concerns are identified, the clinician a calm, comfortable atmosphere, free of and patient can collaboratively decide which distractions. issues to tackle during the visit. Undivided Attention ○ Even with a clear agenda, last-minute ○ Providing the patient with full attention is concerns may still arise, often referred to as critical. Small talk can ease initial tensions, but PAGE 8 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] the “oh by the way” issues that surface near the end of the visit. B3 INVITING THE PATIENT’S STORY Prioritizing the Agenda First ○ Before inviting the patient’s story, clinicians should establish and prioritize the agenda to ensure both parties are clear on the most pressing issue to address. Disease/illness distinction model Open-Ended Invitations ○ helps elucidate the different yet ○ To encourage the patient to speak freely, it’s complementary perspectives of the clinician recommended to use open-ended prompts and the patient such as “Tell me more about…” ○ Disease is the explanation that the clinician ○ This allows the patient to share their concerns uses to organize symptoms that leads to a in their own words, providing richer and more clinical diagnosis. detailed information without being influenced ○ Illness is a construct that explains how the by the clinician’s assumptions. patient experiences the disease, including its Avoid Interruptions and Bias effects on relationships, function, and sense of ○ Clinicians are advised to avoid interrupting or well-being. injecting new information early in the ○ The clinical interview needs to incorporate both conversation, as this can bias the patient’s these views of reality. The melding of these account and potentially suppress important two perspectives forms the basis for planning details. evaluation and treatment ○ Studies indicate that clinicians often interrupt ○ Real-Life Example: after only 18 seconds, and once interrupted, Even a simple complaint like a sore throat patients may not return to their original story. can highlight the difference between the This highlights the importance of patience and patient and clinician’s perspectives. listening. While the clinician may focus on Active Listening diagnosing the cause, the patient may be ○ Active listening techniques, such as leaning more concerned about missed work or the forward, nodding, and using verbal affirmations fear of a serious illness, such as a family like “uh huh” or “go on,” help keep the patient member’s experience with tonsillitis. engaged and comfortable, fostering a trusting Exploring the Patient’s Perspective environment where they feel heard. ○ To fully understand the patient’s experience, Exploring the Story Further clinicians should explore four key domains: ○ After the patient shares their initial story, Feelings clinicians should explore the narrative in more How the patient feels about the illness, depth by asking specific follow-up questions such as concerns or fears. like “How would you describe the pain?” or Questions like “What concerns you most “What happened next?” about the pain?” or “How has this been for ○ This approach helps the patient elaborate OR you?” help to uncover these emotional enriches important details responses. Ideas B4 EXPLORING THE PATIENT’S The patient’s own thoughts or beliefs PERSPECTIVE about the cause of the illness. Asking “Why do you think you have this [symptom]?” helps to reveal any underlying beliefs that may affect how they perceive their condition. Effect on Function PAGE 9 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] How the illness affects the patient’s daily life, including their ability to perform usual NURSE Mnemonic for Responding to activities, social roles, and Emotional Cues: This mnemonic offers a responsibilities. structured approach to addressing emotional Questions like “What did you do before concerns: that you can’t do now?” or “How has this ○ Name: Identify and acknowledge the affected your life at home or work?” are emotion. Example: “That sounds like a scary essential for understanding the broader experience.” impact of the illness. ○ Understand or Legitimize: Show empathy Expectations and validate the patient’s feelings. Example: What the patient hopes to achieve from “It’s understandable that you feel that way.” the visit or from treatment. ○ Respect: Acknowledge the patient’s strength Questions such as “How can I help you and resilience. Example: “You’ve done better now?” help the clinician align care with than most people would with this.” the patient’s needs and expectations ○ Support: Offer continued support and The FIFE Framework: A helpful mnemonic for commitment. Example: “I will continue to exploring the patient’s perspective is FIFE: work with you on this.” ○ Feelings: How the patient feels about their ○ Explore: Invite further discussion about their illness. feelings. Example: “How else were you ○ Ideas: What the