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CHAPTER 1

The Patient Interview

Sneha Baxi Srivastava, PharmD, BCACP

LEARNING OBJECTIVES

•  Explain the basic communication skills needed when performing a patient interview.

•  Describe the components of the patient interview.

•  Conduct a thorough medication history.

•  Compare and contrast the different patient interview approaches in various clinical settings.

•  Adapt the interview technique based on the needs of the patient.

KEY TERMS

•  Active Listening

•  Rapport

•  Empathy

•  Open-Ended Questions

•  Leading Questions

•  Probing Questions

•  Nonverbal Communication

•  Chief Complaint

•  History of Present Illness

•  Pertinent Positive

•  Pertinent Negative

•  Past History

•  Medication History

•  Family History

•  Personal and Social History

•  Review of Systems

•  Physical Exam

•  QuEST/SCHOLAR-MAC

INTRODUCTION

The patient interview is the primary way of obtaining comprehensive information about the patient in order to provide effective patient-centered care, and the medication history component is the pharmacist’s expertise. A methodological approach is used to obtain information from the patient, usually starting with determining the patient’s chief complaint, also known as the reason for the healthcare visit, and then delving further into an exploration of the patient’s specific complaint and problem. A comprehensive patient interview includes inquiring about the patient’s medical, medication, social, personal, and family history, as well as a thorough review of systems and possibly a physical examination.

The medication history is the part of the patient interview that provides the pharmacist the opportunity to utilize his or her expertise by precisely collecting each component of the medication history (however, a medication history may also be collected independent of a comprehensive patient interview). The questions that you ask the patient, as well as the technique used, will enable you to learn exactly how, when, and why a patient takes each medication, as well as about any adverse reactions, allergies, or issues with medication cost the patient may have experienced.

The approach to the patient interview and medication history will change based on the setting in which you are practicing. For example, if the setting is a community pharmacy and you are responding to a problem that may allow for self-care, your questions will be directed at meticulously characterizing the patient’s complaint and obtaining specific information that will influence your assessment and plan for the patient. However, if you are in a hospital, the focus of the interview may need to be modified based on the patient’s condition and the particular unit or department in which he or she is being cared for so that the patient’s needs may be met.

Regardless of the setting, your goal during the interview will be to provide patient-centered care; this can be accomplished by combining your pharmacotherapeutic knowledge with a solid foundation of excellent communication and patient-interviewing skills. Excelling in these communication skills is a learned technique that takes time and practice to master. Once these skills are employed in practice, the relationship that is developed with the patient is often stronger, allowing for the patient to have increased confidence and trust in your role as a healthcare provider.

The purpose of this chapter is to describe the various components of the comprehensive health history and to provide an overview of the skills and techniques required when communicating with the patient. This chapter will focus on the best practices to follow when collecting information from the patient.

COMMUNICATION SKILLS

Communication skills are the fundamental link between the pharmacist’s expertise about drugs and his or her contribution to providing excellent patient-centered care. Although communicating with a patient may seem like a simple task, it actually takes practice and knowledge to communicate with the patient in a manner that encourages respect for the healthcare provider and that enables the pharmacist to obtain an accurate and complete history. Some practitioners are able to naturally communicate with patients more effectively, whereas others have difficulty communicating with patients due to a variety of reasons, including their personality, comfort level, and confidence. However, regardless of one’s natural abilities, communication skills and questioning techniques, especially when it comes to communicating with patients, are learned and take time to develop. A variety of excellent in-depth resources describe communication skills. This chapter examines the most pertinent skills required to conduct a comprehensive medication history. These skills and questioning techniques include:

•  Active listening

•  Empathy

•  Building rapport

•  Open-ended questions

•  Closed-ended questions

•  Leading questions

•  Silence

•  “Why” questions

•  Nonverbal communication cues

Active Listening

The first communication skill to be mastered is listening, specifically active listening. Listening is defined as hearing what is being said, whereas active listening is a dynamic process that includes both hearing what is being said as well as processing and interpreting the words that are spoken (and/or unspoken) to understand the complete message that is being delivered. Whereas listening is a passive process, active listening requires the listener to consciously choose to give the patient attention and concentration that is free of distractions and interruptions, both external and internal.

