The health history interview is a conversation with a purpose. As you learn to elicit the patient’s story, you will draw on many of the interpersonal skills that you use every day, but with unique and important differences. In social conversation, you freely express your own views and are responsible only for yourself. In contrast, the primary goals of the patient interview are to listen and to improve the well-being of the patient through a trusting and supportive relationship (Fig. 3-1).
FIGURE 3-1 History-taking involves empathic listening.
Relating effectively with patients is among the most valued skills of clinical care. For the patient, “a feeling of connectedness…of being deeply heard and understood…is the very heart of healing.” For the clinician, this deeper relationship enriches the rewards of patient care.–
High-quality patient–clinician communication has also been shown to improve patient outcomes, decrease symptoms, improve functional status, reduce litigation, and decrease errors.– The interview is also the most commonly performed clinical intervention, occurring thousands of times in a clinician’s career. These are all salient and compelling reasons to develop expertise in this skill (Fig. 3-2).
FIGURE 3-2 Establish connections with patients.
This chapter introduces you to the essentials of interviewing and establishing trust, the foundations of your therapeutic alliance with patients. At first, you will focus on gathering information, but with experience and empathic listening, you will allow the patient’s story to unfold in its most authentic and detailed form.
Interviewing is both a skill and an art. Skilled interviewing is both patient-centered and clinician-centered. The clinician must focus on the patient to elicit the full story of the patient’s symptoms, but the clinician must also interpret key information to reach an assessment and plan. Patient-centered interviews “recognize the importance of patients’ expressions of personal concerns, feelings, and emotions” and evoke “the personal context of the patient’s symptoms and disease.”
Experts have defined patient-centered interviewing as “following the patient’s lead to understand their thoughts, ideas, concerns and requests, without adding additional information from the clinician’s perspective.” In contrast, in the more symptom-focused, clinician-centered approach, the clinician “takes charge of the interaction to meet her or his own need to acquire the symptoms, their details, and other data that will help her or him identify a disease,” which can bypass the personal dimensions of the illness.,
Evidence suggests that the patient is best served by integrating these interviewing styles, leading to a more complete picture of the patient’s illness and allowing clinicians to more fully convey the caring attributes of “respect, empathy, humility and sensitivity.”, Current evidence shows that this approach is not only more satisfying for the patient and the clinician, but also more effective in achieving desired health outcomes (Fig. 3-3).,
FIGURE 3-3 Interviewing is symptom- and patient-focused.
The interviewing process is quite different from the format of the health history, presented in Chapter 1. The interview is more than just a series of questions; it requires a highly refined sensitivity to the patient’s feelings and behavioral cues. The health history format provides an important framework for organizing the patient’s story into various categories pertinent to the patient’s present, past, and family health. The interview and the health history format have distinct but complementary purposes. Keep these differences in mind as you learn the techniques of skilled interviewing.
The interviewing process that generates the patient’s story is fluid and draws on numerous relational skills to respond effectively to patient cues, feelings, and concerns. The adaptability of the interviewer has been compared to the improvisation of jazz musicians who listen attentively to notes and themes and play to each other’s cues. This “in-the-moment” flexibility lets the interviewer adapt to the patient’s leads as the story unfolds.
The interview should be “open-ended,” drawing on a range of techniques to cue patients to tell their stories—active listening, guided questioning, nonverbal affirmation, empathic responses, validation, reassurance, and partnering. These techniques are especially valuable when eliciting the patient’s chief concerns and the History of the Present Illness.
The health history format is a structured framework for organizing patient information in written or verbal form. This format focuses your attention on the specific kinds of information you need to obtain, facilitates clinical reasoning, and standardizes communication to 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.
Above all, skilled interviewing requires your lifelong commitment to masterful listening, easily sacrificed to the time pressures of daily health care. In the words of Sir William Osler, one of our greatest clinicians and co-founder of Johns Hopkins School of Medicine in 1893: “Listen to your patient. He is telling you the diagnosis” and “The good physician treats the disease; the great physician treats the patient who has the disease.”
Different Kinds of Health Histories
As you learned in Chapter 1, the scope and detail of the history depends on the patient’s needs and concerns, your goals for the encounter, and the clinical setting (inpatient or outpatient, the amount of time available, primary care or subspecialty).
See Chapter 1, Overview: Physical Examination and History Taking, pp. 3–43.
? For new patients, in most settings, you will do a comprehensive health 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; this is sometimes known as a focused or problem-oriented history.