patient thinks is causing their feeling about it?” symptoms. ○ Function: How the illness affects the patient’s ability to function. ○ Expectations: What the patient expects from treatment or the clinical encounter. B5 IDENTIFYING AND RESPONDING TO THE PATIENT’S EMOTIONAL CUES Prevalence of Emotional Distress ○ Emotional issues such as anxiety and depression are prevalent among patients in primary care, affecting 30% to 40% of visits. Missing Emotional Cues ○ Clinicians who overlook emotional cues may experience longer visits and potentially missed issues. B6 EXPANDING AND CLARIFYING THE ○ Patients often provide clues to their PATIENT’S STORY emotional state through various means—directly, indirectly, verbally, Seven Attributes of a Symptom: To accurately nonverbally, or through related ideas and assess a symptom, you need to explore its emotions. essential characteristics. The attributes include: Recognizing Emotional Cues ○ Onset: When did the symptom start? ○ To check on and address emotional clues, ○ Location: Where is the symptom located? clinicians should ask questions like, “How did ○ Duration: How long does the symptom last? you feel about that?” or use statements such ○ Character: What is the nature or quality of the as, “Many people would be frustrated by symptom? something like this.” ○ Aggravating/Alleviating Factors: What ○ This approach encourages patients to makes the symptom worse or better? express their emotional concerns and ○ Radiation: Does the symptom spread to other provides a pathway to address them. areas? PAGE 10 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] ○ Timing: How often does the symptom occur? ○ As you gain experience, you develop skills in clinical reasoning that involve generating and Mnemonics for Symptom Attributes: testing hypotheses about potential diseases ○ OLD CARTS: Onset, Location, Duration, based on the patient’s symptoms. Character, Aggravating/Alleviating Factors, ○ Recognizing patterns and generating a Radiation, Timing. differential diagnosis are crucial steps in the ○ OPQRST: Onset, Palliating/Provoking Factors, diagnostic process. Quality, Radiation, Site, Timing. ○ This requires a thorough understanding of each symptom’s features. Using Patient’s Words Avoiding Premature Closure ○ To ensure clarity and avoid confusion, repeat ○ One common pitfall in clinical practice is the patient’s exact words and phrases. premature closure, which occurs when ○ This practice confirms their experience and clinicians form a diagnosis too quickly and fail avoids introducing medical jargon that may be to fully explore the patient’s story. confusing. ○ To avoid this, ensure that you fully flesh out the ○ For example, instead of saying "pressure," patient’s narrative and explore all relevant ask, "You described a 'heavy weight' on your symptoms and their characteristics. chest. Can you elaborate on that?" ○ Each symptom should be detailed in its own Clarifying Symptoms “cone” or paragraph within the History of ○ To further clarify symptoms, offer specific Present Illness (HPI). response options. Symptom Clusters and Clinical Entities ○ For instance, if a patient says they felt ○ Familiarity with symptom clusters associated light-headed, ask, “Did you feel like fainting or with common clinical entities can guide the just weak in the legs?” This helps in diagnostic process. pinpointing the exact nature of their symptoms. Interview as Primary Evidence Establishing Chronology ○ The patient interview serves as the primary ○ Understanding the sequence and time course source of evidence for and against various of symptoms is crucial for accurate diagnostic possibilities. assessment. Use questions like “What ○ It is essential to use the information obtained happened next?” or “Please start from when through the interview to test and refine your you last felt well and describe step by step.” diagnostic hypotheses. Types of Questions Balancing Focused Questions and Patient ○ Use a mix of open-ended and focused Perspective questions to gather comprehensive details. ○ While focused questions are necessary for ○ Begin with broad, open-ended questions to gathering specific details, avoid letting them allow the patient to describe their experience dominate the interview to the detriment of the freely, then use more focused questions to fill patient’s perspective. in specific details or clarify aspects of their ○ A clinician-centered approach that overly story. prioritizes specific details can obscure the Interview Flow broader context of the patient’s experience. ○ The interview should flow back and forth ○ Strive to maintain an empathic therapeutic between open-ended and focused questions. connection by balancing focused questions ○ This approach ensures a thorough exploration with open-ended inquiries that allow the patient of symptoms while keeping the patient actively to share their perspective and concerns fully. involved