Which of the following is most important when conducting a patient interview?

During the first minutes of the interview the physician actively sets the stage for an effective interaction. Since the interview begins with a meeting between strangers—the physician and patient—clear introductions are important. They communicate the physician's respect for the patient as a unique individual. Feelings of anxiety are common during the initial moments of the encounter and may be particularly intense for the beginning student who is uncertain of his or her role. A simple statement is usually a good way to start.

Hello Mrs. Parish, my name is John Simmons. I am a second year medical student here at the school. I will be interviewing you for about 30 minutes to learn what kinds of problems you are having and how they have affected you. Will this be O.K. with you?

This introduction establishes names, roles, purpose (including an interest in the patient's response to illness) and the time limits of the interview. Of course, it is important to knock before entering the patient's room to begin the interview. Unfortunately, this courtesy is often neglected during hospital rounds.

Assessing the patient's comfort is the next step. An IV or oxygen mask, facial expressions of distress, or an emesis basin at the bedside provide nonverbal clues to the alert clinician. Bringing a cup of water, raising the head of the bed, or helping the patient to the bathroom may be greatly appreciated. They also provide a natural opportunity for a caring touch. Questions such as "How are you feeling?" "Are you comfortable now?" "Do you feel well enough to talk now?"are helpful.

It is best to conduct the interview in a quiet and private environment. This may be impossible in a busy hospital. However, televisions can be turned off, doors closed, and curtains pulled. The bedrail should be lowered to remove this physical barrier to communication. If the patient feels well enough, it may be best to help him or her into a chair. The difference between interviewing a patient who is lying flat in bed and one who is sitting in a chair can be striking. This simple act can emphasize patient autonomy and active involvement in the interview.

If family members or other visitors are in the patient's room, the physician should introduce him- or herself to all those present and explain the purpose of the interview. If they are allowed to stay, the interviewer should inform the family that the patient must be given an opportunity to speak without excessive interruptions or editorial comments. If family do not comply, this problem must be addressed directly.

"Calibrating" the Interview

The first minutes give the observant physician valuable information about the patient's communication style and behavior, as well as providing a tentative list of problems. Some patients need considerable prompting to discuss their current problems, while others need limits set because of a rambling history. The patient's vocabulary and clarity of expression can be assessed early in the encounter. Emotional reactions such as anxiety, defensiveness, or hostility are often evident. All these elements are important in determining the patient's reliability as a historian. The first minutes give the interviewed time to "calibrate" his/her techniques to the individual patient (Engel). By recognizing the patient's emotions and responding to them in a supportive manner, the clinician can conduct an effective patient-centered interview. As examples, the interviewer will expect the confused patient to give a confused history; the emotionally reactive patient to embellish and exaggerate symptoms or reactions; and the depressed patient to be withdrawn and require considerable support.

Questioning, Listening, and Observing

With introductions completed and patient comfort assessed the physician must decide how to initiate further questioning. Some physicians like to ask about the patient's social and personal background, including residence, employment, and family. Although this technique works well with some patients, others find it distracting. They seem to expect a more direct inquiry about their health and current problems. Frequently used opening questions include, "What problems brought you to the hospital (or office) today?" or "What kind of problems have you been having recently?" or "What kind of problems would you like to share with me?" These open-ended, nondirective questions encourage the patient to report any and all problems. At this point in the interview it is important to let the patient talk spontaneously rather than restricting and directing the flow of information with multiple questions. Let the patient talk freely for the first few minutes before initiating a more detailed inquiry.

From observations of internal medicine residents it appears that physicians all too frequently interrupt their patients in the first few seconds of the interview. Patients are prevented from expressing their major concerns. These unexpressed concerns may become part of a "hidden agenda" not because the patient is hiding them but because the physician hasn"t given the patient a chance to talk. What the patient patient says first may not be the only or even the most important complaint.

Premature selection of a direction for detailed questioning (for example, a report of generalized fatigue) can confuse or distract the patient from reporting other, perhaps more significant problems (for example, chest pains and the fear of heart problems). Beginning with directive, closed questions early in the interview communicates that the patient should remain silent until asked a specific question. The patient may feel, for good reason, that his major complaint is being ignored. The physician, in turn, may feel frustrated as direct questions lead to dead ends. The physician's task is arduous because he/she must think of a new question after each patient response. In such situations, describing the patient as a "poor historian" obscures the fact that the major problem stems from the physician's premature selection of a line of inquiry before the full scope of the patient's concerns was defined and the physician's overuse of a closed question–answer interactional technique.

