82-102 BDD

Closing Health History Interviews and Visits

• Inform patients of the approaching end of the interview OR visit is approaching to allow for final
questions (Allow patient to ask final questions).
• Ensure patient understands mutual plans developed.
• Summarize plans for future evaluation, treatments, and follow-up.
• Use "teach back" technique to assess patient's understanding.
• Invoke the patient to express their understanding of their plan of care.
• Avoid introducing new topics in last few minutes.
• If concern is not life-threatening, assure patient of interest and plan future discussion.
• Reaffirm ongoing commitment to patient's health.

Taking Time for Self-Reflection.

• nonjudgmentally attentive to one's own experiences, thoughts, and feelings, is crucial for developing
clinical empathy.
• Recognizing and respecting individual differences.
• Personal values, assumptions, and biases influence our interactions with patients.
• Self-reflection, enhancing personal awareness and patient care.

The Cultural Context of the Interview

Cultural Humility
• Effective communication with diverse patient backgrounds is crucial.
• Difference in disease, morbidity, and mortality risks are evident across different population groups.
• Moderation requires self-reflection, critical thinking, and cultural humility.

Cultural Competence in Healthcare

• Cultural competence refers to the ability to work effectively in cross-cultural situations.
• It involves: understanding and respecting the health-related beliefs, attitudes, practices, and
communication patterns of clients and their families.
• Culturally competent care improves: services, strengthens programs, increases community
participation, and closes health status gaps among diverse population groups.
• Cultural competence is not static, but dynamic and constantly evolving.
• Mismatches between patients and providers can compromise this dynamic.
• Mismatches arise from: clinicians' lack of knowledge about patient beliefs and experiences, and
unintentional or intentional enactment of stereotypes and bias.
• Cultural humility involves: self-reflection and self-criticism as lifelong learners.

Self-Reflective Practice Commitment

• Study vignettes.
• Understand cultural differences and bias.
• Avoid poor communication and patient outcomes.

Cultural Humility: Scenario 1

Ghanaian Taxi Driver's Experience with U.S. Clinical Care
• 28-year-old taxi driver from Ghana, recently moved to the U.S., complained about U.S. clinical care.
• Experienced fever and fatigue, weighed, and had his temperature taken.
• Clinician, a 36-year-old woman from Washington, D.C., asked numerous questions and examined him.
• Patient refused to take blood, stating he didn't receive chloroquine.
• Patient expected few questions, no examination, and malaria treatment.

Cultural Humility: Scenario 2

Teen Health Center Interrogation and Mistreatment

• A 16-year-old high school student experienced menstrual cramps affecting her concentration.
• A 30-year-old male clinician pressured her into accepting birth control pills, despite her clear
intentions to postpone intercourse.
• The clinician dismissed her concerns and suggested ibuprofen as a solution.
• The patient refused to take the prescribed birth control pills and avoid seeking healthcare again.
• The clinician's questions made assumptions about her life and did not respect her health concerns.
• The patient received ineffective care due to conflicting cultural values and clinician bias.

Case Study: Mistaken Assumptions and Biases in Healthcare

• First case: Clinician failed to consider patient beliefs and care expectations.
• Second case: Stereotypes dictated agenda, neglecting patient's individuality.
• Each clinician's cultural background and biases persist as they become clinicians.

• Culture is a system of shared ideas, rules, and meanings that shape our worldview, emotional
experiences, and interactions.
• It's the "lens" through which we perceive and make sense of our world.
• Cultural systems are not limited to minority groups; they exist in all social groups, including clinical
professionals.

Managing Cultural Stereotypes in Healthcare

• Avoid personal impressions about cultural groups.
• Evaluate each patient as an individual, not reducing analgesic dose.
• Develop communication skills

