The History and Interviewing Process

Developing a Relationship With the Patient

In this chapter we offer instruction in learning about the well and the sick as they seek care. History and physical examination are at the heart of this effort. It is not easy to get the sense of another person or to fully appreciate someone else’s orientation in the world. You and the patient may seem to have a similar experience but may in all likelihood interpret it differently (see Clinical Pearl, “‘ Unique ,’ Originally Derived From Latin ‘Unus,’ Meaning ‘One’”). On the other hand, you and your patient may come from very different backgrounds without any shared experiences. To prevent misinterpretations and misperceptions, you must make every effort to sense the world of the individual patient as that patient senses it. (See Chapter 1 for additional discussion.)

The first meeting with the patient sets the tone for a successful partnership as you inform the patient that you really want to know all that is needed and that you will be open, flexible, and eager to deal with questions and explanations. You can also explain the boundaries of your practice and the degree of your availability in any situation. Trust evolves from honesty, candor, and demonstrating dignity and respect toward the patient.

A primary objective is to discover the details about a patient’s concern, explore expectations for the encounter, and display genuine interest, curiosity, and partnership. Identifying underlying worries, believing them, and trying to address them optimizes your ability to be of help. You need to understand what is expected of you. If successful, the unique and intimate nature of the interview and physical examination will be reinforced. You will savor frequent tender moments with patients when you recognize that your efforts are going well and that trust is there. We want to help ensure those moments occur.

Much has been written about technology replacing the history and physical examination in some part, but personalized care of patients goes far beyond any scientific or technical advances. Appropriate care satisfies a need that can be fully met by a human touch, intimate conversation, providing education, and respect for privacy. Personal interactions and physical examination play an integral role in developing meaningful and therapeutic relationships with patients ( Kugler and Verghese, 2010 ).

This actual realization of relationships with patients, particularly when illness compounds vulnerability, cannot be replaced (see Clinical Pearl, “The Patient Relationship”).

Because cost containment is also essential, the well-performed history and physical examination can justify the appropriate and cost-effective use of resources. This underscores the need for judgment and the use of resources in a balance appropriate for the individual patient.

At a first meeting, you are in a position of authority and your patients are vulnerable. You may not have similar perspectives, lifestyles, sexual orientation, or gender identity but you need to understand the patient’s if you are to establish a meaningful partnership. This partnership has been conceptualized as patient-centered care, identified by the Institute of Medicine (IOM) as an important element of high-quality care. The IOM report defined patient-centered care as “respecting and responding to patients’ wants, needs and preferences, so that they can make choices in their care that best fit their individual circumstances” (IOM, 2001). Box 2.1 identifies questions that represent a patient-centered approach in building a history. Your own beliefs, attitudes, and values cannot be discarded, but you do have to discipline them. You have to be aware of your cultural beliefs, faith, and conscience so that they do not inappropriately intrude as you discuss with patients on a variety of issues. That means knowing yourself (Curlin et al., 2007; Gold, 2010 ) (see also Chapter 1 ).

You react differently to different people. Why? How? Do you want to be liked too much? Does thinking about how you are doing get in the way of your effort? Why does a patient make you angry? Is there some frustration in your life? Which of your prejudices may influence your response to a patient? Bias is an example of mental associations that can influence behavior or feelings toward an individual, and encompasses attitudes, stereotypes, and prejudices. Possible sources of bias include race, ethnicity, religion, sexual orientation, gender identification, socioeconomic status, and disabilities. In medicine, these constructs can affect how we care for a patient. If providers are unaware of these biases, then the biases are considered implicit. Implicit biases can be further confounded by stigmatizing diagnoses such as physical handicap, HIV, obesity, psychiatric illness, and substance use disorders. In total, implicit bias is an attribution of certain qualities (prejudices and perceived stigma) by an individual to a person. Implicit bias can be shaped by experience ( Greenwald and Banaji, 1995 ). Implicit bias, if not taken into consideration with each encounter, can lead to discriminatory care without conscious intent (Narayan et al., 2019; Pritlove et al., 2019). Discuss and reflect on potential bias with others you trust rather than make this an introspective effort. You will better control possible barriers to a successful outcome.