Facilitation Techniques

To obtain accurate, unbiased information, exert only as much control over the interview as is needed. The physician's task is to keep the patient talking about the illness in a productive fashion. Facilitation techniques are employed to encourage and guide the patient's spontaneous report. These include the use of posture, gesture, and words to indicate that the interviewer is interested in what the patient is saying. These techniques reassure the patient that he or she should go on speaking and provide time for the patient to think and respond. A shared silence often helps the flow of the interview if the interviewer maintains eye contact and an interested manner. It is not necessary to come up with a question each moment the patient falls silent. Silences often help the patient reexperience emotions and provide the time needed for reflection. Most interviewers can judge if a patient is actively thinking during the silence or needs help getting started again. Prompt the patient to continue with a spontaneous report by repeating the patient's last phrase in a questioning tone such as "… you felt short of breath?" Or, make an observational statement such as, "You stopped talking a few moments ago after telling me about your weight loss … can you tell me what you are thinking about?" Occasional nods of the head, following the patient's response with "Yes?" or "and then?" or "huh, huh?" in a questioning tone may keep the patient talking.

The Patient's Chief Complaint

Before selecting the focus for questioning, ask, "Anything else?" or "Do you have any other problems?" If the list is extensive and obviously beyond the time limit available for the interview, ask, "Which of these problems concerns or bothers you the most?" or "Which of your problems did you hope I could help you with today?" The physician then ranks the problems in order of importance and listens for patterns that suggest disease processes. Some problems will be clearly related to the chief complaint. Others are unrelated or of only possible relevance.

It may become evident that the patient is most troubled by problems that the physician considers of lower priority or less urgent. For example, the patient may be most concerned about his finances, while the physician wants to learn more about the chest pain and palpitations. In general, the clinician should briefly communicate concern for the patient's major concerns even if they do not seem to be medically significant. For example,

You have mentioned quite a few problems and we may not have time to clarify all of them now. I can see that you are very worried about your finances. Those concerns will need further attention … and we will work on them. What I would like to do now is find out more about your chest pain and the fainting spell that you mentioned.

The physician cannot assume that all of the patient's concerns will be raised early in the interview. Patients may talk about embarrassing or confidential problems when rapport and trust have been deepened. Not infrequently, the patient brings up important issues only at the end of the encounter by stating, "Oh, by the way doctor. …"

The History of Present Illness (H.P.I.) or Story of Illness

The clinician now explores as fully as possible the patient's major problems, following leads obtained during the discussion of the chief complaint. The history of the present illness (HPI) includes all of the patient's history, both recent and remote, that is pertinent to understanding the current illness. In completing the HPI, the physician will often collect pertinent information about the patient's past history (for example, a history of hypertension in a patient with stroke), the patient's family history (for example, a family history of breast cancer in a patient with a breast lump), and the social history (for example, domestic discord in a patient with insomnia and fatigue).

Each new piece of information is assessed for reliability, completeness, and relevance to the patient's problem. The physician should repeatedly scan the information already gathered looking for symptom complexes or diagnostic patterns. For example, the physician interviewing a 30-year-old woman with fever, back pain, and urinary frequency would immediately consider the possibility of a urinary tract infection. With increasing knowledge of clinical syndromes, the clinician's ability to form more complex diagnostic hypotheses improves. Each hypothesis is tested for validity with further specific questions such as, "Have you ever had a bladder or kidney infection? Any kidney stones? Are you sexually active?" Through this process, speculations are tested against objective reality and accurate hypotheses are generated.

Type of Questions

Begin each line of inquiry with an open-ended question and proceed to more specific questions to fill in the gaps. Encourage the patient to provide primary data in his or her own words about the symptoms rather than provide diagnostic labels or "hearsay" from other doctors or family members (secondary or tertiary information). The patient may need coaching about what information the physician seeks. For example, the patient who complains of her "esophagitis" should be asked to describe her symptoms before the physician accepts this diagnostic label. Questions should be worded so that the patient has no difficulty understanding what is being asked. Avoid using technical terms and diagnostic labels. The interviewer's questions should indicate what type of information is requested, but not what answer is expected. The difference between asking, "Are you having any stomach problems?" and "You"re not hurting in your stomach, are you?" is obvious, but it is easy to fall into the pattern of asking leading questions. Effective questions are usually simple. Avoid double-barreled questions, such as "Are you having any stomach pains or bladder problems?"

Characterizing the Patient's Symptoms

describes seven dimensions that characterize the bodily and emotional aspects of a symptom: its chronology, bodily location, quality, quantity, setting, any aggravating or alleviating factors, and associated manifestations. In general, the clinician should gather information clarifying all seven dimensions for each area of major concern. A directive statement may be needed to direct or coach the patient about what information is needed. "A detailed description of your symptoms will help me to help you. Let's start at the beginning."

