PATIENT INTERVIEW

Throughout Introduction of Clinical Medicine (ICM) 2 through 5, we learn how to conduct patient interviews, one section at a time. During ICM 2, we learn how to introduce ourselves and by the time we reach ICM 4, we learn how to interview patients with advanced issues, like mental illnesses, domestic violence, and substance abuse. There are many ways and approaches to structure a patient interview, and the one I outline here is the order in which I personally like to do interviews. Here are some tips for interviewing:

  • Whenever possible, start each section of the interview with patient-centered, open-ended questions (i.e. “Can you please talk more about…”). Continue encouraging the patient to talk (with “can you explain more?” or a head nod). Once the patient has said what he/she wants to say, fill in the rest with closed-ended, doctor-centered questions.
  • Establish rapport whenever you can, by relating to the patient or giving supporting comments, especially in the beginning part of the interview. This way, the patient becomes more open to answering your questions.
  • Whenever your patient mentions to you how frustrated or stressed they are about something, you know that’s a clue that your patient is looking for your support and understanding. Whenever they express joy about something, that’s a clue that your patient wants your praise or respect. Always be on the lookout for these clues because you never know when or what your patient’s going to say at any time. Take advantage of these moments to do NURS (Name the emotion, Understand, Respect, Support) and establish rapport, but be genuine about it, of course.
  • Body language is half the interview. Not only does the patient’s body language reveal things about what the patient is feeling, but also your own body language as an interviewer. Keep your eyes on the patient and less on your notes. Apologize whenever you do find yourself looking at your notes too long (and this will let your patient feel more comfortable around you). Lean your posture in a little whenever you talk with your patient so show you are listening and connecting… Since I think it’s hard to fake your body language, the best way is to really connect with your patient and talk to them naturally as if you were having a regular conversation. If you connect with your patient, a good body language flows out naturally without you thinking.
  • Make sure to avoid asking any compound questions (multiple questions all at once) like “Do you do any exercises, like jumping jacks, or running, or are you too busy at work to do exercises…?” The patient will get confused as to what you’re asking and probably answer the last part of your question only.
  • Avoid making any suggestions in your questions, like “What kind of pain is it, is it a sharp pain?” Questions like these suggests to the patient that they’re probably supposed to answer “yes, it’s a sharp pain” even though the patient may not normally think of his/her pain that way. Simply ask a more open-ended question like “Can you describe your pain?”
  • Leave the most uncomfortable parts of the interview for last, after you establish rapport, namely questions about Domestic Violence and Sexual History.
  • Don’t forget to do Review of Systems!! You may catch things your patient has never mentioned.

In the beginning of ICM 5, every student does a one-on-one interview that simulates a real patient interview. The student interviews a professional patient (actor) one-on-one privately in a patient room. Since the interview simulates a real interview, we needed to have all the sections of the interview memorized (i.e. the questions for HPI, PMH, Social History, Family History, etc.). The only part we don’t have to memorize is the Review of Systems (ROS), in which we may bring in a checklist (which is what doctors do anyway). The patient may present to you with any (or multiple) problems, so we must be prepared to face and tackle any type of interview.

So here is an example outline for a patient interview:

INTRODUCTION

  1. “Hello, my name is Benjamin Ho. I am a second year student at the American University of the Caribbean and I was sent in by Dr. X to ask you some question…” (Introduction)
  2. “May I have your name please? Do you go by Miss or Mrs.? It’s nice to meet you, Mrs. Y.”
  3. “Before we start, are you comfortable? Let me know if you need anything.” (Support, Rapport-building)
  4. “Is it OK if I take some notes?”

CHIEF COMPLAINT

  1. “Alright Mrs. X, What brings you in today?”

