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You just don't luck into things as much as you'd like to think you do. You build step by step whether it's friendships or opportunities.

Barbara Bush

This chapter describes a user-friendly step-by-step method for the beginning of the medical interview that has been effective in many hands during the last 20 years.18 Your first task is to master the 5 steps and 21 substeps shown in Figure 3-1. We urge you to learn these thoroughly; to the point that they become reflexive—this is easily accomplished by studying, and then practicing them. Even though this may seem like a lot to learn, just as you learn the intricacies of cardiac physiology, this is your major task in mastering the medical interview. Using these steps and substeps will make you a more scientific and more humanistic physician—and your patients will benefit (see Appendix B for a detailed humanistic and scientific rationale for being patient-centered). To assist you, we also have developed a video that demonstrates the same skills described here: (see Preface).

Figure 3-1.

5-Step Beginning of the Interview.

When first learning these steps, use them in the order presented, primarily as a learning tool. As you become more skilled, you can vary the steps and substeps to experiment as well as to adapt to specific occasions and needs. You may find that some substeps can be omitted and, in other instances, you may want to change the ordering. The steps and substeps are simply a pathway to lead you through the interview; use them flexibly to individualize and enhance your own style and the patient's individuality.

The five steps in the beginning of the interview establish the clinician–patient relationship and encourage the patient to express what is most important to her or him. Throughout this book, an ongoing interview with “Mrs. Joanne Jones” will illustrate each step; this and other examples are derived from real patients and situations; we have changed all names and identifying information to protect the confidentiality of our patients.

Let's first talk about some preparatory skills: setting the stage (Step 1) and determining the agenda (including the chief concern/complaint) for the interview (Step 2). These steps prepare both you and the patient for the patient-centered interviewing skills you will use in Steps 3 and 4, which is where the data-gathering and relationship-building skills you learned in Chapter 2 will be incorporated.

The skills in Step 1 are simple, but often overlooked911 courtesies that ensure a patient-centered atmosphere. Table 3-1 lists these substeps in their usual order of use at the first meeting with a patient; appropriate adjustments are made when the patient is already known to the interviewer. These skills establish or reaffirm participants' identities, put both the interviewer and the patient ...

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