• Build therapeutic partnerships based on respect for each patient's life experience.
• Use a framework to approach each patient as a unique individual.
The Three Dimensions of Cultural Humility [SRC]
1. Self-awareness. Learn about your own biases.
• Explore personal cultural identity, including ethnicity, class, region, religion, and political
affiliation.
• Consider characteristics like gender, life roles, sexual orientation, physical ability, and race.
• Understand how these identities influence beliefs and behaviors.
• Bring personal values and biases to a conscious level.
• Values are standards used to measure beliefs and behaviors.
• Biases are attitudes or feelings attached to perceived differences.
• Recognize and acknowledge biases without feeling guilty.
• Start with less threatening constructs like time and physical appearance.
• Consider how cultural norms shape our behavior and perceptions.
2. Respectful communication. eliminate assumptions about what is “normal.”
• Allow patients to be experts in their unique cultural perspectives.
• Maintain an open, respectful, and inquiring attitude.
• Ask about the patient's cultural background.
• Be aware of assumptions in questions.
• Acknowledge areas of ignorance or bias.
• Read about the life experiences of individuals in ethnic or racial groups.
• Explore the explicit health agendas of different consumer groups.
• Talk with different types of healers and learn about their practices.
• Be open to learning from each patient and not assume that your impressions about a given
cultural group apply to the individual before you.
3. Collaborative partnerships. Build your patient relationships on respect and mutually
acceptable plans
• Clinicians should work on self-awareness and see through others' lenses to establish
collaborative relationships.
• Trust, respect, and willingness to re-examine assumptions foster open communication.
• Listening to patients' emotions, such as anger or shame, is crucial.
• Be willing to re-examine beliefs about the "right approach" to care.
• Flexibility is key in developing shared plans that align with patients' best interests and
effective clinical care.

Advanced Interviewing
• Clinical skills development involves understanding reactions to different patient types.
• Experience aids in eliciting patient histories.
• Stressors like fatigue, mood, and overwork can affect interview success.
• Self-care is crucial in caring for others.
• Listening to patients and clarifying concerns is crucial, even in challenging situations.
The Silent Patient
• Silence in interviews can be used for various reasons, including collecting thoughts, remembering
details, or assessing trustworthiness.
• Clinicians should be attentive and respectful, encouraging the patient to continue when ready.
• Nonverbal cues like difficulty controlling emotions can be observed.
• Silence may be therapeutic, prompting the patient to reveal deeper feelings.
• Patients with depression or dementia may appear subdued, giving short answers, then falling silent.
• Silence may be a response to inappropriate questioning, such as rapid questioning, offending, or
failure to recognize overwhelming symptoms.

The Confusing Patient

• Some patient stories may be confusing due to the patient's style or underlying issues interfering with
communication.
• Some patients present a confusing array of multiple symptoms, requiring a psychosocial assessment.
• Other patients may have vague histories, poorly connected ideas, or appear distant or inappropriate.
• Symptoms may seem bizarre, suggesting a mental status change, mental illness, or a neurologic
disorder.
• If a psychiatric or neurologic disorder is suspected, a shift to mental status examination is suggested,
focusing on level of consciousness, orientation, memory, and understanding capacity.
• Questions can help ease this transition by asking about the patient's last appointment, address, and
phone number.

The Patient with Altered Cognition

• Patients with delirium, dementia, or mental health conditions may struggle to provide their own
histories.
• In such cases, information from family members or caregivers is required.
• Interviewing principles should be applied, including establishing a private conversation, assessing
credibility, and establishing the patient's relationship.
• Information should not be disclosed unless the informant is the health care proxy or has a durable
power of attorney, or with patient permission.
• The Health Insurance Portability and Accountability Act (HIPAA) sets strict standards for patient
information disclosure.
• Patient decision-making capacity is the ability to understand health information, weigh choices,
reason through options, and communicate a choice.
• Capacity is a clinical designation assessed by clinicians, while competence is a legal designation
decided by a court.
• If a patient lacks capacity, identify a healthcare proxy or agent with power of attorney.
• If a surrogate decision-maker is not identified, shift to a spouse or family member.
• Decision-making capacity is both temporal and situational, fluctuating based on the patient's condition
and decision complexity.
• Despite lack of capacity, it's crucial to seek patient input as they may have definite opinions about
their care.
Elements of Decision-Making Capacity [UUCA]
must have the ability to:

● Understand the relevant information about proposed diagnostic tests or treatment,

● Use reason to make a decision, and

● Communicate their choice.

● Appreciate their situation (including their underlying values and current clinical situation)

The Talkative Patient.

• Allow the patient to express their concerns freely for the first 5-10 minutes.
• Identify any obsessive detail, anxiety, or thought disorder in the patient.
• Focus on the patient's most important concerns and ask questions in those areas.
• Interrupt only if necessary, but be courteous.
• Set limits when needed to gain important health information.
• Use a brief summary to validate any concerns and change the subject.
• Avoid showing impatience and set a time limit for a second visit if time runs out.

The Crying Patient

• Crying signals strong emotions, ranging from sadness to anger.
• Pausing, gentle probing, or empathy allow the patient to cry.
• Crying is therapeutic and a quiet acceptance of distress.
• Offer a tissue and wait for recovery.
• Supportive remarks can help patients resume their story.
• Crying can make clinicians uncomfortable, so learn to accept emotional displays.