SETTING THE AGENDA

  1. “Is there anything else you’d like to talk about today?” (keep asking this question until there’s nothing else)
  2. “Well, you’ve come to the right place. We’ll definitely address that today and we’ll see how we can help you.” (Support, Rapport-building)
  3. “OK, so we will be talking about X, Y, and Z. Let’s start with X.” (Summarizing, Setting agenda)

HISTORY OF PRESENT ILLNESS (HPI)

  1. Open-Ended Question — “Can you tell me more about X?”
  2. Closed-Ended Questions — OLDCARTS
    1. Onset — “When did you start noticing the pain?”
    2. Location — “Where do you feel the pain?”
    3. Duration — “How long does the pain last?”
    4. Character — “How would you describe the pain?”
    5. Alleviate/Aggravate — “Is there anything you do that would make the pain go away? What makes it worse?”
    6. Radiate — “Did your pain spread anywhere?”
    7. Time — “Do you feel pain during certain parts of the day?”
    8. Severity — “On a scale of 0 to 10, with 0 being no pain and 10 being the greatest pain, how would you rate your pain?”
  3. Associated Symptoms — “Does your pain come with any other symptoms?”
  4. Impact of Symptoms
    1. “How has your pain impacted your life?” (Open-ended Question)
    2. “You seem frustrated about not being able to do what you love because of your pain. But we’re glad you came here today to do something about it. We are here to help you get back on your feet.” (NURS — Name the emotion, Understand, Respect, Support)
  5. Explanatory Model — “What do you think is causing your symptoms?” (See what the patient is thinking.. sometimes they’ll reveal clues)
  6. Repeat steps 1-5 for all the other current complaints of the patient.

PAST MEDICAL HISTORY (PMH)

  1. Transition — “OK, now let’s talk about your past medical history.”
  2. Conditions
    1. Illnesses — “Have you had any major illnesses or conditions in your past? present? as a child? How is it now?”
    2. Hospitalizations — “Have you ever been hospitalized? For what? When? How is it now?”
    3. Surgeries — “Have you had any surgeries in the past? For what? When? How is it now?”
    4. Injuries — “Have you had any serious injuries in the past? What happened? When? How is it now?”
    5. Pysch — “Have you ever been diagnosed with any psychological conditions in the past? What? When? How is it now?”
    6. Allergies — “Are you allergic to anything? How do you handle it?”
  3. Treatments
    1. Medications — “Are you taking any medications? Dose? Frequency?”
    2. Complementary/Alternative Medicine (CAM) — “Are you taking any complementary or alternative medicines? Dose? Frequency?”
    3. Supplements — “Are you taking any supplements? Dose? Frequency?”
  4. Prevention Measures
    1. Vaccines — “Are you up to date on your vaccines?”
    2. Seat Belt — “Do you wear a seat belt when driving?”
    3. Helmet — “Do you wear a helmet when riding a bike or motorcycle?”
    4. Physical — “When was the last time you’ve had a physical? What were the results?”
    5. Tests
      1. Pap/PSA — “When was the last time you’ve had a pap smear? What were the results?”
      2. Mammogram — “When was the last time you’ve had a mammogram? What were the results?”
      3. Colonoscopy — “Have you had a colonoscopy? When did you have it? What were the results?”
      4. Breast/Testicular Self-Exam — “Do you regularly do breast self-exams? It’s important to do regular self-exams as breast cancer is very common in women your age. It’s easy to do. If you like, we can show you how to perform them.”

FAMILY HISTORY

  1. Transition — “OK, now let’s talk about some of your family history.”
  2. Family Members — For each of these, ask about age, current health, cause of death, or any other problems.
    1. Mother
    2. Father
    3. Paternal Grandmother
    4. Paternal Grandfather
    5. Maternal Grandmother
    6. Maternal Grandfather
    7. Siblings
    8. Children
  3. Major Illnesses in Family — “Is there anyone in your family with…”
    1. Cancer?
    2. High blood pressure?
    3. Heart Disease?
    4. Diabetes?
    5. Alcoholism?
    6. Depression?