in sharing their story and returning the lead in the interview to the patient. B7 GENERATING AND TESTING DIAGNOSTIC HYPOTHESES Clinical Reasoning and Diagnostic Hypotheses PAGE 11 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] change and improve health outcomes. Key aspects include: Guiding Style: Instead of direct advice, motivational interviewing uses a guiding approach to encourage patients to explore their own reasons for change. Engaging in Pros and Cons: It helps patients articulate the benefits and drawbacks of their behaviors. Empowering Patients: The technique empowers patients to develop their own ideas, solutions, and timelines for change. B8 SHARING TREATMENT PLAN ○ Creating a Shared Picture Understanding both the disease and the patient’s experience allows for a comprehensive view of the patient’s issues. This shared understanding forms the basis for planning further evaluation and treatment. ○ Shared Decision-Making This approach is considered the pinnacle of patient-centered care. It involves: Introducing Choices: Presenting B9 CLOSING THE INTERVIEW AND THE different options and using patient VISIT decision support tools if available. Exploring Preferences: Discussing Preparing to Close with the patient their preferences and ○ Indicating the End of the Interview or Visit values regarding the treatment Notify the patient that the end of the options. interview or visit is approaching. Making a Decision: Ensuring the This allows them time to ask any patient is ready to decide and remaining questions and ensures they offering additional time if needed. are not left with unresolved concerns. Behavior Change and Motivational Example: “We need to stop now. Do Interviewing: you have any questions about what ○ Behavior Change Discussions we’ve covered? Many patient visits involve discussing Summarizing and Confirming Plans necessary behavior changes, such as ○ Summarize Plans diet, exercise, smoking cessation, or Clearly summarize the plans for medication adherence. These changes future evaluations, treatments, and are crucial for optimizing health or treating follow-ups. illness. This helps reinforce the patient’s ○ Motivational Interviewing understanding and agreement with technique designed to help patients the proposed plan. resolve ambivalence about behavior PAGE 12 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] ○ Teach Back Technique ○ Impact of Personal Biases Use the “teach back” method to assess Each clinician brings their own the patient’s understanding. values, assumptions, and biases to Ask the patient to explain the plan of care patient interactions. in their own words. Self-reflection helps in recognizing This ensures they have correctly how these factors might influence understood the information. your perceptions and behavior, Example: “Could you please tell me what ensuring they do not negatively you understand is our plan of care?” impact patient care. Addressing Final Questions Practice of Self-Reflection ○ Allow for Final Questions ○ Continual Awareness Ensure the patient has the opportunity to Self-reflection is a continual part of ask any last questions. professional development in clinical This reinforces their engagement and work. allows for any clarifications before It brings a deepening personal concluding the visit. awareness to our work with patients. ○ Handling New Topics ○ Rewarding Aspect of Patient Care If new topics arise at the end of the visit One of the most rewarding aspects that are not life-threatening, acknowledge of patient care is the personal growth the concern and suggest scheduling a that comes from deepening your follow-up appointment to address it in awareness through self-reflection. detail. Example: “That knee pain sounds concerning. Why don’t you make an appointment for next week so we can C CULTURAL CONTEXT OF THE discuss it further?” INTERVIEW Reaffirming Commitment ○ Show Ongoing Commitment Reaffirm your commitment to the C1 DEMONSTRATING CULTURAL HUMILITY- patient’s health and well-being. A CHANGING PARADIGM This helps build trust and demonstrates your ongoing involvement in their care. Importance of Addressing Disparities B10 TAKING TIME FOR REFLECTION ○ Disparities in Health Outcomes Health disparities are evident in risks of disease, morbidity, and mortality across Importance of Self-Reflection various demographic groups. ○ Mindfulness These disparities are influenced by Mindfulness involves being “purposefully factors such as healthcare access, and nonjudgmentally attentive to [one’s] income, insurance, education, language own experience, thoughts, and feelings.” proficiency, and provider This means being aware of your internal decision-making. state and how it influences your ○ Role of Self-Reflection and Critical interactions with patients. Thinking ○ Respect for Diversity Clinicians are encouraged to engage in In clinical care, you encounter patients self-reflection