Options For Clarifying The Patients Story

■ Directed questioning—from general to specific

■ Questioning to elicit a graded response

■ Asking a series of questions, one at a time

■ Offering multiple choices for answers

■ Clarifying what the patient means

Directed questioning is useful for drawing the patient's attention to specific areas of the history. It should follow several principles to be effective. Directed questioning should proceed from the general to the specific. A possible sequence, for example, might be "Tell me about your chest pain?" (Pause) "What else?" (Pause) "Where did you feel it?" (Pause) "Show me. Anywhere else?" (Pause) "Did it travel anywhere?" (Pause) "To which arm?" Directed questions should not be leading questions that call for a "yes" or "no" answer. If a patient says yes to "Did your stools look like tar?" you run the risk of turning your words into the patient's words. A better phrasing is "Please describe your stools."

If necessary, ask questions that require a graded response rather than a single answer. "What physical activity do you do that makes you short of breath?" is better than "How many steps can you climb before you get short of breath?" which is better than "Do you get short of breath climbing stairs?" Be sure to ask one question at a time. "Any tuberculosis, pleurisy, asthma, bronchitis, ^pneumonia?" may lead to a negative answer out of sheer confusion. Try "Do

§ou have any of the following problems?" Be sure to pause and establish eye ontact as you list each problem.

Sometimes patients seem quite unable to describe their symptoms without help. To minimize bias, offer multiple-choice answers. "Is your pain aching, sharp, pressing, burning, shooting, or what?" Almost any direct question can provide at least two possible answers. "Do you bring up any phlegm with your cough, or is it dry?"

At times patients use words that are ambiguous or have unclear associations. To understand their meaning, you need to request clarification, as in "Tell me exactly what you meant by 'the flu'" or "You said you were behaving just like your mother. What did you mean?"

Nonverbal Communication. Communication that does not involve speech occurs continuously and provides important clues to feelings and emotions. Becoming more sensitive to nonverbal messages allows you to both "read the patient" more effectively and to send messages of your own. Pay close attention to 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. Matching your position to the patient's can be a sign of increasing rapport. Moving closer or engaging in physical contact (like placing your hand on the patient's arm) can convey empathy or help the patient gain control of feelings. Bringing nonverbal communication to the conscious level is the first step to using this crucial form of patient interaction. You also can mirror the patient's paralanguage, or qualities of speech such as pacing, tone, and volume, to increase rapport.

Facilitation. You use facilitation when, by posture, actions, or words, you encourage the patient to say more but do not specify the topic. Pausing with a nod of the head or remaining silent, yet attentive and relaxed, is a cue for the patient to continue. Leaning forward, making eye contact, and using contin-uers like "Mm-hmm," "Go on," or "I'm listening" all maintain the flow of the patient's story.

Echoing. Simple repetition of the patient's words encourages the patient to express both factual details and feelings, as in the following example:

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.

This reflective technique has helped to reveal not only the location and severity of the pain but also its meaning to the patient. It did not bias the story or interrupt the patient's train of thought.

Empathic Responses. Conveying empathy is part of establishing and strengthening rapport with patients. As patients talk with you, they may express——with or without words—feelings they have not consciously acknowl-

2ged. These feelings are crucial to understanding their illnesses and to estab-hing a trusting relationship. To empathize with your patient you must first ientijy his or her feelings. When you sense important but unexpressed feel-igs from the patient's face, voice, words, or behavior, inquire about them ither than assume how the patient feels. You may simply ask "How did you eel about that?" Unless you let patients know that you are interested in feelings as well as in facts, you may miss important insights.

Once you have identified the feelings, respond with understanding and acceptance. Responses may be as simple as "I understand," "That sounds upsetting," or "You seem sad." Empathy may also be nonverbal—for example, offering a tissue to a crying patient or gently placing your hand on the patient's arm to show understanding. When you give an empathic response, be sure that you are responding correctly to what the patient is feeling. If your response acknowledges how upset a patient must have been at the death of a parent, when, in fact, the death relieved the patient of a long-standing financial and emotional burden, you have misunderstood the situation.

Validation. Another important way to make a patient feel accepted is to legitimize or validate his or her emotional experience. A patient who has been in a car accident but has no significant physical injury may still be experiencing distress. Stating something like "Being in that accident must have been very scary. Car accidents are always unsettling because they remind us of our vulnerability and mortality. That could explain why you still feel upset" reassures the patient. It helps the patient feel that such emotions are legitimate and understandable.

Reassurance. When you are talking with patients who are anxious or upset, it is tempting to reassure them. You may find yourself saying "Don't worry. Everything is going to be all right." While this may be appropriate in nonprofessional relationships, in your role as a clinician such comments are usually counterproductive. You may fall into reassuring the patient about the wrong thing. Moreover, premature reassurance may block further disclosures, especially if the patient feels that exposing anxiety is a weakness. Such admissions require encouragement, not a cover-up. The first step to effective reassurance is identifying and accepting the patient's feelings without offering reassurance at that moment. Doing so promotes a feeling of security. The actual reassurance comes much later after you have completed the interview, the physical examination, and perhaps some laboratory studies. At that point, you can interpret for the patient what you think is happening and deal openly with the real concerns.