SOCIAL HISTORY

  1. Transition — “OK, let’s talk about some of your social history.”
  2. Healthy Stuff
    1. Leisure
      1. “What do you like to do in your free time?” (Seeing if patient has stress-relievers and emotionally healthy)
      2. “That’s great that you really enjoy painting! I always wished I could paint too.” (Building rapport)
    2. Sleep
      1. Quality — “How is your sleep? (Open-ended question)
      2. Quantity — “How many hours do you sleep per night?” (Closed-ended question)
    3. Exercise
      1. “Do you exercise regularly?”
      2. “What kind of exercises do you do? How much?
    4. Diet
      1. “How’s your diet?” (Open-ended question)
      2. “What do you eat in a typical day?” (Closed-ended question)
  3. Unhealthy Stuff
    1. Alcohol
      1. “Do you drink alcohol?”
      2. “How often do you drink?”
      3. “How much do you drink?”
      4. “Can you show me what you mean by a glass of wine?”
      5. If they drink alcohol, then CAGE them:
        1. C — “Have you ever felt you should cut down on your drinking?”
        2. A — “Have you ever felt annoyed when others confront you about drinking?”
        3. G — “Have you ever felt guilty from drinking?”
        4. E — “Have you ever drank alcohol in the morning to get over a hang over?” (Eye-opener)
      6. Support — “We can discuss some options to help in your drinking if you like.”
    2. Smoking/Tobacco
      1. “Do you smoke?”
      2. “How many packs per day?”
      3. “How many years have you smoked?”
      4. “Have you thought about quitting?”
      5. Support — “We can discuss some options for helping you quit smoking if you like.”
    3. Caffeine
      1. “Do you drink caffeinated drinks?”
      2. “How often?”
      3. “How much?”
      4. Support — “We can discuss some options to help your caffeine intake if you like.”
    4. Drugs
      1. “Do you take any recreational drugs?”
      2. “Do you take any prescription drugs for anything other than treating illness?”
      3. Support — “We can discuss some options to help your drug concerns if you like.”
  4. Education — “What is your highest level of education?”
  5. Finances
    1. Employment — past and present
      1. “Do you currently work?”
      2. “What do you do for a living?”
      3. “Tell me about your work.” (open-ended question)
      4. “Do you enjoy your work?” (closed-ended question)
    2. Financial Situation — “How are your finances?” (see if finances is a stress factor on the patient’s emotional health)
    3. Occupational Hazards
      1. Exposures — “Are there any potential hazards you are exposed to in the workplace?”
      2. Stress — “How is the stress at work?”
    4. Support — “Sounds like you find a lot of stress at work, but it’s admirable to see how well you deal with it. If you ever feel like you have too much stress and would like to talk about it, we’re here to support you.” (NURS, Rapport-building)
  6. Support
    1. Living Situation
      1. “How are things at home? (open-ended)
      2. “Who do you live with?” (closed-ended)
    2. Relationships
      1. “Are you currently in a relationship?”
      2. “How is your relationship?”
    3. Support Groups
      1. “Do you participate in any clubs or organizations?”
      2. “Do you practice religion?”
      3. “Do you find support at your church/temple/organization/group?” (see if patient finds emotional or social support from religion, groups, or communities)
  7. Depression
    1. “Have there ever been times when you’ve felt down or hopeless? Tell me more about it…” (remember to keep it open-ended)
    2. “Have you had any loss of interest? Tell me more about it…” (remember to keep it open-ended)
    3. “For how long?” (if over 2 weeks, it may be depression)
    4. If you suspect depression in the patient, continue with SIGECAPS:
      1. Sleep — “How has your sleep been ever since you started feeling down?”
      2. Interest — “How has your interests changed ever since you started feeling down?”
      3. Guilt — “Do you ever feel guilty?”
      4. Energy — “Do you feel tired?”
      5. Concentration — “How has your concentration been recently since you started feeling down?”
      6. Appetite — “How has your appetite been recently since you started feeling down?”
      7. Psychomotor — “How do you feel physically?”
