The interview we have presented thus far in the vignette with Mrs. Jones is just one example of how the interaction between a clinician and a patient can unfold. You might be wondering how to adapt the interview to different clinical settings, such as the hospital or emergency department. Perhaps you worry about interviewing a patient who cannot seem to stop talking, or one who it feels hard to pull information from. In this chapter, we will discuss how to adjust the interview to different clinical situations. Such fine tuning occurs primarily in the beginning of the interview (Steps 1–5: setting the stage, agenda setting, opening the history of present illness (HPI), continuing the HPI, and transition). This chapter focuses only on how you can tailor the process of the interview and does not consider the content that needs to be addressed in specific clinical situations. Clinical texts will help you obtain the details that must be incorporated into many of the encounters discussed here.1
There is no fixed rule on how to distribute the time you have for an interview between the beginning of the interview, the middle, and the end. Based on the patient's needs, you will determine the initial balance during Steps 1–5. You might average 10% of your time in the beginning of the interview for most patients, but this allocation of time can vary from 2% for, say, a patient who needs a medication refill and has no personal issues to more than 50% with, for example, a patient with severe marital problems. As you can see the amount will depend on the severity and urgency of the patient's personal issues. It may also be necessary to return again and again to using patient-centered interviewing skills even late in the interview.
In the beginning of the interview, the main block of controllable time lies in Step 4, continuing the HPI. Steps 1–3 and Step 5 usually take little time and are similar from patient to patient. Consider the following examples.
New Patient without Urgent or Complex Personal Problems
First consider a typical new patient, like Mrs. Jones, who comes to the clinician without urgent (where immediate action is required) or complex personal problems. Physical symptom complaints often predominate and we usually devote about 10% of our time to the initial patient-centered process of the interview. This will be your experience with many new patients in a medical setting, whether in- or outpatient. Such patients, like Mrs. Jones, have definite personal issues but they are not urgent or overwhelming; for example, a patient with known cancer is admitted to the hospital for chemotherapy but is more worried about his wife being home alone with the flu; an outpatient presents with a weight loss of 5 pounds and is somewhat concerned about possible cancer and wants “to be sure.”
New Patient with Urgent or Complex Personal Problems