I keep six honest serving-men
(They taught me all I knew);
Their names are What and Why and When
And How and Where and Who.
Rudyard Kipling, The Elephant's Child. In: Just So Stories.1
In the beginning of the interview, you greeted the patient (Step 1) and set the agenda for the visit (Step 2). You then obtained the first portion of the history of present illness (HPI) by eliciting the patient's unique description of his/her chief concern and its personal and emotional contexts (Steps 3 and 4); you responded to the patient's emotions with empathy. In Step 5, you informed the patient of the transition to the middle of the interview.
The data you collected in the beginning of the interview, while essential, are rarely complete. In the middle of the interview, you will gather more detailed information on the patient's HPI and other active problems (OAP). You will also ask about other symptoms, the patient's life and medical history to help you make a diagnosis, identify medical issues other than the chief concern, assess for disease risk, and come to know the patient better. This additional information falls under the headings of past medical history (PMH), social history (SH), family history (FH), and review of systems (ROS). We will cover each of these in detail in Chapter 5.
In the middle of the interview, you will be more directive, guiding the topics discussed by using the clinician-centered interviewing skills as contrasted with the patient-centered interviewing skills you used in the beginning of the interview. Clinician-centered skills, such as “coning-down”—following open-ended questions with closed-ended ones (see Chapter 2)—help you to clarify and explore details of the patient's symptoms to test hypotheses and make a diagnosis, as well as to efficiently gather the large amount of data required. Even though you will often be asking lists of clinician-centered questions, it is important to remain alert to the patient's emotional state and any verbal or nonverbal cues of emotion, and respond with emotion-seeking and empathy skills (NURS) as needed.
Your first goal in the middle of the interview is to develop as complete and precise a characterization as possible of the patient's symptom story. To do this, you will use symptom-defining skills. Just as you learned facilitating skills before conducting the beginning of the interview, symptom-defining skills will help you perform the middle of the interview.
But first, what is a symptom? Generally speaking, a symptom is an indicator of the existence of something else. In medicine, we take it to mean the subjective evidence of the patient's underlying problem. In this way, it differs from a sign, which is the objective evidence of a disease or disorder. The patient tells the clinician about a symptom (chest pain, shortness of breath), while the clinician observes a sign on physical examination (tender ribs, ...