Effective Communication

Establishing a positive patient relationship depends on communication built on courtesy, comfort, connection, and confirmation ( Box 2.2 ).

BOX 2.2

Communication Courtesy, Comfort, Connection, Confirmation

Courtesy

• Knock before entering a room.

• Address, first, the patient formally (e.g., Miss, Ms., Mrs., Mr.) It is all right to shake hands.

• Meet and acknowledge others in the room and establish their roles and degree of participation.

• Learn their names.

• Ensure confidentiality.

• Be in the room, sitting, with no effort to reach too soon for the doorknob.

• If taking notes, take notes sparingly; note key words as reminders but do not let note-taking distract from your observing and listening.

• If typing in the electronic medical record, type briefly and maintain eye contact with patient, if possible.

• Respect the need for modesty.

• Allow the patient time to be dressed and comfortably settled after the examination. Follow-up discussion with the patient still “on the table” is often discomfiting.

Comfort

• Ensure physical comfort for all, including yourself.

• Try to have a minimum of furniture separating you and the patient.

• Maintain privacy, using available curtains and shades.

• Ensure a comfortable room temperature or provide a blanket—a cold room will make a patient want to cover up.

• Ensure good lighting.

• Ensure necessary quiet. Turn off the television set.

• Try not to overtire the patient. It is not always necessary to do it all at one visit.

Connection

• Look at the patient; maintain good eye contact if cultural practices allow.

• Watch your language. Avoid professional jargon. Do not patronize with what you say.

• Do not dominate the discussion. Listen alertly. Let the patient order priorities if several issues are raised.

• Do not accept a previous diagnosis as a CC. Do not too readily follow a predetermined path.

• Find out whether the patient has turned from other healthcare providers to come to you.

• Take the history and conduct the physical examination before you look at previous studies or tests. Consider first what the patient has to say.

• Avoid leading or direct questions at first. Open-ended questions are better for starters. Let specifics evolve from these.

• Avoid being judgmental.

• Respect silence. Pauses can be productive.

• Be flexible. Rigidity limits the potential of an interview.

• Assess the patient’s potential as a partner.

• Seek clues to problems from the patient’s verbal behaviors and body language (e.g., talking too fast or too little).

• Look for the hidden concerns underlying CCs.

• Never trivialize any finding or clue.

• Problems can have multiple causes. Do not leap to one cause too quickly.

• Define any concern completely: Where? How severe? How long? In what context? What soothes or aggravates the problem?

Confirmation

• Ask the patient to summarize the discussion. There should be clear understanding and uncertainty should be eased.

• Allow the possibility of more discussion with another open-ended question: “Anything else you want to bring up?”

• If there is a question that you cannot immediately answer, say so. Be sure to follow up later if at all possible.

• If you seem to have made a mistake, make every effort to repair it. Candor is important for development of a trusting partnership. Most patients respect it.

Be courteous; ensure comfort, both physical and emotional; be sure that you have connected with the patient with trust and candor; and confirm that all that has happened during the interaction is clearly understood and your patient is able to articulate the agreed-on plan. That is communication.

Seeking Connection

Examine your habits and modify them when necessary so that you are not a barrier to effective communication. Stiff formality may inhibit the patient; a too-casual attitude may fail to instill confidence. Do not be careless with words—what you think is innocuous may seem vitally important to a patient who may be anxious and searching for meaning in everything you say. Consider intellectual and emotional constraints related to how you ask questions and offer information, how fast you talk, and how often you punctuate speech with “uh-huh.” The interaction requires the active encouragement of patient participation with questions and responses addressed to social and emotional issues as much as the physical nature of health problems.

