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Recommended Reading Audience: 2016 Clinical Medicine, Acupuncture and Tuina, Rehabilitation Therapy Technology students
Concurrent Learning Courses: “Diagnosis Ia (Basic Diagnostic Skills)”, “Fundamentals of Diagnosis”, “Overview of Clinical Medicine (Diagnosis)”
Concurrent Learning Progress: Diagnosis | Inquiry (History Collection)
Diagnosis | How Much Do You Know About Inquiry Techniques
The methods and techniques of inquiry are closely related to the quality of the collected medical history, involving general communication skills, completeness of information, doctor-patient relationships, medical knowledge, etiquette, and providing consultation and education to patients. In different clinical situations, appropriate methods and techniques should be adopted accordingly.
The methods and techniques of inquiry mainly include the following aspects:
1. Greeting and self-introduction at the beginning;
2. Starting with the patient’s main symptoms and feelings, gradually deepening the inquiry in a purposeful, layered, and orderly manner;
3. Listening carefully during the inquiry, guiding when necessary, avoiding suggestions and leading questions, avoiding repetitive questioning, avoiding medical jargon, and recording immediately to prevent forgetting;
4. Clarifying any unclear statements or questions from the patient in a timely manner, showing care, consideration, friendliness, and sympathy, ensuring patient privacy, allowing patients to speak freely without reservations.
Creating a Good Medical Atmosphere
1. At the beginning of the inquiry, create a good medical atmosphere. Generally, start with polite conversation, introduce yourself (wearing a name badge is a good way to introduce oneself), and explain your responsibilities. Using appropriate language or body language to express willingness to relieve the patient’s pain and meet their needs will help establish a good doctor-patient relationship, quickly shorten the distance between doctor and patient, and facilitate the smooth collection of medical history. It is important to protect patient privacy; it is best not to start the inquiry in front of strangers. If the patient requests a family member to be present, the doctor can agree.
Listening and Guiding
2. To ensure the smooth progress of the inquiry, the inquirer should listen carefully and not interrupt the patient easily, allowing them enough time to answer questions. Sometimes, allowing necessary pauses (such as during reflection) is beneficial; intentional silence may be uncomfortable but can encourage the patient to provide additional relevant information or to address sensitive issues. Without such silence, patients may omit important details. If the patient’s behavior indicates a need for calm reflection on certain issues, a brief pause may be beneficial. Silence can be a double-edged sword, and its effectiveness depends on how it is used. Your intuition can help judge the appropriateness of pauses in the conversation; if it feels awkward, the patient may be struggling to articulate their thoughts, while if you feel it could yield more information, then the pause is an effective inquiry technique. Summarizing the collected medical history can help the inquirer clarify their thoughts. To save time, you can ask prepared questions, such as “Can you tell me how you usually spend your day?” A good inquirer does not rush to ask a series of questions that leave the patient little time to consider their answers. If the patient goes off on a tangent discussing unrelated issues, you can subtly guide them back to the medical history, such as saying, “I understand your concerns; now please tell me about your abdominal pain situation?”
Determining the Sequence of Events
3. Trace back to the exact time the initial symptoms began and their evolution to the present. If multiple symptoms appeared sequentially, it is essential to determine their chronological order. Patients usually start narrating from the most prominent symptoms and their timing, but when collecting information, do not forget to ask about the onset time of the initial symptoms. Of course, during the inquiry, it is not necessary to strictly follow the order of symptom appearance, but the information obtained should adequately reflect the onset and evolution of the disease, allowing for a chronological narration or written account of the chief complaint and present illness history. For example: A 70-year-old male patient presents with chronic cough and sputum for over twenty years, worsening for two weeks. The patient has experienced cough and sputum every winter for the past twenty years, with white sputum lasting 2-3 months, without other respiratory symptoms such as shortness of breath or chest pain, improving after treatment with antibiotics and other expectorants. This time, the cough and sputum worsened about two weeks ago after the weather turned cold, with the sputum turning yellow and increasing in quantity, diagnosed as chronic bronchitis, treated with anti-infection, cough relief, and expectorant therapy, resulting in symptom improvement. This information accurately reflects the disease’s progression.