The Angry or Disruptive Patient.

• Patients may express anger due to illness, loss, loss of control, or overwhelmed healthcare system.
• Acknowledge the situation and try to make amends.
• Patients often displace their anger onto the clinician as a reflection of frustration or pain.
• Accept angry feelings without getting angry in return or retreating from the patient’s affect.
• Avoid reinforcing criticism of other clinicians, the clinical setting, or the hospital.
• Validate patients’ feelings without agreeing with their reasons.
• Help the patient work through their angry feelings and move on to other concerns.
• Alert security staff and stay calm and nonthreatening.
• Listen carefully and try to understand what the patient is saying.
• Gently suggest moving to a more private location once rapport is established.
The Patient with a Language Barrier
• These individuals are less likely to receive regular primary or preventive care and are more likely to
experience dissatisfaction and adverse outcomes from clinical errors.
• Working with qualified interpreters is essential for optimal outcomes and cost-effective care.
• The ideal interpreter is a "cultural navigator" who is neutral and trained in both languages and
cultures.
• When working with an interpreter, establish rapport and review the most useful information.
• Ask the interpreter to translate everything, not to condense or summarize.
• Arrange seating for easy eye contact with the patient and speak directly to the patient.
• When available, bilingual written questionnaires are invaluable, especially for system review.
• In some clinical settings, use speakerphone translators, if available.

Guidelines for Working with an Interpreter: “INTERPRET”

• Introductions: Clearly introduce all individuals and their roles.
• Note Goals: Outline the interview's objectives, including diagnosis, treatment, and follow-up.
• Transparency: Ensure all statements will be interpreted.
• Ethics: Use qualified interpreters to maintain patient autonomy and informed care decisions.
• Respect Beliefs: Consider cultural beliefs of Limited English Proficient (LEP) patients.
• Patient Focus: Ensure the patient remains the focus of the encounter, not the interpreter.
• Retain Control: Maintain control over the interaction, not letting the patient or interpreter dominate.
• Explain: Use simple language and short sentences to ensure clear communication.
• Thanks: Express gratitude to the interpreter and patient for their time.

The Patient with Low Literacy or Low Health Literacy.

To detecting Low Literacy Assessing literacy levels through school years, reading habits, and comfort
with health forms.
• Handing written texts upside down to patients to understand their level of literacy.
• Understanding the reasons for impaired literacy, such as language barriers, learning disorders, poor
vision, or education level.

Low Health Literacy

• Health literacy includes print literacy, numeracy, and oral literacy.
• Importance of these skills in healthcare environment.

The Patient with Hearing Loss.

• Factors affecting this population include hearing loss degree, age of onset, preferred language, and
psychological issues.
• Communication and trust are crucial, with high risk of miscommunication.
• Patient's preferred communication method is crucial.
• Understanding the patient's culture, schooling, and language preferences is essential.
• Some patients use American Sign Language (ASL) for low English reading levels and prefer certified
interpreters.
• Partial hearing deficits vary, and hearing aids should be checked and functioning.
• For unilateral hearing loss, sit on the hearing side and avoid background noise.
• Speak at normal volume and rate, emphasizing key points and asking patients to "teach back."
• When closing, write out instructions for patients to take home.

The Patient with Impaired Vision.

• Establish contact with blind patients through handshakes.
• Orient patients to unfamiliar surroundings.
• Report any other present individuals.
• Adjust light if necessary.
• Encourage wearing glasses.
• Focus on verbal explanations due to unseen gestures.

The Patient with Limited Intelligence.

• If a disability is suspected, focus on the patient's school record and independence.
• Assess their education, course completion, and any testing.
• Determine if they live alone and require assistance with activities.
• Check if the patient is sexually active and provide information about pregnancy or STIs.
• If unsure about the patient's intelligence, conduct a mental status examination to assess simple
calculations, vocabulary, memory, and abstract thinking.
• For severe mental retardation patients, consult family or caregivers first.
• Show interest in the patient, establish rapport, and avoid condescending behavior.

The Patient with Personal Problems.

• Patients may seek advice on personal issues beyond clinical expertise.
• Instead of responding, ask about alternatives, pros and cons, and advice from others.
• Allowing patient to discuss the problem is more therapeutic than giving personal opinions.

The Seductive Patient.

• Clinicians may experience physical attraction or flirtatious behavior from patients.
• Awareness of these feelings is crucial to avoid inappropriate responses.
• Sexual contact or romantic relationships with patients are unethical.
• Clinicians should maintain professional boundaries and seek help if needed.
• Ignoring seductive patient behavior can be tempting.
• Clear limits should be set on professional relationships.
• Clinicians should evaluate their own behavior and avoid sending misleading signals to patients.