At the start, greet the patient. If it is your first meeting, introduce yourself, share the pronouns you use, ask the patient how they would like to be addressed, and what pronouns they use. This introduction (for use with every patient) forms the foundation of the rest of the interaction. By stating how you want to be addressed and your pronoun, you invite the patient to share this information about themselves and avoid assumptions on your part. For transgender and gender-diverse patients, this helps create a welcoming and supportive environment. Welcome others and ask how they are connected to the patient. Begin by asking open-ended questions (“How have you been feeling since we last met?” “What are your expectations in coming here today?” “What would you like to discuss?” “What do you want to make sure we cover in today’s visit?”). Resist the urge to interrupt in the beginning. You will be amazed how many times a complete history is provided without prompting. Later, as information accumulates, you will need to be more specific. However, early on, it is entirely appropriate to check the patient’s agenda and concerns and let the information flow. It is important not to interrupt the patient at the start of the interview. By initially remaining silent and then asking whether there is “anything else” a few times you will be amazed how the patient’s primary concerns are identified early in the visit. Thus, you and the patient can collaboratively set the visit’s agenda.

Having clear and agreed-upon goals for each interaction leads to successful communication. You must be a skilled listener and observer with a polished sense of timing and a kind of repose that is at once alert and reassuring. Your nonverbal behavior complements your listening. In the absence of infectious control issues, your face should not be a mask. Be expressive and nod in agreement. It is better to avoid the extremes of reaction (e.g., startle, surprise, or grimacing). Eye contact should be assured and comfortable, and your body language should show that you are emotionally present, open to and engaged with the patient. You should be comfortably seated close to the patient and, if using an electronic medical record, so you and the patient can both visualize the screen. Do not stand and do not reach for the doorknob (see Clinical Pearl, “Professional Dress and Grooming”).

Remember that patients also communicate nonverbally, and understanding this is advantageous to both you and the patient (Henry et al., 2012).

Clinical Pearl

Professional Dress and Grooming

Appropriate dress and grooming go a long way toward establishing a first good impression with the patient. Although clean fingernails, modest clothing, and neat hair are imperative, you need not be formal to be neat. You should avoid extremes so that appearance does not become an obstacle in the patient’s response to care.

Confidentiality, which is important in all aspects of care, is another essential element. The patient should provide the information. It is important to identify everyone in the room to be sure the patient is comfortable and wants others to participate in the visit. You may want to ask the parent, spouse, or other person to step out of the room so you can have a confidential discussion with the patient. If language is a barrier, a professional interpreter, rather than a family member, should be used ( Fig. 2.1A and B ).

Gentle guidance and polite redirection are sometimes necessary to keep the visit focused and moving forward (e.g., “Now let’s also talk about …” or “I’m sorry to interrupt, but let me make sure I understand …”). Be prepared with questions you think are important to address based on the patient’s history and main concerns. If the patient touches on something that does not seem immediately relevant to your purposes (e.g., introducing a possible problem not previously mentioned), be flexible enough to clarify at least the nature of the concern. Some apparent irrelevancies may contain clues to the care-seeking behaviors or concerns that may be hidden beneath the primary concern or concerns may be held until a certain level of trust has developed between you and the patient. The patient’s body language will also suggest the intensity of an underlying feeling. Although too many digressions can lead to misspent time, paying attention may save a lot of time later, and information learned may be important to the future plan of care.

Enhancing Patient Responses

Carefully phrased questions can lead to more accurate responses. Ask one question at a time, avoiding a barrage that discourages the patient from being complete or that limits answers to a simple yes or no:

• The open-ended question gives the patient discretion about the extent of an answer: “Tell me about …” “And then what happened?” “What are your feelings about this?” “What else do you need to talk about?”

• The direct question seeks specific information: “How long ago did that happen?” “Where does it hurt?” “Please put a finger where it hurts.” “How many pills did you take each time?” and “How many times a day did you take them?”

• The leading question is the most risky because it may limit the information provided to what the patient thinks you want to know: “It seems to me that this bothered you a lot. Is that true?” “That wasn’t very difficult to do, was it?” “That’s a horrible-tasting medicine, isn’t it?” When asking how often something happened, allow the patient to define “often,” rather than asking, “It didn’t happen too often, did it?”

