1. At the beginning of the consultation, patients often feel anxious due to unfamiliarity with the medical environment and fear of illness. The physician should actively create a relaxed and harmonious environment to alleviate the patient’s anxiety. It is important to protect the patient’s privacy. Ideally, the consultation should not begin in front of strangers. If the patient requests a family member to be present, the physician may agree. Generally, start with polite conversation, introducing oneself (wearing a name badge is a good way to introduce oneself) and explaining one’s responsibilities. Using appropriate language or body language to express a willingness to alleviate the patient’s pain and meet their needs will help establish a good doctor-patient relationship, quickly shorten the distance between them, and improve the unfamiliar situation, allowing for a smooth collection of medical history.
2. Allow the patient to fully express and emphasize what they consider important situations and feelings. Only when the patient’s statements stray too far from the illness should the physician flexibly steer the conversation back to the main clues, without abruptly interrupting the patient’s narrative or replacing the patient’s personal experiences with the physician’s subjective speculations. Only the patient’s personal experiences and the actual process of changes in their condition can provide objective evidence for diagnosis.
3. Trace back to the exact time when the initial symptoms began and their evolution up to the present. If several symptoms appear simultaneously, it is essential to determine their order of occurrence. While collecting information, it is not necessary to strictly follow the order of symptom appearance in questioning, but the information obtained should be sufficient to narrate or write the chief complaint and present illness history in chronological order. For example: a 56-year-old male patient presents with intermittent retrosternal pain for 2 years, which has recurred and worsened over the past 2 hours. Two years ago, the patient first experienced chest pain after activity, which disappeared after a few minutes. One year ago, the chest pain became more frequent, diagnosed as angina pectoris, and treated with 10 mg of nifedipine three times a day, after which the pain disappeared. The patient has continued taking the medication until now. Two hours ago, the retrosternal pain recurred, accompanied by sweating, dizziness, and palpitations, with the chest pain radiating to the left shoulder. The information collected in this way can accurately reflect the temporal development of the disease.
4. Use transitional language between the two items of inquiry, explaining to the patient the new topic to be discussed and its rationale. This will prevent confusion about why the topic is changing and why these situations are being inquired about. For example, before transitioning to family history, one might explain that some diseases have a hereditary tendency or are more likely to occur in a family, thus we need to understand these situations. Before transitioning to a systems review, explain that in addition to what has already been discussed, it is necessary to understand the conditions of all body systems, and then begin the systems review.
5. Use different types of questions based on the specific situation. General questions (or open-ended questions) are often used at the beginning of the consultation to obtain a large amount of information on a particular aspect, allowing the patient to narrate their condition like telling a story. This type of questioning should be used at the beginning of each part, such as present illness history, past history, and personal history. For example: “What brings you in today?” After obtaining some information, focus on asking some key questions.
Direct questions are used to collect specific details. For example, “How old were you when you had your tonsillectomy?” “When did your abdominal pain start?” The information obtained is more targeted. Another type of direct question requires the patient to answer “yes” or “no” or respond to provided choices. For example, “Have you ever had a heavy headache?” “Is your pain sharp or dull?” To systematically and effectively obtain accurate information, the inquirer should follow the principle of moving from general questions to direct questions. Incorrect questioning may lead to erroneous information or omissions of relevant data. The following types of questioning should be avoided: leading questions or suggestive questions, which imply the expected answer in their wording, making it easy for the patient to agree or conform to the physician’s suggestion, such as: “Your chest pain radiates to your left hand, right?” “Your condition improved a lot after taking this medication, right?”
Accusatory questions often make patients defensive, such as: “Why do you eat such unhealthy food?” If the physician indeed requires the patient to answer this, they should first explain the reason for asking the question; otherwise, the patient may perceive it as an accusation. Another inappropriate type is consecutive questioning, which involves asking a series of questions that may confuse the patient about what to answer, such as: “How does it feel after eating? Is it different from before eating? Is it sharp or dull?”
6. When questioning, pay attention to systematic and purposeful inquiry. Disorganized and repetitive questioning can reduce the patient’s confidence and expectations in the physician. For example, if during the collection of present illness history it has already been learned that one sister and one brother of the patient also have similar headaches, asking again if the patient has siblings indicates that the inquirer was not paying attention. Sometimes, to verify information, the same question may need to be asked multiple times, but this should be explained. For example: “You have told me that you have blood in your stool, which is very important information; please tell me more about your stool situation.” Sometimes using techniques like rhetorical questions and explanations can avoid unnecessary repetitive questioning.
7. At the end of each part of the medical history inquiry, summarize briefly, which can achieve the following purposes: ① Stimulate the physician’s memory and organize thoughts to avoid forgetting to ask questions; ② Let the patient know how the physician understands their medical history; ③ Provide an opportunity to verify the patient’s reported condition. Summarizing the present illness history is often particularly important. When summarizing family history, a brief overview is sufficient, especially for negative or uncomplicated positive family histories. When summarizing the systems review, it is best to summarize only positive findings.