? For patients seeking care for ongoing or chronic problems, focusing on the patient’s self-management, response to treatment, functional capacity, and quality of life is most appropriate.
? Patients frequently schedule health maintenance visits with the more focused goals of keeping up screening examinations or discussing concerns about smoking, weight loss, or sexual behavior.
? A specialist may need a more comprehensive history to evaluate a problem with numerous possible causes.
By knowing the content and relevance of the different components of the comprehensive health history, you are able to select the elements most pertinent to the visit and shared goals for the patient’s health. This chapter sets guideposts for interviewing and the health history, outlined below.
The Fundamentals of Skilled Interviewing
- The Techniques of Skilled Interviewing: Active listening. Empathic responses. Guided questioning. Nonverbal communication. Validation. Reassurance. Partnering. Summarization. Transitions. Empowering the patient.
The Sequence and Context of the Interview
- Preparation: Reviewing the clinical record. Setting goals for the interview. Reviewing your clinical behavior and appearance. Adjusting the environment.
- The Sequence of the Interview: Greeting the patient and establishing rapport. Taking notes. Establishing the agenda for the interview. Inviting the patient’s story. Identifying and responding to emotional cues. Expanding and clarifying the patient’s story. Generating and testing diagnostic hypotheses. Sharing the treatment plan. Closing the interview and the visit. Taking time for self-reflection.
- The Cultural Context of the Interview: Demonstrating cultural humility—a changing paradigm.
- Challenging Patients: The silent patient. The confusing patient. The patient with impaired capacity. The talkative patient. The angry or disruptive patient. The patient with a language barrier. The patient with low literacy or low health literacy. The hearing impaired patient. The blind patient. The patient with limited intelligence. The patient seeking personal advice. The seductive patient.
- Sensitive Topics: The sexual history. The mental health history. Alcohol and prescribed and illicit drug use. Intimate partner and family violence. Death and dying.
Ethics and Professionalism
The Fundamentals of Skilled Interviewing
You may have many reasons for choosing to enter the health care professions, but building effective and healing relationships is undoubtedly paramount. “Those who suffer empower healers to witness, explain, and relieve their suffering.” This section describes the fundamental techniques of therapeutic interviewing, the timeless skills you will continually polish as you care for patients.
These skills require practice and feedback from your teachers so that you can monitor your progress. Over time, you will learn to select the techniques best suited to the ever-changing dynamics of human behavior in your patient relationships. Key among these techniques are active listening and empathy, the golden links to a therapeutic alliance.
Skilled Interviewing Techniques
- Active listening
- Empathic responses
- Guided questioning
- Nonverbal communication
- Empowering the patient
Active listening lies at the heart of the patient interview. Active listening means closely attending to what the patient is communicating, connecting to the patient’s emotional state, and using verbal and nonverbal skills to encourage the patient to expand on his or her feelings and concerns. Active listening allows you to relate to those concerns at multiple levels of the patient’s experience.
This takes practice. It is easy to drift into thinking about your next question or possible diagnoses and lose your concentration on the patient’s story. Focus on what the patient is telling you, both verbally and nonverbally. Sometimes your body language tells a different story from your words.
Empathic responses are vital to patient rapport and healing., Empathy has been described as the capacity to identify with the patient and feel the patient’s pain as your own, then respond in a supportive manner. Empathy “requires a willingness to suffer some of the patient’s pain in the sharing of suffering that is vital to healing.”
As patients talk with you, they may convey, in their words or facial expressions, feelings they have not consciously acknowledged. These feelings are crucial to understanding their illnesses. To express empathy, you must first recognize the patient’s feelings, then actively move toward and elicit emotional content., At first, exploring these feelings may make you feel uncomfortable, but your empathic responses will deepen mutual trust.
When you sense unexpressed feelings from the patient’s face, voice, behavior or words, gently ask: “How do you feel about that?” or “That seems to trouble you, can you say more?” Sometimes a patient’s response may not correspond to your initial assumptions. Responding to a patient that the death of a parent must be upsetting, when in fact the death relieved the patient of a heavy emotional burden, reflects your interpretation, not what the patient feels.
Instead, you can ask: “You have lost your father. What has that been like for you?” It is better to ask the patient to expand or clarify a point than assume you understand. Empathy may also be nonverbal—placing your hand on the patient’s arm or offering tissues when the patient is crying. Unless you affirm your concern, important dimensions of the patient’s experience may go untapped.