      8. Suicidality — “Do you ever think about ending your life?”
  8. Domestic Violence — since this is uncomfortable for a lot of people, you leave this part of the interview until close to the end, after you’ve established rapport with the patient.
    1. Transition — “Since your well-being is very important to us, it’s important we routinely ask all our female/senior patients about safety at home.” (make sure your patient knows you ask this routinely!!!)
    2. Confidentiality — “You are in a safe place and whatever you tell us today will be kept confidential between you and the clinic, unless there are children involved.” (let your patient know their confidentiality rights as well as let them feel more open about sharing their lives)
    3. “Do you feel safe at home?”
    4. “Why not?” (open-ended question… let the patient talk)
    5. If you suspect domestic violence, ask PEACE:
      1. P — “Have you ever been physically hurt by someone you love?”
      2. E — “Do you ever feel you’re walking on eggshells to avoid conflicts with someone you love?”
      3. A — “Have you ever been sexually abused or forced to into sexual practices you did not want?”
      4. C — “Has your partner ever tried to control where you go, who you talk to, or who you hang out with?”
      5. E — “Have you ever been emotionally abused or threatened by your partner?”
    6. NURS — “It sounds like things at home have been very difficult for you. Thank you for share this information with us. It’s very courageous and strong of you to do that. Your safety is of utmost concern to us and you have our support here at the clinic.”
    7. Safety Plan — For domestic violence patients, give them advise to help with their safety:
      1. “Whenever you find yourself in an argument, move to a room where you’ll least likely get injured — avoid kitchens, garages, bathrooms, and rooms without outside doors.”
      2. “If you have a protective order, keep a copy with you at all times. Keep at copy at your workplace, and with a friend.”
      3. “Here is the number to the domestic violence hotline. Keep emergency numbers with you at all times.”
      4. “If you have kids, teach your kids how to call 911.”
      5. “Park your car so that you’re not blocked in, and make an extra set of keys.”
      6. “Plan out a few places you can go to be safe, like a friend’s house or workplace, and keep some cash and extra clothes there.”
      7. “Open a separate savings account at another bank so you’ll have emergency money in case you need it.”
      8. “Make extra copies of important documents and keep them somewhere you know it’s safe.”
      9. “Use caller ID, voice mail, or screen your calls.”
      10. “Make a safety plan with a friend, your co-workers, or your neighbor.”
    8. “Do you feel safe to go home now? Do you have a safe place to stay tonight? Are you sure?” (ultimately, it’s the patient’s decision whether or not to go home and we must respect that.)
  9. Sexual History — since this is uncomfortable for a lot of people, you leave this part of the interview until close to the end, after you’ve established rapport with the patient.
    1. Transition — “As this next part of the interview is very important to the patient’s health and well-being, it is important we ask all of our patients about their sexual history.”
    2. Confidentiality — “We can assure you that anything we talk about today is strictly confidential between you and the clinic.”
    3. Permission — “Is it OK if I ask you about your sexual history? Do you have any questions before we begin?”
    4. “Are you currently sexually active?”
    5. If yes, ask the Six P’s: PPPPPP
      1. Partners — “How many partners have you had in the past? Do you have sexual relations with men, women, or both?”
      2. Practices — “What kind of sexual practices do you engage in?”
      3. Protection from STD’s — “Do you use protection? What kind?”
      4. Past history of STD’s — “Have you ever been diagnosed with a sexually transmitted disease?”
      5. Prevention of Pregnancy — “Are you seeking to become pregnant? Do you use any contraceptives?”
      6. Performance changes — “Are you satisfied with your performance? Have you had any chances in performance lately?”
    6. Give support if necessary

