In some cases, discussion of family history may cause the patient to become anxious. In asking about family diseases, you imply a possible relationship to the patient’s current medical problem. It is helpful to emphasize the “routine” nature of the inquiry. Here is an example of a clinician who stumbles on anxiety-provoking information in asking a rou- tine family history question.
Clinician Yeah, okay. Very good. Now your mother and father, what did they. … Are they still alive?
Patient Um, my mother is alive, my …
Age?
Notice how the clinician hesitates over the initial question, realizing that the first fact he needs to know is whether the parents are living; then, barely listening to the response, he asks another question. The dialogue continues:
Patient She is 64.
Clinician She have any illnesses you know of?
Uh …
Heart disease, lung disease, anything?
No, nothing of that sort; she’s had a well-known skin cancer and uh, and she seems to have a recurring, it’s a problem with her back, but actually it’s a nerve that has to be blocked every once in a while.
Okay. Your father?
I never really knew that much about my father, but as I understand it he died of a cerebral hemorrhage.
How old was he?
Oh, he must have been in his early 40s.
Was an autopsy done or anything to find out … ?
There was so little … there was a bad occurrence, bad divorce between our mother and father when I was real young and I never saw him after age 9 months really. So I’m very hazy on the particulars of this.
The clinician here stumbles on two kinds of loaded information: (1) the father died of a cerebral hemorrhage at about the same age the patient is now, and (2) the patient does not know much about it because of a “bad occurrence.” The clinician ignores the “bad occurrence” and goes after a possible cause of the hemorrhage, a cerebral aneurysm being relevant here because this condition can be hereditary.
Clinician But nobody knew whether it was traumatic; did he get hit or anything?
Patient I don’t know the details, to tell you the truth. He had, well, I just don’t really know enough to talk about it.
Cerebral hemorrhage at a young age would be an unusual thing. No other causes being known.
I could find out more, my mother may know more about it.
If she knew, it would be important to you—if she would know,
for instance, if he had an aneurysm in his brain that burst, which is one of the ways you can have a cerebral hemorrhage at a young age. I think that would be very important, for instance, for your general health information, so perhaps you can find out. Okay? Do you know anything more in terms of other problems?
Note the interviewer’s graphic description of “an aneurysm in his brain that burst” and the statement that this “would be very important” while quickly moving on to “other problems.” The patient, whom we first met in Chapter 2, Respect, Genuineness, and Empathy, now goes on to talk about the “painful subject” while the clinician completely ignores the affective content.
Patient Well, my understanding is, the context of this, that my mother was raised in the Catholic church and divorce was a terrible scandal in her mind, and she tried to forget about it as quickly as she could. It’s such a painful subject that there was never any discussion about who he was and so forth. And as a consequence, all I’ve really heard are niblets, and one of the things I understand is that he was an alcoholic, or at least had a problem with alcohol, but really caused my mother a lot of problems. So, I don’t know if that would be a complicating factor in terms of aneurysm or not.
Clinician Not that I know of. How about brothers and sisters?
I have one full natural brother and then four half-brothers.
Any medical problems in any of them that you know of?
No.
This example demonstrates insensitivity to the patient’s feelings and self-disclosure. It also shows that, by pursuing an item of family history, the clinician can increase the patient’s anxiety and raise new questions in the patient’s mind about his or her own health. A person who tells you that his sister had breast cancer, that his father (who smoked two packs of cigarettes per day for 40 years) developed lung cancer, or that his uncle (an asbestos worker) died from mesothelioma may feel that he is at high risk for developing the same diseases, or some other form of cancer. The more you press for details, the more your patient may believe that there is a connection with his or her present illness. Such a patient may need reassurance that he or she is not at special risk, if the environmental risk factors do not apply.
Another source of anxiety arises from the psychological bias called
availability. An unusual illness that happens to occur in a family mem-
ber is highly visible and “available” to the patient. Therefore, it has a greater impact on his or her fears than we, as clinicians, might feel is jus- tified. We look at the disease statistically and understand that it is not familial and that the chance of its occurring twice in a small number of people is extremely remote. However, as a clinical student, resident, or practicing clinician, you will find that availability plagues you all the time, just as it plagues your patients. After you diagnose your first case of glioblastoma multiforme, you are likely to overreact to your next group of patients who complain of headaches. For the same reasons, you must be especially sensitive to the anxieties of the dizzy patient whose sister has multiple sclerosis, or the mother of a child with vomiting and recent vari- cella whose nephew had Reye’s syndrome.
• Make it clear that taking a family history is a routine part of your complete medical interview.
• Listen carefully for any emotional overlay or any connections made by the patient between family illnesses and his or her own. • Demand no more detail than is required.
• If the patient does become anxious, direct your attention to the anxiety by allowing the patient to express his or her concerns directly. In some cases, you may have to give an additive response (see Chapter 2, Respect, Genuineness, and Empathy) to relate the patient’s free-floating anxiety to some unconsciously held causal belief (e.g., the coincidence of the patient’s current age and her mother’s age at the time she died).
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RACTICEP
OINTYou can avoid creating anxiety by being clear about why you need the information, being sensitive to the patient’s responses, and being informative in your explanations.