Once the patient has shared these feelings, reply with understanding and acceptance. Your responses may be as simple as: “I cannot imagine how hard this must be for you” or “That sounds upsetting” or “You must be feeling sad.” For a response to be empathic, it must convey that you feel what the patient is feeling.
Guided Questioning: Options for Expanding and Clarifying the Patient’s Story
There are several ways to elicit more information without changing the flow of the patient’s story. Your goal is to facilitate full communication, in the patient’s own words, without interruption. Guided questions show your sustained interest in the patient’s feelings and deepest disclosures (Fig. 3-4). They help you avoid questions that prestructure or even shut down the patient’s responses. A series of “yes-no” questions makes the patient feel more restricted and passive, leading to significant loss of detail. Instead, use guided questioning to absorb the patient’s full story.
FIGURE 3-4 Employ guided questioning.
Techniques of Guided Questioning
- Moving from open-ended to focused questions
- Using questioning that elicits a graded response
- Asking a series of questions, one at a time
- Offering multiple choices for answers
- Clarifying what the patient means
- Encouraging with continuers
- Using echoing
For further practice see SmithPatient-Centered Interviewing .8
Moving from Open-Ended to Focused Questions
Your questions should flow from general to specific. Think about a cone, open at the top, then tapering to a focal point. Start with the most general questions like, “How can I help?” or “What brings you in today?” Then move to still open, but more focused, questions like, “Can you tell me more about what happened when you took the medicine?” Then pose closed questions like, “Did the new medicine cause any problems?”
Begin with a truly open-ended question that does not prefigure an answer. A possible sequence might be:
“Tell me about your chest discomfort.” (Pause)
“What else?” (Pause)
“Where did you feel it?” (Pause) “Show me.”
“Anywhere else?” (Pause) “Did it travel anywhere?” (Pause) “To which arm?”
Avoid leading questions that already contain an answer or suggested response like: “Has your pain been improving?” or “You don’t have any blood in your stools, do you?” If you ask “Is your pain like a pressure?” and the patient answers yes, the patient’s response is truncated instead of what he or she experienced. Adopt the more neutral “Please describe your pain.”
Questioning That Elicits a Graded Response
Ask questions that require a graded response rather than a yes-no answer. “How many steps can you climb before you get short of breath?” is better than “Do you get short of breath climbing stairs?”
Asking a Series of Questions, One at a Time
Be sure to ask one question at a time. “Any tuberculosis, pleurisy, asthma, bronchitis, pneumonia?” may prompt “No” out of sheer confusion. Try “Do you have any of the following problems?” Be sure to pause and establish eye contact as you list each problem.
Offering Multiple Choices for Answers
Sometimes, patients need help describing their symptoms. To minimize bias, offer multiple-choice answers: “Which of the following words best describes your pain: aching, sharp, pressing, burning, shooting, or something else?” Almost any specific question can contrast two possible answers. “Do you bring up any phlegm with your cough, or is it dry?”
Clarifying What the Patient Means
Sometimes the patient’s history is difficult to understand. It is better to acknowledge confusion than to act like the story makes sense. To understand what the patient means, you need to request clarification, as in “Tell me exactly what you mean by ‘the flu’” or “You said you were behaving just like your mother. What did you mean?” Taking time for clarification reassures the patient that you want to understand his or her story and builds your therapeutic relationship.
Encouraging with Continuers
Without even speaking, you can use posture, gestures, or words to encourage the patient to say more. Pausing and nodding your head, or remaining silent, yet attentive and relaxed, is a cue for the patient to continue. Leaning forward, making eye contact, and using phrases like “Mm-hmm,” or “Go on,” or “I’m listening” all enhance the flow of the patient’s story.
Simply repeating the patient’s last words, or echoing, encourages the patient to elaborate on details and feelings. Echoing also demonstrates careful listening and a subtle connection with the patient by using the same words. For example:
Patient: “The pain got worse and began to spread.” (Pause)
Response: “Spread?” (Pause)
Patient: “Yes, it went to my shoulder and down my left arm to the fingers. It was so bad that I thought I was going to die.” (Pause)
Response: “Going to die?”
Patient: “Yes, it was just like the pain my father had when he had his heart attack, and I was afraid the same thing was happening to me.”
This reflective technique helped to reveal not only the location and severity of the pain but also its meaning to the patient. It did not bias the story or interrupt the patient’s train of thought.