Sometimes the patient does not quite understand what you are asking and says so. Recognize the need when it is appropriate to:

• Facilitate—encourage your patient to say more, either with your words or with a silence that the patient may break when given the opportunity for reflection.

• Reflect—repeat what you have heard to encourage more detail.

• Clarify—ask, “What do you mean?”

• Empathize—show your understanding and acceptance. Do not hesitate to say “I understand,” or “I’m sorry” if the moment calls for it.

• Confront—do not hesitate to discuss a patient’s disturbing behavior.

• Interpret—repeat what you have heard to confirm the patient’s meaning.

What you ask is complemented by how you ask it. Take the following actions, if necessary, to clarify the patient’s point of view. Do not assume you know what a patient is thinking:

• Ask what the patient thinks and feels about an issue.

• Make sure you know what the chief concern (CC) is.

• Ask about the patient’s life situation, so that nothing seemingly extraneous to the CC and present illness has gone unnoticed.

• Suggest at appropriate times that you have the “feeling” that the patient could say more or that things may not be as well as they are reported.

• Suggest at appropriate times that it is all right to be angry, sad, or nervous, and it is all right to talk about it.

• Make sure that the patient’s expectations in the visit are met and that there are no further questions.

Make sure your questions are clearly understood. Define words when necessary and choose them carefully. Avoid technical terms if possible. Adapt your language when necessary to the patient’s education level. Adapt your terminology, particularly in reference to how a patient identifies or how they describe their anatomy or illness, to mirror the patient’s language. Ask the patient to stop you if he or she does not understand what you are talking about. Similarly, do the same if you do not grasp the patient’s meaning. For example, a patient may report that he had “low blood” (anemia), “high blood” (hypertension), “bad blood” (syphilis), and “thin blood” (he was taking anticoagulants). It can take a bit of exploring to sort it all out. Do not assume every question needs a complex and technical answer. Avoid medical jargon with all patients, even those who are in the healthcare field.

Moments of Tension: Potential Barriers to Communication

Curiosity About You

Patients will sometimes ask about you. Although you are not the point, you may be comfortable revealing some relevant aspects of your experience (“I have trouble remembering to take medicines too” or “I remember when my children had tantrums”). A direct answer will usually do. Often, simply informing your patients that you have experienced similar life events (e.g., illness, pregnancy, and childbirth) can help alleviate fears and, with further exploration, can help in the identification of the patient’s concerns. The message that you are a “real” person can lead to a trust-enhancing or even therapeutic exchange. At the same time, it is wise to exercise caution and remain professional in what and how much you disclose ( Lussier and Richard, 2007 ).

Anxiety

Anxiety has multiple sources, such as an impending procedure, risk-exposure, or anticipated diagnosis. Some disorders will be more likely to cause an intense response, such as those associated with crushing chest pain or difficulty in breathing; with other disorders, just seeing a healthcare professional can cause anxiety. You can help by avoiding an overload of information, pacing the conversation, and presenting a calm demeanor.

Silence

Sometimes intimidated by silence, many healthcare providers feel the urge to break it. Be patient. Do not force the conversation. You may have to move the moment along with an open-ended question (“What seems to worry you?”) or a mild nudge (“And after that?”). Remember, though, that silence allows the patient a moment of reflection or time to summon courage. Some issues can be so painful and sensitive that silence becomes necessary and should be allowed. Most people will talk when they are ready. The patient’s demeanor, use of hands, facial expressions, or teary eyes will help you interpret the moment. For the teary eyes, be prepared to offer a tissue. Silence may also be cultural: for example, some cultural groups take their time, ponder their responses to questions, and answer when they feel ready. Do not push too hard. Be comfortable with silence and give it reasonable bounds.