External distractions are the easier of the two to avoid. External distractions include ringing telephones, flickering computer screens, and other infringing personal and/or other duties. These external distractions can be avoided by interacting with your patient in a place that is free of such distractions.

Internal distractions occur for two major reasons: (1) many matters, unrelated to the patient in front of you, may occupy your mind and (2) it is difficult to perceive what the patient is saying without tainting his or her message with your personal judgment. The first reason can be addressed by making a conscious effort to concentrate solely on your interaction with the patient. This is more difficult to accomplish than it sounds, but, with practice, turning on the “listening switch” in your mind will become easier.¹ The second reason is more difficult to address, because instinct often leads us to judge or evaluate what the patient is saying based on our own frame of reference. Biases, prejudices, and judgments cloud the message that is being delivered by the patient, which, in turn, affect the patient interaction, and possibly clinical outcomes.² For example, as you prepare for a patient who has been referred to you for smoking cessation counseling, you read in several progress notes that the patient “refuses to give up smoking.” As you meet with that patient, in your mind you may be thinking that “it’s so difficult to give up smoking and most people don’t really want to give up smoking” based on your previous encounters with other patients. After reading the patient’s notes, your preconception may be strengthened. Therefore, as your patient is talking about reasons why it is difficult for him to quit smoking, your mind is hearing what is being said but is interpreting it as excuses rather than reasons that you may be able to address with the patient to assist him in quitting smoking. One way to overcome internal distractions is by being present in the moment, during your patient visit, addressing your patient’s current concerns without focusing on your preconceived notions.

Empathy

Empathy is defined as the “intellectual identification with or vicarious experiencing of the feelings, thoughts, or attitudes of another.”³ The terms empathy and sympathy are often confused. Sympathy is when you feel sorry for the patient but do not feel the same emotions or are not in the same situation, whereas empathy is when you place yourself in your patient’s situation and respond based on either similar personal experiences or through vicarious understanding. When you express empathy, it allows your patient to feel as though you understand his or her unique experience and that you are applying your expertise to the patient as an individual.

Empathy can be shown in several ways, and each way will depend upon the particular patient as well as the situation. For example, nodding your head, making a statement, or asking a follow-up question can show empathy.² Additionally, it is important to distinguish between an empathetic statement and the assumption that you know exactly what the patient is feeling. For example, saying to your patient who has been diagnosed with cancer, “I know just how you are feeling. My grandfather had cancer and it was such a shock to all of us. At first, he was just so overwhelmed and upset” may make the patient feel like you are not truly listening to her, but rather assuming that she will respond like anyone else with a cancer diagnosis. It may be better to say, “I know from some personal experiences that finding out about cancer can be very overwhelming. How are you feeling?” Although there is no one way to show empathy, focusing on the key factors of allowing patients to feel understood while maintaining the uniqueness of their experience(s) may allow for a better patient interaction.

Building Rapport

The first impression you make on your patient will weigh on the rest of the patient interview as well as affect your relationship with the patient. Building a good rapport sets the tone for the interview and allows the patient to feel comfortable with you, thereby making the lines of communication more open and honest. Patients may sometimes withhold information if they feel uncomfortable or anxious about sharing their complaints because of a lack of feeling respected, feeling as though their words are not being heard, or quite simply not knowing who you are and what your role is in their care. Therefore, starting the interview by greeting the patient by name, making sure you are pronouncing the patient’s name correctly, asking how he or she prefers to be addressed, and adding a title to his or her name, if preferred, will indicate your interest in the patient and show that you care. You should also give your name and title and then briefly describe the purpose of the interview. For example, you could say, “Hello Mrs. Smith, my name is Ankur Kumar. I am the pharmacist who is part of your medical team, and I am here to ask you a few questions about what brought you to the hospital and discuss the medications you have been taking at home.” If there are others in the room, you should greet each person in the room, and then ask your patient for permission to continue with the interview in the presence of others. For example, you may say, “I have a few questions for you, Mrs. Smith. Is it okay for me to speak to you with your family/friends in the room or would you prefer to be alone while we talk?”

Even if you have met the patient before, you may want to remind the patient of your role, especially if you are in a hospital setting where the patient may be overwhelmed by the many providers participating in his or her care.⁴ Making appropriate introductions, interacting respectfully with the patient, and making the patient feel comfortable will build excellent rapport, leading to a strong foundation for the patient–pharmacist relationship.

