■ The patient's thoughts about the nature and the cause of the problem
■ The patient's feelings, especially fears, about the problem
■ The patient's expectations of the clinician and health care
■ The effect of the problem on the patient's life
■ Prior personal or family experiences that are similar
■ Therapeutic responses the patient has already tried
The clinician should ask about the cause of the problem by saying, for example, "Why do you think you have this stomachache?" To uncover the patient's feelings, you might ask, "What concerns you most about the pain?" A patient may worry that the pain is a symptom of serious disease and want reassurance. Alternatively, the patient may be less concerned about the cause of the pain and just want relief. You need to find out what the patient expects from you, the clinician, or from health care in general . . . "I'm glad that the pain is almost gone. How specifically can I help you now?" Even if the stomach pain is almost gone, the patient may need a work excuse to take to an employer.
It may be helpful to ask the patient about previous experiences, what he or she has tried so far, and any related changes in daily activities.
Clinician: "Has anything like this happened to you or your family before?"
Patient: "I was worried that I might have appendicitis. My Uncle Charlie died from a ruptured appendix."
Explore what the patient has done so far to take care of the problem. Most patients will have tried over-the-counter medications, traditional remedies, or advice from friends or family. Ask how the illness has affected the patient's lifestyle and level of activity. This question is especially important for a patients ith chronic illness. "What can't you do now that you could do before?" How has your backache (shortness of breath, etc.) affected your ability to work?" . . . "Your life at home?" . . . "Your social activities?" . . . "Your role as a parent?" . . . "Your role as a husband or wife?" . . . "The way you feel about yourself as a person?"
3Negotiating a Plan. Learning about the disease and conceptualizing the lness give you and the patient the opportunity to create a complete picture of the problem. This multifaceted picture then forms the basis for planning further evaluation (physical examination, laboratory tests, consultations, etc.)
and negotiating a treatment plan. More specific techniques for negotiating a plan can be found in Chapter 18. Advanced skills, such as steps for motivating change and the therapeutic use of the clinician-patient relationship, are beyond the scope of this book.
Planning for Follow-Up and Closing. You may find that ending the interview is difficult. Patients often have many questions and, if you have done your job well, they are enjoying talking with you. Giving notice that the end of the interview is approaching allows time for the patient to ask any final questions. Make sure the patient understands the agreed-upon plans you have developed. For example, before gathering your papers or standing to leave the room, you can say "We need to stop now. Do you have any questions about what we've covered?" As you close, reviewing future evaluation, treatments, and follow-up is helpful. "So, you will take the medicine as we discussed, get the blood test before you leave today, and make a follow-up appointment for 4 weeks. Do you have any questions about this?" Address any related concerns or questions that the patient brings up.
The patient should have a chance to ask any final questions; however, the last few minutes are not the time to bring up new topics. If that happens (and the concern is not life-threatening), simply reassure the patient of your interest and make plans to address the problem at a future time. "That knee pain sounds concerning. Why don't you make an appointment for next week so we can discuss it?" Reaffirming that you will continue working to improve the patient's health is always appreciated.
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