Chronology

A chronologic description provides the framework for characterizing the course of an illness. The interviewer should obtain a chronologic report by asking when the problem first started and facilitate a continuing flow of information with questions such as "And then what happened? … and then? … and after that?" Dating the onset of illness may be difficult for some patients, but a general estimate should be made. Questions such as, "When did you last feel really well?" or "How did you feel at Christmastime?" can help time the onset of illness. Ask specifically if the patient has ever had similar symptoms in the past.

Chronology also includes the duration of a symptomatic episode (for example, minutes for the chest pain of angina, days for the chest pain of rib fractures), its periodicity (for example, the on-and-off pain of an early small bowel obstruction versus the constant pain of peritonitis), and whether the symptom has gotten better or worse over time.

Bodily Location and Radiation

The bodily location of pain or other discomfort should be defined as accurately as possible. The patient may be encouraged to indicate the location and radiation of pain using hand gestures, which also indicate how large an area is involved. Remember that the patient may have more than one pain and that multiple pains may indicate multiple disease processes. Ask the patient to characterize and differentiate each.

Quality

Most patients use analogies to describe the quality of a sensation. The pain of a myocardial infarction is often described as similar to a "vise" tightening around the chest or "someone standing on the chest." The patient's exact words are important, and a "tightness" should not be assumed to be a "pain." Try to use the patient's own vocabulary if possible. Some patients use highly descriptive or emotion-laden terms like, "It felt like someone was stabbing me with a knife." This provides important clues about the patient's emotional state and reactivity. Other patients need the interviewer's help to find descriptive language. Providing the patient with a choice of descriptions such as "Was the pain sharp or dull?" may be necessary, although the clinician should realize that limiting the patient's response to these two alternatives can bias the history.

Quantity

The intensity of pain can be estimated on a scale of 1 to 10 or compared to another pain the patient has experienced. The scalar method is particularly helpful in following the intensity of symptoms over time. Other examples of quantity include volume (for example, the quantity of sputum expectorated in a day), number (for example, the number of times the patient has lost consciousness), and the degree of impairment the patient suffers. Impairment or disability is best characterized in terms of the patient's usual daily activities, such as dyspnea with climbing stairs at home or chest pain while sweeping the floor. Some patients minimize while others amplify the quantity or intensity of their symptoms—important indicators of emotional responses and communication styles.

Setting

The setting in which the symptoms occur is often critical in developing a clear description of an illness. "Where were you when you first felt ill?" "What were you doing?" "Who was with you?" are excellent questions to use early in the interview. Hypotheses regarding the etiology of symptoms frequently evolve from an understanding of the accompanying physical, social, or emotional events that surround an episode of illness.

Aggravating and Alleviating Factors

Initial data about what makes a symptom worse and what makes it better flows from the patient's spontaneous account. Chest tightness brought on by exertion or shortness of breath at night relieved by sitting up points to specific pathologic processes, effort angina, and paroxysmal nocturnal dyspnea. A knowledge of clinical syndromes sharpens the physician's ear for clues and provides the basis for a directed line of inquiry. For example, the physician would ask the patient who reports the sudden onset of shortness of breath and chest pain four days after a fractured tibia if the pain was pleuritic—worsened with deep breath or cough—a symptom associated with pulmonary embolus. The clinician also collects data concerning what kinds of help the patient has sought for the symptom and types of treatments already tried, including prescribed and over-the-counter medications.

Associated Manifestations

Symptoms rarely occur singly. The clinician should listen for groups of related symptoms that provide diagnostic clues about pathologic processes and involved organs. The physician might ask, "When you had the joint pains, did you notice anything else?" If the patient's response is positive, he or she is asked to describe the associated symptoms through open-ended questions. Further clarification can be obtained later using more specific questions. Even if the patient reports no associated symptoms, the physician may decide to ask directed questions which help support or reject a given diagnostic possibility. When the patient complains of joint pains, the physician might ask, "Have you had any fevers? Night sweats? Rash? Sensitivity to the sun? Irritation in your eyes? Negative answers, often termed pertinent negatives, may be as important as positives in defining the nature and severity of the illness. They help "rule in" or "rule out" specific diagnoses.

Other Pertinent Aspects of a Symptom

Several other dimensions should be pursued in a comprehensive interview, including the patient's emotional reactions to the illness and the patient's means of coping with discomfort and disability. The patient's reactions to events are often as important as the events themselves. In addition, the patient's thoughts and fantasies about what may have caused the illness are important in understanding why, when, and from whom the patient decided to seek care. The majority of illness episodes are treated outside the physician's office. In both the problem-oriented and the health promotion interviews it is interesting to ask why the patient decided to seek care now. Patients often have specific, perhaps unrealistic, fantasies about what the physician will or can do. The interviewer should try to identify these. The patient's explanatory model of illness, differing with each patient and with each cultural group, may significantly determine an individual's behavior during an illness and affect compliance with medical therapy. Negotiation may bring doctor and patient closer together ().