and critical thinking to from diverse backgrounds—different address these disparities. ages, gender identities, social classes, This involves acknowledging and races, and ethnicities. Being respectful addressing personal and systemic and open to these differences requires biases. ongoing self-awareness and reflection. PAGE 13 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] having a cloth wrapped tightly, to the point of pain, around his arm. The clinician, a 36-year-old woman Cultural Competence vs. Cultural Humility from Washington, D.C., asked the patient many ○ Cultural Competence questions, examined him, and wanted to take blood, defined as “a set of attitudes, skills, which the patient had refused. The patient’s final behaviors, and policies that enable comment was “... and she didn’t even give me organizations and staff to work chloroquine!”—his primary reason for seeking care. effectively in cross-cultural situations.” The man from Ghana was expecting few questions, It reflects the ability to acquire and use no examination, and treatment for malaria, which is knowledge of the health-related beliefs, what fever usually means in Ghana attitudes, practices, and communication patterns of clients and their families to INTERPRETATION: improve services, strengthen programs, In this example, cross-cultural miscommunication is increase community participation, and understandable and thus less threatening to close the gaps in health status among explore. Unconscious bias leading to diverse population groups. miscommunication, however, occurs in many clinical ○ Limitations of Cultural Competence interactions. Cultural competence can sometimes be reduced to a static set of traits and beliefs that objectify patients, reinforcing dominant cultural perspectives and CULTURAL HUMILITY: SCENARIO 2 failing to address dynamic cultural contexts. A 16-year-old high school student came to the local ○ Cultural Humility teen health center because of painful menstrual Defined as a “process that requires cramps that interfered with her concentration at humility as individuals continually school. She was dressed in a tight top and short engage in self-reflection and self-critique skirt and had multiple piercings. The 30-year-old as lifelong learners and reflective male clinician asked the following questions: “Are practitioners.” you passing all of your classes? What kind of job do It emphasizes the dynamic and evolving you want after high school? What kind of birth nature of culture. control do you want?” The teen felt pressured into Key Aspects: accepting birth control pills, even though she had Self-Reflection and Self-Critique: clearly stated that she had never had intercourse Clinicians regularly examine their and planned to postpone it until she got married. own cultural beliefs and biases. She was an honor student plan- ning to go to Power Imbalances: Addressing college, but the clinician did not elicit these goals. and balancing power dynamics in The clinician glossed over her cramps by saying, clinician-patient interactions. “Oh, you can just take some ibuprofen. Cramps Dynamic Partnerships: Building usually get better as you get older.” The patient will mutually respectful and adaptable not take the birth control pills that were prescribed, relationships with patients and nor will she seek health care soon again. She communities. experienced the encounter as an interrogation, so failed to gain trust in her clinician. In addition, the clinician’s questions made assumptions about her CULTURAL HUMILITY: SCENARIO 1 life and did not show respect for her health concerns. Even though the provider pursued A 28-year-old taxi driver from Ghana who had important psychosocial domains, she received recently moved to the United States complained to a ineffective health care because of conflicting cultural friend about U.S. clinical care. He had gone to the values and clinician bias. clinic because of fever and fatigue. He described being weighed, having his temperature taken, and PAGE 14 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] In both of these cases, the failure stems from This type of framework will allow you mistaken assumptions or biases. to approach each patient as a unique In the first case, the clinician did not individual. consider the many variables affecting patient beliefs about health and THREE DIMENSIONS OF CULTURAL HUMILITY expectations for care. In the second case, the clinician 1. Self-awareness. Learn about your own allowed stereotypes to dictate the biases; we all have them. agenda instead of listening to the 2. Respectful communication. Work to patient and respecting her as an eliminate assumptions about what is individual. “normal”. Learn directly from your patients; Each of us has our own cultural they are the experts on their culture and background and our own biases. illness. These do not simply fade away as we 3. Collaborative