The health history interview is a conversation with a purpose. As a clinician, you will draw on many of the interpersonal skills that you use every day, but with unique and important differences. Unlike social conversation, in which you express your own needs and interests with responsibility only for yourself, the primary goal of the clinician-patient interview is to improve the well-being of the patient. At its most basic level, the purpose of conversation with a patient is threefold: to establish a trusting and supportive relationship, to gather information, and to offer information. Communicating and relating therapeutically with patients are the most valued skills of clinical care. As a beginning clinician, you will focus your energies on gathering information. At the same time, by using techniques that promote trust and communication, you will allow the patient's story to unfold in its most full and detailed form. Establishing a supportive interaction enhances information-gathering and itself becomes part of the therapeutic process of patient care.
As a clinician facilitating the patient's story, you will come to generate a series of hypotheses about the nature of the patient's concerns. You will then test these various hypotheses by asking for more detailed information. You will also explore the patient's feelings and beliefs about his or her problem. Eventually, as your clinical experience grows, you will respond with your understanding of the patient's concerns. Even if you discover that little can be done for the patient's disease, discussing the patient's experience of being ill can be therapeutic. In the example that follows, a research protocol made the patient ineligible for treatment of her long-standing and severe arthritis.
The patient had never talked about what the symptoms meant to her. She had never said "This means that I can't go to the bathroom by myself, put my clothes on, even get out of bed without calling for help."
When we finished the physical examination, I said something like "Rheumatoid arthritis really has not been nice to you." She burst into tears, and so did her daughter, and I sat there, very close to losing it myself.
She said "You know, no one has ever talked about it as a personal thing before. No one's ever talked to me as if this were a thing that mattered, a personal event."
That was the significant thing about the encounter. I didn't really have much else to offer . . . But something really significant had happened between us, something that she valued and would carry away with her.1
Hastings C: The lived experiences of the illness: Making contact with the patient. In Benne P, Wrubel J. The Primacy of Caring: Stress and Coping in Health and Illness. Menlo Park, CA, Addison-Wesley, 1989.
As you can see from this story, interviewing patients consists of much more than just asking a series of questions.
You will find that the interviewing process differs significantly from the format for the health history presented in Chapter 1. Both are fundamental to your work with patients, but each serves a different purpose. The health history format is a structured framework for organizing patient information in written or verbal form: it focuses the clinician's attention on specific pieces of information that must be obtained from the patient. The interviewing process that actually generates these pieces of information is more fluid. It requires knowledge of the information you need to obtain, the ability to elicit accurate and detailed information, and interpersonal skills that allow you to respond to the patient's feelings.
As you learned in Chapter 1, the kinds of questions you ask as you elicit the health history vary according to several factors. The scope and degree of detail depend on the patient's needs and concerns, the clinician's goals for the encounter, and the clinical setting (e.g., inpatient or outpatient, amount of time available, primary care or subspecialty). For new patients, regardless of the setting, you will do a comprehensive health history, described for adults in Chapter 1. For other patients who seek care for a specific complaint, such as a cough or painful urination, a more limited interview tailored to that specific problem may be indicated, sometimes known as a problem-oriented history. In a primary care setting, clinicians frequently choose to address issues of health promotion, such as tobacco cessation or reduction of high-risk sexual behaviors. A subspecialist may do an in-depth history to evaluate one problem that incorporates a wide range of areas of inquiry. Knowing the content and relevance of all the components of a comprehensive health history, reviewed for you below, enables you to select the kinds of information that will be most helpful for meeting both clinician and patient goals.
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