Summarizing the Hpi

The interviewer uses clinical discretion in determining when the history of present illness has been clearly defined. Summarizing the history is a useful way of concluding this section of the interview. "Before we go on, let's see if I understand your history. Last March you first noticed …" This summary gives the patient a chance to check the accuracy of the history and gives the physician a chance to review the history for gaps or lack of clarity.

When the HPI is completed, the physician will have collected a great deal of data about the remaining segments of the medical history: the past medical history, family history, social history/patient profile, and review of systems. Of course, new information may appear at any time. During the remainder of the interview, the physician directs the patient to fill in the blanks, completing the rest of the history.

Transitional Statements

Before proceeding with each new section, make a clear transitional statement. For example, "I think I"ve got a pretty good idea of your major problems and how they have developed. Now I would like to ask you some questions about your past health." Transitional statements prepare the patient for what is coming next.

Past Medical History

A review of past medical problems and treatments not directly pertinent to the HPI completes the past medical history. A prior diagnosis of diabetes mellitus in a patient with a gangrenous toe belongs with the HPI, whereas a remote appendectomy does not. The past medical history defines a data base for future reference. Major elements of the past medical history include childhood and adult illnesses, operations, trauma, allergies and drug sensitivities (characterized in detail), immunizations, and health maintenance (for example, PPD status and whether or not the patient performs a breast self-examination, has routine pap smears or sigmoidoscopies).

Family History

Medical problems in family members should be reviewed with special attention to heritable disorders. Furthermore, the patient's reaction to an illness in the family may influence response to personal medical problems. A family history of hypertension and myocardial infarction would be included with the HPI of a patient with new-onset chest pain. Time limitations may preclude a detailed inquiry into the health of each family member. Use discretion if the family is very large, and, in elderly patients, remember that the major purpose of the family history is to assess risk factors for the patient's current and future health.

Social History/Patient Profile

The physician collects personal data about the patient to complete the patient profile. Much of this information will have emerged as the patient describes his story of the present illness but gaps are often apparent. During the social history portion of the interview, the physician can gather data about the patient's education, occupation, usual daily activities, functional status, relationships with friends and family, social supports and stresses, financial status/insurance coverage and habits such as use of cigarettes or alcohol that have known health consequences. Again, relevance to the patient's health and life adaptation guide the interviewer in deciding how much information to gather.

Review of Systems (R.O.S.)

Before concluding the interview, the physician should complete a symptom checklist to assure that all important areas of the patient's physical and psychologic health have been considered. Some clinicians prefer to complete the review of systems while examining the patient but this may be distracting for the beginning student. Begin the review of systems with an open-ended question such as "Are you having any other problems that we haven"t discussed?" If the patient mentions a new problem, the symptoms can be further characterized. A transitional statement prepares the patient for the next line of questioning. "Before we move on to the physical examination, I would like to ask you a series of questions about specific health problems. Stop me if you are having one of these problems, and we will find out more about it." The interviewer should inquire about each system in an orderly fashion. Questions such as "Have you ever had headaches?" may have the unwanted effect of inspiring an overly complete patient response. Try providing direction and limits with the following. "I would like to ask you about your other recent health problems. Have you had any severe headaches recently?" The entire review of systems should take less than 5 minutes if the physician begins with an open-ended request for information before proceeding. Some patients have a "positive review of systems"—problems in every area. This may indicate emotional problems that cause the patient to amplify symptoms and use them to gain attention and emotional support.

Closing the Interview

Before closing the interview ask the patient if there is anything else he or she would like to discuss or if there are any questions. The clinician then proceeds with the physical examination. Interestingly, some patients become quite talkative during the examination. They seem reassured by the physician's touch and may feel more at ease than when sitting face to face during the interview. Examination of a specific body region or system may remind the patient of previously forgotten details of considerable diagnostic importance. The alert physician will take the stethoscope from his or her ears long enough to hear what the patient has to say.

Communication techniques are of critical importance as the physician reports the findings of the history and physical examination. Diagnostic and prognostic discussions are most effective if tailored to the patient's individual cognitive and communication style. Special emotional concerns discovered during the interview can guide a sensitive approach to sharing news and preparing for the future. The physician's knowledge of the patient as a person provides the foundation for patient education. In a very real sense the interview continues throughout the clinical encounter.

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