Summarization. Giving a capsule summary of the patient's story in the course of the interview can serve several different functions. It indicates to the patient that you have been listening carefully. It can also identify what you know and what you don't know. "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?" lets the patient add other information and confirms that you have heard the story correctly. You can use summarization at different points in the interview to struc-ire the visit, especially at times of transition (see below). This technique also lows you, the clinician, to organize your clinical reasoning and to convey our thinking to the patient, which makes the relationship more collaborative.

^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. As you move from one part of the history to another and on to the physical examination, orient the patient with brief transitional phrases like "Now I'd like to ask some questions about your past health." Make clear what the patient should expect or do next . . . "Now I'd like to examine you. I'll step out for a few minutes. Please get completely undressed and put on this gown." Specifying that the gown should open in the back may earn the patient's gratitude and save you some time.

Ifc Adapting Interviewing Techniques _to Specific Situations_

Interviewing patients may precipitate several behaviors and situations that seem particularly vexing or perplexing. Your skill at handling these situations will evolve throughout your career. Always remember the importance of listening to the patient and clarifying the patient's agenda.

The Silent Patient. Novice interviewers may be uncomfortable with periods of silence and feel obligated to keep the conversation going. Silence has many meanings and many purposes. Patients frequently fall silent for short periods to collect thoughts, remember details, or decide whether they can trust you with certain information. The period of silence usually feels much longer to the clinician than it does to the patient. The clinician should appear attentive and give brief encouragement to continue when appropriate (see facilita-tive techniques on pp - and pp. - ). During periods of silence, watch the patient closely for nonverbal cues, such as difficulty controlling emotions. Alternatively, patients with depression or dementia may lose their usual spontaneity of expression, give short answers to questions, then quickly become silent afterwards. You may need to shift your inquiry to the symptoms of depression or begin an exploratory mental status examination (see Chapter 16, The Nervous System, pp. - ).

At times, silence may be the patient's response to how you are asking questions. Are you asking too many direct questions in rapid sequence? Have you offended the patient in any way, for example, by signs of disapproval or criticism? Have you failed to recognize an overwhelming symptom such as pain, nausea, or dyspnea? If so, you may need to ask the patient directly, "You seem very quiet. Have I done something to upset you?"

Finally, some patients are naturally laconic. Be accepting and try asking the patient for suggestions about other sources to help you gather more information. With the patient's permission, talking with family members or friends may be worthwhile.

Th diff ma1

e Talkative Patient. The garrulous, rambling patient may be just as fficult. Faced with limited time and the need to "get the whole story," you ay grow impatient, even exasperated. Although this problem has no perfect lutions, several techniques are helpful. Give the patient free rein for the first or 10 minutes and listen closely to the conversation. Perhaps the patient sim ply has lacked a good listener and is expressing pent-up concerns. Maybe the patient's style is to tell stories. Does the patient seem obsessively detailed or unduly anxious? Is there a flight of ideas or disorganized thought process that suggests a psychosis or confabulation?

Try to focus on what seems most important to the patient. Show your interest by asking questions in those areas. Interrupt if you must, but courteously. Remember that part of your task is to structure the interview. It is acceptable to be directive and set limits when necessary. A brief summary may help you change the subject yet validate any concerns (see p._). "Let me make sure that I understand. You've described many concerns. In particular, I heard about two different kinds of pain, one on your left side that goes into your groin and is fairly new, and one in your upper abdomen after you eat that you've had for months. Let's focus just on the side pain first. Can you tell me what it feels like?" Finally, do not show your impatience. If there is no more time, explain the need for a second meeting. Setting a time limit for the next appointment may be helpful. "I know we have much more to talk about. Can you come again next week? We'll have a full hour then."

The Anxious Patient. Anxiety is a frequent and normal reaction to sickness, treatment, and the health care system itself. For some patients, anxiety is a filter for all their perceptions and reactions; for others it may be part of their illness. Again, watch for nonverbal and verbal cues. Anxious patients may sit tensely, fidgeting with their fingers or clothes. They may sigh frequently, lick dry lips, sweat more than average, or actually tremble. Carotid pulsations may betray a rapid heart rate. Some anxious patients fall silent, unable to speak freely or confide. Others try to cover their feelings with words, busily avoiding their own basic problems. When you detect anxiety, reflect your impression back to the patient and encourage him or her to talk about any underlying concerns. Be careful not to transmit your own anxieties about completing the interview to the patient!

The Crying Patient. Crying signals strong emotions, ranging from sadness to anger or frustration. If the patient is on the verge of tears, pausing, gentle probing, or responding with empathy allows the patient to cry. Usually crying is therapeutic, as is your quiet acceptance of the patient's distress or pain. Offer a tissue and wait for the patient to recover. Make a facilitating or supportive remark like "I'm glad that you got that out." Most patients will soon compose themselves and resume their story. Aside from cases of acute grief or loss, it is unusual for crying to escalate and become uncontrollable.

Co rying makes many people uncomfortable. If this is true for you, as a clinician, you will need to work through your feelings so that you can support patients at these significant times.

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