Getting Started

The diagnostic process begins at the first moment of meeting. You should be dressed appropriately, wearing a white coat with your name badge identifying you as a member of the health-care team. Patients expect this standard of professional attire. Casual attire may signify condescension.

Introduce yourself, greet the patient by last name, make eye contact, shake hands firmly, and smile. You may wish to say something like

"Good morning, Mr. Smith; I'm Mary Jones, a medical student at the ... School of Medicine. I've been asked to interview and examine you in the next hour.''

Alternatively, you may say,

''Good morning, I'm Mary Jones; are you Mr. Smith? [Pause and wait for answer.] I am a medical student at the ... School of Medicine. I've been asked to interview and examine you in the next hour.''

''Good morning, I'm Mary Jones; please tell me how to pronounce your name? [Pause and wait for answer.] I am a medical student at the ... School of Medicine. I've been asked to interview and examine you in the next hour.''

''Good morning, I'm Mary Jones, are you Mr. Smith? Did I pronounce your name correctly? [Pause and wait for answer.] I am a medical student at the ... School of Medicine. I've been asked to interview and examine you in the next hour.''

The term student doctor should generally be avoided because patients may not actually understand this term; they may hear only the word doctor. The introduction also includes a statement of the purpose of the visit. The welcoming handshake can serve to relax the patient.

It is appropriate to address patients by their correct titles—Mr., Mrs., Dr., Ms.—unless they are adolescents or younger. A formal address clarifies the professional nature of the interview. Name substitutes such as ''dear,'' ''honey,'' or ''grandpa'' are not to be used. If you are not sure about the pronunciation, ask the patient how to say his or her name correctly.

The patient may address an interviewer as Ms. Jones, for example, or might elect to use the interviewer's first name. It is not correct for an interviewer to address the patient by his or her first name, because this changes the professional nature of this first meeting.

If the patient is having a meal, ask whether you can return when he or she has finished eating. If the patient is using a urinal or bedpan, allow privacy. Do not begin an interview in this setting. If the patient has a visitor, you may inquire whether the patient wishes the visitor to stay. Do not assume that the visitor is a family member. Allow the patient to introduce the person to you.

The interview can be helped or hindered by the physical setting in which the interview is conducted. If possible, the interview should take place in a quiet, well-lit room. Unfortunately, most hospital rooms do not afford such luxury. The teaching hospital with four patients in a room is rarely conducive to good human interactions. Therefore, make the best of the existing environment. The curtains should be drawn around the patient's bed to create privacy and minimize distractions. You may request that the volume of neighboring patients' radios or televisions be turned down. Lights and window shades can be adjusted to eliminate excessive glare or shade. Arrange the patient's bed light so that the patient does not feel as if he or she is under interrogation.

You should make the patient as comfortable as possible. If the patient's eyeglasses, hearing aids, or dentures were removed, ask whether the patient would like to use them. It may be useful to use your stethoscope as a hearing aid for hearing-impaired patients. The ear tips are placed in the ears of the patient, and the diaphragm serves as a microphone. The patient may be in a chair or lying in bed. Allow the patient the choice of position. This makes the patient feel that you are interested and concerned, and it allows the patient some control over the interview. If the patient is in bed, it is a nice gesture to ask whether the pillows should be arranged to make him or her more comfortable before the interview begins.

Normally, the interviewer and patient should be seated comfortably at the same level. Sometimes it is useful to have the patient sitting even higher than the interviewer to give the patient the visual advantage. In this position, the patient may find it easier to open up to questions. The interviewer should sit in a chair directly facing the patient to make good eye contact. Sitting on the bed is too familiar and not appropriate. It is generally preferred that the interviewer sit at a distance of about 3 to 4 feet from the patient. Distances greater than 5 feet are impersonal, and distances closer than 3 feet interfere with the patient's ''private space.'' The interviewer should sit in a relaxed position without crossing arms across the chest. The crossed-arms position is not appropriate because this body language projects an attitude of superiority and may interfere with the progress of the interview.

If the patient is bedridden, raise the head of the bed, or ask the patient to sit so that your eyes and the patient's eyes are at the same level. Avoid standing over the patient. Try to lower the bed rail so that it does not act as a barrier to communication, and remember to put it back up at the conclusion of the session.

Regardless of whether the patient is sitting in a chair or lying in bed, make sure that he or she is appropriately draped with a sheet or robe.

Once the introduction has been made, the interview may begin with a general, open-ended question, such as ''What medical problem has brought you to the hospital?'' or ''I understand you are having ... Tell me the problem.'' This type of opening remark allows the patient to speak first. The interviewer can then determine the patient's chief complaint: the problem that is regarded as paramount. If the patient says, ''Haven't you read my records?'' it is correct to say, ''No, I've been asked to interview you without any prior information.'' Alternatively, the interviewer could say, ''I would like to hear your story in your own words.''

Patients can determine very quickly if you are friendly and personally interested in them. You may want to establish rapport by asking them something about themselves before you begin diagnostic questioning. Take a few minutes to get to know the patient. If the patient is not acutely ill, you may want to say, ''Before I find out about your headache, tell me a little about yourself.'' This technique puts the patient at ease and encourages him or her to start talking. The patient usually talks about happy things in his or her life rather than the medical problems. It also conveys your interest in the patient as a person, not just as a vehicle of disease.

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