8. Avoid medical jargon. When choosing language for the consultation and judging the patient’s narrative, it is important to note that patients from different cultural backgrounds have significant differences in their understanding of various medical terms. When communicating with patients, it is essential to use common, easily understandable words instead of difficult medical jargon. Just because a patient occasionally uses one or two medical terms does not mean they have a high level of medical knowledge. For example, some patients may have heard the term “otitis media” due to a previous ear condition, but they may not actually understand what “otitis media” means, or even where the middle ear is located. Since patients generally do not want to admit that they do not understand the physician’s questions, using jargon may lead to misunderstandings. Sometimes, the inquirer should provide appropriate explanations for difficult terms before using them, such as: “Have you ever had blood in your urine, in other words, has your urine ever been red?”
9. To collect the most accurate medical history, sometimes the physician needs to verify the information provided by the patient. If the patient uses diagnostic terminology, the physician should verify the reliability of the information by inquiring about the symptoms and examinations at that time. For example, if the patient says, “I had tuberculosis 5 years ago”; the physician might ask, “Did you have a chest X-ray at that time?”; the patient replies, “Yes”; the physician continues, “Did you receive anti-tuberculosis treatment?”; the patient replies, “Yes, I was treated with medication.” The physician might then ask, “Do you know the name of the medication?” Similarly, if a patient states, “I am allergic to penicillin,” the physician should follow up with, “How do you know you are allergic?” or ask, “Was the penicillin skin test positive, or what reaction did you have when you took penicillin?” Frequently verified information includes the amount of blood in vomit, weight changes, stool and urine output, important medications such as corticosteroids, anti-tuberculosis drugs, and psychiatric medications, as well as alcohol and smoking history, and allergy history.
10. Appearance, etiquette, and friendly gestures help develop a harmonious relationship with patients, making them feel warm and approachable. Gaining the patient’s trust can even lead them to disclose sensitive issues they initially intended to conceal. Appropriate moments should include smiling or nodding in approval. During the consultation, notes should be kept as simple and quick as possible; do not just focus on writing without maintaining necessary eye contact with the patient. During conversation, leaning forward can indicate active listening. Additionally, when the patient discusses sensitive issues such as their sex life, the inquirer can use crossed arms to show acceptance and understanding of their concerns. Other friendly gestures include tone of voice, facial expressions, neutral language, and encouraging phrases for the patient to continue talking, such as “I understand,” “Please continue,” or “Can you elaborate on that?”
11. Appropriately using some evaluative, praising, and encouraging language can promote cooperation between the patient and physician, encouraging the patient to actively provide information, such as: “I can understand that.” “That must be very difficult for you.” Some common praise phrases, such as “You have quit smoking? That takes willpower,” or “You are able to do a self-exam of your breasts every month, that’s great.” However, for patients with mental disorders, it is inappropriate to use praise or encouraging language indiscriminately.
12. Inquire about the patient’s economic situation, showing concern for whether the patient has economic and emotional support from family and work. The physician can provide appropriate explanations based on different situations to increase the patient’s trust. Sometimes, it is necessary to encourage the patient to seek economic and emotional support and introduce some individuals or groups that can help the patient.
13. The physician should understand the patient’s expectations and clarify the exact purpose and requirements of the patient’s visit. Sometimes, when patients are asked about their condition, they may feel passive; in reality, they may have other purposes, such as consulting on certain medical issues or needing to establish a long-term relationship with the physician due to long-term medication. In some cases, patient education and consultation are key to successful treatment and may even be the goal of treatment itself. The physician should assess what the patient is most interested in, what they want to know, and the amount of information they can understand each time, in order to provide appropriate information or guidance.
14. In many cases, when patients do not answer questions appropriately or show poor compliance, it is often because they do not understand the physician’s meaning. Various clever and careful methods can be used to check the patient’s level of understanding. The inquirer can ask the patient to repeat what has been said or present a hypothetical situation to see if the patient can respond appropriately. If the patient has not fully understood or has misunderstood, timely correction should be made.
15. If the patient asks questions that the physician is unclear about or does not understand, the physician should not casually respond, pretend to understand, or provide incorrect explanations. Neither should they simply answer with “I don’t know.” If the physician knows part of the answer or related information, they can explain and provide what they know for the patient’s reference. For questions that are not understood, the physician can respond that they will look it up or consult others before answering, or suggest the patient consult someone else or indicate where they can resolve the issue.
16. At the end of the consultation, thank the patient for their cooperation, inform them of the importance of doctor-patient collaboration through verbal or body language, explain the next steps required from the patient, what will be done next, the next appointment time, or follow-up plans. It must be pointed out that only through theoretical learning combined with practical training can one master the methods and techniques of consultation well. Just like other forms of human interaction and communication, there cannot be a mechanical, unchanging model and method of consultation; one should be sensitive to specific situations and flexibly grasp them. Beginners may sometimes have disorganized thoughts, difficulty articulating, and struggle to ask appropriate questions, leading to unsatisfactory progress in the consultation. They should continuously summarize experiences and learn from lessons. When necessary, they can ask themselves: Is the patient particularly uncomfortable at this moment? Is the patient unable to express themselves? Is there a language barrier? Is the patient intimidated by the illness? Is the physician too nervous? Is the physician’s behavior affecting the doctor-patient relationship? Is the patient’s trust level insufficient? By striving to identify and resolve the factors affecting the consultation, one can continuously improve their consultation skills.
| Internal Medicine | Symptoms and Signs |
| Pediatrics | Practical Skills |
| Surgery | Obstetrics and Gynecology |