Open- and Closed-Ended Questions

Open-ended questions are questions that require the patient to answer with more than a simple yes or no or nod of the head, whereas closed-ended questions generally limit the patient’s response to either a yes or no or a nod of the head. In general, open-ended questioning is the preferred technique to use during patient interviews to compel the patient to provide more in-depth and insightful responses. Because open-ended questions do not limit the patient to responding with a yes or no, they encourage the patient to disclose more information. For example, you can start the interview by asking an open-ended question, such as “How are you feeling today?” or a closed-ended question, such as “Are you feeling well today?” The first approach allows for the patient to answer in free form and possibly give you more detail about the condition of his or her health, whereas the second way leads the patient to answer with either a yes or no, thereby limiting the information that you obtain from the patient.² This, in turn, may lead to a rapid sequence of more closed-ended questions.

For example, if you ask the patient a closed-ended question such as, “Do you take your medications as directed by your physician?” you will most likely receive a response of “yes.” Although the patient may indeed be taking each medication as directed by his or her physician, you may be missing the opportunity to discover how the patient is actually taking each medication. Instead, if you ask the patient an open-ended question, such as “How are you taking this medication?” the answer will likely include more details, such as the dose and frequency of the medication. By gathering more information with open-ended questioning, you may learn that there are discrepancies between how the patient is actually taking the medication and how it has been prescribed. Oftentimes, a patient answers, “Yes, I am taking it as directed,” but you then discover that this is not the case, perhaps as a result of dishonesty but more likely because the patient believes that he or she is taking the medication correctly. The use of open-ended questions enables you to gather more information from the patient and to be more complete and accurate in your assessment; this, in turn, leads to appropriate patient-specific care.

Closed-ended questions do play a role in communicating with a patient; however, the use of close-ended questions should be specific to the information you want to collect. For example, if you would like to know whether the patient took his or her blood pressure medication in the morning to more accurately assess his or her blood pressure reading, you might ask, “Did you take your blood pressure medications this morning?”

Additionally, you can use open-ended questions to determine the presence or absence of certain symptoms or to further explore a symptom that the patient is experiencing. For example, after asking an open-ended question such as “What symptoms are you currently experiencing?” and hearing the response “My head hurts,” an appropriate closed-ended follow-up question would be “Is the pain behind your eyes?”

Leading Questions

Leading questions are those that suggest a particular answer. These questions lead a patient to provide a response that he or she perceives to be the answer that the interviewer wants to hear. An example of a leading question is “You do not miss any doses of your medication, do you?” By phrasing the question in this manner, the patient feels obliged to say, “No, I don’t” because the question implies that the patient should not be missing doses, and, rather than contradicting your expectation, the patient merely agrees. Therefore, to obtain an accurate response to your questions, leading questions should be avoided.

Silence

The role of silence during your interaction with the patient is more significant than you may realize. By allowing moments of silence after asking a question, the patient is able to reflect upon your question and provide a more thoughtful and accurate response. However, silence may also indicate that the patient has not understood your question. Nonverbal cues will help you determine the difference. You can use nonverbal cues to gauge each patient independently to determine the appropriate length of time to be silent and/or when to break the silence. Determining the appropriate length of silence to use is definitely an art. In general, the silence should be long enough to provide the patient a chance to gather his or her thoughts but not so long as to make the patient feel uncomfortable.

“Why” Questions

As you are interviewing your patient, avoiding “why” questions may prevent the patient from feeling as though he needs to defend his choices and actions. Although it may be necessary to learn the reasoning behind the patient’s choices and actions, the wording that you use may impact the response. For example, if you desire to learn why a patient is missing doses of hydrochlorothiazide, instead of asking “Why do you miss your doses?” you might ask “What causes you to miss your doses?” or “What are some reasons for missing your doses of the hydrochlorothiazide?” The difference is subtle, but it may be enough to affect the way the patient perceives the question. With the “why” method, the patient may feel the need to defend him- or herself, whereas the “what” method allows the patient to reflect on his or her reasons without feeling as though you are offering judgment.