Using Transitional Language
4. Use transitional language between different inquiry topics, explaining to the patient the new topic and its rationale, so they do not feel confused about why the topic is changing and why you are asking these questions. For instance, before transitioning to family history for an asthma patient, inform them that asthma has a hereditary component, so it is necessary to understand the patient’s family history over several generations. 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.
Employing Different Types of Questions
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 inquiry to gather a large amount of information on a particular aspect, then focus on specific key questions. Allow the patient to narrate their condition as if telling a story. This type of questioning should be used at the beginning of each section, such as asking during the present illness history collection, “What brings you here today?” to gather the main symptoms and/or signs of the disease; during the past medical history collection, ask, “What illnesses have you had before?” or “What surgeries have you had?” to understand previous diseases. Then, through direct questioning, collect specific details, such as “How old were you when you had your tonsillectomy?” or “When did your chest pain start?” to obtain more targeted information. Another type of direct choice question requires the patient to answer “yes” or “no,” or to respond to provided options, such as “Have you ever had tuberculosis?” or “Is there blood in your sputum?” 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 questions should be avoided: leading questions or suggestive questions, which imply expected answers in their wording, making it easy for patients to agree or confirm the doctor’s suggestions, such as, “Your chest pain radiates to your left arm, right?” or “Your condition improved significantly after taking this medication, right?”
Accusatory questions often put patients on the defensive, such as, “Why do you eat such unhealthy food?” If the doctor genuinely needs 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, where a series of questions are posed in quick succession, potentially confusing the patient about which question to answer, such as, “How does it feel after eating? Is it different from before eating? Is it sharp pain or dull pain?”
Attention to Systematic and Purposeful Inquiry
6. When questioning, pay attention to systematic and purposeful inquiry. Disorganized and repetitive questioning can undermine the patient’s confidence in the doctor and their expectations. For example, if during the collection of present illness history, it is already known that the patient has a sister and a brother with 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, such as, “You have told me that you have blood in your stool, which is important information; please tell me more about your stool situation.” Sometimes, using techniques like rephrasing and explaining can avoid unnecessary repetitive questioning.
Summarizing
7. At the end of each section of the medical history inquiry, summarize and inform the patient, which can achieve the following purposes: 1) to jog the doctor’s memory and clarify their thoughts to avoid forgetting questions; 2) to let the patient know that the doctor is listening attentively and understands their medical history; 3) to verify the patient’s reported condition; 4) to allow the patient to remind the doctor of any omissions and restate their medical history. Summarizing the present illness history is often particularly important. Summarizing family history can be brief, especially for negative or uncomplicated positive family histories. When summarizing the systems review, it is best to summarize only positive findings.
Avoiding Medical Terminology
8. Avoid medical terminology. When choosing language for the inquiry and interpreting the patient’s narrative, it is important to note that patients from different cultural backgrounds may have significant differences in their understanding of various medical terms. When conversing with patients, it is essential to use layman’s terms instead of difficult medical jargon. For example, ask, “Have you noticed any redness in your urine recently?” instead of “Have you had hematuria recently?”
Attention to Verification
9. To collect the most accurate medical history possible, sometimes physicians need to verify the information provided by the patient. For instance, if the patient uses diagnostic terminology, the doctor should inquire about the symptoms and examinations at that time to verify the reliability of the information. For example, if a patient says, “I had tuberculosis five years ago,” the physician should ask, “How was it diagnosed? Did you have an X-ray? Did you have a sputum test?” The patient then provides further answers; the physician may ask, “Did you receive anti-tuberculosis treatment?” The patient replies, “Yes, I was treated with medication.” The physician may 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 did you react?” or ask, “Was it a positive skin test for penicillin, or did you have a reaction when you used penicillin?” Information that often needs verification includes the amount of blood in vomit, changes in weight, the amount of stool and urine, important medications such as corticosteroids, anti-tuberculosis drugs, and psychiatric medications, as well as alcohol and smoking history, and allergy history.
Editor: Lin Hong
Reviewer: Yao Yueying
Xiamen Medical College, Clinical Medicine Department
