INTERVIEWING AND THE

HEALTH HISTORY
 THE FORMAT OF THE
COMPREHENSIVE HEALTH HISTORY
THE SEQUENCE OF THE INTERVIEW
 EXPANDING AND CLARIFYING THE
HEALTH HISTORY (PATIENT’S
PERSPECTIVE)
• We must guide the patient into elaborating areas of the health history that
seem most significant.
EXPLORING THE PATIENT’S
PERSPECTIVE
FACILITATING THE PATIENT’S STORY:
THE TECHNIQUES OF SKILLED
INTERVIEWING
 THE TECHNIQUES OF SKILLED
INTERVIEWING

Active listening

- process of fully attending to what the patient is

communicating, being aware of the patient’s emotional state,
and using verbal and nonverbal skills to encourage the speaker to
continue and ex- pand. Active listening takes practice.
THE TECHNIQUES OF SKILLED
INTERVIEWING
 THE TECHNIQUES OF SKILLED
INTERVIEWING
Non Verbal Communication:

- Communication that does not involve speech occurs

continuously and provides important clues to feelings and emotions

- eye contact, facial expression, posture, head position and

movement such as shaking or nodding, interpersonal distance, and
placement of the arms or legs, such as crossed, neutral, or open
 THE TECHNIQUES OF SKILLED
INTERVIEWING
Facilitation

- by posture, actions, or words, you encourage the patient

to say more but do not specify the topic

- Leaning forward, making eye contact, and using

continuers like “Mm-hmm,” “Go on,” or “I’m listening” all
maintain the flow of the patient’s story.
 THE TECHNIQUES OF SKILLED
INTERVIEWING
Echoing

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.
 THE TECHNIQUES OF SKILLED
INTERVIEWING
Empathic Response

- Conveying empathy is part of establishing and strengthening

rapport with patients

- To empathize with your patient you must first identify his or her
feelings.

- “How did you feel about that?”

 THE TECHNIQUES OF SKILLED
INTERVIEWING

Validation

- important way to make a patient feel accepted is to legitimize or validate

his or her emotional experience

- “Being in that accident must have been very scary.”

 THE TECHNIQUES OF SKILLED
INTERVIEWING

Reassurance:

- The first step to effective reassurance is identifying and

accepting the patient’s feelings without offering reassurance at
that moment.
 THE TECHNIQUES OF SKILLED
INTERVIEWING
Summarization
- It indicates to the patient that you have been listening carefully.
- It can also identify what you know and what you don’t know.

Example:

“Now, let me make sure that I have the full story. You said you’ve had a cough
for 3 days, it’s especially bad at night, and you have started to bring up yellow
phlegm. You have not had a fever or felt short of breath, but you do feel
congested, with difficulty breathing through your nose.”

Following with an attentive pause or “Anything else?”

 THE TECHNIQUES OF SKILLED
INTERVIEWING
Highlighting Transitions
- Patients have many reasons to feel worried and vulnerable. To put them more at
ease, tell them when you are changing directions during the interview.
- This gives patients a greater sense of control.

Example:

“Now I’d like to ask some questions about your past health.”

“Now I’d like to examine you. I’ll step out for a few minutes. Please get completely undressed
and put on this gown.”
 ADAPTING INTERVIEWING TECHNIQUES
TO SPECIFIC SITUATIONS
- The Silent Patient

- The Talkative Patient

- The Anxious Patient

- The Crying Patient

- The Confusing Patient

- The Angry or Disruptive Patient

- The Patient With a Language Barrier

 ADAPTING INTERVIEWING TECHNIQUES
TO SPECIFIC SITUATIONS
- The Patient With Reading Problem

- The Patient With Impaired Hearing

- The Patient With Impaired Vision

- The Patient With Limited Intelligence

- The Poor Historian

- The Patient With Personal Problems

 SPECIAL ASPECTS OF INTERVIEWING

The Alcohol and Drug History

-Two or more affirmative answers to the CAGE

Questionnaire suggest alcoholism

-
 SPECIAL ASPECTS OF INTERVIEWING

The Sexual History

“Now I’d like to ask you some questions about your sexual health and practices.”
“When was the last time you had intimate physical contact with anyone?”
“Did that contact include sexual intercourse?”
“Do you have sex with men, women, or both?”
“How many sexual partners have you had in the last 6 months?”
“In the last 5 years?”
“In your lifetime?”
 SPECIAL ASPECTS OF INTERVIEWING
Domestic and Physical Violence
- “Because abuse is common in many women’s lives, I’ve begun to ask about it routinely.”
- “Are there times in your relation- ships that you feel unsafe or afraid?”