Nonverbal Communication

Nonverbal communication is the sending of messages to or from your patient without the use of words. This type of communication plays an important role in your interactions with your patients because it can be as powerful as the words that are spoken. Nonverbal communication includes tone of voice, choice of language, facial expressions, body posture and position, gestures, eye contact, appearance, and overall behavior.¹ A patient’s perception of nonverbal communication may be influenced by individual and cultural differences. Therefore, you should be sensitive to cultural differences prior to making inferences about the patient based on nonverbal communication. Table 1.1 describes the various types of nonverbal communication and provides examples for tone of voice, choice of language, and facial expression.

The Issue of Reliability

During the patient interview, you must assess the reliability of the information that is being conveyed to you. Many factors may affect a patient’s reliability, including certain psychiatric conditions, impaired cognitive function, inadequate memory recall, or even a lack of understanding of the questions being asked. Therefore, it is important to assess the patient’s reliability during the interview. Listening for and recognizing clues that the patient may not be relaying accurate information, no matter the reason, takes experience. One way to address potential unreliability is to cross-reference the information from a variety of sources, including the patient’s profile, medical records, and information from the pharmacy. In some cases, it may be necessary to include a caregiver or family member in the interview session. This would need to be done in a manner that is consistent with the HIPAA procedures at your institution.

THE PATIENT INTERVIEW

The patient’s story is considered to be the key to the medical interview, and asking the right questions and actively listening to the patient can best obtain this story. As you interview the patient, you will come to realize that an organized approach provides a solid foundation, but you must follow the patient’s story in the order it is being told versus the patient answering your questions in a predetermined order. This being said, it is necessary to know the core elements of the systematic approach to a patient interview to ensure that all of the components are addressed and eventually documented and/or communicated in an organized manner that is recognized by all healthcare professionals. It has been well documented in the medical field that effective communication with patients leads to better diagnosis and treatment, as well as an improved provider–patient relationship.⁵ Although most of this research is related to physician–patient communications, it can easily translate to communications between the pharmacist and the patient. This is because pharmaceutical care, like the care provided by a physician, involves (1) curing a patient’s disease, (2) eliminating or reducing a patient’s symptoms, (3) arresting or slowing a disease process, and (4) preventing a disease or symptoms.⁶ Even though a pharmacist does not make disease diagnoses like physicians do, a pharmacist must nonetheless evaluate the information obtained from the patient interview, including the possibility of certain diagnoses, to appropriately create an assessment and plan, which may include a referral to the patient’s physician or an emergency room for further evaluation.

TABLE 1.1 Types of Nonverbal Communication

Components of the Health History

Chief Complaint

The chief complaint (CC) is the issue or issues that the patient is presenting with and the primary reason for the visit. This is typically documented in the patient’s own words and is therefore quoted in the written or oral presentation. One way to determine the patient’s chief complaint is by asking, “What brings you here today?” Some patients may have an actual complaint, while at other times they may be visiting for a general reason, such as to pick up a new or refill prescription or for a follow-up visit. In the case of no overt complaint, the chief complaint may be goal-oriented, such as “I am here to pick up my refills,” “I am here to discuss my labs,” or “My doctor told me to see you about my sugars.”⁴ At times, the patient’s chief complaint may seem relatively minor compared to the assessment; however, regardless of the final diagnosis, the chief complaint should be the patient’s primary complaint. For example, a patient may come in complaining of “being out of his furosemide” and, upon evaluation, it may be determined that the patient is experiencing acute heart failure. This assessment and the subsequent plan will be discussed elsewhere in your documentation.

History of Present Illness

The history of present illness (HPI) is the story of the illness.⁷ The pharmacist will further explore the chief complaint as well as any other potential problems by asking questions about any recent or remote history that may be related to the current illness. The goal of the HPI is to ascertain a complete, accurate, and chronological account of the illness from the patient. Seven attributes need to be addressed to obtain a well-characterized description of the complaint or symptom: location, quality, quantity or severity, timing, setting, factors that aggravate or relieve the symptoms, and associated manifestations.² Table 1.2 describes each attribute in more detail and provides an example. As you talk with the patient, the flow of the HPI may depend on what the patient wants to tell you; however, most of the time all seven attributes of a symptom must be addressed to completely characterize the patient’s complaint and to develop the HPI. For example, if a patient complains of a cough, it is not necessary to ask about the “location” of the cough. However, if a patient complains of a headache, specifying the exact “location” of the pain (i.e., front, back, or side of the head) will assist in the assessment.

TABLE 1.2 Seven Attributes of a Symptom