Sensitive Topics
can be awkward for novices or unfamiliar patients.
• Topics include: alcohol/drug abuse, sexual practices, financial concerns, racial/ethnic bias, domestic
violence, psychiatric illness, physical deformity, and bowel function.
• These topics often trigger personal responses influenced by family, cultural, and societal values.
• Mental illness, drug use during pregnancy, and same-sex practices can evoke biases.

Guidelines for Broaching Sensitive Topics

• Be nonjudgmental and learn from patients to improve their health.
• Explain the necessity of certain information to reduce patient apprehension.
• Find opening questions for sensitive topics and learn the necessary information for shared assessment
and plan.
• Acknowledge discomfort and avoid avoiding the topic altogether.

The Sexual History.

• Sexual behaviors can determine pregnancy, STIs, and HIV risks.
• Sexual practices are linked to patient symptoms and integral to diagnosis and treatment.
• Sexual health can be addressed through questions about sexual health.
• Sexual dysfunction may result from medication or clinical issues that can be corrected.
• Sexual history can be elicited at multiple points in the interview, including genitourinary
symptoms, health maintenance, and lifestyle issues.
• Coverage of sexual history is crucial in older patients, patients with disability, or chronic
illness.
• Use specific language, referring to genitalia with explicit words, and asking about
satisfaction with sexual activity.

The Sexual History: Sample Questions

• Ask about last intimate physical contact and whether it included sexual intercourse.
• Discuss sex with men, women, or both partners.
• Ask about number of sexual partners in the last 6 months, 5 years, or lifetime.
• Explain the importance of new partners and routine use of condoms.
• Ask about concerns about HIV infection or AIDS.
The Mental Health History.
• Cultural constructs of mental and physical illnesses can influence social acceptance and attitudes.
• Open-ended questions can help understand patients' experiences with mental illnesses.
• Specific questions can include past experiences with counseling, medication, hospitalization, and
family history.
• For patients with depression or thought disorders, a careful history of symptoms and illness course is
crucial.
• Screening questions for depression include feeling down, depressed, or hopeless, and feeling little
interest in activities.
• If a patient appears depressed, ask about suicide.
• Severity of depression and angina should be evaluated.
• Community-based patients can provide information about diagnoses, symptoms, hospitalizations, and
medications.
• Stability of symptoms and functioning should be investigated, and support systems and care plan
reviewed.

Alcohol and Prescription and Illicit Drugs.

• High prevalence of substance abuse and dependence in the US.
• In 2013, 8.2% of Americans aged 12 and older were classified with a substance abuse or dependence
disorder.
• Increased abuse of prescribed pain medications, with 1.9 million people affected.
• 28% of Americans aged 12 years or older report binge or heavy drinking.
• 7 million have used prescription drugs for nonclinical reasons, especially pain relievers, stimulants, and
antidepressants.
• Regular assessment of current and past use of alcohol and drugs, patterns of use, and family history is
essential.

Addiction, Physical Dependence, and Tolerance

• Tolerance: An adaptation state where drug exposure leads to reduced effects over time.
• Physical Dependence: Adaptation manifested by drug-specific withdrawal syndrome.
• Addiction: A primary, chronic, neurobiological disease influenced by genetic, psychological, and
environmental factors.
• Characterized by impaired control over drug use, compulsive use, continued use despite harm, and
craving.

Alcohol.
• Alcohol and drug use questions follow questions about caffeine and cigarettes.
• Positive answers to "Have you ever had a drinking problem?" and "When was your last drink?" are
suspicious.
• Common screening questions include CAGE questions about cutting down, annoyance when criticized,
guilt feelings, and eye-openers.
• Affirmative answers suggest alcohol misuse, with sensitivity ranging from 43% to 94% and specificity
ranging from 70% to 96%.
• Short screening tests like MAST and AUDIT are useful.
• Detecting misuse includes blackouts, seizures, accidents, job problems, and personal relationship
conflict.