The Mental Health History

- “Have you ever had any problem with emotional or mental illnesses?”
- “Have you or has anyone in your family ever been hospitalized for an emotional or mental
health problem?”
 SPECIAL ASPECTS OF INTERVIEWING

Death and Dying Patient

- Kubler-Ross has described five stages in a person’s response to loss or
the anticipatory grief of impending death :

1. Denial and isolation

2. Anger

3. Bargaining

4. Depression or sadness

5. Acceptance
 SPECIAL ASPECTS OF INTERVIEWING
Sexuality in the Clinician–Patient Relationship.
- Clinicians occasionally find themselves physically attracted to their patients

- If you become aware of such feelings, accept them as a normal human response and
bring them to the conscious level so they will not affect your behavior.

- Denying these feelings makes it more likely for you to act inappropriately.

- Any sexual contact or romantic relationship with patients is unethical; keep your
relationship with the patient within professional bounds and seek help if you need it.
 ETHICAL CONSIDERATIONS
Nonmaleficence or primum non nocere

- is commonly stated as “First, do no harm.”

- In the context of an interview, giving information that is incorrect or
not really related to the patient’s problem can do harm.
- Avoiding relevant topics or creating barriers to open
communication can also do harm.
- Your success in facilitating the patient’s full expression of
experiences, thoughts, and feelings determines the quality of your
assessment.
 ETHICAL CONSIDERATIONS

Beneficence is the dictum that the clinician needs to “do good” for the patient. As
clinicians, our actions need to be motivated by what is in the patient’s best interest.

Autonomy reminds us that patients have the right to determine what is in their own best
interest. This principle has become increasingly important over time and is consistent with
collaborative rather than paternalistic patient relationships.

Confidentiality can be one of the most challenging principles. As clinicians, we are

obligated not to tell others what we learn from our patients. This privacy is fundamental to our
professional relationships with patients. In the daily flurry of activity in a hospital, it must be
carefully guarded.
A broadly representative group that initially met in Tavistock
Square in London in 1998 has continued to work on an evolving
document of ethical principles to guide behavior in health care for
both individuals and institutions. A current iteration of the Tavistock
Principles is provided below.
 INTERVIEWING PATIENTS OF DIFFERENT
AGES
Talking with Children

Talking with Adolescents

Talking with Aging Patients

 TALKING WITH CHILDREN
- Unlike adults, children usually are accompa- nied by a parent or
caregiver. Even when adolescents are alone, they are often seeking
health care at the request of their parents

- Establishing Rapport:
- “Now, are you Jimmy’s grandmother?”
- “Please help me by telling me Jimmy’s relationship to everyone
here”

- Working With Families

- “Your mother tells me that you get a lot of stomachaches. Tell
me about them.”

The presence of family members also provides a rich opportunity to

observe how they interact with the child. As you talk with the parent,
see how a young child relates to a new environment
 TALKING WITH ADOLESCENTS

Adolescents, like most other people, usually respond positively to anyone who
demonstrates a genuine interest in them.

Remember also that adolescents’ behavior is related to their developmental stage and
not necessarily to chronologic age or physical maturation. Their age and appearance
may fool you into assuming that they are functioning on a more future-oriented and
realistic level.
 TALKING WITH ADOLESCENTS

Your goal is to help adolescents bring their concerns or

questions to their par- ents. Encourage adolescents to discuss
sensitive issues with their parents and offer to be present or
help

This entails a careful assessment of the parents’ perspective

and the young person’s full and explicit consent.
 TALKING WITH AGING PATIENTS

At the other end of the life cycle, aging patients also have special needs
and concerns. Their hearing and vision may be impaired, their responses
and explanations may be slow or lengthy, and they may have chronic
illnesses with associated disabilities.

Elderly people may not report their symptoms. Some may be afraid or
embarrassed; others may be try- ing to avoid the medical expenses or
the discomforts of diagnosis and treat- ment. They may think their
symptoms are merely part of aging, or they may simply have forgotten
about them. They may be inhibited by fears of losing their
independence.
 TALKING WITH AGING PATIENTS

Functional Assessment.

- Learning how the elderly, and those with chronic illness, function in
terms of daily activities is essential and provides a baseline for future
comparisons. There are two standard categories of assessment:
physical activities of daily living (ADLs) and instrumental activities of
daily living (IADLs).
TALKING WITH AGING PATEINTS
 THE END

Bates' Guide to Physical Examination and History Taking

Chapter 2

Dr. Lloyd E. Tria II