REVIEW OF SYSTEMS (ROS)

  1. Transition — “In this next part of the interview, I’ll be reading a list of symptoms, and you can just tell me yes or no, OK? Have you noticed any…” (for the list of conditions in the ROS, use layman’s terms, rather than medical terms, so the patient can understand. Do ROS last because it involves the least conversational interaction between patient and doctor and has the least rapport-building value. The ROS also runs through symptoms that you may normally not “catch” in the previous conversational parts of the interview, so that’s another reason why it’s good to end the interview with it.)
  2. General/Skin/Sleep — Change in weight, Fatigue, Weakness, Fevers, Chills, Rash, Itching, Dryness, Change in hair, Change in nails.
  3. HEENT:
    1. Eyes — Vision, Pain, redness, Tearing, Double Vision.
    2. Ears — Hearing, Ringing in ears (tinnitus), Vertigo, Earache, Discharge.
    3. Nose — Colds, Stuffiness, Hay fever, Nosebleed, Sinus problems, Loss of smell (anosmia).
    4. Mouth — Change in teeth, Bleeding gums, Sore throat, Hoarseness.
    5. Throat — Difficulty swallowing (dysphagia), Lumps, Swelling (goiter), Pain, Stiffness.
  4. Respiratory — Cough (blood? sputum? color? quantity?), Trouble breathing (dyspnea), Wheezing, Asthma, Bronchitis, Emphysema, Pneumonia, TB.
  5. Cardiovascular — High blood pressure, Low blood pressure, Murmurs, Trouble breathing when laying down (orthopnea), Difficulty breathing at night (nocturnal dyspnea), Swelling (edema), Chest pain, Palpitations (rapid? skip?), Cramping pains (claudication), Big veins in your legs and feet (varicose veins), Clotting, Easy bruising or bleeding, Anemia, Transfusions.
  6. Gastrointestinal — Change in appetite, Heartburn, Nausea, Vomiting, Abdominal pain, Bloating, Lactose intolerance, Diarrhea, Constipation, Gas, Hemorrhoids, Yellow skin or eyes (Jaundice)
  7. Musculoskeletal — Joint pain or back ache, Swelling in joints, Morning stiffness, Arthritis, Gout, Cramps, Weakness, Limits in movement.
  8. Neuro/Psych — Headache, Fainting, Blackouts, Seizures, Paralysis, Numbness, Tingling, Dizziness (vertigo), Difficulty walking, Confusion, Memory loss, Tremor, Problems with coordination, Anxiety or stress, Depression, Suicide attempts.
  9. Urinary — Painful urination (dysuria), Wake up at night to urinate (nocturia), Excessive urine (polyuria), Blood in urine (hematuria), Urgency, Hesitancy, Incontinence, Urinary tract infections, Stones, Change in stream.
  10. Endocrine — Heat intolerance, Cold intolerance, Excessive thirst (polydypsia), Excessive hunger (polyphagia), Excessive sweating (diaphoresis), Thyroid problems, Diabetes, Changes in skin color, Excessive hair growth
  11. Genital/Sexual — Discharge, Itching, Sores, Sexually-transmitted diseases, Hernias, Testicular/Vaginal pain, Testicular mass, Change in sexual interest, Change in sexual function, Change in sexual satisfaction, Change in performance.
  12. Gynecological — Ask these for female patients:
    1. “At what age did you have your first period?”
    2. “Are they regular?”
    3. “How frequent do you have your periods?”
    4. “How long do your periods last?”
    5. “Any changes in bleeding?”
    6. “When was your last period”
    7. “At what age did you have your menopause?” (if patient is post-menopausal)
    8. “Have you had any breast lumps?”
    9. “Have you had any breast pain?”
    10. “Have you had any breast discharge?
    11. “How many pregnancies have you had? How many children have you had?”
    12. “Have you had any complications during pregnancy?” (if patient has had pregnancy)

CONCLUSION

  1. Summarize — “So to summarize everything we’ve talked about today…” (give a summary of the big points in the chief complaints, HPI, PMH, Family History, Social History, and ROS. It shows the patient you’ve been listening, and it’s a good way for you to review information for yourself so you can report it to your Attendings or other members of your medical team).
  2. If the patient asks what condition he/she most likely has, and if you have already have a likely idea of what it is, say something along the lines of “People who have symptoms X or Y, it’s often due to this disease Z.” Don’t ever say “you most likely have disease Z.” Always say it in terms of other people.
  3. Follow-up — “So we will perform a physical exam as well as run X, Y, and Z lab tests so we can figure out what’s going on and help you feel better soon, so you can do the leisure activities you liked to do again. Once we get the results back, we can meet up again to discuss some of your options.” (It’s always good to mention how treatment can impact the patient’s everyday life, like leisure activities, so the patient can understand the importance of treatment to their happiness. Also, remember the patient has options.)
  4. “Thank you very much, Mrs. Y. Have a good day.”