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Use language that is understandable and appropriate to the patient. Technical language confuses patients and blocks communication. Whenever pos- sible, repeat back the patient’s words and expressions as the history unfolds, to af rm the patient’s experience as you clarify what he or she means. Facilitate the patient’s story by using different types of questions and the techniques of skilled interviewing on pp. 42–44. Often you will need to use directed questions (see pp. 42–43) that ask for speci c information the patient has not already offered. In general, an interview moves back and forth from open-ended questions to increasingly focused questions and then on to another open-ended question, returning the lead in the interview to the patient. Establishing the sequence and time course of the patient’s symptoms is important. Encourage a chronologic account by asking such questions as “What then?” or “What happened next?”

■ Generate and test diagnostic hypotheses. As you listen to the patient’s

concerns, you will generate and test diagnostic hypotheses about which dis- ease process might be present. Identifying all the features of each symp- tom is fundamental to recognizing patterns of disease and to generating the differential diagnosis. It is important to fully esh out the patient’s story. This avoids the common trap of premature closure, or shutting down the patient’s story too quickly, which can lead to errors in diagnosis.

It is helpful to visualize the process of evoking a full description of each symptom(s) as “the cone” (Fig. 3-1). Each symptom has its own “cone,” which becomes a paragraph in the History of Present Illness in the writ- ten record.

Firs t, ope n-ende d que s tions to he a r “the s tory of the s ymptom” in the pa tie nt’s own words

The n more s pe cific que s tions to e licit “the s e ve n fea ture s of e ve ry s ymptom”

Fina lly, the ye s -no que s tions or “pe rtinent pos itive s a nd ne ga tive s ” from the re levant s e ction of the re view of s ys tems

Chapter 3 | Interviewing and the Health History 49

■ Share the treatment plan. Learning about the disease and conceptual-

izing the illness give you and the patient the basis for planning further evaluation (physical examination, laboratory tests, consultations, etc.). Shared decision-making involves a three-step process: introducing choices and describing options, using patient decision support tools when available; exploring patient preferences; and moving to a decision, checking that the patient is ready to make a decision and offering more time if needed. Motivational interviewing may help the patient achieve desired behavior changes.

T h e G u id in g S t y le o f M o t iv a t io n a l In t e r v ie w in g

● “Ask” o en-ended questions—invite the tient to consider how nd why

they ight ch nge

● “Listen” to underst nd your tient’s ex erience—“c ture” their ccount

with brief su ries or reflective listening st te ents such s “quitting s oking feels beyond you t the o ent”; these ex ress e thy, encour- ge the tient to el bor te, nd re often the best w y to res ond to resis- t nce

● “Infor ”—by sking er ission to rovide infor tion, nd then sking wh t

the i lic tions ight be for the tient.

Source: Quoted directly fro Rollnick S, Butler CC, Kinnersly P, et l. Motiv tion l Interview- ing. BMJ. 2 1 ;34 :1242.

■ Close the interview and visit. Make sure the patient fully understands

the plans you have developed together. You can say, “We need to stop now. Do you have any questions about what we’ve covered?” Review future evaluation, treatments, and follow-up. Give the patient a chance to ask any nal questions. Ask the patient to “teach back” the plan of care to you in his or her own words.

■ Take time for self-re ection. As clinicians, we encounter a wide variety

of people, each one unique. Because we bring our own values, assump- tions, and biases to every encounter, we must look inward to clarify how our expectations and reactions may affect what we hear and how we behave. Self-re ection brings a deepening personal awareness to our work with patients and is one of the most rewarding aspects of providing patient care.

T h e C u lt u r a l C o n t e x t o f t h e In t e r v ie w

Cu lt u ra l Hu m ilit y—a Ch a n g in g P a ra d ig m . As you provide care for an ever-expanding and diverse group of patients, it is important to understand how culture shapes not just the patient’s beliefs, but your own. Culture is a system of shared ideas, rules, and meanings that in uences how we view the world, experience it emotionally, and behave in relation

to other people. This de nition of culture is broader than the term ethnicity. The in uence of culture is not limited to minority groups—it is relevant to everyone, including the culture of clinicians and their training. Cultural competence commonly is viewed as: “a set of attitudes, skills, behaviors, and policies that enable organizations and staff to work effectively in cross- cultural situations. It re ects the ability to acquire and use knowledge of the health-related bene ts, attitudes, practices, and communication pat- terns of clients and their families to improve services, strengthen programs, increase community participation, and close the gaps in health status

among diverse population groups.”

Clinicians are increasingly challenged to adopt cultural humility, a “process that requires humility as individuals continually engage in self-re ection and self-critique as lifelong learners and re ective practitioners.” This pro- cess includes “the dif cult work of examining cultural beliefs and cultural systems of both patients and providers to locate the points of cultural dis- sonance or synergy that contribute to patients’ health outcomes.” It calls for clinicians to “bring into check the power imbalances that exist in the dynamics of (clinician)–patient communication” and maintain mutually respectful and dynamic partnerships with patients and communities. The following three-point framework will help you.

T h e T h r e e D im e n s io n s o f C u lt u r a l H u m ilit y

1. Self-awareness. Le rn bout your own bi ses; we ll h ve the .

2. Respectful communication. Work to eli in te ssu tions bout wh t is

“nor l.” Le rn directly fro your tients; they re the ex erts on their culture nd illness.

3. Collaborative partnerships. Build your tient rel tionshi s on res ect nd

utu lly cce t ble l ns.