Depression

Being sick or thinking that you are sick can be enough to provoke situational depression. Indeed, serious or chronic, unrelenting illness or taking certain prescription medications (e.g., steroids) is often accompanied by depression. A sense of sluggishness in the daily experience; disturbances in sleeping, eating, and social contact; and feelings of loss of self-worth can be clues. In addition to screening for depression at every visit, pay attention. First ask, “When did you start feeling this way?” Then ask, “How do you feel about it?” “Have you stopped enjoying the things you like to do?” “Do you have trouble sleeping?” “Have you had thoughts about hurting yourself?” “Are you depressed?” A patient in this circumstance cannot be hurried and certainly cannot be relieved by superficial assurance. You need not worry about introducing the idea of suicide (see Clinical Pearl, “Adolescent Suicide”). It has most often been considered, if only briefly (see Chapter 7 , Risk Factors box, “Suicide”).

Clinical Pearl

Adolescent Suicide

Suicide is a major cause of mortality in the preteen and teen years, more often in boys. If the thought of it occurs to you, you can be quite sure that it has to the patient too. You can mention it and thus give permission to talk about it. You will not be suggesting anything new. You may actually help prevent it.

Crying and Compassionate Moments

People will cry. Let the emotion proceed at the patient’s pace. Resume your questioning only when the patient is ready. If you suspect a patient is holding back, give permission. Offer a tissue or simply say, “It seems like you’re feeling sad. It’s OK to cry.” Name the emotion. Be direct about such a tender circumstance, but gently, not too aggressively or insistently. Do not hesitate to say that you feel for the patient, that you are sorry for something that happened, and that you know it was painful. At times, the touch of a hand or even a hug is in order. Sometimes, a concern—a difficult family relationship, for example—must be confronted. You may have to check an assumption and hope that you have guessed correctly in bringing the patient’s feelings to the surface. If uncertain, ask without presupposing what the response might be.

Physical and Emotional Intimacy

It is not easy to be intimate with the emotions and the bodies of others. Cultural norms and behaviors are at once protective of and barriers to trusting relationships. The patient is in a dependent status as well. You cannot be sure of the degree to which a given patient has been “desensitized” to the issues of intimacy. You also cannot be sure of the patient’s trauma history. You can acknowledge this while explaining clearly and without apology what you must do for the patient’s benefit while ensuring your care is patient-centered and allows for the patient to maintain control. Be careful about the ways in which you use words or frame questions. Box 2.3 discusses a trauma informed care (Roberts et al., 2019). Mirror the patient’s language about their anatomy, and respect modesty, using covers appropriately without hampering a complete examination. By being calm and asking questions with professional poise and by being empathetic yet straightforward, explaining the consequences of not performing an examination, such as skipping examination of the genitals, due to modesty or past-trauma concerns, may help keep the necessary from becoming too big an issue.

BOX 2.3

CAGE and CAGE-AID Questionnaire

The CAGE questionnaire was developed in 1984 by Dr. John Ewing, and it includes four interview questions designed to help screen for alcoholism. The CAGE questions were adapted by Dr. Richard Brown in 1991 to include illicit drugs. It is a screening questionnaire to help determine if a more complete assessment is needed.

The CAGE acronym helps practitioners quickly recall the main concepts of the four questions ( C utting down, A nnoyance by criticism, G uilty feeling, E ye-openers). The CAGE-AID Questionnaire is publicly available and can be downloaded at http://www.integration.samhsa.gov/clinical-practice/screening-tools .

Inappropriate Attraction

Some patients can be excessively flattering and manipulative and even seductive. Their illness and insecurity beg for extra-special attention. Do not be taken in by this. There are limits to warmth and cordiality. Certainly not all touch is sexually motivated; a heartfelt hug is sometimes just right. Nevertheless, beware of that trap. Avert it courteously and firmly, delivering the immediate message that the relationship is and will remain professional. It takes skill to do this while maintaining the patient’s dignity, but there is no room for sexual misconduct in the relationship, and there can be no tolerance for exploitation of the patient in this regard.

