The objective of this step is to remind students of the tenets of the patient-centered interview that they learned in their first year. Students interview their assigned patients and record their personal and psychosocial history . In Chap. 12, I referred to two main components of the personal history of asymptomatic persons, namely, risk indicators of disease and resistance resources . In symptomatic patients, the personal and psychosocial history also includes a patient’s concerns and perceptions of the cause of his/her illness, its severity, and expected outcome; the extent of a patient’s disability and dependence on others for daily activities; a patient’s self-description (outgoing, sociable, energetic/quiet, introspective, moody, meticulous), and state of mind (optimistic, hopeful, confident/resigned, anxious, pessimistic).

These three additional components of a patient’s profile are important because first, they provide care-providers with insight into a patient’s psychological resources, frame of mind, and amount of support and assistance s/he will need in coping with disease. Second, patients’ perceptions of the causation and seriousness of their diseases may affect their adherence to treatment. And last, it has been my impression that making students ask themselves, “What kind of person is the patient? What are his/her concerns? And how does s/he view the disease and life in general?” is an effective means of promoting empathetic attitudes. After completing the interview, each student prepares a written description of a patient’s profile, and the clinical relevance of the personal and psychosocial history is explored during group discussions.

The following is an example of the personal and psychosocial history of a patient with a chronic heart disease:

Dr B, age 60, lives with his wife in a three-room apartment. They have three married children and five grandchildren living in the same city. The patient holds a PhD degree in history and, until about 6 months ago, was a college professor; however, he had to retire because of his disease and in recent months, he has been mostly homebound. Although capable of taking care of himself and performing the activities of daily life, he tires easily and experiences shortness of breath even after little effort. The family income includes his pension/disability allowance and the salary of Mrs B who is a librarian. His health insurance covers outpatient, in-hospital and home care. The patient describes himself as a “loner” with only few friends beyond his wife and extended family.

For the past 10 years, he has known that he has heart disease. Even before that, he was aware of his hereditary susceptibility to heart disease (see family history), and has adhered to a low-fat diet, regular exercise and the recommended immunizations. Although satisfied with the home care he receives from a nurse specialist in heart disease and a cardiologist, the patient is worried by the deterioration in his health in the past year, and is pessimistic about the future. He appears resigned and does not believe that he is likely to recover.

The objective of this step is to impart the ability to formulate and record the CC and its duration. The CC is defined as the immediate reason that led a patient to seek medical care. Beginning at this stage, students are encouraged to generate provisional hypotheses about the origin of a patient’s complaints, and to list additional symptoms which, if present, would support these hypotheses. Examples:

• 
  
  CC: Chest pain of 3 hours’ duration on the day of admission
  
  
• 
  
  CC: Low back pain for the past week
  
  
• 
  
  CC: None, patient referred with an incidental finding of a round shadow on chest X ray.

During the group discussions, patients’ CCs are grouped into categories: pain (e.g., abdominal), symptoms due to organ dysfunction (e.g., cough), incidental findings (e.g., jaundice), and general symptoms (fever, fatigue, loss of weight). The tutor makes an effort to select patients whose CCs are localized pain or symptoms of organ dysfunction and in whom the differential diagnosis can be based on anatomic locations. The students’ initial hypotheses are confined to designating the anatomic region from which the complaint originates, for example, “pain in the chest could be a manifestation of a disease of the heart, lung, or esophagus; possible additional symptoms: dyspnea, cough, dysphagia;” or “epigastric pain could result from a disease in the stomach, duodenum, pancreas or gall bladder; possible additional symptoms: vomiting and heartburn;” or “diarrhea could be caused by a disease of the small or large bowel; possible additional symptoms: abdominal pain, vomiting, tenesmus.”

In these early stages of the course, students are already taught to perform a focused physical examination looking for findings that could support their provisional hypothesis, for example: “dyspnea could be caused by a disease of the heart or the lungs; in this patient, it is probably caused by a disease of the heart because the apex beat is displaced to the left and the heart rhythm is irregular,” or “the epigastric pain in this patient may originate in the liver or the bile ducts as suggested by his jaundice.”

Earlier, I emphasized the importance of gaining insight into patients’ concerns , which may or may not be identical to the CC. For example, a patient’s CC may be “pain in the chest on exertion for the past three months,” or “low back pain during the past week,” and these may also be his/her main concern. However, in a case where chest pain was the CC, a patient’s main concern may differ, for example, it may be whether he needs the bypass surgery that was recommended to him (“Perhaps, I should have a second opinion?”) other fears (“I am afraid of dying,” “I think things will never be the same again,”), or how the disease will affect his lifestyle (“Will I be able to travel?” “Will I be able to resume my work?”) In a case where low back pain was the CC, the patient’s main concern may be her teenage son’s trouble with the police (“Well doctor, since you ask… my main worry, right now, is my boy, not my back”).

The advantage of adding a patient’s main concern(s), preferably expressed in the patient’s own words, is that it brings them to the doctor’s awareness, thereby triggering the empathetic process. Furthermore, while the CC is restricted to symptoms and signs, a patient’s concerns include all possible sources of her/his distress and needs for help. In the case of a patient whose main fear is the coronary artery bypass operation that has been recommended, the doctor may review the necessity of surgery, rather than make a needless change in a patient’s medications. In the instance of a mother whose main concern is her teenage son’s trouble with the police, the doctor may lend support, show understanding, and offer sensible advice. By making the main concern, rather than the CC, the point of departure for subsequent patient management, doctors may considerably expand their ability to help their patients.

The objective of this step is to identify and list a patient’s symptoms . Students listen to a patient’s narrative with special attention to symptoms, and list them in the order of their appearance. At this stage, students refrain from detailed descriptions of the symptoms and their course. The required written report consists of the first two sentences of the statement of the PI, for example:

The present illness began 3 years ago. Its manifestations were bouts of chest pain, shortness of breath, and swelling of the legs

The present illness began 3 days ago. Its manifestations were fever (39 °C), shaking chills, dry cough, and sore throat.

As in the previous stage, patients with a single problem, preferably localized pain, or organ dysfunction, are assigned. If the student succeeds in identifying the diseased organ or system, he is referred to appropriate sources and encouraged to suggest more specific diagnostic hypothesis , for example, “pain in the right flank and dysuria may be caused by disease of the urinary tract, possibly a bacterial infection or a stone” or “fever, cough, and pain in the chest of 2 days’ duration may be due to an inflammation of the respiratory tract, for example, bronchitis or pneumonia.”

The objective of this step is to introduce the student to the problem-oriented approach. At this stage, patients with more than one problem are selected for interview and examination. Students now have to differentiate between groups of symptoms that may indicate different medical problems. The criteria for grouping symptoms are (a) obvious origin in the same organ system and (b) similar duration, or simultaneous onset, or both. For example:

1.

The present illness began 6 h before hospitalization. Its manifestations were chest pain, profuse sweating, and palpitations.

 

2.

During the past 2 years, the patient has complained of bouts of epigastric pain and heartburn.

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Related posts:

1. Difficulties in Learning and Teaching Patient Interviewing
2. Doctor–Patient Relations
3. Recording a Patient’s Personal/Psychosocial History and Examination of Asymptomatic Persons
4. Intuitive Versus Analytic Clinical Reasoning

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