National Institute of Alcohol Abuse and Alcoholism Definitions of Drinking at Low Risk
for Developing and Alcohol Use Disorder
● Men: no more than 4 drinks on a single day or 14 drinks a week

● Women: no more than 3 drinks on a single day or 7 drinks a week

● Healthy adults over age 65 years and not taking medications: no more than 3 drinks on a single day
or 7 drinks a week

● 1 drink is defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of spirits

Illicit Drugs.
• The National Institute on Drug Abuse recommends asking about non-clinical use of illegal drugs or
prescription medications.
• If positive, ask about past use of marijuana, cocaine, prescription stimulants, methamphetamines,
sedatives, hallucinogens, street opioids, and prescription opioids.
• For those who answered yes, additional questions are recommended.
• Modify CAGE questions by adding "or drugs" to each question.
• Probe further with questions about control, bad reactions, drug-related accidents, injuries, arrests, job
or family problems, and attempts to quit.

Intimate Partner Violence and Domestic Violence.

• Intimate partner violence is the leading cause of serious injury and death among U.S. women of
reproductive age.
• U.S. Preventive Services Task Force and American College of Obstetricians and Gynecologist
recommend routine screening of all women of childbearing age for intimate partner violence.
• Elders are highly vulnerable to neglect and abuse.
• Sensitive interviewing is essential, as only 25% of patients disclose their abuse experience.
• Experts recommend starting with normalizing statements and then in-depth direct questions.
• Empathic validating and nonjudgmental responses are critical, but occur less than half the time.

Clues to Physical and Sexual Abuse

• Recognize unspoken signs of abuse, such as human sex trafficking victims.
• Spend part of the visit alone with the patient, asking others to leave the room.
• Avoid forcing the situation if the patient is resistant.
• Be aware of diagnoses associated with abuse, such as pregnancy and somatic symptom disorder.
• Screen for child abuse by asking parents about their approach to discipline.
• Understand how parents cope with a child who is crying or misbehaving.

Physical and Sexual Abuse Clues

• Unexplained injuries, inconsistent with patient's story, or cause embarrassment.
• Delay in trauma treatment.
• History of repeated injuries or "accidents."
• Presence of alcohol or drug abuse.
• Young pregnancy with multiple partners.
• Repeated vaginal infections and STIs.
• Partner dominating visit, unusually anxious or solicitous.
• Difficulty walking or sitting due to genital/anal pain.
• Vaginal lacerations or bruises.
• Fear of pelvic examination or physical contact.

Death and the Dying Patient.

• Health care education is focusing on improving care for dying patients and their families.
• Studies have advanced understanding of palliative care and set standards for quality care.
• Clinicians need to communicate effectively with patients and families about managing symptoms and
their care preferences.
• Interventions that improve symptom management and avoid hospitalization reduce grief and
bereavement, improve outcomes, reduce costs, and sometimes prolong survival.
• Advocacy for open discussions about patients' feelings and treatment preferences is crucial.
• The World Health Organization defines early identification and treatment of pain and other problems
as the goal.
• Patients' wishes about treatment at the end of life should be clarified.
• The health status of the patient and the health care setting often determine what needs to be
discussed.
• Discussing Do Not Resuscitate (DNR) status is often difficult if the patient has not had a previous
relationship with the patient or is unsure of their understanding of the illness.
• Encourage adults, especially the elderly or chronically ill, to establish a health proxy who can act as the
patient’s health decision maker.
• The interview can be a “values history” that identifies what is important to the patient and makes life
worth living.

Ethics and Professionalism

• Clinical ethics are principles derived from reflection and discussion to define right and wrong.
• These principles guide professional behavior and are not static or simple.
• Traditional maxims in healing professions, known as "principalism," are fundamental.
• As clinical ethics expands, other ethical systems like utilitarianism, feminist ethics, casuistry, and
communitarianism are used.
• utilitarianism emphasizes providing the greatest good for the greatest number, while feminist ethics
address marginalization of social groups.
• Casuistry analyzes paradigmatic prior cases, while communitarianism emphasizes community interests
and social responsibilities.

Building Blocks of Professional Ethics in Patient Care

• Nonmaleficence: The principle of "do no harm" to prevent harm from incorrect or irrelevant
information.
• Beneficence: The principle that clinicians act in the best interest of the patient.
• Autonomy: Informed patients have the right to make their own clinical decisions.
• Confidentiality: Clinicians are obligated not to repeat patient information.
• Justice: Frameworks suggest fair treatment and equitable distribution of healthcare resources for all
patients.

The Tavistock Principles

• Rights: Individuals have a right to health and care.
• Balance: Care of individual patients and population health is central.
• Comprehensiveness: Treating illness, easing suffering, minimizing disability, preventing disease, and
promoting health.
• Cooperation: Success depends on cooperation with patients, each other, and other sectors.
• Improvement: Improving healthcare is a continuous responsibility.
• Safety: Do no harm.
• Openness: Being open, honest, and trustworthy is vital.