Anger

Sometimes the angriest patients (or persons with them) are the ones who may need you the most. Of course, it can be intimidating. Confront it. It is all right to say, “It seems like you’re angry. Please tell me why. I want to hear.” Speak softly and try not to argue the point. You may not know if or why you made someone angry. Most often, you have done nothing wrong, and the patient’s emotion is unrelated to you or the visit. Still, the stress of time, heavy workload, and the tension of caring for the acutely—even terminally—ill can generate your own impatience and potential for anger. Avoid being defensive but acknowledge the problem. Only when appropriate, apologize and ask how to make things better. Explore the feelings. Often, you can continue on a better footing after anger is vented. On occasion, nothing will seem to help. It is then all right to defer to another time or even to suggest a different professional ( Thomas, 2003 ).

Afterward, do not hesitate to talk about the episode with a trusted colleague. It helps. Discussing the incident later may lend insight into behaviors and help prevent the occurrence again. Better ways of responding can be explored.

Avoiding the Full Story

Patients may not always tell the whole story or even the truth, either purposely or unconsciously. Dementia, illness, substance abuse, past experience of, or fear of, discrimination because of sexual orientation or gender identity in healthcare settings, intimate partner violence (IPV), and child abuse are among some of the reasons. Do not push too hard when you think this is happening. Allow the interview to go on and then come back to a topic with gentle questioning. You might say, “I think that you may be more concerned than you are saying” or “I think you’re worried about what we might find out.” Unless there is concern about the safety of the patient or another individual, learning all that is necessary may not come in one sitting. You may have to pursue the topic at a later visit or perhaps with other members of the family or friends or your professional associates.

Financial Considerations

The cost of care and the resulting drain on resources (and the potential impact on employment or insurance coverage) are often sources of stress for the patient. Talk about them with candor and accurate knowledge. Provide resources (social worker or financial counselor). Otherwise, an appropriate care plan acceptable to the patient cannot be devised or implemented. Pressing circumstances and obligations may still present barriers to appropriate care. (See Clinical Pearl, “Social Determinants of Health”)

Modified from https://health.gov/healthypeople/objectives-and-data/social-determinants-health , https://www.who.int/gender-equity-rights/understanding/sdh-definition/en/ , and https://www.cdc.gov/socialdeterminants/index.htm

Clinical Pearl

Social Determinants of Health

Social determinants of health (SDOH) are conditions a nd environments where people live, learn, worship, work, play, and age. SDOH have a major impact on health, functioning, well-being, and quality of life. SDOH contribute to health disparities and inequities. For example, people without access to healthy foods/grocery stores are less likely to have good nutrition and are more likely to have heart disease , diabetes, and obesity. As a result, these individuals have a shorter live expectancy. SDOH can be divided into five domains:

• 1.

  Economic stability

• 2.

  Education access and quality

• 3.

  Healthcare access and quality

• 4.

  Neighborhood and working environment

• 5.

  Social and community context

The Patient History

A first objective in building the history is to identify those matters the patient defines as problems, the subtle as well as the obvious. You need to establish a sense of the patient’s reliability as an interpreter of events. Consider the potential for intentional or unintentional suppression or underreporting of certain experiences that may give context to a problem that is at odds with your expectation. Constantly evaluate the patient’s words and behavior. The history is built on the patient’s perspective and story, not yours. Make modifications as required for the patient’s age and his or her physical and emotional disabilities. There are times that collateral information is needed to fully appreciate the patient’s narrative.

Setting for the Interview

Regardless of the setting, make everyone as comfortable as possible. Position yourself so that there are no bulky desks, tables, computer screens, or other electronic equipment between you and the patient ( Fig. 2.2 ). If possible, have a clock placed where you can see it without obviously looking at your watch (preferably behind the patient’s chair). Sit comfortably and at ease, maintaining eye contact and a conversational tone of voice. Your manner can assure the patient that you care and that the patient is your primary focus. You can do this only by concentrating on the matter at hand, giving the encounter primacy in your life and putting aside both personal and professional distractions.