partnerships. Build your become clinicians. patient relationships on respect and mutually acceptable plans. As you provide care for an ever-expanding and diverse group of patients, you must recognize how culture shapes not only the SELF-AWARENESS. patient’s beliefs, but also your own. Start by exploring your own cultural identity. Culture is the system of shared ideas, rules, How do you describe yourself in terms and meanings that influences how we view the of ethnicity, class, region or country of world, experience it emotionally, and behave in origin, religion, and political affiliation? relation to other people. Don’t forget the characteristics we often take It can be understood as the “lens” for granted— gender, life roles, sexual through which we perceive and make orientation, physical ability, and sense out of the world we inhabit. race—especially if we belong to majority The meaning of culture is much groups. broader than the term “ethnicity.” What aspects of your family of origin Cultural systems are not limited to do you identify with, and how are you minority groups; they emerge in many different from your family of origin? social groupings, including clinical How do these identities influence your professionals. beliefs and behaviors? Avoid letting personal impressions about A more challenging task is to bring our own cultural groups turn into professional values and biases to a conscious level. stereotyping. Values are the standards we use to For example, you may have heard that measure our own and others’ beliefs Hispanic patients are more dramatic and behaviors. when they express pain. Biases are the attitudes or feelings Recognize that this is a stereotype. that we attach to perceived Evaluate each patient as an individual, differences. not decreasing the dose of analgesics, Instinctively knowing members of one’s own but staying attuned to your reactions group is a survival skill that we may have to the patient’s style. outgrown as a society, but that is still actively Work on an informed clinical approach at work. to each patient by consciously acknowledging your own values and Feeling guilty about our biases makes them biases, developing communication hard to recognize and acknowledge. skills that transcend cultural 1. Start with less threatening differences, and building therapeutic constructs, like the way an individual partnerships based on respect for relates to time, a culturally determined each patient’s life experience. phenomenon. PAGE 15 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] Are you always on time—a positive Learning about the patient’s specific culture value in the dominant Western broadens the areas you, as a clinician, need to culture? Or do you tend to run a little explore. late? Do some reading about the life How do you feel about people whose experiences of individuals in ethnic or habits are opposite to yours? racial groups who live in your area. Next time you attend a meeting or Go to movies filmed in foreign class, notice who is early, on time, or countries, which can help you better late. Is it predictable? understand different cultures. 2. Think about the role of physical Learn about the explicit health appearance. agendas of different consumer groups. Do you consider yourself thin, Talk with different kinds of healers and mid-size, or heavy? learn about their practices. How do you feel about your weight? Most importantly, be open to learning What does prevailing U.S. culture from each patient. teach us to value in physique? Do not assume that your impressions How do you feel about people who about a given cultural group apply to have different weights? the individual before you. COLLABORATIVE PARTNERSHIPS. RESPECTFUL COMMUNICATION. Through continual work on self-awareness and Given the complexities of global society, no seeing through the “lens” of others, the one can possibly know the health beliefs and clinician lays the foundation for the practices of every culture and subculture. collaborative relationship that best supports Let your patients be the experts on their own the patient’s health. unique cultural perspectives. Communication based on trust, respect, and Even if patients have trouble your own willingness to re-examine describing their values or beliefs, they assumptions allows patients to be more open can often respond to specific to expressing views that diverge from the questions. dominant culture. Find out about the patient’s cultural They may have strong feelings such as anger background. or shame. You, the clinician, must be willing to Maintain an open, respectful, and inquiring listen to and validate these emotions, and not attitude. let your own feelings of discomfort or time “What did you hope to get from this pressure prevent you from exploring painful visit?” areas. If you have established rapport and Be willing to re-examine your beliefs about the trust, patients