Building the History

Introduce yourself to the patient and accompanying persons if you have not already met, clearly stating your name and your role. If you are a student, say so. Be certain that you know the patient’s full name and that you pronounce it correctly. Ask if you are not certain.

Ask the patient how they would like to be addressed, and then address the patient properly (e.g., as Mr., Miss, Mrs., Ms., Mx.) or the manner of address preferred by the patient) and repeat the patient’s name at appropriate times. Avoid the familiarity of using a first name when you do not expect familiarity in return. Do not use a surrogate term for a person’s name; for example, when the patient is a child, do not address the parent as “Mother” or “Father.” It is respectful and courteous to take the time to learn each name.

It is respectful to look at the patient and not at the electronic medical record. Use it if you must but position it so that it does not distract you from the patient. More and more electronic devices for documentation and educational purposes (e.g., capturing a picture of a lesion to follow overtime, demonstrating the findings on an imaging study, showing the trend of a laboratory result over time, or reviewing a website together) are used. Unless you already know the patient and know that there is urgency, proceed at a reasonable pace, asking for the reason for the visit with the intent of learning what their specific expectations of the visit are. Listen, and do not be too directive. You will often be surprised at how much of the story and details you will hear without pushing. Let the patient share his or her full story and reasons for seeking care.

You have begun to give structure to the present illness or problem, giving it a chronologic and sequential framework. Unless there is urgency, go slowly, hear the full story, and refrain from interrupting with what seems the obvious course of questioning. The patient will take cues from you on the leisure you will allow. You must walk a fine line between permitting this leisure and meeting the many time constraints you are sure to have. Fix your attention on the patient, avoid interjecting as much as possible, and do not ask the next question before you have heard the complete answer to the prior one.

The patient’s responses may at times be unclear. Seek certainty:

• “Of what you’ve told me, what concerns you the most?”

• “What do you want to make sure we pay attention to today?”

• “Do you have any ideas about what we ought to do?”

• Or a leading question sometimes, “I think _________ worries you the most. Am I right? Shall we talk about that first?”

• As the interview proceeds, thoroughly explore each positive response with the following questions:

• Where? Where are symptoms located, as precisely as possible? If they seem to move, what is the range of their movement? Where is the patient when the complaint occurs—at work or play, active or resting?

• When? Everything happens in a chronologic sequence. When did it begin? Does it come and go? If so, how often and for how long? What time of day? What day of the week?

• What? What does it mean to the patient? What is its impact? What does it feel like? What is its quality and intensity? Has it been bad enough to interrupt the flow of the patient’s life, or has it been dealt with rather casually? What else happened during this time that might be related? What makes it feel better? Worse?

• How? The background of the symptom becomes important in answering the “how” question. How did it come about? Are other things going on at the same time, such as work, play, mealtime, or sleep? Is there illness in the family? Have there been similar episodes in the past? If so, how was it treated or did it resolve without treatment? Is there concern about similar symptoms in friends or relatives? Are there spouse complaints or concerns? How is the patient coping? Are there social supports? Nothing ever happens in isolation.

• Why? Of course, the answer to “why” is the solution to the problem. All other questions lead to this one.

Once you have understood the patient’s CC and present problem and you have a sense of underlying issues, you may go on to other segments of the history: the family and past medical histories; emotional, spiritual, and cultural concerns; and social and workplace accompaniments to the present concerns. Remember that nothing in the patient’s experience is isolated. Aspects of the present illness or problem require careful integration with the medical and FH. The life of the patient is not constructed according to your outline, with many factors giving shape to the present illness and with one CC possibly involving more than one illness.

A visit should conclude with a review:

• Ask the patient to try to satisfy gaps in your understanding.

• Ask for questions.

• Interpret and summarize what you have heard.

• Ask the patient to summarize for you to ensure complete understanding.

• Repeat instructions and ask to hear them back.

• Explain the next steps: needed examinations and/or studies, appointment times, keeping in touch.