will be willing to teach “right approach” to clinical care in a given you. situation. Be aware of questions that contain Make every effort to be flexible as you assumptions. develop shared plans that reflect patients’ And always be ready to acknowledge your knowledge about their best interests that are areas of ignorance or bias. congruent with both their beliefs and effective “I know very little about Ghana. What clinical care. would have happened at a clinic there Remember that if the patient stops listening, if you had these concerns?” fails to follow your advice, or does not return, Or, with the second patient and with your care has not been successful. much more difficulty, “I mistakenly made assumptions about you that are not right. I apologize. Would you be willing to tell me more about yourself and your future goals?” PAGE 16 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] At times, silence may be the patient’s ADVANCED INTERVIEWING response to how you are asking questions. Are you asking too many short-answer questions in rapid succession? A INTERVIEWING THE CHALLENGING Have you offended the patient by PATIENT showing disapproval or criticism? As you spend time inviting patient stories, you Have you failed to recognize an will find that some patients are more difficult to overwhelming symptom such as pain, interview than others. nausea, or shortness of breath? For some clinicians, a quiet patient might If so, you may need to ask the patient seem difficult, for others, a patient who is more directly, “You seem very quiet. Have I assertive. done something to upset you?” Being aware of your reactions helps develop your clinical skills. Your success in eliciting the history from A2 The Confusing Patient different types of patients grows with experience, but take into account your own Some patient stories are confusing and do not stressors, such as fatigue, mood, and seem to make sense. overwork. Just as you develop a differential Self-care is also important in caring for diagnosis from the symptoms of the others. Present Illness, keep several Even if a patient is challenging, always possibilities in mind as you assess remember the importance of listening to the why the story is confusing. patient and clarifying his or her concerns. It may be the patient’s style, and by using your skills of guiding questions, clarification, and summarizing, you A1 The Silent Patient can put together a coherent story. Novice interviewers often feel uncomfortable Watch for an underlying issue, with periods of silence and try to keep the however, that is interfering with conversation going. communication. Patients fall silent to collect their thoughts, Some patients present a confusing array of remember details, or decide if they can trust multiple symptoms. you with certain information. They seem to have every symptom Periods of silence usually seem longer to the that you ask about, or “a positive clinician than the patient. review of systems.” Be attentive and respectful, and encourage the With these patients, focus on the patient to continue when ready. context of the symptom, emphasizing Watch the patient closely for nonverbal cues, the patient’s perspective, and guide such as difficulty controlling emotions. the interview into a psychosocial Being comfortable with periods of silence may assessment. be therapeutic, prompting the patient to reveal At other times, you may feel baffled and deeper feelings. frustrated because the history is vague, and Patients with depression or dementia may ideas are poorly connected and hard to follow. seem subdued and lose their usual affect, Even with careful wording, you cannot prompt giving only short answers to questions, then clear answers to your questions. falling silent. The patient may seem peculiar, distant, aloof, If you have already tried guided or inappropriate. questioning, try shifting to more direct Symptoms may seem bizarre: “My fingernails inquiry about symptoms of depression, feel too heavy” or “My stomach knots up like a or begin an exploratory mental status snake.” examination. PAGE 17 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] Perhaps there is a mental status For example, when a child is brought in for change like psychosis or delirium, a health care, the accompanying adult may not mental illness such as schizophrenia, be the parent or caregiver, but just the most or a neurologic disorder. available driver. If you suspect a psychiatric or neurological Remember that while you are disorder: gathering information about the Gathering a detailed history can tire history, you should not disclose and frustrate both you and the patient. information about the patient unless Shift to the mental status examination, the informant is the health care proxy focusing on level of consciousness, or has a durable power of attorney for orientation, memory, and capacity to health care, or you have permission understand. from the patient. You can ease this transition by asking Health Insurance Portability and questions like: Accountability Act (HIPAA) passed by ➔ “When was your last Congress in 1996, sets strict standards for appointment at the clinic? disclosure for both institutions and providers Let’s see...that was about how when sharing patient information. long ago?” Some patients can provide a history, but lack ➔ “Your address now is...?...and the ability to make informed health care your phone number?” decisions. You can confirm these responses in You then need to determine whether a the chart or ask permission to speak patient has “decision-making with family members or friends to capacity,” which is the ability to obtain their perspectives. understand information related to health, weigh choices and their consequences, reason through the A3 The Patient with Altered Condition options, and communicate a choice. Some patients cannot provide their own Capacity is a clinical designation and can be histories because of delirium, dementia, or assessed by clinicians, whereas competence mental health conditions. is a legal designation and can only be decided Others are unable to remember by a court. certain parts of the history, such as If a patient lacks capacity to make a events related to a febrile illness or a health care decision, then identify the seizure. health care proxy or the agent with Under these circumstances, you will need to power of attorney for health care. obtain historical information from other If the patient had not identified a sources such as family members or surrogate decision-maker, then that caregivers. role may shift to a spouse or family Always seek the best-informed source. member. Apply the basic principles of interviewing to It is critical to remember that your conversations with relatives or friends. decision-making capacity is both Find a private place to talk. “temporal and situational”. Introduce yourself, state your purpose, It can fluctuate depending on the inquire how they are feeling under the condition of the patient and the circumstances, and recognize and complexity of the decision involved. acknowledge their concerns. ➔ A patient who is quite ill may As you listen to their accounts, assess be unable to make decisions their credibility in light of the quality of about care, but can regain their relationship with the patient. capacity with clinical Establish how they know the patient. improvement. ➔ A patient may be unable to make a complex decision, but PAGE 18 BATCH TALAGHAY  Interviewing and the Health History MEDICINE 1 Dr. Jervis Salvador Trans by: [Baggayan, Domingo, Lacanilao, Quiamco] still able to make simple Focus on what seems most important to the decisions. patient. ➔ Even if patients lack capacity Show your interest by asking for certain decisions, it is still questions in those areas. important to seek their input, Interrupt only if necessary, but be as they may have definite courteous. opinions about their care. Learn to set limits when needed, since part of your task is structuring the interview to gain important information about the patient’s health. ELEMENTS OF DECISION-MAKING CAPACITY A brief summary may help you change the subject, yet validate any concerns. Patients must have the ability to: ➔ “Let me make sure that I 1. Understand the relevant information about understand. You have proposed diagnostic tests or treatment described many concerns. In 2. Appreciate their situation (including their particular, I heard about two underlying values and current clinical different kinds of pain, one on situation) your left side that goes into 3. Use reason to make a decision, and your groin and is fairly new, 4. Communicate their choice. and one in your upper abdomen after you eat that ★ The Aid to Capacity Evaluation (ACE) is an you have had for months. instrument that has been validated against a Let’s focus just on the side gold standard, is free and available online, can pain first. Can you tell me be performed in less than 30 minutes, and what it feels like?” uses the patient’s actual clinical scenario in the ➔ “What is your #1 concern evaluation. today?” Finally, avoid showing impatience. If time runs out, explain the need for a A4 The Talkative Patient second visit and prepare the patient by The garrulous rambling patient is also setting a time limit. challenging. ➔ “I know we have much more Faced with limited time to “get the whole to talk about. Can you come story,” you may grow impatient, even again next week? We will exasperated. have a 30-minute visit then.” Although this problem has no perfect solution, several techniques are helpful. Give the patient free rein for the first 5 A5 The Crying Patient or 10 minutes, while listening closely. Perhaps the patient simply needs a Crying signals strong emotions, ranging from good listener and is expressing sadness to anger or frustration.